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Discharge summary
|
report
|
Admission Date: [**2175-12-1**] Discharge Date: [**2175-12-19**]
Date of Birth: [**2128-2-22**] Sex: M
Service: MEDICINE
Allergies:
Vitamin K
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
RML collapse, bilateral pneumonia
Major Surgical or Invasive Procedure:
large volume paracentesis
diagnostic paracentesis
hemodialysis
History of Present Illness:
47M h/o ESLD [**2-17**] alcohol abuse and HCV, ESRD on HD, who presents
after large volume paracentesis of 8L and dialysis in [**Hospital1 8**].
Treated with 12.5gx4 of Albumin. Pt had a CXR on [**2175-11-28**] with
showed right middle lobe collapse. Dr. [**Last Name (STitle) 118**] (Renal) has been
unable to get in touch with him about this result. He was
contact[**Name (NI) **] at dialysis yesterday and was directly admitted for
w/u of pulmonary process. Upon admission, patient was alert and
oriented to person and hospital. However, as the evening
progressed, he became more somnolent. Patient later desatted on
room air to 84-88%RA which went up to 96% on 6L face mask. ABG
was done. pH was 7.38, pCO2 48, p02 of 62%. Repeat CXR again
demonstrated R middle lobe collapse, thought unlikely to be
result of infectious process. Patient was intially started on
levaquin empirically, but after he decompensated, coverage was
advanced to Vanco, Zosyn. Sputum gram stain from [**12-1**] was
positive for 4+ GPCs in pairs and chains.
Past Medical History:
--GI/liver
Cirrhosis [**2-17**] untreated HCV, alcohol abuse, not transplant
candidate
Esophageal varices s/p [**12-20**] banding
h/o SBP
--GU
ESRD on HD T/Th/Sat (from ATN, HRS)
--Heme
Anemia of chronic disease
--Pulmonary
Asthma
--Neuro/psych
Depression
Schizotypal personality disorder
Social History:
# Personal: Lives with wife.
# Substance abuse: Denies current tobacco, ETOH, or drug use.
Heavy ETOH use in past, prior IV drug use in [**2148**], but last
reportedly [**4-21**]. Former smoker.
Family History:
# No history of liver disease.
# Maternal aunt with DM.
Physical Exam:
Physical Exam on MICU admission:
GENERAL: Difficult to arouse. Sat up for lung exam. Very drowsy.
VITALS: T 97 92/54 (78-103) 74 (62-74) RR 10 96% 6L
HEENT: Unable to cooperate w exam, PERRL
NECK: No stiffness, No masses, No LAD, 2+ carotid pulses, no
bruits, no JVP elevation
CHEST: Lungs rhoncherous throughout.
HEART: RRR. S1S2, No Murmurs/rubs/gallops
BACK: No CVA Tenderness, No spinal tenderness.
ABDOMEN: Soft, (?)nontender, distended. Umbilical hernia and
ventral hernia. Normal bowel sounds. No guarding, No rebound.
EXT: Tense edema to the knees bilaterally with some chronic
venous stasis changes.
NEURO: AAO x 2 (knows name and [**Hospital1 18**]). He was very somnolent
and poorly attentive. Moving all extremities, but not
cooperative with exam. Asterixis noted on hand grip.
Pertinent Results:
****************SALIENT ADMISSION LABS [**2175-11-30**]
CBC:
WBC-8.7 RBC-2.84* Hgb-10.1* Hct-33.6* MCV-118* MCH-35.5*
MCHC-30.0* RDW-19.4* Plt Ct-68*
.
COAGS:
PT-20.2* PTT-40.7* INR(PT)-1.9*
.
CHEMISTRY:
UreaN-51* Creat-8.6* Na-135 K-4.1 Cl-97 HCO3-27 AnGap-15
Hapto-<20*
.
LFTs:
ALT-34 AST-56* AlkPhos-155* TotBili-5.8* Albumin-2.4*
Ammonia-114*
.
AFP-<1.0
.
TOX SCREEN:
ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
.
ASCITIC FLUID:
WBC-125* RBC-65* Polys-33* Lymphs-8* Monos-43* Mesothe-2*
Macroph-14*
.
***************SUBSEQUENT IN-HOSPITALIZATION LABS:
PERITONEAL TAPS:
[**2175-12-12**] 04:00PM ASCITES WBC-88* RBC-134* Polys-1* Lymphs-10*
Monos-55* Mesothe-6* Macroph-28*
[**2175-12-16**] 03:21PM ASCITES WBC-25* RBC-7350* Polys-38* Lymphs-25*
Monos-31* Mesothe-6*
.
***************MICROBIOLOGY:
[**2175-12-1**] 5:32 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
**FINAL REPORT [**2175-12-8**]**
AEROBIC BOTTLE (Final [**2175-12-8**]): NO GROWTH.
AEROBIC BOTTLE (Final [**2175-12-8**]): NO GROWTH.
**********ALL SUBSEQUENT BLOOD CULTURES WERE NEGATIVE
.
[**2175-12-1**] 10:54 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2175-12-7**]**
GRAM STAIN (Final [**2175-12-2**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2175-12-7**]):
HEAVY GROWTH OROPHARYNGEAL FLORA.
ENTEROBACTER CLOACAE. SPARSE GROWTH.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
ENTEROBACTER CLOACAE. RARE GROWTH. 2ND MORPHOLOGY.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE
| ENTEROBACTER CLOACAE
| |
CEFEPIME-------------- 4 S 32 R
CEFTAZIDIME----------- =>64 R =>64 R
CEFTRIAXONE----------- =>64 R =>64 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S <=1 S
IMIPENEM-------------- <=1 S 4 S
MEROPENEM-------------<=0.25 S 1 S
PIPERACILLIN---------- =>128 R =>128 R
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
.
[**2175-12-4**] 11:02 am URINE Source: Catheter.
**FINAL REPORT [**2175-12-4**]**
Legionella Urinary Antigen (Final [**2175-12-4**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
.
[**2175-12-12**] 4:00 pm PERITONEAL FLUID
**FINAL REPORT [**2175-12-18**]**
GRAM STAIN (Final [**2175-12-12**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2175-12-15**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2175-12-18**]): NO GROWTH.
.
[**2175-12-14**] 10:58 pm STOOL CONSISTENCY: SOFT Source:
Stool.
**FINAL REPORT [**2175-12-15**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2175-12-15**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
.
[**2175-12-12**] 4:00 pm PERITONEAL FLUID
**FINAL REPORT [**2175-12-18**]**
GRAM STAIN (Final [**2175-12-12**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2175-12-15**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2175-12-18**]): NO GROWTH.
.
********************STUDIES:
.
ADMISSION CHEST XRAY (PORTABLE AP) [**2175-12-1**] 8:38 PM
IMPRESSION: Developing right lower lobe infiltrate. Follow-up to
resolution is recommended.
.
CT TRACHEA W/O C W/3D REND [**2175-12-2**] 3:57 PM
IMPRESSION:
1. Extensive areas of bronchial wall thickening, peribronchial
inflammation, ground-glass and centrilobular nodules, likely due
to an acute infection spreading via the airways (e.g. viral or
mycoplasma). Focal subsegmental right middle lobe atelectasis is
likely due to transient bronchial impaction.
2. Anemia.
3. Lower esophageal thickening most likely related to esophageal
varices in a patient with known cirrhosis, although focal
esophageal abnormality cannot be excluded given the lack of
intravenous and oral contrast.
4. Bilateral symmetric gynecomastia.
5. Ascites and stigmata of cirrhosis.
6. Bilateral anterior healing rib fractures
.
Portable TTE (Complete) Done [**2175-12-4**] at 3:01:26 PM
IMPRESSION: Normal study. Normal biventricular cavity sizes with
preserved global and regional biventricular systolic function.
No intracardiac shunt identified.
Compared with the prior (non-contrast) study of [**2175-7-3**], the
findings are similar.
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2175-12-9**] 5:12 PM
IMPRESSION:
1. No evidence of pulmonary embolus.
2. Bilateral lower lobe collapse and some consolidation with
atelectasis of inferior aspect of right middle lobe.
3. Evidence of cirrhosis and gross ascites.
4. Multiple anterior rib fractures.
.
CHEST (PA & LAT) [**2175-12-14**] 4:34 PM
IMPRESSION: infiltrates are present within both the right and
left lower lobes consistent with ongoing pneumonia. No failure
is seen. The costophrenic angles are sharp. No effusion to layer
on decubitus films.
Brief Hospital Course:
47M h/o decompensated liver failure who presented after routine
large volume paracentesis with cough, leukocytosis, and sputum
GS positive for GPCs and CXR showing right middle lobe collapse,
and with encephalopathy. Pt was transferred to the MICU x2 with
respiratory distress and worsening mental status during his
hospitalization. His hospital course is detailed
chronologically:
.
While in MICU for first time for hypoxia (occurred at HD), he
did not require intubation. A-line placed. His respiratory
status slowly improved on abx and as MS improved. He underwent
TTE w/ bubble study, which showed no intracardiac shunt or
evidence of hepatopulmonary syndrome to explain hypoxia. EF
>55%. Bld cx's NGTD. Legionella urinary ag negative. His abx
regimen was changed to levofloxacin (from vanc/zosyn). His 02
requirement improved to 2L NC from 6L face-mask. ABG on AM of
transfer was 7.41/43/80.
.
Was transferred back to floor on [**12-6**] given clearing MS and
improved hypoxia. 2L taken off at HD. Spiked on day of transfer,
also productive sputum. Pt was switched back to Vanc/Zosyn. Was
86% on 2L at HD. Sats went up to 96% on FM. After this, pt
improved again. Plans were made to discharge soon with outpt HD
to resume. Sputum from [**12-1**] came back with Enterobacter. Abx
switched to IV meropenem.
.
On [**12-9**], dialysis was performed again. 0.5L were taken off. Pt
developed again SOB and desaturations to 80% on 2L NC. Also
brief episode of sharp, retrosternal CP associated, lasting for
2 min, relieved by 1x SL Nitro and sitting up (per pt only
fleeting episode of CP, per intern as described). ASA 325mg was
given. Pt was placed on 100% NRB with improvement of sats. pH
7.38/48/61 (100%NRB). Pt was also tachy to 120s. EKG showed no
significant changes except for sinus tach. CXR with no
significant change to previous from [**12-6**]. Pt was transferred
back to ICU for closer O2 monitoring on NRB, also airway
monitoring during planned CTA to r/o PE and possible intubation
should his respiratory status worsen further. CTA demonstrated
large bilateral collapsed lower lobes and consolidation with
atelectasis of inferior aspect of right middle lobe.
Antitussives were discontinued, with plan to institute
aggressive chest PT; pt continued on meropenem for Enterobacter
in sputum from [**12-1**] sputum cx. Pt's O2sats improved while in
MICU without intubation or any aggressive intervention, and
given stable respiratory status, was deemed stable to transfer
to floor again.
.
His floor course since [**12-10**] has shown marked improvement. He
did continue to have desaturations at HD. After close
examination, the renal team deemed this to be an allergy to a
component of his HD filter. Via trial and error we discovered a
new membrane that did not evoke an allergic response with
desaturations at hemodialysis. This membrane will continue to be
used at his outpatient HD. His sevelemer was increased to 1600mg
tid with meals and he continued on his nephrocaps.
.
While on the floor (i.e. when not at HD) Mr. [**Known lastname **] continued to
demonstrate an O2 requirement for some time. It was unclear what
the patient's exact pulmonary process might have been (likely
multifactorial), and which intervention ultimately improved his
hypoxia. It was felt that given his pneumonia was a likely
contributor, as his sats improved with a course of IV meropenem
x 12 days. Also considered a reactive airways component as pt
with h/o asthma and intermittent wheezing on exam. Pulmonary was
consulted and recommended beginning Advair and standing
albuterol/atrovent nebs. PE and intracardiac shunt were ruled
out. An LVP was performed as it was thought that patient's tense
ascited might be causing some splinting.
.
By discharge he had been weaned off his oxygen and was stable at
92% on RA. When exercising with PT he maintained his O2 sats in
the mid to low 90's. He was scheduled for outpatient pulmonary
followup with PFTs.
.
Another complication of his floor course was a slow but steady
HCT drop in the setting of being guaiac positive. With a history
of bleeding varices, liver was concerned and we pursued an
inpatient EGD, but Mr. [**Known lastname **] refused. He received a total of 2
units of PRBCs with more than appropriate responses, and was
always hemodynamically stable. As such liver felt that a
semi-urgent outpatient EGD could be arranged. He was scheduled
for this by the time of discharge.
.
In terms of his liver disease, he underwent a 5 liter LVP and a
subsequent diagnostic tap, and each were negative for SBP. The
diagnostic tap was persued [**2-17**] a rising white blood cell count
(as high as 38,000). The leukocytosis was probably more
reflective of his allergic reaction to repeated attempts at
dialysis, as no source for infection was seen on CXR or blood
culture, and he was C. Diff negative x 1. He was continued on
his liver regimen of nadolol, lactulose, and rifaximin. We
continued prilosec for history of Upper GI ulcer. He was never
grossly encephalopathic but his mental status was slowed at
times, which appears to be near his baseline. MELD scores were
in the 33-34 range (has been deemed not to be a transplant
candidate in the past).
.
Prophylactically, he was on a PPI for h/o gastric ulcer,
pneumoboots, and lactulose for a bowel regimen.
.
CODE: full throughout.
Medications on Admission:
Rifaximin 400 mg TID
Nadolol 20 mg DAILY
Lactulose 60 ML QID
Nephrocaps 1 DAILY
Thiamine 100 mg DAILY
Folic Acid 1 mg DAILY
Sevelamer 800 mg TID W/MEALS
Prilosec 20 mg [**Hospital1 **]
Albuterol 1-2 puffs Q4-6hours prn
Flovent 2 puffs [**Hospital1 **]
Sucralfate 1 gm QID
Discharge Medications:
1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
2. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO QID (4
times a day).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
Disp:*180 Tablet(s)* Refills:*0*
8. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*2 Disk with Device(s)* Refills:*2*
10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every six (6) hours.
Disp:*1 inhaler* Refills:*2*
11. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
puff Inhalation every four (4) hours.
Disp:*1 inhaler* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Bilateral Enterobacter Pneumonia
.
Secondary:
allergic reaction to dialysis filter
Hepatic encephalopathy
Cirrhosis, End Stage renal disease
Discharge Condition:
Stable, without oxygen requirement, afebrile
Discharge Instructions:
You were admitted to the hospital with a pneumonia. You required
oxygen and spent some time in the intensive care unit for closer
monitoring. You received IV antibiotics in the hospital and
slowly improved, requiring less oxygen. You do not need to take
any more antibiotics while you are at home. You have a follow-up
appointment scheduled with the pulmonary (lung) doctors as
detailed below.
.
It also appear that you have developed an allergy to certain
dialysis filters and membranes. As a result, the kidney doctors
worked [**Name5 (PTitle) **] to find you a suitable replacement filter which you
can use as an outpatient without developing an allergic
reaction. This new filter will be available beginning at your
first outpatient dialysis appointment, which is scheduled for
this Thursday [**2175-12-21**].
.
While you were in the hospital your blood counts began to drop,
and it appeared that you were slowly losing blood through your
GI tract. You received several blood transfusions. The liver
team recommended an upper endoscopy to look inside your stomach
for a source of bleeding, but your refused this study as an
inpatient. We strongly recommend that you have this study
performed PROMPTLY as an outpatient. You have an appointment for
this as detailed below.
.
You will be taking a new asthma medicine called Advair, as well
as 2 inhalers (albuterol and ipratropium). Please take your
medications as prescribed unless otherwise directed by your
physician.
.
You should follow up with your primary care doctor, Dr [**First Name (STitle) **],
within 1-2 weeks. Please continue to keep your outpatient
hemodialysis and all other appointments.
.
Please return to the emergency room if you develop any worrisome
symptoms such as bleeding from the rectum, shortness of breath,
fever, chills, or chest pain.
Followup Instructions:
You have an appointment to follow up with the Pulmonary team as
follows:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2176-1-11**] 1:30
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2176-1-11**] 1:30
Provider: [**Name10 (NameIs) 1571**] BREATHING TEST Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2176-1-11**] 3:10
.
You have an appointment to follow up with the GI team for your
upper endoscopy as follows. Please arrive at 12:30 for your
appointment:
Provider: [**Name10 (NameIs) **] WEST,ROOM ONE GI ROOMS Date/Time:[**2175-12-28**] 1:30
Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2175-12-28**] 12:30
.
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2176-2-29**] 11:00
.
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] within 1-2 weeks.
Provider: [**Name10 (NameIs) **] [**First Name8 (NamePattern2) 18443**] [**Name12 (NameIs) 815**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2176-1-19**] 4:00
|
[
"286.7",
"261",
"070.44",
"789.59",
"E879.1",
"518.0",
"482.83",
"585.6",
"280.0",
"311",
"518.82",
"493.92",
"570",
"571.2",
"V45.1",
"285.21",
"995.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"39.95",
"99.07",
"38.91",
"99.06"
] |
icd9pcs
|
[
[
[]
]
] |
16286, 16292
|
9506, 14841
|
305, 369
|
16486, 16533
|
2861, 9483
|
18398, 19633
|
1975, 2032
|
15163, 16263
|
16313, 16465
|
14867, 15140
|
16557, 18375
|
2047, 2842
|
232, 267
|
397, 1433
|
1455, 1745
|
1761, 1959
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,056
| 110,588
|
49033
|
Discharge summary
|
report
|
Admission Date: [**2115-10-23**] Discharge Date: [**2115-10-28**]
Service: SURGERY
Allergies:
Sulfonamides
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
fall from standing
Major Surgical or Invasive Procedure:
none
History of Present Illness:
88F s/p fall from standing with + [**Hospital 63213**] transferred from outside
hospital to [**Hospital1 18**] for management of L frontal IPH w/ small SDH,
and a L orbital wall fracture.
Past Medical History:
HTN
Echo [**2108**]: EF 55%, 2+ MR/TR
depression
Claudication with negative LE arterial studies
Social History:
Lives at home with husband. [**Name (NI) **] 2 grown children on the West
Coast. [**12-23**] drinks/week. Smoking hx 1 ppd x 20 years, quit 30
yrs ago. no other drug use.
Family History:
Non-contributory, no heart disease on family.
Physical Exam:
Gen: NAD
Chest: CTAB RRR
Abd: S/S/NT
Ext: WNL
Pertinent Results:
[**2115-10-25**] 07:35AM BLOOD WBC-7.8 RBC-4.40 Hgb-13.4 Hct-37.5 MCV-85
MCH-30.5 MCHC-35.8* RDW-13.5 Plt Ct-185
[**2115-10-23**] 12:20PM BLOOD PT-12.5 PTT-26.1 INR(PT)-1.1
Brief Hospital Course:
The patient was admitted to [**Hospital1 18**], where neurosurgery was
consulted. They recommended a repeat Head CT, and an MRI of the
head and C-spine with the patient to remain in a C-collar until
this had been done. The Head CT showed unchanged hemorrhages,
while the MRI of the brain was consistent with a bleed, and did
not show any underlying lesion. The MRI C-spine was unchanged
from previous and the patient's C-spine was subsequently
cleared. Plastic surgery recommended antibiotics for 7 days and
non operative management of the patient's orbital fracture. The
etiology of the patients' fall was discussed with cardiology -
they recommended an echocardiogram which showed significant L
ventricular outflow obstruction with an EF of 75%, with mild AR,
MR, and moderate TR. A CTA of the chest requested by cardiology
was also negative for PE. At this time, the cardiology service
recommended a further arrhythmia workup as an outpatient. The
patient is tolerating regular diet, having bowel function, and
was cleared to go home by physical therapy. She is therefore
being discharged to follow up with cardiology.
Medications on Admission:
asa 81, ativan 0.5 qhs prn, cartia xt 120', ditropan 5', fosamax
70 qwk, lopressor 25", ritalin 0.5", simvastatin 20'
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO twice a day for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for Insomnia.
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
8. Codeine Sulfate 30 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4
hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
9. Polyethylene Glycol 3350 100 % Powder Sig: One (1) dose PO
DAILY (Daily) as needed.
10. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Fall from standing
Left frontal intraparenchymal hemorrhage with subdural hematoma
Left medial/lateral orbital wall frcature
Discharge Condition:
Stable, pain well controlled
Discharge Instructions:
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* 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 prescribed.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Followup Instructions:
Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 80069**] to arrange appropriate
follow-up regarding your heart monitoring.
Please call the [**Hospital **] [**Hospital **] at [**Telephone/Fax (1) 1669**] to arrange
appropriate follow-up with Dr. [**Last Name (STitle) **].
You can follow-up with the Trauma [**Last Name (STitle) **] as needed. They can be
reached at [**Telephone/Fax (1) 2359**].
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2115-10-30**] 10:00
Provider: [**Name10 (NameIs) 13644**],NURSE [**First Name (Titles) 13644**] [**Last Name (Titles) **] Date/Time:[**2115-11-7**] 1:15
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2115-12-16**] 1:40
|
[
"332.0",
"802.8",
"E885.9",
"401.9",
"440.8",
"733.00",
"356.9",
"311",
"496",
"801.22",
"746.84",
"425.1",
"780.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3423, 3481
|
1117, 2241
|
239, 245
|
3650, 3681
|
920, 1094
|
4516, 5291
|
792, 839
|
2409, 3400
|
3502, 3629
|
2267, 2386
|
3705, 4493
|
854, 901
|
181, 201
|
273, 463
|
485, 583
|
599, 776
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,697
| 151,359
|
33153
|
Discharge summary
|
report
|
Admission Date: [**2101-12-13**] Discharge Date: [**2101-12-26**]
Date of Birth: [**2019-11-17**] Sex: F
Service: MEDICINE
Allergies:
Norvasc / Dyazide
Attending:[**First Name3 (LF) 21990**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
1. Anoscopy with oversewing of rectal ulcer with multiple 3-0
Vicryl sutures.
2. Colonoscopy x3
3. EGD x1
4. Arteriogram x3
History of Present Illness:
Ms. [**Known lastname 77059**] is a 82 female from [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] who presents
with BRBPR since this morning; also found to have ARF in ED
today. Found clots without stool in diaper this morning. Noted
to have hematuria and UTI since [**12-8**]; started on Bactrim DS.
Hematuria worsening lately.
On ROS, + constipation, no N/V/D.
In ED, found to have new renal failure (baseline creatinine 1.2
-> 4.5 in ED), BUN 110; hyperkalemia to 6. + BRB on rectal
exam. Got Na bicarb for hyperkalemia. U/A and culture sent.
Past Medical History:
- DJD
- UTI on Bactrim start [**12-8**]
- venous stasis dermatitis with recent cellulitis ([**9-/2101**])
- HTN
- hyperlipidemia
- anemia (last Hct 35)
- h/o TIA
- CHF per NH records
- BOOP in [**2084**]
- ?PMR in [**2098**]; short trial of steroids stopped
- spinal stenosis
Social History:
Lives at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] since [**2098-1-20**]. Quit smoking 20 yrs
ago, no etoh.
Family History:
N/C
Physical Exam:
Vital signs: Temp 97.3, HR 64, BP 127/52, RR 16, O2 Sat 98% RA
General: Slightly flushed, NAD, Alert and oriented x3
HEENT: PERRL
Neck: JVP <5
CV: Regular rhythm, normal S1 S2, no murmers, rubs, gallops
Pulm: Clear to auscultation bilaterally
GI: obese, + BS, soft, + LLQ tenderness
Rectal: guaiac positive
Ext: 1+ lower extremity, + erythema bilaterally from knees to
feet R>L (normal per PCP), erythematous areas not warm
Pertinent Results:
[**2101-12-13**]
WBC-12.7* HGB-11.8* HCT-35.0* MCV-90 RDW-15.7* PLT-459
NEUTS-58.1 LYMPHS-34.6 MONOS-5.4 EOS-1.4 BASOS-0.6
PT-13.0 PTT-34.7 INR(PT)-1.1
8:30 am: GLUCOSE-88 UREA N-112* CREAT-4.7* SODIUM-122*
POTASSIUM-hemolyzed
CHLORIDE-87* TOTAL CO2-22
ALT(SGPT)-16 AST(SGOT)-89* ALK PHOS-99 TOT BILI-0.3
LIPASE-56
11:00 am: GLUCOSE-89 UREA N-110* CREAT-4.5* SODIUM-126*
POTASSIUM-6.0*
CHLORIDE-87* TOTAL CO2-24 ANION GAP-21*
LACTATE-1.1 K+-5.4*
.
U/A: Mod LE (>50 WBCs); Lg blood ([**10-12**] RBCs), 30 protein, small
bili, no bacteria, no epis
.
OSH studies:
Echo [**2101-10-24**]: EF 59%, mild MR, mod TR, no WMA.
Brief Hospital Course:
Ms. [**Known lastname 77059**] is an 82 year old woman with DJD, HTN, recent UTI
admit with ARF and BRBPR.
1. BRBPR: Initially no clear source, but thought likely GI. Had
initial colonsocopy that could not go past 30 cm because of
stool. Had 3 tagged red cell scans which did not show the source
of bleeding. Went for angiography which did not show source of
bleeding. Second colonoscopy attempted but could not enter
rectum secondary to blood. Received a total of 19 units of blood
and 1 bag platelets. Finally on third colonoscopy attempt a
small vessel was seen above the dentate line, which was oversewn
in surgery the following day. Since surgery, her hematocrit
remained stable. Her hematocrit was to be rechecked at the
[**Last Name (un) 1188**] house as needed. Pantoprazole IV was started in the ICU
and changed over to PO on the floor. She will continue this on
transfer to the nursing home and further treatment can be
addressed by her PCP.
2. Acute Renal Failure: Baseline creatinine thought to be about
1-1.5. Considered to be most likely secondary to prerenal
etiology from BRBPR and poor PO intake. Urine lytes were
consistent with a prerenal etiology, and a urine culture was
negative. Her renal failure resolved with fluid and packed red
cells over the following days, and at the time of transfer from
the ICU, her creatinine was 0.5.
3. ?Adrenal insufficiency: Given steroids in the ED secondary to
hyperkalemia and hyponatremia in context of hypotension.
Baseline cortisol (AM cortisol) was low, and ACTH was also
borderline low. She was continued on a steroid taper, tapering
off prior to transfer from ICU.
4. Atrial fibrillation. Developed atrial fibrillation during the
admission with tremendous transfusion/fluid requirements. Rate
controlled with 12.5mg PO metoprolol, which was transitioned to
PO amiodarone to chemically convert her back to sinus. Patient
reverted to sinus rhythm and amio was d/c'ed before discharge.
Patient was restarted on a lower dose of lasix to diuresis the
excess fluid which had likely caused the A-fib.
5. Other EKG irregularities: In examining the multiple EKG's, it
was determined that the patient had a left anterior fasicular
block at baseline. When the patient's heart rate increases, she
can develop a bundle branch block, which was seen in V2.
Overall, she appears to have conduction abnormalities at
baseline.
6. Pain control. Osteoarthritis. Continued on Tylenol standing
with PRN oxycodone, as well as morphine IV PRN. Morphine
discontinued when patient transferred from ICU. Celebrex held
while in hospital, and can be restarted as necessary at the
nursing home. Patient's pain from her chronic lower extremity
edema is normally treated with lyrica, which was held during her
hospitalization. The lyrica can be restarted as needed when
patient is at the nursing home.
7. Hyponatremia: Patient was slightly hyponatremic (130) at
discharge. Likely related to fluid retention and stress response
of ADH. To be rechecked when patient transferred to [**Last Name (un) 1188**]
house.
8. Lower extremity edema: Lasix were restarted before discharge
at 40mg [**Hospital1 **] (patient normally on 80mg [**Hospital1 **]. Can increase as
needed when patient is at [**Last Name (un) 1188**] house.
9. Hyperlipidemia: Continued statin
10. Depression: Patient's remeron was initially held due to
sedation concerns and then restarted when patient was
transferred from the ICU.
11. Chronic constipation: Patient's outpatient bowel regimen was
continued.
Medications on Admission:
Lyrica 25 TID (?held)
Celebrex 200 [**Hospital1 **]
Vicodin 2 tabs Q6H
Ibuprofen 200 mg Q6H prn
Lactulose
Lasix 80 mg [**Hospital1 **]
Kcl
Simvastatin
senna
colace
niferex
calcium, vitamin D
Bactrim DS
Discharge Medications:
1. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO once a
day.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO every other day as needed.
5. Niferex 60 mg Capsule Sig: One (1) Capsule PO once a day.
6. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Dulcolax 10 mg Suppository Sig: One (1) suppository Rectal
once a day as needed for constipation.
13. Vicodin 5-500 mg Tablet Sig: Two (2) Tablet PO every six (6)
hours as needed.
14. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) Rectal
every 3rd day as needed for constipation.
15. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ml
PO twice a day as needed for constipation.
16. Lactulose 10 gram/15 mL Solution Sig: Fifteen (15) ml PO
once a day.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
Primary:
1. Gastrointestinal Bleeding secondary to exposed vessel
2. Atrial fibrillation
3. Acute renal failure
Secondary
1. Hyperlipidemia
2. Hypertension
Discharge Condition:
Improved: No further bleeding, stable hematocrit, partial
resolution of lower extremity edema. In normal sinus rhythm.
Discharge Instructions:
You were admitted for a gastrointestinal bleed which was likely
secondary to a bleeding vessel in your rectal area, which was
sutured by surgery. You experienced no further bleeding episodes
after this surgical repair and your red blood cell count has
remained stable.
You were also found to have an irregular heart beat which was
likely secondary to fluid overload. This was treated with
amiodarone and diuresis.
Please continue to take your medications as prescribed. Please
attend all future doctors [**Name5 (PTitle) 4314**] as [**Name5 (PTitle) 1988**].
Please return to the hospital or call your primary care doctor
if you experience any further bleeding or syncope, palpitations,
lightheadedness, chest pain, nausea/vomiting, or any other
symptom that concerns you.
Followup Instructions:
Please follow up with your primary care doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
within two weeks regarding your hospital visit.
|
[
"276.7",
"578.9",
"599.0",
"584.9",
"427.31",
"276.1",
"403.90",
"785.59",
"255.41",
"585.9",
"569.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.24",
"88.47",
"45.23",
"49.95",
"49.21",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
7775, 7871
|
2628, 6145
|
288, 418
|
8072, 8194
|
1957, 2605
|
9018, 9188
|
1492, 1497
|
6397, 7752
|
7892, 8051
|
6171, 6374
|
8218, 8995
|
1512, 1938
|
243, 250
|
446, 1023
|
1045, 1322
|
1338, 1476
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,277
| 180,072
|
45321
|
Discharge summary
|
report
|
Admission Date: [**2141-11-16**] Discharge Date: [**2141-11-30**]
Date of Birth: [**2063-12-13**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine / Latex
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Per daughter - pt. w/ respiratory distress
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
HPI per daughter
77 y.o. Italian speaking woman with multiple medical problem who
was discharged from [**Hospital 100**] rehab 1 day PTA, and presented from
home with respiratory distress. She apparently had multiple
failed swallow tests but was reportedly had been advanced to
pureed diet at rehab. She returned to home after a pureed diet
meal and reportedly did not have anything else after arriving
home. She is minimally communicative at baseline. She was only
home for several hours before she developed shortness of breath
and had to go to the hospital.
In ED, her initial vitals were P142 BP191/101 R27 76% NRB. She
was started on vanco/levo/flagyl. Her CXR was clear. Due to
persistent hypoxia on the NRB, the trachea was intubated. Pt
was continued on levaquin and flagyl but vanco was d/c'd. She
had a low grade fever of 99.9 on initial presentation. She was
extubated on [**11-17**], and respiratory status has been stable all
day. In addition, she became agitated that evening, which per
the family is her usual pattern.
She was admitted in [**8-22**] with altered MS with a negative workup
that included CT head, EEG, LP. At the time she had a failed
swallow eval and a PEG was placed for nutrition.
Past Medical History:
Ascending Aortic Aneurysm
Polymyalgia Rheumatica
Recurrent UTI's on Macrodantin ppx. chronically
HTN
CVA (multiple?) with residual Lt. hemiparesis and expressive
aphasia
? of a seizure d/o
Pacemaker for sick sinus syndrome and PAF (overdrive pacing)
GERD
PAF on coumadin
Anxiety
PTSD (initial trauma WWII)
Depression
Multinodular goiter
Diabetes (type 2)
Social History:
Was at rehab and had recently been taken to live w/ daughter, is
italian and has "reverted to her native language" since her CVA.
She worked as a laundress. Unknown tobhx/etho hx
Family History:
Maternal fatal MI
Physical Exam:
PE:
VS Tm 98.1 HR 75 BP 118/60 75 RR 20 99% RA (93-99)
Gen- elderly, cachectic, sedated but responsive to voice and
touch.
HEENT- Pupils equal, min reactive b/l, anicteric, conj
noninjected. OP clear but dry MM (pt's mouth open).
Neck: no JVD appreciated.
Lungs: rhonchi b/l with decreased BS at right base and minimal
bibasilar crackles.
CV: heart sounds masked by breath sounds; irregular, no murmurs
appreciated.
Abdomen: PEG in place, + BS, site C/D/I
Ext: no edema, DP 1+b/l, warm.
Neuro: exam limited by sedation, but moving all 4 extremities,
responds to voice.
Pertinent Results:
[**2141-11-20**] 06:30AM BLOOD WBC-4.9 RBC-3.69* Hgb-9.5* Hct-28.9*
MCV-78* MCH-25.8* MCHC-32.9 RDW-15.1 Plt Ct-160
[**2141-11-19**] 06:25AM BLOOD WBC-6.0 RBC-3.82* Hgb-10.0* Hct-30.1*
MCV-79* MCH-26.3* MCHC-33.4 RDW-15.1 Plt Ct-189
[**2141-11-18**] 06:15AM BLOOD WBC-8.0 RBC-4.08* Hgb-10.8* Hct-32.3*
MCV-79* MCH-26.5* MCHC-33.5 RDW-14.9 Plt Ct-194
[**2141-11-17**] 04:21AM BLOOD WBC-5.4# RBC-3.70* Hgb-9.6* Hct-29.2*
MCV-79* MCH-26.0* MCHC-32.8 RDW-14.8 Plt Ct-134*
[**2141-11-16**] 04:36PM BLOOD Hct-32.7*
[**2141-11-16**] 06:27AM BLOOD WBC-11.9* RBC-4.03* Hgb-10.2* Hct-31.2*
MCV-77* MCH-25.4* MCHC-32.8 RDW-14.8 Plt Ct-186
[**2141-11-16**] 03:26AM BLOOD WBC-19.3*# RBC-5.11 Hgb-12.7 Hct-39.9
MCV-78* MCH-24.9* MCHC-31.9 RDW-14.8 Plt Ct-278
[**2141-11-16**] 03:26AM BLOOD Neuts-82.9* Bands-0 Lymphs-13.6*
Monos-3.1 Eos-0.2 Baso-0.2
[**2141-11-16**] 03:26AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+
[**2141-11-20**] 11:15AM BLOOD PT-18.2* PTT-29.6 INR(PT)-2.3
[**2141-11-20**] 06:30AM BLOOD Plt Ct-160
[**2141-11-19**] 06:25AM BLOOD PT-20.9* PTT-32.8 INR(PT)-3.1
[**2141-11-18**] 06:15AM BLOOD PT-22.6* PTT-36.4* INR(PT)-3.7
[**2141-11-17**] 07:34AM BLOOD PT-23.2* PTT-37.1* INR(PT)-3.9
[**2141-11-16**] 06:27AM BLOOD PT-21.6* PTT-34.3 INR(PT)-3.3
[**2141-11-20**] 06:30AM BLOOD Glucose-78 UreaN-11 Creat-0.6 Na-144
K-3.3 Cl-109* HCO3-25 AnGap-13
[**2141-11-19**] 06:25AM BLOOD Glucose-121* UreaN-15 Creat-0.6 Na-142
K-4.4 Cl-114* HCO3-18* AnGap-14
[**2141-11-18**] 06:15AM BLOOD Glucose-79 UreaN-12 Creat-0.5 Na-143
K-3.6 Cl-110* HCO3-20* AnGap-17
[**2141-11-17**] 04:21AM BLOOD Glucose-75 UreaN-13 Creat-0.6 Na-144
K-3.4 Cl-114* HCO3-23 AnGap-10
[**2141-11-16**] 06:27AM BLOOD Glucose-130* UreaN-15 Creat-0.7 Na-138
K-3.9 Cl-103 HCO3-22 AnGap-17
[**2141-11-16**] 03:26AM BLOOD Glucose-134* UreaN-15 Creat-0.7 Na-139
K-4.4 Cl-100 HCO3-25 AnGap-18
[**2141-11-16**] 06:27AM BLOOD CK(CPK)-27
[**2141-11-18**] 06:15AM BLOOD calTIBC-306 Ferritn-108 TRF-235
[**2141-11-19**] 05:52PM BLOOD Type-ART pO2-158* pCO2-36 pH-7.43
calHCO3-25 Base XS-0
[**2141-11-16**] 03:40PM BLOOD Type-ART Temp-37.1 PEEP-5 FiO2-50
pO2-196* pCO2-40 pH-7.39 calHCO3-25 Base XS-0 Intubat-INTUBATED
[**2141-11-16**] 06:27AM BLOOD Type-ART Tidal V-400 FiO2-100 pO2-513*
pCO2-36 pH-7.45 calHCO3-26 Base XS-2 AADO2-180 REQ O2-38
[**2141-11-16**] 04:50AM BLOOD Type-ART pO2-555* pCO2-35 pH-7.44
calHCO3-25 Base XS-0
[**2141-11-16**] 03:26AM BLOOD Comment-GREEN TOP
[**2141-11-19**] 05:52PM BLOOD Lactate-1.0 K-3.5
[**2141-11-16**] 03:26AM BLOOD Lactate-2.9*
[**2141-11-16**] 04:04AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.019
[**2141-11-16**] 04:04AM URINE Blood-SM Nitrite-NEG Protein-500
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2141-11-16**] 04:04AM URINE RBC-[**4-22**]* WBC->50 Bacteri-MANY Yeast-NONE
Epi-0-2
EKG: EKG ([**11-16**]): Atrial fibrillation with normal vent rate; nml
int; TWI in III, no ST changes.
IMAGING:
CXR [**11-28**]: new line placement -IMPRESSION:
1. Termination of PICC catheter at cavoatrial junction.
2. Improved aeration of the left lower lobe.
CXR: [**11-23**]: Resolving congestive heart failure. No definite
pneumonia.
CXR: [**11-19**]: 1. Persistent patchy right lower lobe consolidation,
which may be due to focal pneumonia. 2. Early/mild congestive
heart failure
CXR ([**11-17**]): developing RLL infiltrate
.
CT ([**11-26**]): Stable appearance of the brain.
CT ([**11-19**]) No evidence of new stroke or bleed
.
KUB ([**11-26**]): No intestinal obstruction or pneumoperitoneum
Sputum culture ([**11-16**]): [**2141-11-16**] 8:17 am SPUTUM Source:
Endotracheal.
**FINAL REPORT [**2141-11-18**]**
GRAM STAIN (Final [**2141-11-16**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2141-11-18**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
Blood Cx([**11-16**]): NGTD
.
Urine Ctx:
URINE Site: CATHETER
**FINAL REPORT [**2141-11-20**]**
URINE CULTURE (Final [**2141-11-20**]):
THIS IS A CORRECTED REPORT ([**2141-11-18**]).
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Trimethoprim/sulfa sensitivity confirmed by
[**Doctor Last Name 3077**]-[**Doctor Last Name 3060**].
AZTREONAM SENSITIVITY REQUESTED PER DR [**Last Name (STitle) **] ([**Numeric Identifier 96800**]).
AZTREONAM SENSITIVE <=1 MCU/ML BY MIC.
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
AZTREONAM sensitivity performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
AZTREONAM SENSITIVITY REQUESTED BY [**Doctor Last Name **] [**Last Name (un) **] ([**Numeric Identifier 96800**]).
SENSITIVE TO AZTREONAM. PREVIOUSLY REPORTED AS
([**2141-11-17**]).
GRAM POSITIVE BACTERIA.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| PSEUDOMONAS AERUGINOSA
| |
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S 8 S
CEFTAZIDIME----------- <=1 S 4 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S =>16 R
IMIPENEM-------------- <=1 S 4 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- <=4 S 8 S
PIPERACILLIN/TAZO----- <=4 S 8 S
TOBRAMYCIN------------ <=1 S =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
77 yo F with h/o CVA, HTN, PAF, dementia, and DM2 presented 2d
ago with hypoxic respiratory failure thought to be secondary to
aspiration pneumonia and now w/ mild CHF after fluid
resuscitation, along w/ levo resistant UTI.
.
Hypoxic respiratory failure/Pneumonia: Pt. came to ED and was
intubated for resp. distress. Most likely etiology is
aspiration pneumonitis/pneumonia given high risk (pt. has failed
swallow studies in the past and had recently gone home and
allowed to eat pureed foods)and CXR that indicated RLL
pneumonia. Unlikely PE given that pt. was anticoagulated. Pt.
was extubated 12 hrs later and called out to the floor. On the
floor patient was not in respiratory distress and had good O2
sats. Pt. treated with levo/flagyl given risk of aspiration
pneumonia and received a total of 10 days. Pt. had been
receiving fluids and began to have crackles on [**11-19**]. CXR showed
mild CHF. Fluids were stopped and pt. was given 10mg IV lasix
and responded. Repeat CXRs showed resolving pneumonia and no
CHF. Pt. continued to have good sats throughout the hospital
stay. Pt. continued to have a lot of secretions, as she cannot
clear them. Pt. did not appear to be fluid overloaded. It is
very likely that pt. will continue to re-aspirate.
.
Nutrition - Pt. had been cleared at nursing home w/ swallow
study? and was taken home, allowed to eat and then aspirated.
During this hospitalization, pt. with possible aspiration with
tube feeds, increased secretions and cough. Held TF for a night
and pt. improved. Discussed this with daughter (proxy) who
wants pt. to be fed through G-tube anyway. Pt. failed swallow
study, so will be d/c w/ G-tube. Family aware of aspiration
risk.
.
Mental Status changes - per daughter, pt. was walking around w/
walker week prior to admission w/ minimal talking, but was
responsive and even had foley out for a while. During
admission, pt. very sedated at times, possibly secondary to
ativan as pt. was sundowning and requiring chemcial restraint.
Did an infectious and metabolic work-up. Got a CT with no
evidence of new stroke or bleed, repeat lactate was 1.0, no
evidence of hypoxia/hypercarbia on ABG. Ativan was d/c and pt.
was less sedated most of the time. Likely pt is at her baseline
after stroke and has episodes where she is more sedated. Pt.
had 2 head CTs while in the hospital b/c of these episodes and
both of these CTs showed no hemorrhage or stroke. Pt's family
understands risk of anticoagulation and bleeding, but wants the
pt. to be anticoagulated for her afib.
.
Recurrent UTI - Pt. w/ E.coli UTI that is resistant to levo and
pt. w/ allergy to penicillin. Pt. was macrodentin chronically
for recurrent UTIs. Pt. received 7 days total of gentamicin for
this infection. Pt. eventually grew psuedomonas in her urine
that was sensitive to aztreonam. Pt. received 7 days of IV
aztreonam. Pt. had a PICC line placed and will receive a total
of 14 days of aztreonam.
. - last doses to be given on [**12-7**].
.
Thrombocytopenia: Pt. had thrombocytopenia soon after receing
heparin, so heparin was d/c and HIT antibody sent which was
negative. Once heparin was d/c, pt's thrombocytopenia began to
resolve. Pt. remained on coumadin throughout hospitalization.
.
Anemia: Pt. had a slow hct drop. Iron studies indicated that
pt. was likely iron deficient so pt. was given iron. Pt's
baseline is in low 30s. No indication of bleeding. Stools were
guiac negative
.
A-fib: Pt. w/ h/o afib who was supratherapeutic on coumadin when
she came to ED so coumadin was held for a few days. Restarted
pt. on coumadin and INR will be monitored at NH with goal INR of
[**3-23**]. Pt. seemed stable w/ 2.5 mg coumadin. Pt. was rate
controlled with verapamil and lopressor. Patient has Pacemaker
for sick sinus syndrome and PAF (overdrive pacing.) Battery was
recently replaced by EP [**8-22**].
.
Hypertension: Pt's hypertension was well controlled during
hospitalization with lisinopril, verapamil, and lopressor.
.
Palliative care consult was called and daughter continues to
want a full-code and to continue feeding, despite the risk of
aspiration pneumonia. Family understands that pt. is very
debilitated and will likely return with another aspiration
pneumonia. There are 8 siblings and they do not agree about
further care. At this time, pt. is to remain full code. If
they change their mind they will inform both the nursing home
and PCP.
Medications on Admission:
CURRENT MEDS:
Flagyl 500mg IV q8h (day 2)
Levaquin 500mg IV daily (day 2)
Lansoprazole
Lactulose 30ml tid (held)
Insulin SS
Coumadin (held for INR 3.9)
Verapamil 160mg PO q8h
Lopressor 50mg tid
Lisinopril 20mg daily
Discharge Medications:
1. Verapamil 80 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Docusate sodium - 100mg liquid NG [**Hospital1 **] Sig: One (1) twice
a day.
4. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
5. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for agitation.
Disp:*60 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): Titrate this as needed for goal INR of [**3-23**].
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
9. Aztreonam 1 g Recon Soln Sig: One (1) Recon Soln Injection
Q8H (every 8 hours).
10. Acetaminophen 160 mg/5 mL Solution Sig: Two (2) PO Q4-6H
(every 4 to 6 hours) as needed for fever/pain.
11. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
12. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO once a day: Put in NG
tube.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of the [**Location (un) 1121**] - [**Location (un) **]
Discharge Diagnosis:
Aspiration Pneumonia
Discharge Condition:
Stable
Discharge Instructions:
There were some changes made in your medication. Please see the
attached list for medication and doses. You need to have IV
antibiotics for 7 more days. The patient's daughter should call
the doctor or return to the emergency room if she experiencs
chest pain/tightness, nausea, vomiting, fevers, chills,
difficulty breathing, signs of aspiration.
Followup Instructions:
You should follow up with Dr. [**Last Name (STitle) 3029**] in the next week. Her office
number is
[**Telephone/Fax (1) 1300**].
|
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icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.6",
"96.04",
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icd9pcs
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[
[
[]
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14858, 15210
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2229, 2804
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254, 299
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377, 1603
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1625, 1981
|
1997, 2179
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,270
| 156,081
|
47745
|
Discharge summary
|
report
|
Admission Date: [**2169-11-6**] Discharge Date: [**2169-11-10**]
Date of Birth: [**2091-4-29**] Sex: M
Service: UROLOGY
Allergies:
Penicillins / Sulfonamides
Attending:[**First Name3 (LF) 1232**]
Chief Complaint:
Left renal mass found incidentally.
Major Surgical or Invasive Procedure:
L partial nephrectomy ([**2169-11-6**])
CVL line placement ([**2169-11-6**])
History of Present Illness:
This is a 78-year-old male with an incidental finding of a left
renal mass on CT scan after MVA. The mass was 4.2 cm in size and
located at the posterior left upper pole.
Past Medical History:
The patient has a significant past medical history including
CAD, MI s/p CABG, and abdominal aortic aneurysm repair.
On exercise tolerance test, he had 1-2 mm ST segment
depressions in the inferior and lateral leads that resolve
with 10 minutes of exercise. He has been cleared for surgery
by his cardiologist with close monitoring.
Social History:
Married, lives in [**Location **], denies tobacco history, occasional EtOH
Family History:
Negative for renal cell CA
Physical Exam:
V/S: T100.0 P98 BP159/79 R23 sat:97%4.5 liters NC
Gen - elderly male in NAD
Skin - no rashes or skin breaks
HEENT - NC/AT, EOMI, PERRL bilaterally, MMM, soft neck without
LAD
Cardiac - RRR without m/g/r
Lungs - CTA bilat.
[**Last Name (un) **] - + bowel sounds, soft, appropriately tender, incisions
clean, dry and intact
PVasc - 2+ pulses, no edema
Musc/Skel - full active and passive ROM
Neuro - A&Ox4, no appreciable deficits.
Pertinent Results:
[**2169-11-6**] 10:47PM GLUCOSE-141* UREA N-19 CREAT-1.4* SODIUM-135
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-22 ANION GAP-14
[**2169-11-6**] 10:47PM CK(CPK)-386*
[**2169-11-6**] 10:47PM CK-MB-5 cTropnT-<0.01
[**2169-11-6**] 02:01PM CK(CPK)-218*
[**2169-11-6**] 02:01PM CK-MB-5 cTropnT-<0.01
Brief Hospital Course:
The patient was admitted on the day of surgery. He tolerated the
procedure well. Please refer to the operative note of [**2169-11-6**]
for further details of the procedure. After surgery, he was
recovered in the ICU and was observed closely overnight. A
post-operative chest x-ray revealed a small L apical
pneumothorax which was not unexpected given that the pleura had
been breached during surgery. Subsequent x-rays confirmed that
the pneumothorax was stable, and on POD#3, it was found to have
decreased in size.
On post-operative day (POD)#0-1, serial cardiac enzymes and ECGs
were obtained. All were negative for an acute myocardial
infarction. His Swan-Ganz catheter and his chest tube were
discontinued. A chest x-ray obtained after the removal of the
chest tube showed no change in size of the previously noted
pneumothorax.
The patient's cardiologist, Dr. [**Last Name (STitle) 120**], was contact[**Name (NI) **] on POD#1,
and agreed with the urology team that the patient was stable
enough to be transferred out of the ICU and onto a regular floor
bed. On POD#1, the patient was ambulating without assistance.
At this time, the patient was noted to have some hoarseness. The
anesthesia records were reviewed and the team was contact[**Name (NI) **]
regarding the details of the patient's intubation. There were no
untoward events and the team and records confirmed that the
intubation was easy and atraumatic. An otolaryngology consult
was obtained to evaluate the patient's hoarseness. It was found
that he had a right-sided paralysis of his true vocal cord. A
conversation with the patient revealed that the vocal cord
injury was long-standing and was thought to have been incurred
during a tonsillectomy when the patient was a child. A swallow
evaluation revealed no signs of aspiration, and the patient's
hoarseness resolved fully on POD#3.
The patient had flatus on POD#3, and his epidural and foley
catheter were discontinued. He tolerated a regular diet and
voided after his catheter was discontinued. On POD#4, he was
discharged home in stable condition ambulating well, on oral
pain medication, and eating a regular diet.
Medications on Admission:
Atenolol 50 mg PO BID
Atorvastatin 20 mg PO DAILY
Lisinopril 15 mg PO DAILY
Diazepam 5 mg PO Q12H:PRN anxiety
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: Take while taking narcotic pain medication to prevent
constipation.
Disp:*60 Capsule(s)* Refills:*0*
Atenolol 50 mg PO BID
Atorvastatin 20 mg PO DAILY
Lisinopril 15 mg PO DAILY
Diazepam 5 mg PO Q12H:PRN anxiety
Discharge Disposition:
Home
Discharge Diagnosis:
Renal cell carcinoma
CAD
HTN well-controlled
Discharge Condition:
Stable
Discharge Instructions:
You may resume taking your pre-hospital medications.
Call Dr. [**Last Name (STitle) **] or come to the emergency room if you have:
* fever above 101.5F
* nausea, vomiting or diarrhea that doesn't stop
* abdominal pain
* a drastic reduction in the amount that you are urinating.
You may shower as you would normally - just pat the wound dry
afterward.
No tub-bathing or swimming - anything that would soak the wound
for extended periods of time - for 4 weeks after surgery.
You may eat what you like.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. Phone:[**Telephone/Fax (1) 127**]
Date/Time:[**2170-5-11**] 11:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 275**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 277**] Call to schedule
appointment
Completed by:[**2169-11-13**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
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] |
icd9pcs
|
[
[
[]
]
] |
4636, 4642
|
1884, 4032
|
323, 402
|
4731, 4740
|
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|
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|
1069, 1097
|
4194, 4613
|
4663, 4710
|
4058, 4171
|
4764, 5270
|
1112, 1543
|
248, 285
|
431, 603
|
625, 961
|
977, 1053
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,854
| 191,228
|
30753
|
Discharge summary
|
report
|
Admission Date: [**2186-6-21**] Discharge Date: [**2186-7-22**]
Date of Birth: [**2134-10-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Intubation
Central venous catheter
Dialysis
Plasmapharesis
History of Present Illness:
This is a previously healthy 51 y/o female with h/o IBS who
recently underwent a complicated surgical course for a ruptured
appy, s/p bowel abscesses, who now p/w abdominal pain, n/v/,
bloody diarrhea, ARF, and thrombocytopenia. Please see OSH
course for details as patient is unable to provide a full
history.
.
OSH course - Presented to OSH 3 weeks ago with c/o abdominal
pain x 2 days duration. Taken to OR and found to have an acute
gangrenous perforated appendicitis, underwent lap appy with
placement of a JP drain. However, continued to have JP drainage
of clear fluid, fevers, tender abd and decreased BS. Covered
with broad-spectrum abx, subsequent CT scan revealed an acute
phlegmon at original surgical site. Therefore, 12-days post-op,
patient was taken back to the OR for an ex-lap with LOA and
drainage of intra-abdominal abscess. She was maintained on
broad-spectrum abx, improved clinically, and was d/c'd home on
post-op day 18 on cholestryamine, lomotil, fosamax, calcium,
colace, percocet, and lactobacillus. However, 3 days PTA to
[**Hospital1 **] on [**6-19**], pt developed abdominal pain, n/v, bloody
diarrhea. She was admitted on [**6-19**] to OSH and found to be tachy
and dehydrated. Afebrile and normotensive initially. Abdominal
KUB on admission showed air fluid level in the right colon with
multiple fluid-filled small bowel loops w/o dilitation. Labs
significant on admission for WBC 16K, BUN 14/Cr 1.3, Plts 425K.
During her course, BUN increased to 45 with Cr up to 4.3 with
oliguria developing. Plts dropped to to 96L, WBC up to 23K.
Concern for HUS-TTP was raised, as peripheral smear also showed
several schistocytes (1 per 50x field). Pt has been vanc and
zosyn for coverage, begun today [**6-21**], and was continued on po
flagyl and vancomycin since admission [**6-19**] for concern of c
diff.
Past Medical History:
1. s/p ruptured appendix [**2185-5-27**], s/p appy
2. s/p 2 bowel abscesses [**2186-6-8**]
2. s/p cholecystectomy
3. IBS
4. osteopenia
Social History:
Lives at home with her husband and daughters. [**Name (NI) 1403**] full-time.
No tobacco, occasional EtOH, no illicits.
Family History:
Father w/history of leukemia, CAD.
Physical Exam:
VS: Tc 97.5, BP 105/65, HR 116, RR 10, SaO2 98%/RA
General: Pleasant female in NAD, AO X 3, difficult historian
HEENT: NC/AT, PERRL, EOMI. MM dry, OP clear
Neck: supple, no LAD or TMG
Chest: CTA-B, no w/r/r
CV: RR tachy, s1 s2 normal, [**3-3**] SM best heard at apex
Abd: distended, slightly firm but not tense, no TTP; surgical
site healing well, c/d/i; decreased BS
Ext: no c/c/e, wwp
Neuro: AO x 3, slow to give history and poor recall. MS [**6-3**]
throughout, sensation intact. CN II-XII intact
Skin: no rashes
Pertinent Results:
[**2186-6-21**] 11:04PM BLOOD WBC-21.6* RBC-4.04* Hgb-12.2 Hct-37.3
MCV-92 MCH-30.2 MCHC-32.8 RDW-14.8 Plt Ct-99*
[**2186-6-24**] 04:28AM BLOOD WBC-15.4* RBC-2.49* Hgb-7.7* Hct-22.1*
MCV-89 MCH-31.1 MCHC-35.0 RDW-16.1* Plt Ct-87*
[**2186-6-28**] 04:25AM BLOOD WBC-20.3* RBC-1.82* Hgb-5.7* Hct-16.5*
MCV-91 MCH-31.2 MCHC-34.5 RDW-20.4* Plt Ct-40*
[**2186-6-22**] 03:28AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-1+ Polychr-1+
[**2186-6-27**] 04:21AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-2+
Macrocy-1+ Microcy-1+ Polychr-OCCASIONAL Ovalocy-OCCASIONAL
Schisto-2+ Stipple-1+
[**2186-6-21**] 11:04PM BLOOD Glucose-142* UreaN-51* Creat-5.4* Na-142
K-4.1 Cl-111* HCO3-19* AnGap-16
[**2186-6-24**] 04:28AM BLOOD Glucose-90 UreaN-48* Creat-6.3* Na-139
K-3.9 Cl-107 HCO3-22 AnGap-14
[**2186-6-28**] 03:08AM BLOOD Glucose-129* UreaN-105* Creat-7.2* Na-143
K-4.6 Cl-107 HCO3-26 AnGap-15
[**2186-6-21**] 11:04PM BLOOD LD(LDH)-1218* TotBili-0.4 DirBili-0.2
IndBili-0.2
[**2186-6-24**] 04:28AM BLOOD ALT-75* AST-104* LD(LDH)-2635* AlkPhos-60
TotBili-0.5
[**2186-6-21**] 11:04PM BLOOD Hapto-30
[**2186-6-24**] 04:28AM BLOOD VitB12-351 Folate-7.6 Hapto-28*
[**2186-6-28**] 03:08AM BLOOD Hapto-<20*
[**2186-6-23**] 05:43PM BLOOD C3-47* C4-9*
[**2186-6-23**] 05:43PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2186-6-23**] 05:43PM BLOOD ANCA-NEGATIVE B
[**2186-6-22**] 04:03AM BLOOD HEPARIN DEPENDENT ANTIBODIES- NEGATIVE
[**2186-6-23**] 05:43PM BLOOD ADAMTS13 ACTIVITY AND INHIBITOR-PND
LYME SEROLOGY (Final [**2186-6-26**]): Negative
RPR - Nonreactive
[**2186-6-22**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT No growth
[**2186-6-22**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT No growth
[**2186-6-22**] Echo The left atrium is normal in size. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. No masses or
vegetations are seen on the aortic valve. The mitral valve
leaflets are structurally normal. The mitral valve leaflets are
elongated. There is mild mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. The timing of the mitral regurgitation is
late systolic. No vegetation/mass is seen on the pulmonic valve.
There is no pericardial effusion.
CT abd/pelvis [**2186-6-22**].
CT OF THE ABDOMEN: There is moderate bilateral dependent
atelectasis with small bilateral pleural effusions. No lung
nodules or definite consolidations are identified. No
pericardial effusion.
There is very mild biliary ductal dilatation. The gallbladder
has been removed. The spleen, adrenal glands, and pancreas are
normal. The kidneys have a very unusual appearance with lack of
enhancement of the cortices, presumably due to patient's acute
renal failure.
There has been increased amount of ascites compared to one day
prior. Again demonstrated is an abnormal loop of proximal-to-mid
ileum with wall thickening. This loop is abutting a pocket of
ascites in the left lower quadrant. The terminal ileum and the
jejunum are both normal. There is no evidence of pneumatosis.
Oral contrast has now passed through to the rectum with no
evidence of obstruction. There is also mild wall thickening of
the ascending colon, also unchanged compared to one day prior.
On the arterial phase of imaging, the aorta and all of its major
vessels are patent. The SMA is opacified into its distal
branches.
CT OF THE PELVIS: Oral contrast has passed through to the distal
colon. There appears to be high density rounded structure in the
sigmoid colon which is likely contrast in a diverticulum. The
uterus is unremarkable. Air is seen within the bladder which has
a Foley catheter.
No suspicious lytic or sclerotic lesions.
RENAL U.S. PORT [**2186-6-25**]
Comparison made to CT from [**2186-6-23**]. The right kidney measures
10.0 cm, the left kidney measures 9.3 cm. Greyscale images
demonstrate mildly increased echogenicity to both kidneys,
suggestive of chronic medical renal disease, but no focal mass,
stone or hydronephrosis. There is no perinephric fluid
collection.
Color doppler examination demonstrates reduced flow bilaterally,
but markedly worse on the right. Identification of arterial
waveforms on the right was difficult, with measurement only
possible centrally. Minimal venous flow is identified on the
right. Single resistive index measured on the right was 0.7.
Flow was slightly better on the left, but still abnormal.
Resistive indices measured in interlobar branches on the left
ranged from 0.7 - 0.9.
Neurophysiology Report EEG Study Date of [**2186-6-23**]
ABNORMALITY #1: At the beginning of the record, 4 minutes after
propofol infusion was stopped, a slow background was noted,
interspersed
with bursts of generalized suppressed background. As the
recording
progressed, the generalized bursts consisted of moderate
amplitude delta
slowing.
ABNORMALITY #2: Occasional triphasic waves were noted with an
anterior
to posterior lag.
ABNORMALITY #3: Infrequent left parasagittal sharp waves were
noted.
ABNORMALITY #4: A [**6-5**] Hz slow and disorganized background rhythm
was
noted.
BACKGROUND: As above.
HYPERVENTILATION: Contraindicated due to patient's mental
status.
INTERMITTENT PHOTIC STIMULATION: Portable study precluded photic
stimulation.
SLEEP: No normal sleep/wake transitions were seen.
CARDIAC MONITOR: A generally regular rhythm was noted with an
average
rate of 96 beats per minute.
IMPRESSION: This is an abnormal EEG due to the bursts of
suppressed
background and then bursts of generalized slowing, triphasic
waves,
infrequent left parasagittal sharp waves and the slow and
disorganized
background rhythm. The bursts of slowing, the triphasic waves,
and the
disorganized background suggest a moderate encephalopathy, which
may be
seen with infections, toxic metabolic abnormalities or
medication
effect. The left parasagittal waves suggest a left parasagittal
focus
of potential epileptogenesis.
MR HEAD W/O CONTRAST [**2186-6-23**]
FINDINGS: Diffusion images demonstrate no evidence of acute
infarct. The ventricles and extra-axial spaces are normal in
size without midline shift, mass effect, or hydrocephalus. There
are no territorial infarcts seen. The suprasellar and
craniocervical regions are normal on the sagittal images. Mild
mucosal thickening is seen in the ethmoid and maxillary sinuses.
Brief Hospital Course:
51 y/o female with complicated surgical history s/p ruptured
appy, now with bloody diarrhea, ARF, thrombocytopenia, ?MS
changes concerning for TTP/HUS.
.
# TTP/HUS: Although hemolytic anemia was not significant
initially, ARF, thrombocytopenia, and altered mental status in
the setting of bloody diarrhea was concerning for HUS. Hem/onc
consultant did not feel that given lack of hemolytic anemia, TTP
was unlikely, thus plasmapheresis was not initiated. Her renal
failure was thought to be due to ATN and did not improve and
became almost anuric. Renal u/s showed no flow to kidneys and
no hydronephrosis. Renal consultant started HD on [**6-25**], but
despite dialysis, her mental status did not improve. Pt then
later developed siginificant hemolytic anemia during her MICU
stay, and daily plasmapheresis was started on [**6-27**]. Her mental
status improved dramatically after her first plasmapheresis and
LDH improved gradually. Her platelets rose to 70-80,000
although her anemia didn't improve significantly. ADAMTS13
level returned low at 26 but there were no inhibitors present.
On [**7-3**], Transfusion team felt that given no significant changes
in hematocrit and plalets despite daily plasmapheresis and
ADAMTS13 findings, weighing the risk:benefit it appears
reasonable to plan to hold off on TPE at this time. Transfusion
followed and further sessions of TPE were held because platelets
continued to trend up. On [**7-4**], a new tunneled catheter line
was placed by IR. The old catheter was pulled by the medical
team on [**2186-7-6**] after the new catheter proved to function well
during HD.
.
# ARF - HUS/TTP. Unable to send urine lytes as pt initially
anuric. Renal consultant started HD on [**6-25**]. Tunnelled HD line
was placed on [**7-4**] as renal failure didn't improve despite
plasmapheresis. Pt continued to have HD on QOD basis, receiving
epoietin at HD. CT abdomen showed no hydronephrosis. Her urine
output trended up throughout her admission with 1.5L on day
prior to discharge. 24 urine collection was completed. Patient
had decreased SBP to 90 after last HD session, and was kept one
extra day for observation.
.
# Thrombocytopenia - HUS/TTP ADAMTS13 Inhibitor(-); ADAMTS13
Activity 26(normal >=67); HIT ab was negative. Initially, smear
here was w/o schistos per heme c/s. Developed worsening mental
status through out hospital stay. On [**6-26**] started having
schistocytes on peripheral smear. Plasmapharesis started on
[**6-27**]- had 6 sessions with improvement in Platelets. Platelets
trended up until [**2186-7-13**]. They began to trend down. Hydralazine
which was started around the time of trend down was stopped as
well as all heparin products. Her HIT antibody was repeated and
again negative. Because of the long half life of Hydralazine, it
was thought that this medication was causing the
thrombocytopenia that continued through [**2186-7-20**]. Transfusion
team and Heme/Onc were reconsulted for the possibility of plasma
exchange. They did not feel that pt would benefit from plasma
exchange because the cause of thrombocytopenia was much more
likely a med effect than exacerbation of TTP. The heme team also
did not feel that a bone marrow biopsy would be helpful because
the other cell lines were not down. Pt's platelets began to
trend back up [**2186-7-20**]. The heme team and transfusion team felt
comfortable with pt being discharged to be followed up with
outpatient labs to be drawn on HD.
# Anemia- [**3-3**] hemolysis. Pt required PRBC intermittently to
keep hct >21, she was started on epoietin with HD. Fibrinogen
and LDH levels were followed and continued to show that pt had
hemolytic process ongoing. LDH did continue to trend down and
fibrinogen trended down. Upon discharge from the MICU, she
required transfusion of 1 unit PRBC's on [**2186-7-12**] on HD. Her HCT
appropriately increased and remained stable throughout the rest
of her admission.
# N/V/diarrhea - many etiologies possible given recent history
of complicated appendectomy/abscess. CT abd showed bowel
thickening concerning for infection. Treated with Zosyn and
flagyl. Serial abdominal exams by MICU and surgical teams
revealed diffuse tenderness that did not change with time.
Repeat CT abd/pelvis on [**6-28**] showed persistent bowel thickening
concerning for inflammation. All her stool cx remained
negative, however. Surgery followed, and pt was kept NPO until
[**7-3**]. Pt was then started on clears on [**7-3**].
On the medical floor, Pt's nausea initially persisted and
appeared to be due to uremia. Repeat CT of her abdomen on [**2186-7-7**]
showed intestinal edema likely due to pt's persistent fluid
overload. Pt tolerated clear diet with some episodes of nausea
that resolved with continued HD. She was tolerated full liquids
and by [**2186-7-11**] tolerated regular diet. Nausea resolved [**2186-7-13**]
with increased urine output and stable HD. She was restarted on
outpatient dose of cholestyramine.
# [**Name (NI) 27035**] Pt was initially placed on vanc/zosyn/flagyl
which were all later discontinued as cultures remained negative.
Leukocytosis improved with plasmapheresis. Pt remained
afebrile. All cultures were negative. Pt remained afebrile and
her leukocytosis improved without intervention other than HD.
# Altered mental status - Initially was unclear of etiology.
Neurology was consulted. Exam, EEG, and MRI all consitent with
metabolic encephalopathy. After one session of plasmapheresis,
pt's mental status significantly improved and returned to
baseline. It remained at baseline for the remainder of her
hospitalization.
# Fluid overload after pt received TPE. Repeat TTE was done
[**2186-7-6**] which showed normal EF and no wall motion abnormalities.
It did show that pt had moderate pulmonary hypertension. (This
should be reevaluated outpatient when pt is not acutely ill.) On
[**2186-7-8**] Pt had episode of flash pulmonary edema, renal did
emergent HD and removed several liters of fluid. She had daily
HD until [**2186-7-11**] when she was started on an every other day
schedule. She had sessions of ultrafiltration for fluid removal
daily from [**2186-7-8**] until [**2186-7-12**].
She had hypertension secondary to her renal failure and fluid
overload. She was started on Metoprolol titrated up to 100mg TID
and was started on Nifedipine 10mg TID. Her BP was well
controlled on this regimen.
Repeat CXR [**2186-7-14**] showed pt w/o pleural effusions or
consolidation, but with persistent fluid in vasculature.
# FEN-Pt was on TPN for nutrition while bowel rest, PICC placed
[**2186-6-28**]. Clear liquid diet was started on [**7-3**]. On [**2186-7-12**], pt
was taking regular PO diet. TPN was d/ced and PICC line was
pulled on the day of discharge.
# PPX- pneumoboots, PT and OT were consulted and worked with the
patient they felt that the pt was stable for discharge home.
Medications on Admission:
1. Vancomycin
2. Zofran
3. Zosyn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
ASDIR (AS DIRECTED): with HD.
3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
4. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO
DAILY (Daily).
Disp:*30 Packet(s)* Refills:*2*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 capsules* Refills:*2*
7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Acquired TTP/HUS from unclear precipitant
Renal failure requiring hemodialysis
Volume overload
Pulmonary Hypertension of unclear etiology
Discharge Condition:
Medically stable to be discharged to rehab facility.
Discharge Instructions:
You were admitted with TTP/HUS and developed renal failure
requiring hemodialysis.
Please take medications as indicated below.
If you develop fevers/chills, chest pain, shortness of breath,
abdominal pain, nausea/vomiting, or any other concerning
symptoms, please tell your rehab doctor or report to the nearest
ER.
Followup Instructions:
Please follow up with Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name12 (NameIs) **], MD
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2186-8-24**] 3:30.
Pt was found to have moderate pulmonary hypertension while
inpatient, please follow up with repeat TTE when not acutely
ill.
Nephrology: Please follow up with Dr. [**Last Name (STitle) 4883**] on Friday [**7-14**]
at 9AM. [**Hospital Ward Name 23**] Clinical Center [**Location (un) 436**]. Please call
[**Telephone/Fax (1) 60**] with questions.
Hematology/oncology:
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2186-8-1**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2503**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2186-8-1**] 1:00. Please call ([**Telephone/Fax (1) 14703**] with
questions.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
|
[
"261",
"416.8",
"283.11",
"584.5",
"558.9",
"458.21",
"564.1",
"403.91",
"446.6",
"348.31",
"599.0",
"428.0",
"733.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"38.95",
"99.15",
"39.95",
"96.71",
"96.04",
"99.71"
] |
icd9pcs
|
[
[
[]
]
] |
17550, 17613
|
9792, 16678
|
320, 380
|
17795, 17850
|
3143, 9769
|
18216, 19426
|
2555, 2591
|
16762, 17527
|
17634, 17774
|
16704, 16739
|
17874, 18193
|
2606, 3124
|
275, 282
|
408, 2243
|
2265, 2402
|
2418, 2539
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,181
| 103,511
|
12036
|
Discharge summary
|
report
|
Admission Date: [**2174-9-9**] Discharge Date: [**2174-10-7**]
Date of Birth: [**2152-3-29**] Sex: M
Service: MED
Allergies:
Benzocaine / Zosyn
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
fever and hypoxia, witnessed aspiration at rehabilitation
facility
Major Surgical or Invasive Procedure:
none
History of Present Illness:
22 y/o male w/ h/o [**First Name3 (LF) **]'s syndrome (DM, DI, optic atrophy,
deafness), presenting from [**Hospital3 **] after a witnessed
aspiration pna and 1 day of fevers. Pt also with central
hypoventilation requiring ventilation at night (now with trach,
peg for meds), h/o MRSA/pseudomonal pna's and persistent pulm
infitrates. Pt was on
Zosyn/caspofungin/amikacin/bactrim/linezolid at rehab (for 2 wk
course) and was scheduled to have CT at [**Hospital1 2025**] to evaluate
infiltrates. Pt also with intermittent agitation treated with
ativan/haldol prn. In ED, given versed, vanco, zosyn, put on
vent/PS.
Past Medical History:
[**Hospital1 **]'s (DIDMOAD) syndrome, Seizures [**12-27**] hypoglycemia, MRSA
pna, pseudomonas, trach collar, Hashimoto's thyroiditis,
anxiety/mdd, avnrt, central hypoventilation,
Social History:
Resident of [**Hospital3 **]; Full Code
Family History:
non-contributory
Physical Exam:
PE on admit to MICU:
Vitals: T 102.3, BP 110/50, HR 62, Vent settings: PS 20, PEEP 5,
Vt 590, RR 8, O2 97-100% O2
Gen: Sedated but in NAD
HEENT: non-icteric, mm dry
Chest: coarse BS bilat.
CV: RRR. no murmurs
Abd: Soft, NT/ND. PEG Tube
EXT: no c/c/e
Neuro: surgical pupils b/l; neuro exam difficult [**12-27**] sedation
Pertinent Results:
[**2174-9-9**] 08:01PM LACTATE-2.2*
[**2174-9-9**] 08:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2174-9-9**] 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2174-9-9**] 07:30PM GLUCOSE-250* UREA N-9 CREAT-0.8 SODIUM-132*
POTASSIUM-3.8 CHLORIDE-95* TOTAL CO2-23 ANION GAP-18
[**2174-9-9**] 07:30PM WBC-9.1 RBC-4.43*# HGB-13.7*# HCT-39.5*#
MCV-89 MCH-30.8 MCHC-34.6 RDW-15.3
[**2174-9-9**] 07:30PM NEUTS-85.3* LYMPHS-10.8* MONOS-2.8 EOS-1.0
BASOS-0.2
[**2174-9-9**] 07:30PM PLT COUNT-189#
[**2174-9-9**] 07:30PM PT-14.2* PTT-27.8 INR(PT)-1.3
[**9-9**] CXR: Bilateral pleural effusions, without definite focal
consolidation
[**9-15**] CTA-chest:
1. No evidence of pulmonary embolism.
2. Bilateral pleural effusions with atelectasis and air
bronchograms in the lung bases.
3. Micronodular opacities are present in the right lung base,
consistent with pneumonia.
[**9-12**] Video Swallow Study:
The patient was unable to swallow the barium tablet with thin
liquid and demonstrated a moderate amount of thin liquid
aspiration during this attempt. There was no spontaneous cough,
and a cued cough was ineffective in clearing the
aspiration.
[**9-29**] Video Swallow Study:
Aspiration of thin and nectar thick barium. Penetration to the
vocal cords with pudding consistency barium. Prominence of the
cricopharyngeus muscle with episodes of apparent spasm.
Brief Hospital Course:
22 y/o M with h/o [**Month/Day (4) **]'s Disease (DIDMOAD), central
hypoventilation, recurrent PNA (h/o
MRSA/Pseudomonas/Klebsiella), presenting s/p witnessed
aspiration event, with intermittent fevers, afebrile since ABX
discontinued on [**9-16**].
1. Pneumonitis: Mr. [**Known lastname 37779**] was admitted on [**9-9**] following a
witnessed aspiration event at [**Hospital3 **]. He had recent
reported histoy of broad spectrum antibiotics over the last 2
weeks (Linezolid/Zosyn/Caspofungin/Bactrim/Amikacin). On
admission to [**Hospital1 18**] he was initially monitored in the ICU given
his central hypoventilation with ventilation dependence. Initial
CXR here was negative for infiltrate (reported as bilateral
atelectasis and small effusions). Sputum cultures grew
Pseudomonas/Klebsiella on two separate days. It was thought that
these organisms could represent colonization vs infection.
Given his persistent fever and bandemia, infection was suspected
and he was initially started on Vanco (D1=[**2174-9-11**]) and Zosyn.
Zosyn was changed to Merepenem (D1=[**2174-9-14**]) after final
sensitivies returned (Pseudomonas resistant to Zosyn and
Ceftaz). Given his persistent fevers, other etiologies of his
fever were pursued including PE and meds. CT-angio was performed
on [**9-15**] which demonstrated multi-nodular opacities in the right
lung base thought to be c/w pneumonia. No evidence of pulmonary
embolism. Non-pathologically enlarged lymph nodes were noted in
the mediastinum and hilar regions. However, repeat CXR's
continued to demonstrate no evidence of infiltrate. In addition,
the patient developed a rash that was thought to be consistent
with drug rash. All antibiotics were discontinued on [**9-16**] given
lack of clinical findings c/w pneumonia and given possible drug
rash/fever. He subsequently remained afebrile off antibiotics
for the next week. His rash subsequently resolved as well, with
suspected [**Last Name (un) **] to Zosyn (no respiratory compromise, no hives).
His respiratory status improved and he was able to maintain O2
sats >93% on 35% trach collar and off ventilation assistance
completely. Given his subsequent improvement without continued
antibiotics, the thought was that he was likely to have
pneumonitis rather than a new pneumonia.
His WBC count remained stable at 9-10 over the following week
off antibiotics. However, on [**9-28**], his WBC count increased to 18
with 3% bands. He remained afebrile, but he was noted to have
increased thick yellow sputum production. Repeat CXR
demonstrated evidence of a right lower lobe pna vs atelectasis.
Therefore he was re-started on antibiotics on [**9-28**] with Vanco
and Cefipime. However, he subsequently had resolution of his WBC
count the following day [**9-29**] (WBC =9, with 0 bands) and
antibiotics were discontinued. A new infection was thought to be
unlikely as he quickly recovered and remained afebrile and
clinically stable throughout the remainder of his course. On
discharge he is off all antibiotics and is afebrile with stable
respiratory status.
1a. Cricothyroid Muscle spasms: Given his recurrent aspirations
and secondary aspiration pnuemonitis/pneumonia he was evaluated
further by the speech and swallow service. Evaluation
demonstrated that he had paroxysmal cricothyroid muscle spasms
leading to aspiration. Spasm was noted to occur despite multiple
preceding normal swallows were documented. In addition he was
noted to have absent cough reflex. These spasms were thought to
be the likely etiology of his aspirations. In addition, GERD was
thought to be exacerbating his symptoms, with noted epiglottic
edema. Manometry [**9-27**] demonstrated no evidence of UES
dysfunction or spasm (over [**2-28**] swallows). However,there was
still concern over paroxysmal muscle spasm. Therefore he
underwent EGD w/dilatation of his UES on [**9-28**]. However, repeat
video swallow study on [**9-29**] demonstrated continued aspiration of
thin liquids with intermittent esophogeal spasms (please obtain
online medical record for full report). There was also noted
difficulty initating swallow. After consultation, we decided to
pursue conservative management of this problem. It is unclear
whether botox injections to his CM muscle would help at this
time. Therefore, we have resumed a diet of thickened liquids
with strict aspiration precautions, including maintaing the chin
down in postition while swallowing. He has tolerated thickened
liquids quite well and has had no evidence of pneumonia. If he
subsequently has reccurrent aspiration pneumonitis or pna, he
may follow-up with Dr. [**Last Name (STitle) 952**] for potential botox injection. He
has follow-up scheduled for [**2174-10-18**] for initial visit w/ Dr.
[**Last Name (STitle) 952**].
**He should have a repeat video swallow study to evaluate for
aspiration and potential advancement of diet.
2. Hyper/Hyponatremia: Over the course of his hospital stay,
Mr. [**Known lastname 37779**] had brittle sodium levels. His difficult sodium
balance was secondary to his central diabetes insipidus in the
setting of decreased PO intake (nutrition was given per tube
feeds). He does have an intact thirst reflex, however PO's were
initially held in the setting of his known aspiration risk. In
the ICU he developed hypernatremia with Na levels up to the
150's, treated with free water flushes. In addition he was
continued on his DDAVP (desmopressin) at 1.0mcg IV BID + and
additional mid-day dose at 0.5mcg. However, he subsequently
developed hyponatremia w/ Na down to 123. He remained
asymptomatic without seizure. His free water flushes were held
in addition to his DDAVP in setting of hyponatremia. He
persisted to have very brittle sodium control, with return of
sodium to 149. He was re-started on DDAVP at 1.0mcg IV BID. This
regimen lead to good sodium control. Of note, since he started
taking in PO's, he has been drinking thickened water,resulting
in sodium fall to 139. However, we do not want to discourage his
PO intake, so instead we have decreased his DDAVP dose. On
discharge we have him on 0.5mcg IV morning dose and 1.0mcg IV
evening dose.
3. Epilepsy: Continued on Dilantin with seizure precautions.
Dosed by levels. [**10-4**] dilantin level was 20.9, so we decreased
dilantin to 200mg [**Hospital1 **].
4. Hypothyroidism: Continued on Synthroid.
5. DMII- insulin dependent: Followed by [**Last Name (un) **] in the hospital.
He also was noted to have brittle diabetes with blood sugars
fluctuating from low's of 40's-50's with highs up to the 300's.
Eventually, he was able to be maintatined with good glycemic
control on the regimen as follows: NPH insulin 30qam/25qhs +
sliding scale humalog.
6. Anemia/Thrombocytopenia: Both stable, initially down from
admission. Concern for HIT/Zosyn-related low platelets. HIT
negative. Plts have since recovered; HCT stable.
7. FEN: Probalance Full strength via PEG. In addition, we would
recommend a calorie count if he continues to take in significant
PO's, since he may not need continued full strength tube feeds.
8. Allergic Derm Rxn: On [**9-11**] had fever,blanching erythematous
rash with non-blanching 1/2 mm papules. The rash abatted in
<2hrs after Benadryl IV. He was also given Albuterol Nebs, but
had no dyspnea. He has had resolution of his rash off of
antibiotics, with no current fever, so leading diagnosis is drug
rash/fever, likley secondary to Zosyn. Of note, he did not
develop rash on Cefipime.
9.Conjunctivitis: [**Month (only) 116**] be related to drug reaction. We do not
have high clinical suspicion that this is a bacterial
conjunctivitis, however have treated with erythromycin eye drops
for a 6 day total course. Clinically resolving.
10. Anxiety: On Ativan 2-4mg PO/IV q6h PRN. Paroxetine 30qday.
Trazadone prn at night.
Medications on Admission:
meds on tx from rehab: NPH 36 U qam/10qpm, DDAVP 1mcg IV BID,
0.5 mcg at 2pm, Zosyn 4.5gm IV q8 (day # 14),Caspofungin (day #
14), Amakacin 375mg IV q12, Dilantin 100mg PO BID, Mag Gluconate
1000mg TID, Protonix 40mg PO QD, Bactrim DS 1 tab po bid (day
#14), Linezolid 600mg PO BId, Synthroid 150 mcg PO Qday, haldol
5mg q 2-4 hours prn, Ativan 1-2 mg q 4-6 hrs prn, colace 100mg
PO TID
Discharge Medications:
1. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO QD
().
2. Phenytoin 100 mg/4 mL Suspension Sig: Two (2) PO twice a
day.
3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
6. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO BID (2 times a day).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
10. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. Desmopressin Acetate 4 mcg/mL Solution Sig: One (1) mcg
Injection qpm.
12. Insulin NPH Human Recomb 100 unit/mL Syringe Sig: One (1)
units Subcutaneous as scheduled: NPH 30 Units qam
NPH 25 Units qhs.
13. DDAVP 4 mcg/mL Solution Sig: 0.5 mcg Injection qam.
14. Lorazepam 1 mg Tablet Sig: 2-4 Tablets PO Q4-6H (every 4 to
6 hours) as needed for agitation.
15. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at
bedtime) as needed.
16. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID
(4 times a day) for 3 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Aspiration pneumonitis
[**Location (un) **] (DIDMOAD) syndrome
Drug fever- secondary to Zosyn
Diabetes II-insulin requiring
Hyper/Hyponatremia
Discharge Condition:
Good. HD stable. Off vent dependence. Afebrile. No evidence of
pneumonia. Able to take in pre-thickened liquids while on strict
aspiration precautions.
Discharge Instructions:
Call your doctor if you experience fever greater than 100.4,
shaking chills, seizure, shortness of breath or worsening cough.
[**Hospital1 **]: Please do a repeat Video Swallow study to evaluate
for aspiration and potential advancement of diet. thank you.
Followup Instructions:
1. Pleae follow-up with Dr. [**Last Name (STitle) 952**] on [**2174-10-18**] at 1pm:
[**Hospital1 69**]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 170**]
2. If you would like to f/u with podiatry, you may call to
schedule an appt at [**Telephone/Fax (1) 543**]
|
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icd9cm
|
[
[
[]
]
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[
"96.72",
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icd9pcs
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[
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339, 345
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373, 993
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1015, 1197
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1213, 1254
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,640
| 145,753
|
3309+3310
|
Discharge summary
|
report+report
|
Admission Date: [**2110-3-23**] Discharge Date: [**2110-4-4**]
Service: Medicine, [**Hospital1 139**] Firm
HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old
female nursing home resident recently diagnosed with a
pulmonary embolism and anticoagulated with Coumadin who
presented after a mechanical fall in the bathroom.
The patient denies any prodromal symptoms, diaphoresis,
shortness of breath, or chest pain. She denies hitting her
head or loss of consciousness. The patient reports she felt
[**9-7**] pain in the left leg after falling and called for her
nurse.
In the Emergency Department, an x-ray of the left lower
extremity was obtained which revealed a displaced fracture of
the tibia and fibula. The Orthopaedic Service evaluated the
patient in the Emergency Department and planned for an open
reduction/internal fixation in the next few days, once her
INR was normalized.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 98.6
degrees Fahrenheit, her heart rate was 90, her blood pressure
was 164/76, her respiratory rate was 20, and her oxygen
saturation was 98% on room air. Generally, she was in no
acute distress. Head, eyes, ears, nose, and throat
examination revealed small bilaterally reactive pupils. The
mucous membranes were moist. The neck was supple. There was
no jugular venous distention. Cardiovascular examination
revealed a regular rate and rhythm. The lungs revealed
decreased breath sounds at the bases bilaterally. The
abdomen was obese, soft, and nontender. There were normal
active bowel sounds. Extremities revealed her left lower
extremity was immobilized with some trace edema of her lower
extremities. Dorsalis pedis pulses were 2+ bilaterally. On
neurologic examination cranial nerves II through XII were
intact. She was alert and oriented times three.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count was 14.8, her hematocrit was 35.2, and her
platelets were 325. Her INR was 4.7. Sodium was 141,
potassium was 4.7, chloride was 109, bicarbonate was 24,
blood urea nitrogen was 32, and her creatinine was 2.
PERTINENT RADIOLOGY/IMAGING: An x-ray of the left lower
extremity showed a displaced spiral fracture of the tibia and
fibula.
SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. RESPIRATORY FAILURE ISSUES: The patient's open
reduction/internal fixation was initially delayed secondary
to her elevated INR.
After correction of her INR, the patient went for open
reduction/internal fixation. This was complicated by some
hypotension intraoperatively with induction. The patient was
given multiple liters of intravenous fluids, after which the
patient could not be extubated secondary to hypoxemia and
hypercarbic respiratory failure; likely secondary to
congestive heart failure with aggressive intravenous fluid
hydration.
The patient was admitted to the Medical Intensive Care Unit
for a transient 3-day stay, where she was diuresed with
Lasix. The patient's respiratory failure improved markedly.
She was extubated and remained on the floor with a chest
x-ray showing some resolving atelectasis and pneumonia.
The patient ended up having an echocardiogram which showed an
ejection fraction of 60% with some evidence of diastolic
dysfunction.
The patient was continued on ceftriaxone and azithromycin for
a left lower lobe infiltrate which improved.
2. INFECTIOUS DISEASE ISSUES: The patient was noted to be
febrile to 101 in the Medical Intensive Care Unit. Her
cultures were negative. She was noted to have a left lower
lobe infiltrate and was treated with ceftriaxone and
azithromycin with improvement in her fever curve and
documented improvement on chest x-ray.
However, once on the floor, the patient continued to spike
fevers on ceftriaxone and azithromycin. Her urinalysis and
chest x-ray were both negative. The patient had a right
internal jugular which was subsequently pulled, and blood
cultures were pending.
3. CONGESTIVE HEART FAILURE ISSUES: The patient had
significant congestive heart failure postoperatively from
aggressive fluid resuscitation in the operating room.
The patient had a 3[**Hospital 15386**] Medical Intensive Care Unit stay
during which she was diuresed with Lasix and extubated with
stable oxygen saturations on the floor.
4. RENAL FAILURE ISSUES: The patient with a baseline
creatinine of 1.3 to 1.6 which peaked to 2.2 postoperatively.
Although her fractional excretion of sodium was greater than
1%, this may be secondary to acute tubular necrosis from
operative hypotension. The patient's creatinine on the floor
subsequently improved to 1.4 (at her baseline).
5. PULMONARY EMBOLISM ISSUES: The patient has a history of
a recent pulmonary embolism, for which she was started on
Coumadin. No clear etiology for her pulmonary embolism. The
patient was continued on Coumadin postoperatively.
6. ORTHOPAEDIC ISSUES: The patient with a left spiral
tibia/fibula fracture, status post open reduction/internal
fixation. The patient's wound on the floor looked to be
healing well without any sign of wound infection in the face
of her spiking fevers. She will continue to work with
Physical Therapy and have range of motion exercises. She was
to have a nonweightbearing status on the left lower
extremity.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: The patient was to be discharged to a
rehabilitation facility for continued physical therapy.
MEDICATIONS ON DISCHARGE:
1. Azithromycin 250 mg by mouth once per day (times four
days).
2. Ceftriaxone 1 gram intravenously once per day (times
four days).
3. Colace 100 mg by mouth twice per day.
4. Pantoprazole 40 mg by mouth once per day.
5. Lisinopril 10 mg by mouth once per day.
6. Atenolol 50 mg by mouth once per day.
7. Morphine 1 mg to 2 mg intravenously q.3-4h. as needed.
8. Atrovent nebulizer q.6h.
9. Albuterol nebulizer q.6h.
10. Clonidine 0.2 mg by mouth three times per day.
11. Atorvastatin 20 mg by mouth once per day.
12. Insulin sliding-scale.
13. Olanzapine 5 mg by mouth at hour of sleep.
14. Tylenol as needed.
15. Coumadin 5 mg by mouth at hour of sleep.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] of the Orthopaedic Service in 10 days after discharge
from the rehabilitation facility.
2. The patient was also instructed to follow up with her
primary care provider in one to two weeks after discharge
from the rehabilitation facility.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 15384**]
Dictated By:[**Last Name (NamePattern1) 5819**]
MEDQUIST36
D: [**2110-4-3**] 18:36
T: [**2110-4-3**] 19:07
JOB#: [**Job Number 15387**]
Admission Date: [**2110-3-23**] Discharge Date: [**2110-4-12**]
Service: MED
SERVICE: [**Hospital1 139**] Medicine
ADDENDUM: This is an addendum for the dates [**2110-4-4**] to
[**2110-4-12**].
1. CONGESTIVE HEART FAILURE: The patient remained euvolemic
and was not given any additional Lasix. She was taking
poor p.o. She underwent calorie counting which revealed
that she was only taking 400 calories per day. She was
initiated on some IV fluids and assisted with her meals.
The patient eats well when assisted with meals.
1. INFECTIOUS DISEASE: The patient continued to spike low-
grade fevers intermittently. No further blood cultures
were positive other than a blood culture on [**2110-4-3**], one
out of two, positive for coagulase-negative
Staphylococcus. The patient was treated with vancomycin
for two days until her culture came back. This was felt
to be a contaminant and vancomycin was discontinued. The
patient was felt to be at high-risk for Clostridium
difficile colitis as she developed diarrhea with elevated
LFTs. She was started on three days of IV Flagyl for
concern of not absorbing her p.o. dosage. The patient
remained afebrile times 48 hours on this dosing and will
be discharged on 500 mg of Flagyl t.i.d. times ten days.
1. RENAL FAILURE: The patient had returned to her baseline
creatinine of 1.4 on the 7th but subsequently elevated her
BUN/creatinine ratio as she took poor p.o. She was
initiated on some IV fluid supplementation and started
with assistance with her meals which subsequently improved
her creatinine to baseline.
1. HISTORY OF PULMONARY EMBOLISM: The patient will continue
on Coumadin with a goal INR of [**12-31**].
1. ORTHOPEDICS: The patient is status post left tib-fib
fracture. She was continued on range of motion exercises
with CPM to continue to a goal of 90 degrees and continue
at rehabilitation. She will follow-up with Dr. [**First Name (STitle) **].
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient will be discharged to a
rehabilitation facility.
DISCHARGE MEDICATIONS:
1. Pantoprazole 40 mg p.o. q.d.
2. Atenolol 50 mg p.o. q.d.
3. Olanzapine 5 mg p.o. h.s.
4. Lipitor 20 mg p.o. q.d.
5. Clonidine 0.2 mg p.o. t.i.d.
6. Albuterol inhaler every six hours.
7. Atrovent inhaler every six hours.
8. Hydrochlorothiazide 12.5 mg p.o. q.d.
9. Morphine 2 mg injection every three to four hours as
needed for pain.
10. Coumadin 7.5 mg p.o. q.h.s.
11. Flagyl 500 mg p.o. t.i.d. times ten days.
12. Celexa 20 mg p.o. q.d.
13. Sulfadiazine 1 percent cream applied topically every
day to effected ulcers on back.
14. MSIR 15 mg p.o. every four to six hours p.r.n.
15. Sliding scale regular insulin.
16. Zofran 2-4 mg IV every six hours p.r.n. nausea.
FOLLOW UP:
1. The patient is to follow-up with Dr. [**Last Name (STitle) **] of Orthopedics
in ten days. She can call [**Telephone/Fax (1) 9118**] for an
appointment.
2. She is also to follow-up with Dr. [**Last Name (STitle) **], her primary care
provider, [**Name10 (NameIs) **] one to two weeks after discharge from
rehabilitation.
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-981
Dictated By:[**Last Name (NamePattern1) 15388**]
MEDQUIST36
D: [**2110-4-11**] 21:08:33
T: [**2110-4-11**] 23:34:14
Job#: [**Job Number 15389**]
|
[
"997.1",
"428.0",
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"428.30",
"518.81",
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] |
icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
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8938, 9650
|
5460, 6140
|
6173, 8800
|
9661, 10234
|
2286, 5295
|
5310, 5433
|
146, 2252
|
8825, 8915
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,334
| 136,306
|
4111
|
Discharge summary
|
report
|
Admission Date: [**2135-5-2**] Discharge Date: [**2109-2-18**]
Date of Birth: [**2058-8-18**] Sex: F
Service: CARDIAC SURGERY
CHIEF COMPLAINT: Worsening chest pain
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old
female who was admitted for cardiac catheterization with
worsening chest pain. She underwent a cardiac
catheterization followed subsequently by an emergent coronary
artery bypass graft and coronary artery bypass graft.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease
2. Paroxysmal atrial fibrillation
3. Hypertension
4. Elevated cholesterol
ADMISSION MEDICATIONS:
1. Amiodarone
2. ASA
3. Zocor
4. Diltiazem
5. Lopressor
6. Solu-Medrol
7. Zithromax
8. Nitropaste
9. Lovenox
ALLERGIES: None known
HOSPITAL COURSE: The patient underwent a catheterization for
coronary artery disease which revealed two vessel coronary
artery disease with unsuccessful percutaneous transluminal
coronary angioplasty and stenting of the OM. She also
developed a large right groin hematoma and pseudoaneurysm in
the catheter lab and was urgently transferred to the
Operating Room for repair of the femoral arteriotomy and for
a coronary artery bypass graft. She underwent a coronary
artery bypass graft x2 with left internal mammary artery to
LAD, RSVG to OM on [**2135-5-2**] with repair of the femoral
arteriotomy. She was extubated on postoperative day 1. She
continued to be stable. She required large transfusion in
the Operating Room. She stayed in the Intensive Care Unit on
postoperative day 1. She was transferred to the regular
floor on postoperative day 2 in a stable condition. She
continued to make good progress hemodynamically over the next
couple of days. She was ambulating with support. Her pain
is under good control with good analgesics and her
respiratory function is good. She is currently ready for
discharge to a rehabilitation facility.
DISCHARGE MEDICATIONS:
1. Lopressor 50 mg [**Hospital1 **]
2. Lasix 20 mg qd x1 week
3. KCL 20 milliequivalents qd x1 week
4. Colace 100 mg [**Hospital1 **]
5. Aspirin enteric coated 325 mg qd
6. Zocor 10 mg q hs
7. Combivent metered dose inhaler 2 puffs qid
8. Flovent metered dose inhaler 110 mcg 2 puffs [**Hospital1 **]
9. Amiodarone 200 mg qd
10. Percocet 1 to 2 tablets q 4 to 6 hours prn
FOLLOW UP: Dr. [**Last Name (STitle) **] in clinic in four weeks and with
primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 18029**], in two weeks.
DISCHARGE CONDITION: Stable
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2135-5-6**] 09:24
T: [**2135-5-6**] 10:00
JOB#: [**Job Number 18030**]
|
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icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.06",
"39.61",
"39.31",
"88.56",
"88.72",
"37.22",
"36.01",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
2577, 2862
|
1954, 2336
|
792, 1931
|
631, 774
|
2348, 2555
|
165, 187
|
216, 466
|
488, 608
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,433
| 142,320
|
53287
|
Discharge summary
|
report
|
Admission Date: [**2178-10-16**] Discharge Date: [**2178-10-24**]
Date of Birth: [**2109-2-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Dyspnea on Exertion
Major Surgical or Invasive Procedure:
PICC line placement
Cardiac catheterization
Transesophageal ECHO
History of Present Illness:
This is a 69-year-old male with a history of hyperlipidemia,
hypertension, pulmonary interstial fibrosis and chronic renal
insufficiency, Hep C, psoriatic arthritis who presents with 1.5
wks of dyspnea and nightsweats for one year. He was seen in the
office of his PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26225**], yesterday with complaints
of right leg discomfort, and swelling of his right leg. He was
referred to [**Hospital3 **] ED for eval and declined admission going
AMA. He was called and asked to come back as he was noted to
have some CHF but declined. Late in the afternoon he was finally
convinced to be admitted with a diagnosis of shortness of
breath/CHF.
.
He reportedly had vague complaints of chest discomfort on the
right, and somewhat on the left, a variable cough, vague chills
but no fever and was noted to be short of breath especially with
inclines, stairs, and exertion. At baseline he can walk up two
flights of stairs, but over the last week he has had decreasing
exercise tolerance and now No orthopnea or PND. He was
admitted, diuresed, and underwent an echocardiogram which showed
severe aortic regurgitation and aortic deformity. He is being
transferred for further evaluation for possible bacterial
endocarditis.
Here, he was found to have aortic and tricuspid valve
vegetations, with aortic lesion on the non-coronary cusp. Dr.
[**Last Name (STitle) **] from Cardiac Surgery was notified. He was admitted to
the CCU for management of bacterial endocarditis and CHF. ROS
also notable for neck pain, history of blood stools.
Past Medical History:
Psoriatic arthritis
Obstructive sleep apnea on BiPAP
Hyperlipidemia
Cervical and lumbosacral disk disease
Bilateral hearing loss
Hypertension
Hepatitis C
s/p bunionectomy and hammertoe excision of L foot complicated by
osteomyelitis in [**1-19**]
s/p R hip arthroplasty in [**2160**]
s/p rectal polyp excision in 5/95
s/p hemorrhoidectomy in 8/97
hx of diverticular disease
s/p liver biopsy in [**6-18**]
Social History:
He is not married. He has no children. He lives alone. No
history of tobacco or alcohol. Denies IVDA. This gentleman is
the uncle of a former [**Hospital1 18**] cardiology fellow, [**First Name8 (NamePattern2) 2197**] [**Last Name (NamePattern1) **].
Family History:
No family history of CAD, MI, cancer. Per patient no family
medical problems.
Physical Exam:
Trazodone 50mg-100mg PO QHS
Xanax 0.25mg PO BID
Zoloft 200mg PO QAM
Nabuemtone 750mg PO BID
Multivitamin PO daily
Glucosamine chondroitin PO daily
Flonase
Methocarbamol
Pertinent Results:
[**2178-10-23**] 06:07AM BLOOD WBC-9.0 RBC-3.68* Hgb-10.3* Hct-30.7*
MCV-83 MCH-28.1 MCHC-33.7 RDW-14.3 Plt Ct-187
[**2178-10-20**] 05:43AM BLOOD Neuts-81.1* Lymphs-14.2* Monos-3.0
Eos-1.5 Baso-0.2
[**2178-10-20**] 05:43AM BLOOD PT-14.7* PTT-34.7 INR(PT)-1.3*
[**2178-10-17**] 05:59AM BLOOD Fibrino-390
[**2178-10-16**] 06:20PM BLOOD ESR-63*
[**2178-10-23**] 06:07AM BLOOD Glucose-101 UreaN-21* Creat-1.1 Na-135
K-4.4 Cl-98 HCO3-29 AnGap-12
[**2178-10-23**] 06:07AM BLOOD Glucose-101 UreaN-21* Creat-1.1 Na-135
K-4.4 Cl-98 HCO3-29 AnGap-12
[**2178-10-18**] 05:58AM BLOOD ALT-17 AST-27 LD(LDH)-187 CK(CPK)-18*
AlkPhos-92 TotBili-0.7
[**2178-10-18**] 05:58AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2178-10-23**] 06:07AM BLOOD Mg-2.4
[**2178-10-20**] 04:30PM BLOOD calTIBC-204* Ferritn-309 TRF-157*
[**2178-10-16**] 06:20PM BLOOD CRP-56.0*
[**2178-10-18**] 05:58AM BLOOD HIV Ab-NEGATIVE
[**2178-10-22**] 09:52AM BLOOD Genta-0.6*
[**2178-10-22**] 06:03AM BLOOD Vanco-11.7
C Diff neg on [**10-18**] and [**10-19**]
[**10-16**] ECHO - The left ventricular cavity is mildly dilated.
Overall left ventricular systolic function is normal (LVEF>55%).
The ascending aorta is moderately dilated. There are simple
atheroma in the descending thoracic aorta. There is a
moderate-sized vegetation on the aortic valve. No aortic valve
abscess is seen. Moderate to severe (3+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is a moderate vegetation on the
tricuspid valve. Moderate [2+] tricuspid regurgitation is seen.
The pulmonic valve leaflets are thickened. There is a
trivial/physiologic pericardial effusion.
CXR:
[**10-16**] - No previous images. The cardiac silhouette is enlarged
though
there is no evidence of elevated pulmonary venous pressure.
Probable small
pleural effusions bilaterally with extension into the major
fissure on the
right. Bibasilar atelectatic change without definite focal
pneumonia.
[**10-20**] - AP single view of the chest demonstrates the presence of
a
left-sided PICC line seen to terminate overlying the SVC at the
level 1 cm
below the carina. No pneumothorax or any other placement-related
complication is identified. The pulmonary vasculature does not
demonstrate any remaining congested pattern and no new acute
infiltrates are seen.
CT Abd [**10-16**]:
1. Bilateral pleural effusions, with associated atelectasis and
consolidation of the lung bases.
2. Tiny rounded hypodensities in bilateral kidneys, too small to
characterize.
3. No evidence for parenchymal infarcts within the abdomen.
4. Complete loss of disc height at L1-2, with irregular endplate
sclerosis. There are no prior studies for comparison. While this
is most likely secondary to severe degenerative disease,
correlate with any symptoms referrable to the lower lumbar
spine, as infection may have a similar appearance in the
appropriate clinical context.
Head CT [**10-16**]:
1. Mild brain atrophy without hemorrhage on head CT.
2. No evidence of an aneurysm greater than 3 mm in size on CT
angiography of the head.
3. It should be noted that mycotic aneurysm in the peripheral
branches of the intracranial arteries could not be excluded by
CT angiography.
Carotid US [**10-19**]: No hemodynamically significant stenosis within
the right or left internal carotid arteries.
Knee X-ray [**10-21**]:
1. No acute fracture detected.
2. Joint effusion.
3. Osteoarthritis.
4. Chondrocalcinosis -- differential diagnosis include CPPD.
5. Prepatellar soft tissue edema.
Cardiac Cath [**10-19**]:
No coronary disease
Brief Hospital Course:
69 M with HTN, hyperlipidemia, IPF, Hep C, and psoriatic
arthritis presenting with bacterial endocarditis and CHF
exacerbation.
BACTERIAL ENDOCARDITIS - On presenation pt had a transesophageal
echo showing tricuspid and aortic vegetations and severe aortic
insufficiency. History of nightsweats for months and
progressive dyspnea argued against acute endocarditis, as does
appearence of vegitations and regurgitation on multiple valves.
Given his heart failure in the setting of endocarditis he was
evaluated by cardiac surgery for emergent valve replacement who
deferred surgery until after antibiotic course as pt was
hemodynamically stable. Pt was initially treated with
Vancomycin, Gentamicin (dosed by levels) and Zosyn and when OSH
BCx grew nutritionally varient strept, was switched to
Vancomycin, Gentamicin and Ceftriaxone. Cultures were then
transferred to [**Hospital1 18**] for reevaluation by our ID team regarding
sensitivities for narrowing of antibiotics. He had daily blood
cultures for several days but all cultures at [**Hospital1 18**] were
negative. He also had daily EKGs to look for PR prolongation as
a result of endocarditis/abscess indicating need for urgent
surgery.
Pt was cleared for surgery with multiple pre-op screening tests
including normal carotid ultrasound, head CT, cardiac cath and
dental eval with panorex.
Prior to discharge pt had a left PICC line place to complete a
6wk course of antibiotics as an outpt.
- Patient will need Gentamycin trough checked two days after
discharge and have Gentamycin dosed accordingly.
.
CONGESTIVE HEART FAILURE - Pt was initially agressively diuresed
at OSH in the setting of infection and contrast and on
presentation was given 20mg IV Lasix daily with slow diuresis.
Pt was euvolemic for the majority of his stay, satting well on
room air at rest and while ambulating.
.
ABDOMINAL TENDERNESS - Pt initially had some RLQ tenderness and
h/o BRBPR, so CT scan was done to look for possible source of
bacteremia. There was no suggested source of infection seen and
pt's symptoms spontaneously resolved. Pt had no changes in his
bowel habits thoughout the admission. Hepatologist was contact[**Name (NI) **]
who confirmed that pt's hep C was cured with neg viral load.
.
INTERSTITIAL PULMONARY FIBROSIS - Normal PFTs in [**2171**] and not on
O2 at home. Was not thought to be the etiology of his initial
hypoxia and pt had normal room air sats after initial diuresis.
.
[**Name (NI) 109664**] - Pt developed worsening right knee pain during his
hospital stay. He was evaluated with an x-ray showing effusion,
osteoarthritis and chondrocalcinosis. He also was tapped by the
rheumatology team and synovial fluid confirmed diagnosis of
pseudogout. In order to avoid NSAIDs or cholchicine to protect
the renal function, pt had a steroid injection by rheumatology
which pt tolerated well and gave pt complete relief.
.
PSORIATIC ARTHRITIS - Pt's pain was controlled with tylenol
.
PSYCH: Pt has anxiety and baseline depression but coped well
thoughout the admission. He was followed by social work and
continued on trazadone for sleep.
- Continue trazadone for sleep
- S/W following
Medications on Admission:
Trazodone 50mg-100mg PO QHS
Xanax 0.25mg PO BID
Zoloft 200mg PO QAM
Nabuemtone 750mg PO BID
Multivitamin PO daily
Glucosamine chondroitin PO daily
Flonase
Methocarbamol
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. Sertraline 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
5. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed.
6. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Heparin Lock Flush (Porcine) 10 unit/mL Solution Sig: Two (2)
ML Intravenous PRN (as needed) as needed for line flush.
10. Normal Saline Flush 0.9 % Syringe Sig: Ten (10) cc Injection
as needed as needed for after PICC use.
11. Clobetasol-Emollient 0.05 % Cream Sig: One (1) use Topical
once a day as needed for psoriasis.
12. Dovonex 0.005 % Cream Sig: one application Topical once a
day as needed for for psoriasis.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 86**] Center - [**Location (un) 2312**]
Discharge Diagnosis:
Bacterial Endocarditis with Nutritionally Variant Streptococcus.
Aortic and tricuspid valve endocarditis
Moderate aortic regurgitation, mild to moderate aortic stenosis
Moderate to severe tricuspid regurgitation
Acute on Chronic Diastolic Congestive Heart Failure
Acute on Chronic Renal Failure
Anemia
Pseudogout
Anxiety and Depression
Discharge Condition:
Stable
Discharge Instructions:
You were found to have bacterial endocarditis with involvement
of your aortic and tricuspid valve. You will need intravenous
antibiotics for at least 6 weeks and a repeat echocardiogram to
make sure the infection has cleared. We placed a PICC line to
give you the antibiotics. You were treated for congestive heart
failure with Lasix. You had a carotic artery ultrasound to check
for blockages, there were no significant blockages found. You
had a cardiac catheterization that showed no coronary artery
disease. You will need to be seen by cardiac surgery team after
the antibiotics are finished and the ECHO is done to see if the
bacteria have been cleared from your valves and if you need
surgery to fix the aortic valve.
.
Please start the following medicines:
1. Lasix 20mg twice a day
2. Lisinopril 2.5mg once a day
3. Ceftriaxone (antibiotic) 1g IV once a day****
4. Vancomycin (antibiotic) 1g IV every 12 hours
5. Gentamicin (antibiotic) 80mg IV every 12 hours
Please ask the facility staff to call the provider for any
fevers, chills, rash, chest pain, trouble breathing, nausea or
any other concerning symptoms.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day
or 6 pounds in 3 days.
Adhere to 2 gm sodium diet
Fluid Restriction:[**2169**] ml daily
Followup Instructions:
Cardiology:
[**Name6 (MD) **] [**Last Name (NamePattern4) 6559**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2178-11-6**]
2:20pm
.
ECHO:
[**2178-11-19**]. Call ([**Telephone/Fax (1) 2037**] for appointment
information.
.
CT surgery:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone: Date/time: [**2178-11-19**] at 1:00 pm
.
Primary Care:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26225**]. Phone: [**Telephone/Fax (1) 72383**] Please call office after
you are home for an appt.
.
Completed by:[**2178-10-24**]
|
[
"327.23",
"515",
"285.21",
"584.9",
"070.54",
"424.1",
"585.9",
"421.0",
"300.4",
"272.4",
"696.0",
"275.49",
"041.09",
"511.9",
"403.90",
"428.33",
"712.36",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.93",
"81.91",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
11159, 11242
|
6715, 9871
|
337, 404
|
11623, 11631
|
3055, 6692
|
12971, 13531
|
2770, 2850
|
10090, 11136
|
11263, 11602
|
9897, 10067
|
11655, 12948
|
2865, 3036
|
278, 299
|
432, 2057
|
2079, 2485
|
2501, 2754
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,561
| 108,382
|
36684
|
Discharge summary
|
report
|
Admission Date: [**2117-7-20**] Discharge Date: [**2117-7-26**]
Date of Birth: [**2087-9-21**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Increasing headache
Major Surgical or Invasive Procedure:
Right craniotomy for partial tumor resection
History of Present Illness:
29F 3yr s/o bilat radical mastectomy for breast ca; has been
well since, on PO tamoxifen; p/w 4 weeks of post. h/a, nausea,
occasional vomitting in the beginning, and progressive
apparition of diff. walking, unsteadiness, tendency to fall to
Lt, occasional blurry or double vision, eye irritation,
decreased
hearing on Rt w/pulsatile tinnitus, vertigo, slight voice
hoarseness; CT neck and MRV head showed Rt occipital/temporal
bone lesion w/ mass effect into the post fossa. She was then
transferred to [**Hospital1 18**] for definitive care.
Past Medical History:
s/p bilat radical mastecomy [**2113**]; chemo + xrt
Social History:
Independent; resides at home in [**Hospital1 487**].
Family History:
family history of ovarian cancer
Physical Exam:
On Admission:
97.6 108/70 80 18 96%
Mental status: sleepy but arousable, attentive, alert, ox3;
(claims was more alert prior to pain medication)
Language: Speech fluent with good comprehension.
II: Pupils equally round and reactive to light, to
mm bilaterally. Could not complete fundoscopic exam.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-4**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, bilaterally.
Reflexes: B T Br Pa Ac
Right tr tr tr tr tr
Left tr tr tr tr tr
Toes downgoing bilaterally
Coordination: slight dysmetria on finger-nose-finger, Rt>Lt;
rapid alternating movements intact, heel to shin intact
Pertinent Results:
Labs On Admission:
[**2117-7-20**] 01:00AM BLOOD WBC-12.7* RBC-3.92* Hgb-11.7* Hct-34.7*
MCV-89 MCH-29.9 MCHC-33.7 RDW-13.1 Plt Ct-328
[**2117-7-20**] 01:00AM BLOOD Neuts-64.5 Lymphs-29.3 Monos-5.4 Eos-0.3
Baso-0.5
[**2117-7-20**] 01:00AM BLOOD Glucose-128* UreaN-9 Creat-0.5 Na-139
K-3.9 Cl-108 HCO3-23 AnGap-12
Labs on Discharge:
XXXXXXXXXXXXXXX
------------------
IMAGING:
-----------------
Brief Hospital Course:
Patient was admitted via the ED from hospital transfer to the
intensive care unit for a newly identified cerebellar mass in
the setting of breast cancer history. Neuro-oncology, radiation
oncology consults were requested. CTA/CTV/CT Torso were
performed for surgical planning and cancer staging. She was
also started on decadron to treat mass effect from tumor
presence. She also had a PET scan which showed the known
cerebellar mass with invasion of the adjacent skull. There were
no other areas of concern seen on the PET scan. The patient
remained neurologically stable in the ICU. She had a craniotomy
for partial tumor resection on [**7-23**]. The procedure went well and
the patient was able to be extubated afterwards. She was then
transferred back to the ICU for close monitoring overnight. The
following day the patient was doing well and was transferred to
the neuro step-down unit for Q2 neuro checks. She had an MRI
which showed slow diffusion seen at the margin of the lesion and
medially could be secondary to surgical procedure or to an
associated
small infarct. There remains mass effect on the fourth ventricle
which is deformed appearance. There remains flow identified
within the right transverse sinus. There has been a cranioplasty
at the previously noted bony erosion changes. No definite area
of residual enhancement identified.
Her steroids were not tapered at that time. She progressed
quickly was tolerating a regular diet, cleared by physcial
therapy. She was neurologically intact on discharge.
Medications on Admission:
tamoxifen 20mg daily, prednisone
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
Take while taking Percocet.
Disp:*60 Capsule(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain: Do not take additional
tylenol with this medication.
Disp:*60 Tablet(s)* Refills:*0*
4. Dexamethasone 2 mg Tablet Sig: 2 tabs [**Hospital1 **] X 3 days; 1 tab tid
X 3days; 1 tab [**Hospital1 **] until follow up Tablets PO see previous
instructions.
Disp:*60 Tablet(s)* Refills:*2*
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Use while on decadron.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Right Cerebellar Mass
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions/Information
??????Have a friend/family member check your incision daily for signs
of infection.
??????Take your pain medicine as prescribed.
??????Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????You may wash your hair only after sutures have been removed.
??????You may shower before this time using a shower cap to cover
your head.
??????Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
??????If you are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
??????Clearance to drive and return to work will be addressed at your
post-operative office visit.
??????Make sure to continue to use your incentive spirometer while at
home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
??????Any confusion or change in mental status.
??????Any numbness, tingling, weakness in your extremities.
??????Pain or headache that is continually increasing, or not
relieved by pain medication.
??????Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
??????Fever greater than or equal to 101?????? F.
Followup Instructions:
??????Please return to the office in [**7-9**] days (from your date of
surgery) for removal of your staples/sutures and/or a wound
check. This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**].
??????You have an appointment in the Brain [**Hospital 341**] Clinic with Dr. [**Last Name (STitle) 724**]
on [**2117-8-16**] at 3:00pm. The Brain [**Hospital 341**] Clinic is located on
the [**Hospital Ward Name 516**] of [**Hospital1 18**], on [**Hospital Ward Name 23**] 8. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
Completed by:[**2117-7-26**]
|
[
"198.4",
"196.3",
"V15.82",
"198.3",
"348.5",
"V10.3",
"198.5",
"V45.71",
"198.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"01.25",
"02.12",
"02.06",
"01.51"
] |
icd9pcs
|
[
[
[]
]
] |
4986, 4992
|
2626, 4153
|
339, 386
|
5058, 5082
|
2205, 2210
|
7195, 7911
|
1122, 1156
|
4237, 4963
|
5013, 5037
|
4179, 4214
|
5106, 7172
|
1171, 1171
|
280, 301
|
2538, 2603
|
414, 960
|
2224, 2519
|
1226, 2186
|
983, 1036
|
1052, 1106
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,732
| 185,303
|
30707
|
Discharge summary
|
report
|
Admission Date: [**2148-5-10**] Discharge Date: [**2148-5-18**]
Date of Birth: [**2096-9-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
OSH transfer for TIPS
Major Surgical or Invasive Procedure:
Transjugular intrahepatic portosystemic shunt
History of Present Illness:
51M presented to OSH with 4 episodes melanotic stool (h/o
cirrhosis w/esophageal varices s/p bleeding 3 yrs ago). Had
upper endoscopy during which he likely aspirated blood and was
intubated, s/p banding of large gastric varices according to
report, then transferred to [**Hospital1 18**] for "emergent TIPS procedure".
Past Medical History:
Hep C
EtOH cirrhosis w/pancytopenia and splenomegaly
NIDDM
h/o GI bleed: erosive espohagitis, esophageal varices, Barrett's
esophagus
hypercholesterolemia
CAD
Social History:
Lives with wife and 2 kids. Never smoked. Stopped drinking EtOH
2 years ago. No other drugs.
Family History:
Father with diabetes. No fam h/o cirrhosis
Physical Exam:
Vitals: T 99.3 BP 104/53 HR 83 RR 20 O2 98% RA
Gen: NAD
HEENT: PERRL. OP clear. Sclera icteric.
Neck: supple
Cardio: RRR, nl S1S2, no m/r/g. L SC central line in place.
Resp: CTAB
Abd: distended, soft, nt, +BS, no rebound/guarding
Ext: trace BL LE edema
Neuro: A&Ox3
Pertinent Results:
Imaging:
[**5-16**] CXR: No evidence of pneumonia or CHF
[**5-13**] Head CT: No acute intracranial hemorrhage or mass effect
[**5-13**] CXR:Mod cardiomegaly stable, mild pulmonary edema, No PTX
[**5-12**] TIPS US: TIPS is patent with elevation of velocities from
proximal to distal as described. This can be a normal finding
immediately post- procedure, however, this can be followed as
clinically indicated. Main portal vein is patent and
demonstrates normal hepatopetal flow.
[**5-12**] CXR: Slight worsening in fluid balance with central
vascular congestion no overt edema at this time.
[**5-11**] CXR: possible LLL consolidation
[**5-11**] Liver U/S- Very limited study. Portal vein and hepatic
veins appear grossly patent.
Micro:
[**5-13**] Sputum rare S. aureus, Urine Neg, BCx NGTD
[**5-10**] BCx P, UCx neg, SCx E coli pan-sensitive
Labs on discharge: [**2148-5-18**]
WBC-5.9 RBC-3.28* Hgb-10.3* Hct-29.0* MCV-89 MCH-31.4 MCHC-35.5*
RDW-18.2* Plt Ct-72*
PT-14.5* PTT-30.4 INR(PT)-1.3*
Glucose-93 UreaN-23* Creat-0.8 Na-137 K-3.9 Cl-106 HCO3-26
ALT-40 AST-49* AlkPhos-96 TotBili-3.3*
AFP-1.3
Brief Hospital Course:
51 yo m with Hep C, EtOH cirrhosis, presented to OSH with GIB
s/p esophageal banding and admitted to [**Hospital1 18**] for TIPS.
#) Hep C/EtOH cirrhosis: Patient was transferred from outside
hospital after large variceal bleed requiring banding and
several units of PRBC (unclear from OSH transfer note) for TIPS.
TIPS was successfully performed on [**2148-5-11**] and post-TIPS U/S
revealed decrease in pressure from 34 to 14 mm Hg. He was
initially monitored in the SICU post TIPS and remained
subsequently hemodynamically stable. His propranolol was
adjusted to 10 mg TID and was on Lasix, aldactone. Patient was
instructed to call to [**Date Range **] an appointment for transplant
evaluation with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**].
#) h/o GIB: Pt has h/o bleeding varices and required total 9
units PRBC's this admission. His last transfusion was on [**5-15**]
and his hct remained stable since.
#) h/o PNA: While in SICU, patient was intubated and sputum Cx
grew coag + Staph aureas and E. Coli (pan sensitive). He was
empirically treated with 5 days of Vanc/Zosyn. However,
clinically he improved, there was no evidence of PNA seen on
recent CXR and Abx were stopped.
#) DM: Patient takes Starlix at home. He was initially on
insulin gtt in ICU and switched to standing insulin. On
discharge, he was started back on home starlix dose.
#) FEN: low-sodium/heart healthy diet
#) PPX: pneumoboots, PPI, bowel regimen
#) Access: Pt L SC central line which was pulled at time of
discharge.
He also has a stitch placed on R subclav, which will need to be
removed 1 week post discharge. Pt was instructed to follow-up
with PCP in one week.
#) Code: Full Code
Medications on Admission:
Enalapril 5
Starlix 120 before supper
Inderal LA 80
Prevacid 30 [**Hospital1 **]
Discharge Medications:
1. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO DAILY
(Daily).
Disp:*2700 ML(s)* Refills:*2*
2. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
5. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
6. Starlix 120 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Propranolol 10 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
8. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
cirrhosis
hepatitis C
esophageal varices
Secondary:
diabetes
coronary artery disease
Discharge Condition:
stable, pain free, ambulating, hemodynamically stable
Discharge Instructions:
You have cirrhosis of your liver. You had TIPS performed this
admission.
Please call your primary doctor if you have any black tarry
stools, coffee ground vomit, bloody stools or vomiting,
increased yellow skin or eyes, fever, chills, nausea, or any
other concerning symptoms.
Please take all medications as prescribed. There have been
changes to your home meds.
1) Stop taking the Inderal.
2) Take propranolol 10 mg three times a day.
Please attend all follow-up appointments.
Followup Instructions:
Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office on Tuesday to make an
appointment for liver transplant evaluation. You should be seen
in the next 2 weeks. His office number is ([**Telephone/Fax (1) 1582**].
Please call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] an appointment
to be seen within the next week for follow-up. You will need
adjustment of your lasix and blood pressure medication doses.
Please have your primary care doctor remove your sutures on your
chest as well.
|
[
"482.82",
"578.0",
"571.2",
"530.85",
"456.8",
"285.1",
"456.20",
"303.93",
"250.00",
"572.3",
"070.44",
"284.8",
"482.41",
"V09.0",
"789.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"96.6",
"99.15",
"96.72",
"89.64",
"99.06",
"42.33",
"99.07",
"39.1",
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5242, 5248
|
2520, 4228
|
336, 384
|
5387, 5443
|
1390, 1458
|
5973, 6533
|
1043, 1087
|
4359, 5219
|
5269, 5366
|
4254, 4336
|
5467, 5950
|
1102, 1371
|
275, 298
|
2252, 2497
|
412, 734
|
1467, 2233
|
756, 917
|
933, 1027
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,257
| 178,509
|
50401
|
Discharge summary
|
report
|
Admission Date: [**2119-1-13**] Discharge Date: [**2119-1-18**]
Date of Birth: [**2055-6-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Proton Pump Inhibitors / hayfever
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Intermittent chest pain and SOB that is unpredicable, it occurs
with rest and activity
Major Surgical or Invasive Procedure:
[**2119-1-13**] - Coronary artery bypass grafting x3: Left internal
mammary artery graft to left anterior descending, reverse
saphenous vein graft to the first diagonal branch and the second
diagonal branch.
History of Present Illness:
Patient is a 62 yo male with history of CAD sp two DES to
proximal and mid LAD after positive stress test in [**2109**],
anterior STEMI in [**2112**] with late in-stent thrombosis s/p DES to
LAD and ostium of diagonal. He also has a history of renal
calculi and on [**2118-5-24**], he underwent bilateral lithotripsy
and ureteral stents. He had been instructed to hold his Plavix
for 5 days leading up to this procedure. He underwent the
urological procedure without complication however post procedure
while in the PACU, developed chest pain and had anterior
ST-elevations. He was brought emergently to the [**Hospital1 18**] cath lab
on [**2118-5-24**] and was found to have total occlusion of the mid-LAD
in the previously placed stent. This was treated with a 5 x 14
mm Integriti stent placed in the mid LAD, a 2.25 x 14 mm
Integriti stent was placed in the distal LAD and a 3.0 x 14 mm
Integriti stent was placed in the proximal LAD. (bare metal
stents) peak CPK increased only slightly to 473. Since [**Month (only) **], the
patient had been doing well until [**Month (only) 359**], when he started to
notice exertional chest discomfort. He describes a left sided
chest discomfort and dyspnea occurring with activity such as
walking on the treadmill for 10 minutes. He denies any symptoms
at rest, pnd/orthopnea, lightheadedness, lower extremity edema,
claudication or weight gain. He was sent for a stress test,
which was abnormal and was referred for cardiac catheterization.
Todays cath revealed signifiant CAD and reinstent stenosis. He
was seen by Dr. [**Last Name (STitle) **] and accepted for CABG.
Past Medical History:
Coronary artery disease s/p anterior Myocardial infarction [**2112**],
[**2117**]
LAD stents [**2109**], [**2112**], [**2117**]
Hyperlipidemia
Renal calculi s/p lithotripsy, ureteral stents
Diabetes type II
Hypertension
GERD
Inguinal hernia- needs to be repaired
Social History:
Race:Caucasian
Last Dental Exam:3 months ago needs tooth removed
Lives with:Wife [**Name (NI) **]
Contact: [**Name (NI) **] Phone # 1-[**Telephone/Fax (1) 105035**]
Occupation:Drives School [**Doctor Last Name **]
Cigarettes: Quit smoking in [**2117**] prior to that smoked on/off [**12-5**]
PPD x 40 yrs
ETOH: None
Illicit drug use: Denies
Family History:
Mother died at 85 of colon cancer, MI in her 70s, DM2
Father with prostate cancer at 60, pacemaker, DM2
Brother with prostate cancer at 51
Brother with prostate cancer
Sister with DM2
Physical Exam:
Pulse: 65 SR Resp: 16 O2 sat:98% RA
B/P Right:Radial cath site Left:117/61
Height: 6ft Weight:210lbs
General:
Skin: Dry [] intact [x]
HEENT: PERRLA xEOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [] large right inguinal hernia
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:inguinal hernia Left: +2
DP Right: +2 Left:+2
PT [**Name (NI) 167**]: +2 Left:+2
Radial Right: cath site Left:+2
Carotid Bruit Right: none Left:None
Pertinent Results:
[**2119-1-13**] ECHO
Pre Bypass The left atrium is mildly dilated. Left ventricular
wall thicknesses and cavity size are normal. There is mild
symmetric left ventricular hypertrophy. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are complex
(>4mm) 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 stenosis or aortic regurgitation. There is no aortic
valve stenosis. The mitral valve appears structurally normal
with trivial mitral regurgitation.
Post Bypass: Patient is in sinus rhythm, on nitroglycerine
infusion. Preserved biventricular function with normal wall
motion. Aortic contours intact. Remaning exam is unchanged. All
findings discussed with surgeons at the time of the exam.
Admission labs:
[**2119-1-13**] 01:59PM HGB-14.8 calcHCT-44
[**2119-1-13**] 01:59PM GLUCOSE-173* LACTATE-2.6* NA+-138 K+-3.7
CL--106
[**2119-1-13**] 04:55PM FIBRINOGE-141*
[**2119-1-13**] 04:55PM PT-14.5* PTT-26.7 INR(PT)-1.4*
[**2119-1-13**] 04:55PM PLT COUNT-154
[**2119-1-13**] 04:55PM WBC-16.1*# RBC-4.14* HGB-12.0*# HCT-33.2*#
MCV-80* MCH-28.9 MCHC-36.0* RDW-13.5
[**2119-1-13**] 06:50PM UREA N-12 CREAT-0.6 SODIUM-144 POTASSIUM-3.5
CHLORIDE-115* TOTAL CO2-22 ANION GAP-11
Discahrge labs:
[**2119-1-17**] 04:50AM BLOOD WBC-9.2 RBC-3.17* Hgb-9.2* Hct-25.9*
MCV-82 MCH-29.1 MCHC-35.6* RDW-14.0 Plt Ct-212
[**2119-1-17**] 04:50AM BLOOD Plt Ct-212
[**2119-1-15**] 02:56AM BLOOD PT-14.4* PTT-29.0 INR(PT)-1.3*
[**2119-1-17**] 04:50AM BLOOD Glucose-173* UreaN-17 Creat-0.7 Na-133
K-3.8 Cl-98 HCO3-28 AnGap-11
Radiology Report CHEST (PORTABLE AP) Study Date of [**2119-1-15**] 9:58
AM
Final Report
Right internal jugular line is at the level of mid SVC. The
patient is
extubated with removal of the NG tube and chest tubes. Bilateral
pleural
effusions are small, associated with atelectasis, unchanged
since the prior study. There is no evidence of pneumothorax.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Brief Hospital Course:
Mr. [**Known lastname 10840**] was admitted to the [**Hospital1 18**] on [**2119-1-13**] for further
management of his coronary artery disease. He was taken to the
operating room where he underwent coronary artery bypass
grafting to three vessels. Please see operative note for
details. Postoperatively he was taken to the intensive care unit
for monitoring. Over the next several hours, he awoke
neurologically intact and was extubated. On postoperative day
two, he was transferred to the step down unit for further
recovery. He was gently diuresed towards his preoperative
weight. His chest tubes and epicardial pacing wires were removed
per protocol. His Foley catheter was reinserted due to failure
to void. Flomax was started and he successfully voided after
removal of his catheter. He worked with the physical therapy
service daily for assistance with his strength and mobility. He
had a brief episode of atrial fibrillation which converted back
to sinus rhythm with beta-blockers and Amiodarone. [**Last Name (un) **] saw
patient on post-op day four due to remaining hyperglycemic
post-op. Glipizide was added and patient will follow-up with
Endocrine as outpatient. He continued to make steady progress
and was discharged home with VNA services on post-op day four.
He will follow-up with Dr. [**Last Name (STitle) **], his cardiologist and his
primary care physician as an outpatient.
Medications on Admission:
LIPITOR 80 mg QD
CLOPIDOGREL 75 mg daily
FLUOXETINE 20 mg daily
LISINOPRIL 5 mg Tablet Daily
METFORMIN 1,000 mg Tablet [**Hospital1 **]
METOPROLOL SUCCINATE 25 mg DAILY
NTG 0.4 mg SL PRN
RANITIDINE 150 mg [**Hospital1 **]
TADALAFIL 20 mg daily
Flomax 0.4mg po bid
ASPIRIN 325 DAILY
Discharge Medications:
1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*2*
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO BID (2 times a day).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
9. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
10. glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
11. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Please take two 200mg tablets twice daily for one week.
Then take one 200mg tablet twice daily for one week. Finally
take one 200mg tablet daily until stopped by cardiologist.
Disp:*60 Tablet(s)* Refills:*2*
12. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
13. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO twice a day for 2
weeks.
Disp:*28 Tablet, ER Particles/Crystals(s)* Refills:*0*
14. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 3
Past medical history:
s/p anterior Myocardial infarction [**2112**], [**2117**]
LAD stents [**2109**], [**2112**], [**2117**]
Hyperlipidemia
Renal calculi s/p lithotripsy, ureteral stents
Diabetes type II
Hypertension
GERD
Inguinal hernia- needs to be repaired
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg- Left - healing well, no erythema or drainage.
Edema 1+ bilat
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for one month or while taking narcotics. Driving
will be discussed at follow up appointment with surgeon.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
WOUND CARE NURSE Phone: [**2119-1-26**] at 11AM Phone: [**Telephone/Fax (1) 170**]
Surgeon: Dr. [**Last Name (STitle) **] on [**2119-2-15**] at 1:30PM
Cardiologist: Dr. [**First Name8 (NamePattern2) 10819**] [**Last Name (NamePattern1) **] on [**2119-2-7**] at 5PM
Phone:[**Telephone/Fax (1) 7773**]
Primary Care: Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 2472**] on [**2119-2-2**] at 10AM
Phone:[**Telephone/Fax (1) 133**]
Please call for the following appointment
Diabetes/Endocrine: Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 65317**] in 1 week
**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:[**2119-1-18**]
|
[
"272.4",
"414.01",
"413.9",
"427.31",
"401.9",
"E878.2",
"250.00",
"V15.82",
"530.81",
"V45.82",
"550.90",
"788.20",
"412",
"996.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
9668, 9731
|
6040, 7436
|
400, 609
|
10096, 10319
|
3845, 4760
|
11151, 11981
|
2919, 3104
|
7768, 9645
|
9752, 9813
|
7462, 7745
|
10343, 11128
|
3119, 3826
|
274, 362
|
637, 2253
|
4776, 6017
|
9835, 10075
|
2555, 2903
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,643
| 181,132
|
48806
|
Discharge summary
|
report
|
Admission Date: [**2101-8-19**] Discharge Date: [**2101-8-22**]
Date of Birth: [**2031-6-19**] Sex: M
Service: CCU
HOSPITAL COURSE: The patient was admitted on [**2101-8-19**], after
ventricular fibrillation cardiac arrest, intubated and
shocked in the field, transferred from outside hospital for
catheterization at [**Hospital1 69**].
Cardiac catheterization showed normal coronary arteries with
n coronary artery disease.
On examination, the patient was intubated and sedated. The
pupils were fixed at 4.0 millimeters and nonreactive. The
patient was with myoclonic jerks.
The laboratories at that time were significant for potassium
1.9. Despite multiple attempts to replete the potassium, it
only climbed slowly. He had a CT scan that showed blurring
of the [**Doctor Last Name 352**] white junction consistent with anoxic injury.
Neurology was consulted and family decided to make the
patient comfort measures only. He was extubated and his
blood pressure and heart rate continued to decline until he
expired [**2101-8-22**], at 7:07 a.m.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
Dictated By:[**Last Name (NamePattern1) 2918**]
MEDQUIST36
D: [**2101-8-22**] 11:29
T: [**2101-8-29**] 18:14
JOB#: [**Job Number 102557**]
|
[
"348.1",
"599.0",
"427.5",
"276.8",
"728.89",
"584.9",
"785.51",
"507.0",
"278.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"88.56",
"37.23",
"88.53",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
150, 1322
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,068
| 103,377
|
47487
|
Discharge summary
|
report
|
Admission Date: [**2167-2-21**] Discharge Date: [**2167-3-6**]
Date of Birth: [**2103-11-18**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
headache, nauesa/vomiting, vertigo
Major Surgical or Invasive Procedure:
Cerebellar lesion resection x2
EVD
VPS placement
History of Present Illness:
The pt is a 63-year-old RH woman with a history of non-small
cell
lung CA (stage IIIa, s/p chemo, XRT, and L upper lobectomy), PE
35 yrs ago, rheumatic fever in childhood, prior tobacco use who
presents with headache, nausea/vomiting, dizziness, and blurry
vision for the last 2 weeks. She reports a holocephalic
headache,
extending from the back of her head up to the front bilaterally
starting about 2 weeks ago. The headache is constant, not
throbbing, and worsens with any movement particularly when she
stands up. It does not seem to worsen with lying down and has
not
woken her from sleep. She says she used to get migraines but has
not had one in years; thinks this headahce feels somewhat
similar
but is atypical in its duration. In addition she has has
worsening nausea with vomiting, and for the last two days has
not
been able to keep anything down. She has also noticed that her
vision appears "cloudy" over the last week and a half. Upon
further questioning she says she thinks it appears double
sometimes but is unsure if the images are vertically or
horizontally displaced. She has not tried covering one eye to
see
if it improves. She is not sure if it is worse when looking
toward one direction or the other. Currently her vision seems a
little blurry but denies diplopia at the moment.
Within the last two days she has also begun to experience
dizziness, which she describes as the room spinning. She has
also
had difficulty walking and says she feels very unsteady on her
feet. Unsure if she is falling toward one side or the other. She
came into the ED today because she was continuing to feel worse
and was unable to keep down anything by mouth.
On neuro ROS, the pt reports headache, blurred/double vision,
vertigo, difficulty walking as above. Denies difficulty
speaking,
loss of vision, focal weakness, numbness/tingling, bowel or
bladder incontinence or retention.
On general review of systems, the pt reports frequent chills but
does not think she has had any fevers. Denies recent weight loss
or gain. Denies cough, shortness of breath. Denies chest pain
or
tightness, palpitations. +Nausea/vomiting, no abdominal pain.
has
not had a bowel movement over the last few days which she
attributes to not eating. No dysuria. Denies rash.
Past Medical History:
Lung cancer, stage IIIa (T1b, N2, M0)
- [**4-1**] persistent nonproductive cough, chest x-ray at that time,
which demonstrated a hilar mass
- [**2166-4-14**] chest CT confirmed the presence of a lobulated, left
suprahilar pulmonary mass with a large, left hilar and
aorticopulmonary window nodal conglomerate
- [**2166-5-1**] PET scan demonstrated FDG avid left upper [**Month/Day/Year 3630**] mass
and
2 FDG-avid left hilar masses, and left mediastinal
lymphadenopathy as well. No other sites of disease were noted.
- [**2166-4-30**] head CT negative for evidence of metastatic disease.
-- [**2166-5-9**] mediastinoscopy --> two left-sided (2L and the 4L
),
ipsilateral lymph nodes were positive for metastatic
undifferentiated carcinoma. Tumor cells stained positive for
TTF-1, cytokeratin 7, synaptophysin, were focally positive for
chromogranin and negative for CK20 and LCA, consistent with a
carcinoma of lung origin.
- [**Date range (3) 100411**] concurrent XRT and cisplatin/etoposide
- [**2166-8-28**] Left thoracotomy with left upper lobectomy, mediastinal
lymph node dissection, intercostal muscle flap buttress
PE 35 years ago in the setting of oral contraceptive use
History of rheumatic fever in childhood
Status post appendectomy many years ago
Left ORIF of the humerus following an MVC (was told she could
not
have an MRI due to metal in her arm)
Social History:
Single, lives with her brother in [**Name (NI) **]. Has a daughter and
a
grandson who live in [**Location (un) 5131**]. Used to work as a social
worker
for the state, has recently stopped working. She smoked one pack
a day for 40 years but quit on [**2166-5-2**]. She drinks
alcohol socially, but recently stopped.
Family History:
Mother had breast cancer in her 70s and heart
disease. She had three maternal aunts with breast cancer.
Father had diabetes. She has five siblings, no history of
cancer
in any of her siblings.
Physical Exam:
Admission Physical Exam:
Vitals: T 98.2 P 104 BP 113/71 RR 18 O2 100%
General: Awake, cooperative, appears somewhat uncomfortable.
HEENT: NC/AT, no scleral icterus noted, mucous membranes dry
Neck: Supple, no nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: Awake and alert, appears tired and somewhat
uncomfortable. Oriented to place, initially says date is
[**2067-8-21**] but then corrects to [**2167-2-19**]. Unsure of day of
month, says 2nd and then 25th. Knows current president. Able to
relate history without difficulty. Language is fluent with
intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Speech was not dysarthric. Able to follow
both
midline and appendicular commands. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch or pinprick throughout. No
extinction to DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
+?Mild dysmetria R>L on FNF initially.
-Gait: Deferred due to severe nausea, vertigo
Exam on Discharge:
Mental status varries, patient on and off confused
CN 2-12 grossly intact
Moves all extremities with good strength
Pertinent Results:
[**2167-2-21**] 12:50PM GLUCOSE-95 UREA N-22* CREAT-0.8 SODIUM-140
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-24 ANION GAP-18
[**2167-2-21**] 12:50PM estGFR-Using this
[**2167-2-21**] 12:50PM CALCIUM-10.1 PHOSPHATE-3.3 MAGNESIUM-2.2
[**2167-2-21**] 12:50PM WBC-5.9 RBC-4.82 HGB-15.1 HCT-41.3 MCV-86
MCH-31.4 MCHC-36.7* RDW-12.8
[**2167-2-21**] 12:50PM NEUTS-84.9* LYMPHS-10.0* MONOS-3.8 EOS-0.6
BASOS-0.7
[**2167-2-21**] 12:50PM PLT COUNT-218
CT head noncontrast [**2-21**]:
IMPRESSION:
1. Two new posterior cranial fossa/cerebellar lesions, with
surrounding edema and mild mass effect on the fourth ventricle,
concerning for metastatic disease.
2. A new 1.1 cm mass lesion in the third ventricle, with mild
hydrocephalus, concerning for additional site of metastatic
disease. An MRI with contrast is recommended for further
evaluation.
CT head with contrast [**2-22**]:
1. Right cerebellar and third ventricle lesions are new from
[**2166-8-18**],
concerning for metastatic disease. If clinically feasible, MRI
is more
sensitive to detect small lesions and leptomeningeal disease.
2. The lateral ventricles are slightly enlarged compared to
[**2166-8-18**],
raising the possibility of mild hydrocephalus due to third
ventricle lesion.
MRI with and without contrast [**2-23**]:
Supra- and infra-tentorial as well as intraventricular
metastatic
disease, notably involving the left insular cortex, right
cerebellar
hemisphere, and third ventricle.
While the right cerebellar lesion is associated with significant
mass effect and distortion of the fourth ventricle, there is
currently no CSF obstruction or hydrocephalus. The third
ventricle lesion is located below the foramen of [**Last Name (un) 2044**] and
likewise does not cause hydrocephalus.
MRI C/T spine [**2-24**]
1. Compression fracture, with mild loss of height of the
Thoracic T5
vertebral body with marrow edema pattern. No retropulsion of the
fragments,
no canal or compression on the cord. While this has the
appearance of a
benign compression fracture, given the history, an associated
pathologic
lesion within the T5 body cannot be completely excluded.
Correlation with
radionuclide studies and CT is recommended. No enhancing lesions
in the cord.
2. Multilevel mild degenerative changes in the cervical spine
without
significant canal or foraminal stenosis.
3. A 3.3 x 3.5 cm nodular lesion in the lower neck/upper
mediastinum, new
since the prior CT chest of [**2166-11-27**]. This needs further
evaluation with CT chest, including the lower neck. There is
moderate amount of pleural
effusion/pleural thickening noted on the left side.
MRI [**Doctor Last Name **] [**2-26**] FINDINGS: Since the prior study, the patient has
undergone biopsy of the
right cerebellar hemispheric lesion. Expected postoperative
change are seen
with relatively extensive intralesional hemorrhage and a
circumscribed tissue
defect. The previously reported extensive vasogenic edema as
well as mass
effect on the fourth ventricle is largely unchanged.
The previously reported additional metastatic lesions within the
left insular cortex and third ventricle demonstrate no short
interval change. However, with less motion artefact and better
image quality further lesions measuringapproximately 3 mm are
identified in the posterior aspect of the left temporal [**Month/Day (4) 3630**] as
well as the left cerebellar hemisphere.
There is no evidence of acute infarction. Flow voids of the
major
intracranial vessels are preserved.
IMPRESSION:
1. Status post biopsy of right cerebellar mass with expteced
intralesional
hemorrhage.
2. No short-term interval change with regard to the left insular
cortex and third ventricle metastatic lesions.
3. Identification of additional small lesions within the left
posterior
temporal cortex as well as the left posterior medial cerebellar
hemisphere.
[**2-27**] CT FINDINGS: Patient is status post a right-sided
ventriculostomy catheter with tip terminating in the frontal
[**Doctor Last Name 534**] of the right ventricle. No associated intraparencymal or
intraventricular hemorrhage identified. Ventricles demonstrate
stable mild dilatation, unchanged from the prior CT.
The patient is status post a right suboccipital craniotomy with
partial
resection of a known right cerebellar mass. Again there is a
small amount of air and expected post-surgical hematoma at the
site of the recent surgical intervention in the posterior
cranial fossa with an increasingly hypodense appearance
consistent with evolution of blood products. A 2.8 x 2.3 cm
rounded hyperdense mass most suggestive of residual tumor,
better identified on the prior MRI, and is located just superior
to the resection site and unchanged. Known left insular cortical
mass is not well seen, and better evaluated on the MRI.
Surrounding vasogenic edema in the cerebellar
hemispheres persists but with minimally improved mass effect on
the patent
fourth ventricle. The known 1.1 x 1.0 cm hyperdense mass in the
third
ventricle is unchanged. No new parenchymal hematoma or infarct
present. The mastoid air cells, middle ear cavities and
visualized paranasal sinuses are clear.
IMPRESSION:
1. Status post partial resection of the right cerebellar mass
with a stable distribution of surrounding vasogenic edema though
with a slight decreased mass effect on the widely patent fourth
ventricle. Continued evolution of blood products within
post-surgical hematoma. Residual tumor as described above.
2. Interval placement of a right-sided ventriculostomy catheter
with tip in the right frontal [**Doctor Last Name 534**]. No intraparenchymal or
intraventricular hemorrhage identified. Stable mild dilatation
of bilateral lateral ventricles.
[**2-27**] CT ABD
FINDINGS: There is a new left paratracheal mass measuring 3.8 x
3.4 x 2.2 cm causing mild deviaiton of the trachea and left
carotid artery concerning for a lymphadenopathy due to
metastasis. There is no , axillary, mediastinal or hilar
lymphadenopathy evident. The central vessels are unremarkable.
Heart size is normal and without pericardial effusion. A small-
to moderate-sized hiatal hernia is evident. There is a small
left pleural effusion with thickened rind evident at the level
of the upper [**Month/Day (4) 3630**], indicating chronicity. Pleural blebs are
identified within the right lung apex. No significant
emphysematous changes are identified. Changes consistent with
left upper lobectomy and mediastinal lymph node dissection are
evident. Nonspecific ground-glass opacities with minimal
associated architectural distortion identified in the left lung
apex are increased compared to prior study and likely represent
post-radiation changes. Minimal dependent atelectasis in
dependent portions of both lungs.
The liver is homogenous in attenuation without discrete masses
or lesions. There is no intrahepatic biliary ductal dilatation.
The gallbladder, pancreas and spleen are normal. The bilateral
adrenal glands have normal limb thickness and are without convex
margin to suggest mass. The bilateral kidneys are normal in size
and excrete contrast symmetrically. The stomach, small and large
bowel are unremarkable. There is no retroperitoneal, mesenteric
or portacaval lymphadenopathy identified. Multiple small foci of
air are noted within the abdomen as well as a layering posterior
to the left rectus sheath muscle, likely due to recent insertion
of a right-sided ventriculoperitoneal shunt with tip ending
lateral to the liver. No free fluid identified within the
abdomen. The rectum, bladder, uterus and adnexa are
unremarkable. No pelvic sidewall or inguinal lymphadenopathy
identified. The aorta is of normal caliber throughout. The main
portal vein and its major tributaries are unremarkable.
No suspicious lytic or blastic lesions evident.
IMPRESSION:
1. New 3.8 cm left paratracheal mass concerning for metastasis.
2. Expected post-surgical changes in the left upper [**Month/Day (4) 3630**]
consistent with
lobectomy and mediastinal biopsy. Increased ground-glass
opacities with
associated architectural distortion evident within the left
upper [**Last Name (LF) 3630**], [**First Name3 (LF) **] be related to radiation changes, though
malignancy is not excluded.
3. Small left pleural effusion, likely chronic.
4. Interval placement of a right-sided ventriculoperitoneal
shunt with tip at the level of the liver and few intraperitoneal
gas bubbles.
5. Small hiatal hernia.
[**2-27**] CT CHEST
FINDINGS: There is a new left paratracheal mass measuring 3.8 x
3.4 x 2.2 cm causing mild deviaiton of the trachea and left
carotid artery concerning for a lymphadenopathy due to
metastasis. There is no , axillary, mediastinal or hilar
lymphadenopathy evident. The central vessels are unremarkable.
Heart size is normal and without pericardial effusion. A small-
to moderate-sized hiatal hernia is evident. There is a small
left pleural effusion with thickened rind evident at the level
of the upper [**Month/Day (4) 3630**], indicating chronicity.
Pleural blebs are identified within the right lung apex. No
significant
emphysematous changes are identified. Changes consistent with
left upper
lobectomy and mediastinal lymph node dissection are evident.
Nonspecific
ground-glass opacities with minimal associated architectural
distortion
identified in the left lung apex are increased compared to prior
study and
likely represent post-radiation changes. Minimal dependent
atelectasis in
dependent portions of both lungs.
The liver is homogenous in attenuation without discrete masses
or lesions. There is no intrahepatic biliary ductal dilatation.
The gallbladder, pancreas and spleen are normal. The bilateral
adrenal glands have normal limb thickness and are without convex
margin to suggest mass. The bilateral kidneys are normal in size
and excrete contrast symmetrically. The stomach, small and large
bowel are unremarkable. There is no retroperitoneal, mesenteric
or portacaval lymphadenopathy identified. Multiple small foci of
air are noted within the abdomen as well as a layering posterior
to the left rectus sheath muscle, likely due to recent insertion
of a right-sided ventriculoperitoneal shunt with tip ending
lateral to the liver. No free fluid identified within the
abdomen. The rectum, bladder, uterus and adnexa are
unremarkable. No pelvic sidewall or inguinal lymphadenopathy
identified.
The aorta is of normal caliber throughout. The main portal vein
and its major tributaries are unremarkable.
No suspicious lytic or blastic lesions evident.
IMPRESSION:
1. New 3.8 cm left paratracheal mass concerning for metastasis.
2. Expected post-surgical changes in the left upper [**Month/Day (4) 3630**]
consistent with
lobectomy and mediastinal biopsy. Increased ground-glass
opacities with
associated architectural distortion evident within the left
upper [**Last Name (LF) 3630**], [**First Name3 (LF) **] be related to radiation changes, though
malignancy is not excluded.
3. Small left pleural effusion, likely chronic.
4. Interval placement of a right-sided ventriculoperitoneal
shunt with tip at the level of the liver and few intraperitoneal
gas bubbles.
5. Small hiatal hernia.
[**2167-3-2**] CTA/V head
IMPRESSION: The venous sinuses are patent without filling
defect. The
non-contrast head CT findings are unchanged compared to [**2167-2-27**].
[**2167-3-6**] MRI:
1. Post operative changes in the right posterior fossa.
Peripheral enhancement
along the resection cavity which likely represents post
operative change or residual tumor.
2. Stable metastatic lesions within the left insular cortex,
third ventricle, left temporal and left cerebellar hemisphere.
3. No acute infarct.
4. Right frontal approach ventriculostomy catheter with tip in
frontal [**Doctor Last Name 534**] of right lateral ventricle.
Brief Hospital Course:
Neuro:
Ms. [**Known lastname **] presented to the ED on [**2167-2-21**] following 2 weeks of
headaches, nausea/vomiting, and vertigo. CT head demonstrated a
large mass in the R cerebellum and a smaller lesion in the third
ventricle. Neurosurgery was consulted in the ED and declined
acute intervention. She was started on Decadron 4mg Q6 and
admitted to the neuro-ICU for monitoring. She did well overnight
without any evidence of hydrocephalus or increasing ICP, and her
symptoms began to improve. She was transferred to the neurology
floor on [**2167-2-22**].
MRI with and without contrast was performed which demonstrated
three lesions, largest in R cerebellar hemisphere as well as two
additional masses in third ventricle and left insula.
Neuro-oncology was consulted and recommended resection of
cerebellar lesion and whole brain radiation.
Her primary oncologists Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 11309**] were also
contact[**Name (NI) **].
Neurosurgery recommended suboccipital craniectomy followed by
VPS placement.
On [**2167-2-24**]: she had increased nausea and headaches. She was taken
to the OR and underwent resection of her cerebellar mass. She
tolerated the procedure well. Post operatively she returned to
the ICU for SBP control and neurochecks. Her exam remained
stable and post operative head CT showed no hemorrhage. On [**2-25**]
she was transferred to the floor. On [**2-26**] she had a routine head
CT for preoperative planning and this showed no change from
previous scans. She was kept NPO after midnight for VPS
placement on [**2-27**].
On [**2167-2-27**]: she was taken to the operating room for VP shunt
placement. She tolerated the procedure well. Post-operatively
she returned to the floor.
Postop MRI demonstrated residual cerebellar tumor and so on [**3-4**]
she returned to the OR for craniotomy for excision of residual
tumor.
On [**3-5**], patient was doing well, having some hallunications, but
knows that they are hallunications. Her decadron was tappered
and she was transferred to the floor. Her exam remains stable;
SQH was started as well.
CV:
She was maintained on telemetry monitoring throughout her
admission.
ENDO:
She was maintained on finger sticks QID and insulin sliding
scale while being treated with steroids.
FEN:
She was maintained on IVF upon admission due to poor PO intake.
She was advanced to a regular diet as her nausea improved. She
was maintained on a bowel regimen as well as a PPI for
prophylaxis.
ID:
She developed no signs of infection during her admission.
Prophylaxis:
She was maintained on SQ heparin for DVT prophylaxis and a PPI
for GI prophylaxis.
Dispo:
Patient was evaluated for PT and OT and discharged to [**Hospital1 **] in [**Location (un) 86**].
Medications on Admission:
Vicodin prn
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Pain.
2. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
4. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for Heart burn.
5. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
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. Ondansetron 4 mg IV Q8H:PRN Nausea
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Cerebellar lesion
Hydrocephalus
Intraventricular hemorrhage
Thoracic compression fx
steroid psychosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair 72 hours from the time of your surgery,
we recommend you use a mild shampoo and do not scrub the area.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen
. If you have been discharged on Keppra (Levetiracetam), you
will not require blood work monitoring.
?????? If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**6-30**] days (from your date of
surgery) for removal of your sutures . This appointment can be
made with the Nurse Practitioner. Please make this appointment
by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our
office, please make arrangements for the same, with your PCP.
[**Name Initial (NameIs) **] [**Name11 (NameIs) **] have a follow-up with Dr. [**First Name4 (NamePattern1) 636**] [**Last Name (NamePattern1) 11309**] on [**2167-3-12**] at 2PM
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12567**] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1844**]
Date/Time:[**2167-3-16**] 4:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2167-3-12**] 2:00
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2167-3-6**]
|
[
"368.8",
"V87.41",
"E932.0",
"V12.55",
"536.2",
"198.3",
"292.12",
"348.5",
"305.1",
"780.4",
"336.3",
"V15.3",
"V10.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"02.34",
"02.21"
] |
icd9pcs
|
[
[
[]
]
] |
22641, 22711
|
18842, 21600
|
321, 371
|
22857, 22857
|
7030, 18819
|
24903, 25905
|
4401, 4597
|
21662, 22618
|
22732, 22836
|
21626, 21639
|
23042, 24880
|
5629, 6875
|
4637, 5086
|
247, 283
|
399, 2665
|
6894, 7011
|
22872, 23018
|
2687, 4052
|
4068, 4385
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,600
| 117,010
|
5596
|
Discharge summary
|
report
|
Admission Date: [**2111-10-14**] Discharge Date: [**2111-10-22**]
Service: MEDICINE
Allergies:
Epinephrine / Adhesive Tape
Attending:[**First Name3 (LF) 2840**]
Chief Complaint:
unresponsiveness
Major Surgical or Invasive Procedure:
EEG
History of Present Illness:
Mr. [**Known lastname **] is an 84 year old male with past medical history of
CAD status-post CABG in [**2103**], systolic CHF, TIA and
adenocarinoma of brain s/p resection, DVT and PE s/p IVC filter
who had witnessed tonic-clonic seizure and subsequent
unresponsiveness. Per EMS report he developed focal R sided sz
that then generalized to tonic clonic sz. He was initially
transported to [**Hospital3 **] where he was dilantin loaded and
then transferred to [**Hospital1 18**] for further care.
In the [**Hospital1 18**] ED, initial vs were: T100.8 P77 BP97/62 R14 O2
sat99% on BIPAP. TMax in the ED was 102.8. Head CT from [**Hospital1 **]
was re-read as post-craniotomy with possible residual tumor. UA
found to be suggestive of UTI. CXR showed L sided pleural
effusion. He received Vancomycin, Levofloxacin and 2g
ceftriaxone.
In the ICU, patient on BIPAP. He moves both of his legs to light
touch but is not moving his upper extremities.
Past Medical History:
1. Dyslipidemia.
2. Hypertension.
3. CABG in [**2103**]
4. Pacemaker/ICD due to AV block and tachybrady syndrome
5. Cardiomyopathy with LVEF = 35% in [**10-6**].
6. PAF
7. TIA in [**2103**].
8. Macrocytic anemia, attributed to MDS with bone marrow biopsy
in [**State 531**].
9. Spinal stenosis.
10. Hypothyroidism.
11. H/o gastric ulcer; GERD.
12. OSA on nocturnal CPAP.
13. Prostate cancer s/p XRT.
14. Adenocarcinoma of unknown primary metastatic to the left
occipitoparietal region s/p resection in [**7-7**]
15. DVT/PE s/p IVC filter on Lovenox [**Hospital1 **]
Social History:
Per OMR: Substantial smoking history with 3 ppd until [**2060**]. No
drinking.
Family History:
Per OMR: Father died of lung cancer at age 50. Mother had an MI
and died at age 86. A brother also had lung cancer. He has two
children that are healthy.
Physical Exam:
At Admission:
General: Obtunded, BIPAP mask in place
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Reduced breath sounds at left base, no wheezes or
crackles appreciated
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
Ext: 2+ LE edema
Neuro: Unresponsive to verbal stimuli. Pupils minimally
reactive. Moves lower extremities with light touch to feet, does
not withdraw upper extremities to painful stim.
Pertinent Results:
[**2111-10-14**] 10:50PM URINE WBCCLUMP-FEW, AMORPH-FEW CA OXAL-RARE,
GRANULAR-0-2, RBC-[**4-2**]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-0,
BLOOD-MOD NITRITE-POS PROTEIN-TR GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-MOD, COLOR-Yellow
APPEAR-Cloudy SP [**Last Name (un) 155**]-1.010
[**2111-10-14**] 10:50PM WBC-16.2* RBC-3.21* HGB-10.4* HCT-33.5*
MCV-104*# MCH-32.3* MCHC-31.0 RDW-18.1* PLT COUNT-473*#,
NEUTS-87.7* LYMPHS-6.1* MONOS-5.4 EOS-0.4 BASOS-0.4
[**2111-10-14**] 10:50PM PHENYTOIN-8.5*
[**2111-10-14**] 10:50PM CK-MB-NotDone proBNP-4425*
[**2111-10-14**] 10:50PM cTropnT-0.20*
[**2111-10-14**] 10:50PM ALT(SGPT)-19 AST(SGOT)-37 LD(LDH)-346*
CK(CPK)-38 ALK PHOS-186* TOT BILI-0.4
[**2111-10-14**] 10:50PM GLUCOSE-214* UREA N-20 CREAT-1.2 SODIUM-135
POTASSIUM-4.8 CHLORIDE-97 TOTAL CO2-28 ANION GAP-15 ALBUMIN-2.8*
CALCIUM-8.4 PHOSPHATE-5.5*# MAGNESIUM-1.9 GLUCOSE-212*
LACTATE-2.6*
[**2111-10-14**] 11:32PM TYPE-ART PO2-368* PCO2-68* PH-7.26* TOTAL
CO2-32* BASE XS-1 INTUBATED-NOT INTUBA
[**2111-10-14**] 10:50PM BLOOD WBC-16.2* RBC-3.21* Hgb-10.4* Hct-33.5*
MCV-104*# MCH-32.3* MCHC-31.0 RDW-18.1* Plt Ct-473*#
[**2111-10-15**] 03:50AM BLOOD WBC-15.3* RBC-3.00* Hgb-9.4* Hct-30.3*
MCV-101* MCH-31.2 MCHC-30.8* RDW-18.1* Plt Ct-425
[**2111-10-16**] 01:54AM BLOOD WBC-11.2* RBC-3.05* Hgb-9.7* Hct-30.4*
MCV-100* MCH-31.9 MCHC-32.0 RDW-18.0* Plt Ct-434
[**2111-10-17**] 07:00AM BLOOD WBC-10.4 RBC-3.53* Hgb-11.1* Hct-35.6*
MCV-101* MCH-31.4 MCHC-31.1 RDW-18.0* Plt Ct-525*
[**2111-10-18**] 07:45AM BLOOD WBC-9.0 RBC-3.73* Hgb-11.7* Hct-36.8*
MCV-99* MCH-31.4 MCHC-31.8 RDW-18.1* Plt Ct-530*
[**2111-10-19**] 07:05AM BLOOD WBC-9.1 RBC-3.73* Hgb-11.9* Hct-37.5*
MCV-101* MCH-31.9 MCHC-31.7 RDW-18.3* Plt Ct-535*
[**2111-10-20**] 05:22AM BLOOD WBC-8.5 RBC-3.51* Hgb-11.3* Hct-35.6*
MCV-101* MCH-32.1* MCHC-31.7 RDW-18.5* Plt Ct-515*
[**2111-10-21**] 09:51AM BLOOD WBC-9.4 RBC-3.28* Hgb-10.7* Hct-32.4*
MCV-99* MCH-32.6* MCHC-32.9 RDW-18.4* Plt Ct-423
[**2111-10-14**] 10:50PM BLOOD Glucose-214* UreaN-20 Creat-1.2 Na-135
K-4.8 Cl-97 HCO3-28 AnGap-15
[**2111-10-15**] 03:50AM BLOOD Glucose-131* UreaN-21* Creat-1.2 Na-134
K-4.6 Cl-96 HCO3-31 AnGap-12
[**2111-10-16**] 01:54AM BLOOD Glucose-114* UreaN-17 Creat-0.8 Na-136
K-4.5 Cl-100 HCO3-28 AnGap-13
[**2111-10-18**] 07:45AM BLOOD Glucose-97 UreaN-16 Creat-0.7 Na-132*
K-4.2 Cl-97 HCO3-26 AnGap-13
[**2111-10-18**] 07:45AM BLOOD Glucose-97 UreaN-16 Creat-0.7 Na-132*
K-4.2 Cl-97 HCO3-26 AnGap-13
[**2111-10-19**] 07:05AM BLOOD Glucose-105 UreaN-15 Creat-0.7 Na-134
K-4.0 Cl-98 HCO3-29 AnGap-11
[**2111-10-20**] 05:22AM BLOOD Glucose-102 UreaN-13 Creat-0.7 Na-136
K-4.1 Cl-99 HCO3-28 AnGap-13
EEG Study Date of [**2111-10-16**]
IMPRESSION: This telemetry captured no pushbutton activations.
On
seizure detection files, there were between 30 and 40
electrographic
seizures consisting of generalized theta frequency spike and
slow wave
discharges intermixed with periods of faster monomorphic sharp
waves
with a beta frequency. The longest seizure lasted around 20
seconds
with the majority of events occurring for 10-15 seconds. Only
two of
the seizures had clinical correlates which are mentioned above.
Routine
sampling showed a background that was slow and poorly organized
with a
theta Hz frequency.
EEG Study Date of [**2111-10-20**]
IMPRESSION: This telemetry captured no pushbutton activations.
It
captures many prolonged episodes of ongoing seizure activity
seen in a
generalized distribution with predominance of the posterior
quadrants
more on the left than on the right. The background activity was
slow
suggestive of a severe encephalopathy.
CHEST (PA & LAT) Study Date of [**2111-10-19**] 2:36 PM
FINDINGS: Prior sternotomy, joint chamber pacemaker, left
pleural effusion and consolidation in the left lower lobe is
again noted. These findings are without change from [**10-16**], [**2111**]. The previously noted PICC line
appears to have been replaced by another, its tip lying at the
junction of the SVC and right atrium.
CONCLUSION: Left pleural effusion and left lower lobe
consolidation without change from [**2111-10-16**].
CT HEAD W/O CONTRAST Study Date of [**2111-10-14**] 11:02 PM
IMPRESSION: Status post left parietooccipital craniotomy with
persistent
small hyperdense focus at the margin of the resection bed, which
may represent residual tumor as suggested previously. New oval
area of hyperdensity adjacent to the parietooccipital craniotomy
site, could be hemorrhage or residual tumor or post-surgical
change. MRI is recommended to characterize this finding further,
if there is no clinical contraindication for MRI.
OUTSIDE FILMS READ ONLY Study Date of [**2111-10-14**] 11:02 PM
IMPRESSION: Status post left parietooccipital craniotomy with
persistent
small hyperdense focus at the margin of the resection bed, which
may represent residual tumor as suggested previously. New oval
area of hyperdensity adjacent to the parietooccipital craniotomy
site, could be hemorrhage or residual tumor or post-surgical
change. MRI is recommended to characterize this finding further,
if there is no clinical contraindication for MRI.
Brief Hospital Course:
Patient is a 84 yom with PMHx of CAD, CHF, adenocarcinoma of the
brain s/p resection in [**7-7**] and DVT/PE admitted to the MICU with
new onset tonic clonic seizure and initial persistent
unresponsiveness. The patient was placed on BiPAP (DNR/DNI) and
loaded on Dilantin at OSH. Per family, the patient is extremely
sharp and functional at his baseline.
# Obtundation: at the time of initial presentation, the patient
was non-verbal and unresponsive. His physical exam was
remarkable for clonus of his upper extremities and withdrawal of
his bilateral lower extremities. In the setting of new onset
seizure, initial differential included post-ictal state,
metabolic process, CVA and underlying infection. Patient was
initially febrile with leukocytosis. Initial head CT showed
post-operative changes, hyperdensity which possibly could
represent residual tumor, edema and possible mild midline shift.
LP was therefore deferred for concern of increased ICP and
empiric antibiotics (ceftriaxone and acyclovir) were started to
cover for meningitis. The patient was initially placed on BiPAP
for recorded O2 desaturations. Serial ABG's were initially
performed showing improving respiratory status and BiPAP was
discontinued within the first several hours of admission. Over
the first few hours, patient's mental status substantially
improved. He became more alert and engageable and neuro findings
on physical exam normalized. The patient continued to have
improving mental status over the first several days of his
admission. Neurology was consulted and felt that post-ictal
state and metabolic disturbance was most likely. EEG was
performed on [**10-16**] which was concerning for underlying seizure
activity and Neurology recommended continuing Dilantin and
adding Keppra for improved seizure control. Subsequently,
patient was transferred to the floor where continous EEG showed
that there were seizure activities. However, given family
wishes and patient's continous state of sedation, anti-seizure
medications were peeled back. Neurotin was stopped and then the
dilantin was stopped. Patient improved in his mentation and is
no longer sedated. He was maintained on keppra till discharge.
# Sepsis: Patient was initially hypotensive to high 80's
systolic on arrival to ICU which responded to fluid boluses.
Initial labs showed + UA thus raising the possibility of
urosepsis. Patient also had numerous open skin sores and thus
osteomyellitis and bactermia were also considered. Given
respirator status, congested lung sounds on physical exam and
serial CXR's pneumonia was also strongly considered. Patient was
initially broadly covered with ceftriaxone, vancomycin and
ciprofloxacin. The patient remained afebrile over the first
several days of admission and leukocytosis trended down. On
[**10-17**], antibiotics were tailored as suspicion for meningitis was
very low considering his rapid clinical improvement and physical
exam findings. Patient was started on Unasyn for possible
pneumonia / aspiration and vancomycin for possible MRSA. After
he stablized on the floor, a two view xray was done and showed
findings of pneumonia. His antibiotics were broaden to zosyn
and vancomycin. He remained afebrile and was maintained on
these medications until discharge. He was discharged on
vancomycin IV and augmentin PO for two additional days.
# Seizure: New onset sz for this patient. Concerning that CT
head shows new areas of hyperdensity as well as ?mild midline
shift. Possible mass effect and edema could contribute to sz.
Given infection must also consider this as an inciting factor.
He is not on meds that are associated with lowering sz
threshold. After peeling back neuroleptics, he was no longer
sedated and did better with her mentation. Baseline answers
questions, able to voice needs.
# Respiratory Acidosis: patient initially presented with
respiratory acidosis and reported desaturations on Bi-PAP.
Serial ABG's showed improving respiratory status amd Bi-PAP was
discontinued after several hours on the floor. Patient
maintained good O2 sats on 3L NC, eventually was wean off
supplemental O2.
# PAF: amiodarone was held as rate was AV paced without any
signs of atrial fibrillation and initial hypotension.
# Cardiomyopathy: Carvedilol and furosemide was initially held
for concern of sepsis. On [**10-17**] Lasix was restarted given his
CXR, congested lung sounds and fluid overload.
# h/o DVT/PE: Cont Lovenox 40mg [**Hospital1 **]
.
# CAD s/p CABG: patient initially presented with TN of 0.2 with
normal CK's and ECG not concerning for ischemia. This was
attributed to sepsis / seizure activity. Cardiac enzymes were
trended and gradually decreased.
# FEN: IVF, replete electrolytes, NPO
.
# Prophylaxis: Lovenox
.
# Access: peripherals
.
# Code: DNR/DNI (confirmed with son Dr. [**Known lastname **]
.
# Communication: Son, Dr. [**Known lastname **]
.
# Disposition: ICU
Medications on Admission:
MEDICATIONS AT HOME: (taken from [**Location (un) 5481**] medication
record)
Lasix 30mg PO daily
Levothyroxine 75mcg PO daily
Protonix 40mg PO daily
Amiodarone 200mg PO daily
Coreg 12.5mg PO BID
Neurontin 400mg PO QHS
Lactobacillus 1 capsule [**Hospital1 **]
MVI
Benefiber
Miralax prn
Percocet 1 tab Q4 hours PRN pain
Robitussin 10cc PO Q6 hours PRN cough
.
Discharge Medications:
1. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for irritation.
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Furosemide 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
11. picc line maintenance
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.
12. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
once a day for 2 days.
Disp:*2 solutions* Refills:*0*
13. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
14. Keppra 750 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 5481**] TCU
Discharge Diagnosis:
Primary:
Aspiration pneumonia
UTI
Altered mental status
Seizure
Hyponatremia
Secondary:
Right wriste pain
Paroxysmal atrial fibrillation
CAD
Hypothyroidism
Discharge Condition:
stable
Discharge Instructions:
You came to the hospital due to an episode of tonic-clonic
seizure and unresponsiveness while you were in rehab. We were
able to stablize you in the hospital. We found on testing that
you had pneumonia and urinary tract infection which we treated
with antibiotics. You were in stable condition and is mentating
better at the time of discharge.
Please follow up with the doctors listed below.
Please note, we made the following changes to your medications.
1. vancomycin 1g IV once a day.
2. augmentin 875 PO twice a day.
3. Keppra 750 PO twice a day
STOPPED:
Neurontin 400mg PO QHS
If you experience any fever, chest pain, nausea, vomiting,
confusion, lethargy, shortness of breath, seizures, or any
symptoms that is of concern to you, please go to the emergency
room.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Followup Instructions:
Please follow up with your primary care physician and the
physicians in your healthcare facility.
|
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"V45.02",
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"401.9",
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"038.9",
"507.0",
"425.4",
"276.1",
"427.31",
"780.39",
"599.0",
"276.2",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14588, 14643
|
7898, 12824
|
254, 260
|
14844, 14853
|
2722, 7875
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15778, 15879
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1941, 2096
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13234, 14565
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14664, 14823
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12850, 12850
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14877, 15755
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12872, 13211
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2111, 2703
|
198, 216
|
288, 1237
|
1259, 1828
|
1844, 1925
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
731
| 197,129
|
257
|
Discharge summary
|
report
|
Admission Date: [**2152-4-6**] Discharge Date: [**2152-4-11**]
Date of Birth: [**2073-11-29**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Gemfibrozil
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
angina,NSTEMI
Major Surgical or Invasive Procedure:
cabg x4 [**2152-4-6**] (LIMA to LAD, SVG to DIAG, SVG to OM 1 and OM
2)
History of Present Illness:
78 yo female with mutiple cardiac risk factors. Recently
admiutted for angina and ruled in for NSTEMI. Cath revealed LAD
70%, DIAG 70%, OM1 99% CX 70%, and small RCA without lesions.
PCI was unsuccessful at cath and now referred for CABG.
Past Medical History:
NSTEMI
CVA ([**8-16**]; MRI showing left internal capsular defect, little
residual effect)
ESRD still not on HD - Cr 3.0 (1.7-6.0) - followed by Dr. [**Last Name (STitle) **]
Congestive Heart Failure (ECHO [**9-27**] [**Hospital1 1474**], technically
limited showed mild concentric LVH with EF at 60%, ?pericardial
effusion (size unspecified)
s/p right renal artery stent ([**9-15**]) by Dr. [**Last Name (STitle) 911**]
Hypertension
Hypercholesterolemia,
Hypothyroidism
Depression
Degenerative Joint Disease
TAH-BSO/repair of umbilical hernia for benign ovarian mass
(path=fibroma [**4-14**])
Social History:
Former light smoker (ages 25-73); quit 4 yrs ago. No history of
EtOH or other drugs. Formerly worked as a paralegal. Now living
in public senior housing in [**Hospital1 1474**]. Mother of two--one
daughter lives nearby.
Family History:
Notable for diabetes and renal failure in a brother.
Physical Exam:
55.9 kg 58"
elderly female in NAD
mild erythema on abd.
neck supple with full ROM, no carotid bruits
CTAB
RRR, no murmur
soft, NT, ND, +BS
warm, well-perfused, no edema or varicosities
neuro grossly intact
fems bil. 2+
DP/PT/radials 1+ bil.
Pertinent Results:
[**2152-4-11**] 07:15AM BLOOD WBC-10.3 RBC-4.05* Hgb-13.2 Hct-38.3
MCV-94 MCH-32.5* MCHC-34.4 RDW-15.0 Plt Ct-111*
[**2152-4-11**] 07:15AM BLOOD Plt Ct-111*
[**2152-4-9**] 06:20AM BLOOD PT-14.9* PTT-28.1 INR(PT)-1.3*
[**2152-4-11**] 07:15AM BLOOD UreaN-44* Creat-2.7* K-3.8
Cardiology Report ECHO Study Date of [**2152-4-6**]
PATIENT/TEST INFORMATION:
Indication: Intraoperative TEE for CABG procedure
Height: (in) 58
Weight (lb): 123
BSA (m2): 1.48 m2
BP (mm Hg): 187/67
HR (bpm): 56
Status: Inpatient
Date/Time: [**2152-4-6**] at 10:51
Test: TEE (Complete)
Doppler: Limited Doppler and color Doppler
Contrast: None
Tape Number: 2007AW1-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Suboptimal
REFERRING DOCTOR: DR. [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **]
MEASUREMENTS:
Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Ejection Fraction: >= 55% (nl >=55%)
Aorta - Ascending: 3.4 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.2 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 6 mm Hg
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A Ratio: 1.00
Mitral Valve - E Wave Deceleration Time: 311 msec
Pericardium - Effusion Size: 0.6 cm
INTERPRETATION:
Findings:
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: Mild symmetric LVH. Normal regional LV systolic
function.
Overall normal LVEF (>55%). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta
diameter. Simple atheroma in ascending aorta. Normal aortic arch
diameter.
Complex (>4mm) atheroma in the aortic arch. Normal descending
aorta diameter.
Complex (>4mm) atheroma in the descending thoracic aorta.
AORTIC VALVE: Three aortic valve leaflets. Filamentous strands
on the aortic
leaflets c/with Lambl's excresences (normal variant). No AS. No
AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Mild (1+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PERICARDIUM: Small pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure. The patient appears to be in sinus rhythm. Results
were personally
Conclusions:
Prebypass
1.No atrial septal defect is seen by 2D or color Doppler.
2.There is mild symmetric left ventricular hypertrophy. Regional
left
ventricular wall motion is normal. Overall left ventricular
systolic function
is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4.There are simple atheroma in the ascending aorta. There are
complex (>4mm)
atheroma in the aortic arch. There are complex (>4mm) atheroma
in the
descending thoracic aorta.
5.There are three aortic valve leaflets. There are filamentous
strands on the
aortic leaflets consistent with Lambl's excresences (normal
variant). There is
no aortic valve stenosis. No aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
7.There is a small pericardial effusion.
POSTBYPASS
1. Patient is being AV paced and receiving an infusion of
phenylephrine.
2. Biventricular systolic function is unchanged.
3. Mild mitral regurgitation persists.
4. Aorta is intact post decannulation.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD on [**2152-4-6**] 16:29.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 2541**])
Brief Hospital Course:
Admitted [**4-6**] and underwent cabg x4 with Dr. [**Last Name (STitle) 914**].
Transferred to the CSRU in stable condition on titrated
propofol, phenylephrine and nitroglycerin drips. Extubated that
evening and remained in the CSRU for 2 days requiring titrated
antihypertensives as well as an insulin drip.Transferred to the
floor on POD #2. HIT screen sent for decreasing platelets, but
results were negative. Chest tubes removed without incident on
POD #3. Pacing wires removed on POD #5 and plavix restarted.
Cleared for discharge to rehab on POD #5. Pt. is to make all
follow-up appts. as per discharge instructions.
Medications on Admission:
ASA 325 mg daily
levothyroxine 88 mcg daily
sertraline 50 mg daily
lipitor 80 mg daily
calcium acetate 667mg TID
protonix 40 mg daily
calcitriol 0.25 mg every other day
metoprolol 12.5 mg TID
Vits. C/E
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 10 days.
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 10
days.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
8. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Sertraline 50 mg daily.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2542**] - [**Hospital1 1474**]
Discharge Diagnosis:
s/p cabg x4
CAD
NSTEMI
CRF with ESRD
CVA
renal artery stent
CHF
HTN
Discharge Condition:
stable
Discharge Instructions:
no driving for one month
no lotions, creams, or powders on any incision
no lifting greater than 10 pounds for 10 weeks
may shower over incisions and pat dry
call for fever greater than 100.5, redness or drainage
Followup Instructions:
see Dr. [**Last Name (STitle) 2539**] in [**12-14**] weeks
See Dr. [**Last Name (STitle) 911**] in [**1-15**] weeks
See Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2152-4-11**]
|
[
"244.9",
"428.0",
"403.91",
"V12.59",
"410.71",
"715.98",
"272.0",
"311",
"585.6",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.14"
] |
icd9pcs
|
[
[
[]
]
] |
7649, 7719
|
5600, 6224
|
291, 367
|
7831, 7840
|
1847, 2177
|
8100, 8324
|
1512, 1567
|
6476, 7626
|
7740, 7810
|
6250, 6453
|
7864, 8077
|
2203, 5508
|
1582, 1828
|
238, 253
|
395, 636
|
5543, 5577
|
658, 1256
|
1272, 1496
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,884
| 157,802
|
3969
|
Discharge summary
|
report
|
Admission Date: [**2161-3-4**] Discharge Date: [**2161-3-10**]
Date of Birth: [**2085-12-13**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
transferred for hypoxia
Major Surgical or Invasive Procedure:
mechanical intubation
History of Present Illness:
75F with hx of stage IIIA nonsmall cell lung ca treated with
chemoradiation, taxol/carboplatin, followed by right
pneumonectomy, recent squamous cell ca of the skin s/p radiation
of the chest, initially presented to [**Hospital 1562**] Hospital with
anuria found to have Cr 8.5, hypotension requiring pressors, now
with improving renal function and hemodynamics but worsening
hypoxia.
.
Per pt and OSH dc summary, pt presented to [**Hospital 1562**] Hospital
[**2161-2-26**] complaining of anuria x3 days, diarrhea x 3-4 days,
nausea and poor appetite. She was found to have a Cr 8.5, K 5.9.
At that time she denied NSAID use, pain, fevers, CP. She did
endorse baseline dyspnea worsened over the past couple months
(thought subsequent to radiation of resected squamous cell ca of
the skin overlying the manubrium in [**Month (only) 1096**]), but denied a home
O2 requirement.
.
At [**Name (NI) 1562**] Hospital, pt was initially hypotensive. She was
admitted to the ICU where she received IVF for [**Last Name (un) **] and
kayexelate for hyperkalemia, and was started on Levophed which
was switched to vasopressin, pressors dced [**2161-3-1**]. She was also
given stress doses of steroids but after ACTH stim test was
negative, was started on hydrocortisone taper. Metronidazole was
started empirically for diarrhea but dced after cdiff cx
negative. Renal u/s was done without hydronephrosis. Over the
course of admission, cr improved to 2.7. However, the pt
developed an O2 requirement and mild dyspnea with increased
interstitial marking in the L lung (while BNP was 400). ECHO on
levophed showed EF 80% with hyperdynamic LV and RV. VQ scan was
done which was neg for PE and B LENIs were neg for DVT. Diuresis
was initiated with lasix. The pt was started on CTX/Azithro on
[**3-1**] though no infiltrate was found, and no fever/cough/sputum
production reported. Despite these measures, O2 requirement
continued to increase. On discussions with the family it seems
she has been increasingly short of breath at home which has
limited her exertion significantly. Of note, the pt also has a
hx of tachyarrhythmias with episodes of SVT which were
reportedly treated with IV dilt and metop during admission.
.
On arrival to the ICU, the pt was sitting comfortabely in bed,
satting low 90s on 100% shovel mask. She denies dyspnea, n/v,
lightheadedness/cp. She does endorse some continued loose
stools. She is somewhat confused, perseverating on issues that
are out of context and not directly answering questions. Knows
she is in a hospital but not that it is [**Hospital3 **].
.
Initial labs at [**Hospital1 18**] showed: WBC 12.4, HCT 32.4, PLT 239. IRN
1.2.
chemistry: 146/3.8; 103/34; 31/2.6<138
Feurea 51%
.
.
Past Medical History:
- [**2145**] stage IIIA nonsmall cell lung ca treated with
chemoradiation, taxol/carboplatin, followed by right
pneumonectomy.
- hx dilatation of her lower thoracic descending aorta
- [**11-3**]? squamous cell ca of skin over manubrium s/p reserction
and radiation x22
- HTN
- HL
- hx of cardiomyopathy ~[**2148**], reportedly improved by [**2154**] EF
55%.
- Mild dementia
Social History:
lives with husband. several children nearby. Was a previous
smoker. no etoh or other drug use.
Family History:
nc
Physical Exam:
ON ADMISSION:
Vitals: T:98.7 BP:111/61 P:90 R:22-28 O2: 95% on 80% high flow
O2 shovel and 6L NC
General: Alert, oriented x2, on shovel mask and NC with somewhat
increased work of breathing
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, pt with right IJ
Lungs: right side without air movement. Left side with
crackles/coarse breaths ounds throughout.
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: has foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. lower extremities with diffuse bruising and thinned skin
.
PT [**Name (NI) 17581**].
Pertinent Results:
OSH
[**3-3**]
wbc 10.3, hct 31, plt 202
Na 141 K4.1 Cl 101 CO2 35 BUN 35 Cr 2.66
Ca 8.3 Mg 2.2 Phos 2.7
.
[**3-2**]
AST 67 ALT 42
Alk Phos 45, albumin 2.9, bili 0.2
CK 34, trop 0.07
.
[**2-26**]
RF + titer 20
[**Last Name (un) **] IgM neg
Hep B core IgM, [**Last Name (un) **] ag nr
Hep C neg
.
LABS ON ADMISSION TO [**Hospital1 18**]:
[**2161-3-4**] 01:12PM BLOOD WBC-12.4* RBC-3.18* Hgb-10.0* Hct-32.4*
MCV-102* MCH-31.3 MCHC-30.8* RDW-12.5 Plt Ct-239
[**2161-3-4**] 01:12PM BLOOD PT-13.4* INR(PT)-1.2*
[**2161-3-4**] 01:12PM BLOOD Glucose-138* UreaN-31* Creat-2.6*#
Na-146* K-3.8 Cl-103 HCO3-34* AnGap-13
[**2161-3-4**] 01:12PM BLOOD ALT-41* AST-35 AlkPhos-47 TotBili-0.2
[**2161-3-4**] 01:12PM BLOOD Calcium-8.9 Phos-2.6* Mg-2.2
.
LABS OF HOSPITAL COURSE:
CBC - anemia and leukocytosis:
[**2161-3-4**] 01:12PM BLOOD WBC-12.4* RBC-3.18* Hgb-10.0* Hct-32.4*
MCV-102* MCH-31.3 MCHC-30.8* RDW-12.5 Plt Ct-239
[**2161-3-7**] 03:03AM BLOOD WBC-10.2# RBC-2.40* Hgb-7.5* Hct-24.4*
MCV-102* MCH-31.1 MCHC-30.6* RDW-13.3 Plt Ct-192
[**2161-3-8**] 06:05AM BLOOD WBC-7.5 RBC-2.50* Hgb-7.8* Hct-25.8*
MCV-103* MCH-31.3 MCHC-30.4* RDW-13.5 Plt Ct-180
[**2161-3-10**] 04:11AM BLOOD WBC-16.7* RBC-2.74* Hgb-8.5* Hct-29.0*
MCV-106* MCH-30.9 MCHC-29.2* RDW-14.2 Plt Ct-205
.
chemistries - Cr trended down then back up.
[**2161-3-4**] 01:12PM BLOOD Glucose-138* UreaN-31* Creat-2.6*#
Na-146* K-3.8 Cl-103 HCO3-34* AnGap-13
[**2161-3-5**] 07:43AM BLOOD Glucose-110* UreaN-27* Creat-2.1* Na-146*
K-3.7 Cl-105 HCO3-34* AnGap-11
[**2161-3-8**] 06:05AM BLOOD Glucose-92 UreaN-24* Creat-1.5* Na-139
K-3.5 Cl-106 HCO3-25 AnGap-12
[**2161-3-9**] 03:30PM BLOOD Glucose-403* UreaN-26* Creat-1.7* Na-129*
K-3.9 Cl-99 HCO3-20* AnGap-14
[**2161-3-10**] 04:11AM BLOOD Glucose-409* UreaN-53* Creat-2.1* Na-123*
K-4.4 Cl-100 HCO3-15* AnGap-12
.
OTHER:
[**2161-3-4**] 01:12PM BLOOD ALT-41* AST-35 AlkPhos-47 TotBili-0.2
[**2161-3-6**] 02:28AM BLOOD CK(CPK)-42
[**2161-3-6**] 03:22PM BLOOD CK(CPK)-31
[**2161-3-6**] 02:28AM BLOOD CK-MB-2 cTropnT-0.05*
[**2161-3-6**] 03:22PM BLOOD CK-MB-1 cTropnT-0.02*
[**2161-3-4**] 01:12PM BLOOD TSH-0.79
.
BLOOD GASES:
[**2161-3-5**] 05:20PM BLOOD Type-ART Temp-36.7 pO2-65* pCO2-65*
pH-7.28* calTCO2-32* Base XS-1 Intubat-NOT INTUBA
[**2161-3-5**] 08:25PM BLOOD Type-ART pO2-265* pCO2-61* pH-7.21*
calTCO2-26 Base XS--4
[**2161-3-6**] 12:35AM BLOOD Type-ART pO2-211* pCO2-46* pH-7.30*
calTCO2-24 Base XS--3
[**2161-3-8**] 12:14PM BLOOD Type-ART pO2-67* pCO2-43 pH-7.34*
calTCO2-24 Base XS--2
[**2161-3-8**] 06:10PM BLOOD Type-ART pO2-57* pCO2-42 pH-7.28*
calTCO2-21 Base XS--6
[**2161-3-9**] 06:48AM BLOOD Type-ART pO2-69* pCO2-50* pH-7.26*
calTCO2-23 Base XS--4
[**2161-3-10**] 01:36AM BLOOD Type-ART Rates-34/ Tidal V-280 PEEP-8
FiO2-70 pO2-57* pCO2-50* pH-7.25* calTCO2-23 Base XS--5
-ASSIST/CON Intubat-INTUBATED
[**2161-3-10**] 04:16AM BLOOD Type-MIX Temp-36.7 Rates-25/1 Tidal V-280
PEEP-8 FiO2-80 pO2-69* pCO2-27* pH-7.39 calTCO2-17* Base XS--6
AADO2-474 REQ O2-81 Intubat-INTUBATED Vent-CONTROLLED
Comment-GREEN TOP
.
IMAGING:
[**2161-3-4**] CT head IMPRESSION: No acute intracranial process. If
clinical suspicion for infarction or mass lesion is high, MRI is
the recommended study of choice.
.
[**2161-3-4**] CT chest
IMPRESSION:
1. Mild and diffuse ground-glass opacity in the left and small
left pleural effusion is likely due to pulmonary edema.
2. Right post-pneumonectomy space is stable, No evidence to
suggest local or regional recurrence.
3. Left hilus is more prominent since [**2157-4-24**] and is
contributed by left
main pulmonary artery (similar in caliber to prior study) and
nodular opacity laterally, likely an engorged pulmonary vein or
potentially lymph node.
4. Mild malacic of lower trachea and left main bronchus.
Following diuresis, repeat chest radiograph is recommended to
monitor
resolution of the pulmonary edema. However, if a repeat CT is
considered
instead of radiograph for any reason, it should be done with
intravenous
contrast so that the left hilar abnormality can be assessed.
.
TTE [**2161-3-5**]
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity is unusually
small. Left ventricular systolic function is hyperdynamic (EF
75%). Right ventricular chamber size and free wall motion are
normal. The descending thoracic aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mitral regurgitation
is present but cannot be quantified. Tricuspid regurgitation is
present but cannot be quantified. There is no pericardial
effusion. There is an anterior space which most likely
represents a prominent fat pad.
.
[**2161-3-8**]
RUextremity U/s:
IMPRESSION: Non-occlusive thrombus in one of the right brachial
veins.
.
CXR [**3-7**]
FINDINGS: The lines and tubes are unchanged. There is persistent
opacification of the right lung with volume loss. There is a
developing
left-sided retrocardiac opacity and there is prominence of the
pulmonary
interstitial markings consistent with pulmonary edema. There is
likely a
left-sided pleural effusion as well.
.
CXR [**3-10**]
FINDINGS: As compared to the previous radiograph, there is
unchanged
appearance of the right pneumonectomy. On the left, the mixed
alveolar and
interstitial opacities, combined to small pleural effusion, and
likely
reflecting a combination of pneumonia and pulmonary edema, are
unchanged. No newly appeared parenchymal opacities. No left
pneumothorax.
.
Brief Hospital Course:
Ms. [**Known lastname 1968**] is a 75F with hx of stage IIIA nonsmall cell lung ca
treated with chemoradiation, taxol/carboplatin, followed by
right pneumonectomy, recent squamous cell ca of the skin s/p
radiation of the chest, who initially presented to [**Hospital 1562**]
Hospital with anuria found to have Cr 8.5, hypotension requiring
pressors who was transferred to [**Hospital1 18**] for further care and who
passed away on [**2161-3-10**]
.
The patient was treated with broad spectrum antibiotics for
suspected health care associated pneumonia. Despite aggressive
measures resuscitative measures the patient's status continued
to decline. She continued to be hypotensive despite 3 pressors.
A family meeting was held where the patient's wishes were
respected. Her family felt that the patient would want to focus
on comfort in this situation. Her pain was controlled with
medication and then she was taken off of pressors and
ventilatory support. She passed away shortly thereafter on
[**2161-3-10**]. Cause of death was septic shock from pneumonia.
Medications on Admission:
Home:
Pravastatin
Benazepril
Metoprolol
.
On transfer:
Ativan 0.5mg IV q6h prn agitation
Cardizem 60mg q6h
Duoneb q4h prn
Heparin 5000 sq q8
Lasix prn (currently 20mg IV q midnight prn I > O)
MVI
PhosLo 1334 mg TID
Pravachol 20mg daily
Protonix 40mg IV daily
Hydrocortisone 25mg q12h
Tylenol prn
Zofran prn
-------------------
dced Azithro/Rocephin
dced Flagyl
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"585.9",
"276.2",
"276.0",
"995.92",
"518.81",
"584.9",
"453.82",
"486",
"276.8",
"285.9",
"038.9",
"275.2",
"V10.11",
"V10.83",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"33.23",
"96.72",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11495, 11504
|
9991, 11051
|
328, 351
|
11555, 11564
|
4402, 5146
|
11620, 11630
|
3617, 3621
|
11463, 11472
|
11525, 11534
|
11077, 11440
|
5163, 9968
|
11588, 11597
|
3636, 3636
|
265, 290
|
379, 3091
|
3650, 4383
|
3113, 3489
|
3505, 3601
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,751
| 140,078
|
1523
|
Discharge summary
|
report
|
Admission Date: [**2192-5-12**] Discharge Date: [**2192-5-18**]
Date of Birth: [**2107-10-8**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Known firstname 1436**]
Chief Complaint:
Shortness of breath and chest pain
Major Surgical or Invasive Procedure:
Coronary Angiography
Percutaneous Coronary Intervention with Drug Eluting Stents to
the Right coronary artery and Circumflex
Intubation
History of Present Illness:
Mr [**Known lastname 8922**] is an 85 y/o M with PMHx s/f CAD with multiple DES
and BMS, HC, HTN, AFIB and PVD who presented on [**5-11**] after 1 day
of shortness of breath and chest pain. On [**5-10**], he was helping
his wife in the nursing home, walking with her and began feeling
SOB and chest pain, which was unusual for him. He described cp
as midline sub-sternal, without radiation. No n/v, light
headedness, syncope, PND, orthopnea. It continued to progress
without improvement until yesterday when he was unable to sleep,
and his son brought him to the [**Name (NI) **].
His prior coronary events have included symptoms of h/a, and
chest pain.
In the ED, initial vitals were stable (Temp: 97.7 HR: 76 BP:
121/67 Resp: 16 O(2)Sat: 95 Normal). EKG revealed Sinus, ST
elevations in leadII andIII with reciprocal ST depressions
anteriorly, new from previous. He was determined to have NSTEMI.
Labs and imaging significant for:
CE CK-MB 11 (8a, 3a), Trop-T 0.45 (8a), 0.46 (3a)
H/H 9.4/30.8
Lytes: K 3.9, Mg 2.3
UA: RBC 24
Patient was given plavix loading dose. On arrival to the floor,
patient was in no acute distress and chest pain free. He was
subsequently started on heparin gtt and nitro gtt in preparation
for [**5-14**] cath. Over the course of the 23rd, the patient was
noted to be increasingly hypoxic with O2 sats ~85% on 4-6L O2
NC. He was triggered and given lasix 40 x 2 with minimal urine
output or improvement in respiratory status. Trops increased to
0.67 at 1900. Repeat EKG was markedly improved from admission
with q waves in III, AvF and small ST deppression in I and V3.
ABG was 7.38/44/66. CXR showed pulmonary edema. Subjective
improvement in respiratory status was noted with duonebs x 3.
However, given his continued worsened respiratory status he was
transferred to CCU.
Past Medical History:
Dyslipidemia
Hypertension
NSTEMI with BMS in RCA + LAD [**2187**]
NSTEMI mid RCA DES [**2182**], [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] and LCX [**2187**]
Afib
Peripheral vascular disease
Bladder cancer s/p chemo and lesion removal
s/p Bilateral carotid endarterectomy '[**83**]
Lumbar DJD
bilateral SFA stents
R internal iliac artery stent
Social History:
Retired from miliary several decades ago
Wife lives in [**Location **], currently in nursing home
Tobacco history: 120 pk-yr hx, now stopped smoking for 45 yrs
ETOH: weekly beer/wine
Illicit drugs: none
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
afebrile 66 112/64 90-92% on 10L face mask
GENERAL- healthy appearing male in minimal distress
HEENT- EOM grossly intact. PERRL
NECK- Supple, Neck veins distended. JVP difficult to appreciate
with BiPAP on
CARDIAC- RR, normal S1, S2. No m/r/g. Distant heart sounds
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, posterior
crackles up to the mid chest, no wheezes or rhonchi.
ABDOMEN- Soft, NTND. No HSM or tenderness.
EXTREMITIES- No edema, cyanosis, clubbing.
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES-
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Discharge Physical Exam:
98.0 65 108/52 96%RA
HEENT: NCAT
CV: RRR no m/r/g
Chest: CTAB
Abdomen: NT/ND, BS+
Ext: WWP
Pertinent Results:
Admission Labs
[**2192-5-12**] 03:00AM BLOOD WBC-8.1# RBC-3.57* Hgb-9.4* Hct-30.8*
MCV-86 MCH-26.5* MCHC-30.7* RDW-14.7 Plt Ct-234
[**2192-5-12**] 03:00AM BLOOD Neuts-73.1* Lymphs-17.8* Monos-6.6
Eos-2.0 Baso-0.6
[**2192-5-12**] 03:00AM BLOOD PT-18.2* PTT-37.5* INR(PT)-1.7*
[**2192-5-12**] 03:00AM BLOOD Glucose-112* UreaN-27* Creat-1.1 Na-143
K-3.9 Cl-108 HCO3-25 AnGap-14
[**2192-5-12**] 03:00AM BLOOD CK-MB-11* MB Indx-4.1
[**2192-5-13**] 01:59AM BLOOD Calcium-8.3* Phos-5.4*# Mg-2.3
Pertinent In House Labs
[**2192-5-12**] 08:13PM BLOOD Type-ART pO2-50* pCO2-48* pH-7.36
calTCO2-28 Base XS-0
[**2192-5-12**] 10:52PM BLOOD Type-ART pO2-42* pCO2-48* pH-7.36
calTCO2-28 Base XS-0
[**2192-5-12**] 11:53PM BLOOD Type-ART Temp-37.2 Rates-/20 FiO2-60 O2
Flow-6 pO2-66* pCO2-44 pH-7.38 calTCO2-27 Base XS-0 Intubat-NOT
INTUBA
[**2192-5-13**] 08:32PM BLOOD Type-ART pO2-84* pCO2-45 pH-7.43
calTCO2-31* Base XS-4
[**2192-5-12**] 03:00AM BLOOD cTropnT-0.46*
[**2192-5-13**] 01:59AM BLOOD CK-MB-9 cTropnT-0.71*
[**2192-5-13**] 06:01PM BLOOD CK-MB-5 cTropnT-0.91*
Discharge Labs
[**2192-5-18**] 07:50AM BLOOD WBC-7.0 RBC-3.52* Hgb-9.1* Hct-29.7*
MCV-85 MCH-25.8* MCHC-30.5* RDW-14.6 Plt Ct-338
[**2192-5-18**] 07:50AM BLOOD PT-22.3* INR(PT)-2.1*
[**2192-5-18**] 07:50AM BLOOD Glucose-153* UreaN-35* Creat-1.5* Na-140
K-3.7 Cl-99 HCO3-33* AnGap-12
[**2192-5-14**] 09:12PM BLOOD CK-MB-8 cTropnT-1.42*
Imaging Studies/Procedures
CXR: There are bilateral increased interstitial opacities with
bibasilar. atelectasis. Minimally enlarged cardiomediastinal
silhouette which appears stable in size in comparison to the
prior study. Otherwise, the lungs are without a focal
consolidation. If any, there is a small left pleural effusion
TTE:
Normal left ventricular wall thickness and cavity size. No ASD
or PFO detected by saline contrast at rest (intubated, sedated,
unable to perform maneuvers). Moderate regional left ventricular
dysfunction as above with overall moderately reduced systolic
function. Mildly dilated aortic root. Mild mitral regurgitation.
RHC/Coronary Angiography/PCI:
Hemodynamics (see above): The right and left heart filling
pressures were elevated (PCWP = 24 mmHg). There was no evidence
of an intracardiac shunt by oximetry. The V waves did not
suggest acute mitral regurgitation. There was no equalization of
the diastolic pressures suggestive of pericardial tamponade.
Coronary angiography: right dominant
LMCA: Very heavily calficied with 40-50% distal left main
LAD: The proximal LAD had minor lumen irregularities.
The
1st diagonal branch was a small caliber (2.0 mm) vessel but
bifurcated and supplied the bulk of the posterolateral wall.
There was a 80% calcified focal mid LAD. The distal LAD was a
2.5
mm vessel with 30-40% diffuse lumen irregularities.
LCX: There was a 40-50% in-stent restenosis within the
stent; there was a 90% stenosis within the mid LCX prior to a
large OMB3. The OMB1 was a small vessel without focal stenoses;
the OMB2 was a medium sized vessel with diffuse disease. The
OMB3 was a large vessel just distal to the LCx lesion and
diffusely diseased with 30-40% diffusely lesions in its more
proximal segment. The LCX gave right to faint left to right
collaterals to the PDA.
RCA: There was a 99% stenosis in the mid RCA with TIMI 1
flow into the distal vessel. This was likely the culprit vessel
(along with the LCx). There were 40-50% stenoses diffusely
distally into a very disease RCA and right posterolateral
branches.
ASSESSMENT
1. NSTEMI due to RCA occlusion v. LCX high grade stenosis
2. Refractory chest pain and ischemia despite maximal medical
therapy
3. Successful drug eluting stent placement RCA and LCx
RECOMMENDATIONS
1. Aspirin 325 mg daily for one month then 81-162 mg daily
thereafter
2. Clopidogrel 75 mg daily
3. Integrilin x 18 hours in the absence of bleeding
4. Staged PCI of the LAD for recurrent/residual ischemia.
Brief Hospital Course:
85M with history of extensive vascular disease (both cardiac
with multiple stents, and peripheral including carotid), who p/w
NSTEMI and worsening respiratory distress while awaiting cath.
ACUTE
# NSTEMI: Patient initially presented with CP and SOB x 1 day
and admitted to the cardiology service. Initial EKG revealed
Sinus, ST elevations in leadII andIII with reciprocal ST
depressions anteriorly, new from previous. ASA, Plavix, Nitro
gtt and hep gtt were started and cath was scheduled for [**5-14**].
His metoprolol, nifedipine, and atorvastatin were continued.
Initial trops were 0.46. He was determined to have NSTEMI and
was scheduled for cath on [**5-14**]. On [**5-12**] trops increased to 0.67
at 1900. Repeat EKG was markedly improved from admission with q
waves in III, AvF and small ST depression in I and V3. After
transfer to the CCU for increasing O2 requirements (see below),
he experienced another episode of CP associate with agitation.
Repeat EKG still remained improved from prior. However, he was
then started on integrillin. Trops steadily increased to 0.91.
On the morning of the 25th at 0330, he became persistently
agitated and delirious. He reported another instance of CP.
EKG demonstrated worsened ST depressions over the anterior
leads. As a result he was intubated and sent to the cath lab
for emergent catheterization. The cath report showed an NSTEMI
due to RCA occlusion v. LCX high grade stenosis. [**Name Prefix (Prefixes) **]'[**Last Name (Prefixes) **] were
placed in the RCA and LCx, and he was continued on aspirin,
plavix, metoprolol, and nifedipine, plus Integrilin x 18 hours
post cath. Trops continued to rise to 1.42 over the course of
the 25th. Cardiology recommended staged PCI of the LAD for
recurrent/residual ischemia- they did not intervene on the LAD
at this time to minimize dye load and it was not the likely
culprit vessel. TTE post procedure showed an LVEF of 30%.
# Respiratory distress: Prior to CCU admission, the patient
became increasingly hypoxic over the course of [**5-12**] while on the
cardiology service, with O2 sats ~85% on 4-6L O2 NC. He was
triggered and given lasix 40 x 2 with minimal urine output or
improvement in respiratory status. ABG was 7.38/44/66,
suggesting no CO2 retention with poor oxygenation. EKG was
improved since admission. CXR showed pulmonary edema and lung
exam revealed wet crackles bilaterally. In the CCU his
respiratory status declined with agitation. He refused BiPAP
but was able to maintain O2 sats in the mid 90's with a
nonrebreather mask at 15L. A lasix gtt was started but
oxygenation did not improve despite effective diuresis. He was
intubated on the morning of the 25th due to worsening agitation
and planned cardiac cath. He was ultimately weaned from the
vent post cath and sat'ing in the mid 90's on 12L o2 by face
tent. On the 25th, his Na started rose to 150 and he developed
a mild contraction alkalosis, as well as profound hypokalemia.
The lasix gtt was discontinued, and he was bolused with IV lasix
to maintain volume status. On days prior to discharge, tolerated
oral lasix and remained euvolemic. Discharged on torsamide 40mg
daily.
# Acute Renal Failure: Admission Cre was 1.1. This rose to 1.9
on the 25th. [**Last Name (un) **] largely believed to be [**12-22**] to poor pump
function in the setting of volume overload. ACEI was not started
early in course of treatment given [**Last Name (un) **]. Lisinopril started once
[**Last Name (un) **] resolved.
# AMS: Per family, he has a hx of becoming delirious while
hospitalized. Upon initial transfer to the CCU on the 23rd, he
was A&Ox3. However, his mental status progressively declined.
He became agitated and beligerent, ultimately requiring
olanzapine, haldol, trazadone. He was finally intubated and
sedated to allow for cardiac cath. Neuro checks revealed no
focal deficit. Additionally, his AMS did not appear to be [**12-22**]
to metabolic derangements. As such, it was likely [**12-22**] to ICU
delirium. Upon extubation, he was placed on a precedex gtt.
His mental status cleared considerably, and the precedex gtt was
turned off. Mental status appeared to recover completely prior
to transfer to the floor and remained that way until discharge.
# Afib: During his stay he was continued on his home metoprolol
and amiodarone. His coumadin was held then resumed later. He
experienced paroxysmal afib while in house, but remained in
sinus rhythm for the majority of the hospital stay.
CHRONIC
# HYPERCHOLESTEROLEMIA
Continued on home dose of atorvastatin 80 po qd
# HTN:
Continued on home dose of metoprolol, had his nifedipine
stopped.
# ANEMIA:
Stool guaiac was negative in the ED. Hgb 9.4 on admission to
9.1 on discharge [**5-18**]
# BLADDER CA:
stable no current therapy and possibly the cause of hematuria
# LUMBAR DJD:
stable
TRANSITIONAL
# Will require repeat TTE for evaluation of EF and further
evaluation for possible ICD placement in ~1 mo.
# Follow up with cardiology for possible elective
revascularization of LAD.
# Please check chemistry panel on [**2192-5-19**]. Consider checking
every other day in setting of relatively new diuretics.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Metoprolol Tartrate 50 mg PO BID
hold if hr <55, sbp < 90
3. Docusate Sodium 100 mg PO BID
4. Amiodarone 200 mg PO DAILY
5. Warfarin 2.5 mg PO DAILY16
except on Fridays 5mg
6. NIFEdipine CR 90 mg PO DAILY
hold if sbp < 90
7. Atorvastatin 80 mg PO DAILY
8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
hold if SBP < 90
9. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 Tablet(s) by mouth Daily Disp #*28 Unit
Refills:*3
2. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 Tablet(s) by mouth Daily Disp #*28
Capsule Refills:*4
3. Acetaminophen 650 mg PO Q6H:PRN pain
4. Amiodarone 200 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Warfarin 2.5 mg PO 6X/WEEK ([**Doctor First Name **],TU,WE,TH,FR,SA)
2.5 mg every day except Monday
9. Warfarin 5 mg PO 1X/WEEK (MO)
Monday
10. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 Tablet(s) by mouth Daily Disp
#*28 Unit Refills:*3
11. Torsemide 40 mg PO DAILY
12. Nystatin Ointment 1 Appl TP QID:PRN for skin irritation
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare - [**Location (un) 1887**]
Discharge Diagnosis:
Primary Diagnosis:
Myocardial Infarction c/b systolic heart failure wtih EF of 30%
Secondary Diagnosis:
Respiratory Distress
Acute Kidney Injury
Hypertension
Hypercholesterolemia
Altered Mental Status
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname 8922**],
You initially came to the hospital with complaints of chest pain
and shortness of breath. You were found to have had a heart
attack. You were admitted to the cardiology service for
management but developed further difficulty breathing and
required a breathing tube. You were then taken to the cath lab
and stents were placed in your heart vessels to open the
blockages. Your breathing improved greatly after the procedure.
Medication Changes:
STOP:
-Imdur
-nifedipine
-metoprolol tartate
START:
-lisinopril 2.5mg daily
-metoprolol succinate XL 100mg daily
-torsemide 40mg daily
Followup Instructions:
Name: [**Last Name (LF) 8923**],[**First Name3 (LF) 275**] S.
Location: [**Hospital3 **] INTERNISTS
Address: [**2192**], [**Apartment Address(1) 8924**], [**Location (un) 8925**],[**Numeric Identifier 8926**]
Phone: [**Telephone/Fax (1) 8927**]
Appointment: Tuesday [**2192-5-22**] 11:30am
Name: Dr. [**Known firstname 122**] [**Last Name (NamePattern1) **]
Location: [**Hospital1 **] Hospital - [**Location (un) 620**]
Address: [**Street Address(2) 3001**] [**Location (un) 620**] [**Numeric Identifier 3002**]
Phone: [**Telephone/Fax (1) 4105**]
Appointment: Thursday [**2192-5-31**] 9:45am
Department: VASCULAR SURGERY
When: THURSDAY [**2192-7-12**] at 11:15 AM
With: VASCULAR LAB [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: VASCULAR SURGERY
When: THURSDAY [**2192-7-12**] at 11:15 AM [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: VASCULAR SURGERY
When: THURSDAY [**2192-7-12**] at 12:00 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1490**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
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71,027
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38375
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Discharge summary
|
report
|
Admission Date: [**2131-5-4**] Discharge Date: [**2131-5-10**]
Date of Birth: [**2048-9-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
82 year old female with significant PMH including DM type 2,
HTN, atrial fibrillation, CAD, COPD and pulmonary fibrosis who
is transferred from [**Hospital 1562**] Hospital for continued management
of [**Last Name (un) **], altered mental status, resolving sepsis and afib with
recent digoxin toxicity.
.
History was obtained from chart as patient is unable to provide
information. She initially presented to [**Hospital 1562**] Hospital on
[**4-24**] with fever to 101, malaise and chills. She was seen in the
ED there and was diagnosed with a UTI based on a mildly positive
UA. She was put on Keflex PO for 2 days without improvement.
Urine culture showed mixed flora. She re-presented with several
days of loose stool and continued fevers to 101 and chills. She
denied any localizing symptoms, but did endorse anorexia for 5
days.
.
At [**Hospital1 1562**], she was found to have a pseudomonal UTI and
subequently developed hypotention, fever and presumed
pseudomonal urosepsis. She was treated initially with
doxy/levaquin prior to culture, then with Cefepime which was
switched to Imipenem. On the second day of hospitalization, she
developed acute respiratory failure requiring intubation and
transfer to the ICU. This was thought to likley be flash
pulmonary edema and cardiogenic in nature. She required
pressors in the ICU and was extubated 6 days prior to transfer.
She did not require further pressors. She was then transferred
to the medical floor. She was found to be confused without
focal neurologic deficits and was seen by Neurology who felt
supportive care with MRI and possible EEG after stabilization
would be indicated. She was also found to have an NSTEMI
thought to be demand related as well as rapid afib treated with
digoxin. This led to junctional bradycardia which was treated
with digibind on the morning of transfer. She also developed
acute renal failure with a peak creatinine of 3.8. She was
treated with hydration. Nephrology at OSH thought this was
likely ATN due to sepsis. This has begun to improve. She
additionally has had intermittent nausea and vomiting as well as
elevated lipase/amylase. No source was found on abdominal US.
She had loose stools and a negative C. Diff x1; however, she was
empirically started on PO vancomycin. And finally, she was
found to have swelling in her left arm after infiltration of an
IV and was found to have a DVT of L cephalic vein. Given
thrombocytopenia, a HIT Ab was drawn which was equivocal and IgM
APLA was positive, she was started on an Argatroban drip. She
was given 2 units prbcs for a low Hct at 23%.
.
On the floor, the patient is alert but not oriented. She is
weak but able to follow simple commands. She states she feels
weak but denies any pain.
.
Review of sytems: Patient is unable to provide. Denies pain,
shortness of breath. She does endorse weakness and malaise.
Past Medical History:
PMHx:
-DM type 2
-GIB 2nd AVM
-CAD with recent positive stress test (apical ischemia)
-CKD, baseline Cr 1.2
-Pulmonary fibrosis
-[**Last Name (LF) 9215**], [**First Name3 (LF) **] 60% prior
-PVD
-COPD
-Refractory HTN
-Chronic low back pain
-Old LBBB
-Afib
-Gout
-Hyperlipidemia
.
[**Hospital1 1562**] hospitalization prior to transfer:
-Pseudomonal urosepsis
-Acute respiratory failure
-Acute on chronic [**Hospital1 9215**]
-NSTEMI
-[**Last Name (un) **]
-Pancreatitis
-?Type 2 HIT
-+IGM APLA
Social History:
Independent with ADLs at home. Does not smoke, drink or use
drugs.
Family History:
NC
Physical Exam:
Afebrile 108/75 75 20 98% on 1.5 L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: +mild bibasilar rales, significantly improving over past
several days.
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
Pertinent Results:
[**2131-5-4**] 08:03PM BLOOD WBC-10.2 RBC-4.15* Hgb-12.5 Hct-38.1
MCV-92 MCH-30.1 MCHC-32.8 RDW-15.0 Plt Ct-202
[**2131-5-8**] 06:34AM BLOOD WBC-9.5 RBC-3.49* Hgb-10.4* Hct-32.1*
MCV-92 MCH-29.7 MCHC-32.4 RDW-15.3 Plt Ct-127*
[**2131-5-9**] 05:44AM BLOOD WBC-8.3 RBC-3.64* Hgb-10.9* Hct-33.2*
MCV-91 MCH-29.8 MCHC-32.7 RDW-15.4 Plt Ct-123*
[**2131-5-10**] 05:25AM BLOOD WBC-7.5 RBC-3.43* Hgb-10.2* Hct-31.1*
MCV-91 MCH-29.8 MCHC-32.9 RDW-15.5 Plt Ct-124*
[**2131-5-7**] 06:00AM BLOOD PT-14.0* PTT-81.5* INR(PT)-1.2*
[**2131-5-8**] 06:34AM BLOOD PT-15.8* PTT-74.0* INR(PT)-1.4*
[**2131-5-9**] 05:44AM BLOOD PT-18.8* PTT-32.2 INR(PT)-1.7*
[**2131-5-10**] 05:25AM BLOOD PT-20.4* PTT-35.5* INR(PT)-1.9*
[**2131-5-5**] 05:14AM BLOOD ACA IgG-PND ACA IgM-PND
[**2131-5-5**] 05:14AM BLOOD Lupus-NEG
[**2131-5-5**] 05:14AM BLOOD Glucose-250* UreaN-74* Creat-2.2* Na-146*
K-4.0 Cl-117* HCO3-20* AnGap-13
[**2131-5-8**] 06:34AM BLOOD Glucose-231* UreaN-58* Creat-1.8* Na-142
K-4.1 Cl-113* HCO3-20* AnGap-13
[**2131-5-9**] 05:44AM BLOOD Glucose-148* UreaN-54* Creat-1.7* Na-145
K-4.0 Cl-114* HCO3-22 AnGap-13
[**2131-5-10**] 05:25AM BLOOD Glucose-138* UreaN-50* Creat-1.6* Na-144
K-3.9 Cl-113* HCO3-24 AnGap-11
[**2131-5-4**] 08:03PM BLOOD ALT-21 AST-22 LD(LDH)-474* AlkPhos-74
Amylase-592* TotBili-0.4
[**2131-5-7**] 06:00AM BLOOD ALT-14 AST-19 AlkPhos-61 Amylase-577*
TotBili-0.3
[**2131-5-7**] 04:06PM BLOOD CK(CPK)-29
[**2131-5-8**] 01:37AM BLOOD CK(CPK)-31
[**2131-5-8**] 12:18PM BLOOD CK(CPK)-51
[**2131-5-4**] 05:08PM BLOOD Lipase-[**2098**]*
[**2131-5-4**] 08:03PM BLOOD Lipase-[**2124**]*
[**2131-5-5**] 05:14AM BLOOD Lipase-[**2149**]*
[**2131-5-6**] 03:48AM BLOOD Lipase-1691*
[**2131-5-7**] 06:00AM BLOOD Lipase-1631*
[**2131-5-7**] 04:06PM BLOOD CK-MB-3
[**2131-5-8**] 01:37AM BLOOD CK-MB-3
[**2131-5-8**] 12:18PM BLOOD CK-MB-9
[**2131-5-10**] 05:25AM BLOOD Phos-2.9 Mg-1.8
[**2131-5-6**] 03:48AM BLOOD Albumin-2.8* Calcium-8.8 Phos-3.1 Mg-2.3
[**2131-5-5**] 05:14AM BLOOD VitB12-878 Folate-18.1
[**2131-5-4**] 08:03PM BLOOD TSH-1.5
[**2131-5-5**] 12:00AM BLOOD HEPARIN DEPENDENT ANTIBODIES- Equivocal
EKG: Probable sinus tachycardia with atrial premature beats.
Left bundle-branch block. No previous tracing available for
comparison.
CHEST PORT. LINE PLACEMENT [**2131-5-5**] IMPRESSION: PICC line at
right SVC/RA junction.
Cardiac Echo: Conclusions
The left atrium is dilated. A small secundum atrial septal
defect is present. Left ventricular wall thicknesses and cavity
size are normal. There is mild regional left ventricular
systolic dysfunction with moderate to severe hypokinesis of the
inferior and inferolateral segments and of the mid to distal
lateral segments. Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Mild focal LV systolic dysfunction consistent with
CAD (inferior ischemia/infarction). Mild mitral regurgitation.
Mild pulmonary artery systolic hypertension. Small secundum ASD.
Brief Hospital Course:
82 year old woman with PMH significant for HTN, DM type II, PVD,
CAD, [**Hospital 9215**] transferred from OSH for continued management of
hypertension, resolving sepsis, [**Last Name (un) **], afib with RVR and diarrhea.
.
# Severe sepsis (at OSH): Appears to have been in the setting of
pseudomonal UTI. Pt had been off of pressors and had been
extubated for several days prior to transfer to [**Hospital1 18**]. The
patient was continued on cefepime for pseudomonal coverage and
has completed 13/14 days of IV Cefepime by the time of discharge
from [**Hospital1 18**] to acute rehab. Culture data was obtained from
[**Hospital 1562**] Hospital which showed pan-sensitive pseudomonas. Due
to the fact that her course of antibiotics was nearing
completion by the time culture data was available, it was
decided to complete the entire coures on Cefepime.
.
# Acute on chronic diastolic heart failure
Pt noted to have episode of flash pulmonary edema requiring
intubation at [**Hospital 1562**] Hospital. Pt found to have acute
decompensated [**Hospital 9215**] at [**Hospital1 18**] on [**5-7**] which responded well to
Lasix 40 iv x 1. Pt was subsequently started on oral lasix which
was uptitated to Lasix 60 mg po BID by the time of discharge,
due to ongoing pulmonary bibasilar rales and mild oxygen
requirement. Renal function has been improving despite diuresis.
The lasix dose will need to be titrated on an ongoing basis,
and her weight should be followed, as she is incontent of urine.
Unfortunately, her dry weight is not currently known.
.
# Diarrhea: Pt had significant diarrhea throughout most of the
hospitalization. C. Diff negative x1 but started empirically on
PO vanco at [**Hospital1 1562**] and Flexiseal was placed. Repeat C.diff was
negative at [**Hospital1 18**], so metronidazole and oral vancomycin were
discontinued. She continued to have diarrhea at [**Hospital1 18**], which is
thought likely an ADR to Cefepime; hopefully her diarrhea will
improve after completion of her course.
.
# NSTEMI: Pt was found to have a Troponin up to 30 at [**Hospital1 1562**],
likely in the setting of demand ischemia with known CAD as well
as flash pulmonary edema/[**Hospital1 9215**]. Cardiac echo showed EF of 40-45%
and mild focal LV systolic dysfunction consistent with CAD
(inferior ischemia/infarction), mild mitral regurgitation, mild
pulmonary artery systolic hypertension, and a small secundum
ASD. She was continued on aspirin, carvedilol, and simvastatin.
ACE inhibitor was held for acute kidney injury, and remains held
at this time. ACE should be resumed once her renal funciton
improves. If her blood pressure is too low to tolerate an
additional blood pressure medication at that time, consider
discontinuation of clonidine.
.
# Altered mental status/Acute delirium:
Pt was found to have an acute delirium on admission, which was
likely toxic-metabolic encephalopathy. Pt's mental status
continued to improve throughout the hospitalization.
.
# Atrial fibrillation: Currently in sinus, but was tachy and
irregular when arrived, in atrial fibrillation. She is being
anticoagulated for DVT with heparin gtt bridge to warfarin, but
it is not clear if she had documented atrial fibrillation prior
to this admission. Heart rate was generally well controlled. The
patient was started on warfarin, with a goal INR [**1-17**], given
CHADS2 score of 4. INR was 1.9 upon transfer to the acute rehab.
Warfarin dosing: pt has been given warfarin 5 mg po q 1600
[**Date range (1) 83456**]. Please see results section for corresponding INR
values for past several days.
.
# Hypernatremia: Admission Na+ level 150. Likely from poor
access to PO fluid. The patient was given multiple hypotonic
fluid infusions to bring her serum [Na+] down. The hypernatremia
resolved and did not recur.
.
# Elevated amylase/lipase: Pt was noted to have significantly
elevated lipase/amylase, although pt denies abdominal pain,
though the patient had reportedly been experiencing intermittent
nausea/vomiting at that time. Her nausea and vomiting had
resolved prior to admission. Amylase was measured in the high
500s and lipase around [**2120**] at [**Hospital1 18**], and trended down. Pt did
not complain of any symptoms suggestive of pancreatitis during
this admission.
.
# Thrombocytopenia: Negative but borderline HIT Ab. Patient was
on argatroban from tranfer from [**Hospital1 1562**]. Argatroban was
discontinued upon arrival, and the patient was restarted on
heparin gttinstead. Platelets were monitored and remained
stable; pt does not have HIT.
.
# Diabetes Mellitus, Type 2: Fingersticks were checked and
glucose was controlled with insulin sliding scale. Pt was
started on Lantus 8 units q HS on [**5-9**], and will need further
titration as needed.
.
# Hypertension: Pt reportedly had a hypertensive emergency at
[**Hospital1 1562**]. Is noted to have "refractory" HTN in admission notes.
On lopressor, lasix, amlodipine, catapres and lisinopril at
home. Upon arrival to [**Hospital1 18**], lopressor was held given reported
digoxin toxicity with junctional bradycardia. Lisinopril was
held given [**Last Name (un) **]. Her clonidine and amlodipine were continued, and
she was started on carvedilol. Her blood pressures were well
controlled on the floor. Consider restarting ACE when renal
function improves, as above.
.
# LUE DVT: Per report in the setting of infiltrated peripheral
line. The patient had no personal or family history of prior
clotting disorders. She was started on warfarin, and INR at time
of transfer to rehab was 1.9. She should continue heparin gtt
until INR is [**1-17**] x at least 48 hours.
.
# Digoxin toxicity: Pt reportedly had digoxin toxicity at
[**Hospital 1562**] Hospital prior to transfer. THis resolved with one dose
of digibind.
.
# Acute renal failure: Likely ATN in the setting of sepsis,
hypotention. Creatinine continued to improve throughout the
hospitalization, and was 1.6 at the time of dishcarge.
.
Code: Full
DISP: discharge to LTAC for ongoing care.
Medications on Admission:
Medications on Transfer:
Acetaminophen Liquid 640 mg Q6H prn
Argatroban 3 mcg/kg/min
Regular insulin SS
Lopressor 5 mg IV Q4H
3L NC O2
Prilosec 20 mg daily
Vancomycin 125 mg PO BID
Allpurinol 100 mg QAM
?Imipenem
.
Medications at home:
Prilosec 20 mg daily
Lopressor 100 mg [**Hospital1 **]
Iron 325 mg daily
Catapres 0.25 mg daily
Simvastatin 40 mg daily
Lasix 20 mg daily
Allopurinol 100 mg daily
Glipizide 5 mg PO BID
Amlodipine 10 mg daily
MVI daily
Lisinopril 5 mg daily
Tylenol 650 mg Q6H prn pain
Discharge Medications:
1. Amlodipine 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
2. Simvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
3. Clonidine 0.2 mg/24 hr Patch Weekly [**Hospital1 **]: One (1) Patch Weekly
Transdermal QFRI (every Friday).
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO TID
(3 times a day).
6. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Warfarin 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAYS
([**Doctor First Name **],MO,TU,WE,TH,FR,SA): Please monitor INR closely and titrate
prn for goal INR [**1-17**].
8. Carvedilol 12.5 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO BID (2 times
a day).
9. Miconazole Nitrate 2 % Powder [**Month/Day (3) **]: One (1) Appl Topical TID
(3 times a day) as needed for fungal rash.
10. Acetaminophen 325 mg Tablet [**Month/Day (3) **]: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
11. Furosemide 20 mg Tablet [**Month/Day (3) **]: Three (3) Tablet PO BID (2
times a day): Please titrate as needed.
12. Cefepime 2 gram Recon Soln [**Month/Day (3) **]: One (1) Recon Soln Injection
Q24H (every 24 hours) for 1 doses: Pt's final dose is [**2131-5-10**] at
20:00.
13. Continue Heparin gtt as per sliding scale
14. 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.
15. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
16. Insulin Glargine 100 unit/mL Solution [**Month/Day/Year **]: Eight (8) units
Subcutaneous at bedtime.
17. Humalog 100 unit/mL Solution [**Month/Day/Year **]: As per sliding scale units
Subcutaneous QACHS: as per sliding scale provided.
18. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
# Severe sepsis due to pseudomonas urinary tract infection
# Acute on chronic diastolic heart failure
# NSTEMI at OSH
# Acute delirium
# Atrial fibrillation
# Elevated pancreatic enzymes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted in transfer from [**Hospital 1562**] Hospital for
multiple medical problems, including sepsis from a urinary tract
infection, heart failure, atrial fibrillation, DVT, and
confusion. You have gotten much better, but you still need
ongoing medical care which you will receive at an acute rehab.
Followup Instructions:
Please continue to titrate Lasix dose as appropriate for [**Hospital 9215**].
Please continue heparin gtt for atrial fibrillation and DVT
until INR is therapeutic ([**1-17**]) for at least 48 hours.
Pt should receive her last dose of Cefepime 2 gm IV x 1 at 8 pm
tonight.
Please continue to increase her lantus dose as needed for
improved glycemic control.
|
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19,953
| 137,095
|
4679
|
Discharge summary
|
report
|
Admission Date: [**2118-12-24**] Discharge Date: [**2118-12-28**]
Date of Birth: [**2046-12-23**] Sex: M
Service: MEDICINE
Allergies:
Oxycodone/Acetaminophen / Mirapex
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
72 year old male with CAD s/p CABG in [**2107**] (LIMA to LAD, SVGs to
OM1 and PDA), DM1, CVA x2, CHF (EF 40%), complete heart block
s/p dual chamber pacer/ICD, and ESRD s/p transplant in [**2117-1-19**]
s/p pulseless arrest w/ CPR x2 minutes then reportedly had
pulse, 'narrow complex,' but bagged for few minutes then woke
up.
.
He states that he was walking back from playing [**Last Name (un) 19768**] when he
began to feel short of breath. The next thing he knew, he was
on the ground w/ people around him. He felt clear-headed when
he awoke. + L Lateral chest wall pain from where CPR was
performed.
.
On review of symptoms, he denies any prior history of 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,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
Past Medical History:
Diabetes type 1 c/b neuropathy, retinopathy, nephropathy (HgbA1c
7.3 in [**5-16**])
Hypertension
CAD status post CABG ([**2107**]; LIMA to LAD, SVGs to OM1 and PDA)
Stroke (right ACA and left PCA)
Peripheral vascular disease s/p B iliac artery stents
H/o thromboembolism ([**2118**])
ESRD status post cadaveric renal transplant ([**1-/2117**])
Peripheral neuropathy
Chronic obstructive pulmonary disease.
Systolic CHF (EF 40% on [**2-/2118**])
Hypercholesterolemia
Hypothyroidism
CRI (baseline Cre 1.4)
Osteoporosis
H/o cardiac arrest during HD
Depression
BPH
H/o seizures ([**2106**], [**2107**])
.
Cardiac Risk Factors: +Diabetes, +Dyslipidemia, +Hypertension
.
Cardiac History: CABG, in [**2107**] at [**Hospital1 112**]: CABG at the [**Hospital1 756**] was
LIMA to LAD, SVG to PPDA, and SVG to ramus. Cath in [**2113**] at the
[**Hospital1 756**] showed the grafts and lima to be patent, but there was a
99% lesion in the ramus and a 70% lesion in the LCx, both of
which required atherectomy/PTCA
.
Pacemaker/ICD placed in [**2118-9-23**]: ICD, Vitality DS T125 placed
for CHB and VT
Social History:
Social EtOH use. Smoked 1 ppd x 35 yrs, quit [**2116**]. Lives
alone, retired accountant for an electrical company. Does all
ADLs.
Family History:
Father died of MI at 62. Brother [**Name (NI) 19762**]. Brother CAD. Sister DM2.
Physical Exam:
VS: T 96, BP 128/44, HR 69, RR 14, O2 91 % on RA, 96% on 2L.
Gen: WDWN older male in NAD, resp or otherwise. Oriented x3.
Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 9 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
Regularly irregular, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. + bibasilar crackles.
Abd: Soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: No c/c/e + arterial insufficiency changes (hairless legs)
Skin: No stasis dermatitis, ulcers, scars, or xanthomas
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Left: Carotid 2+ without bruit; Femoral 2+ with bruit; 1+ DP
Pertinent Results:
Labs:
[**2118-12-24**] 07:05PM BLOOD WBC-4.4 RBC-4.05* Hgb-12.6* Hct-38.7*
MCV-96 MCH-31.0 MCHC-32.4 RDW-14.0 Plt Ct-247
[**2118-12-25**] 06:11AM BLOOD WBC-4.6 RBC-3.78* Hgb-11.6* Hct-36.4*
MCV-96 MCH-30.7 MCHC-31.9 RDW-14.2 Plt Ct-291
[**2118-12-24**] 07:05PM BLOOD Neuts-51.6 Lymphs-40.8 Monos-4.8 Eos-2.6
Baso-0.2
[**2118-12-24**] 07:05PM BLOOD PT-19.4* PTT-31.4 INR(PT)-1.8*
[**2118-12-25**] 06:11AM BLOOD PT-18.1* PTT-124.1* INR(PT)-1.7*
[**2118-12-25**] 01:13PM BLOOD PT-16.5* PTT-81.4* INR(PT)-1.5*
[**2118-12-27**] 06:00AM BLOOD PT-20.5* PTT-51.3* INR(PT)-1.9*
[**2118-12-25**] 06:11AM BLOOD D-Dimer-3865*
[**2118-12-24**] 07:05PM BLOOD Glucose-159* UreaN-43* Creat-1.6* Na-138
K-4.5 Cl-103 HCO3-21* AnGap-19
[**2118-12-26**] 05:22AM BLOOD Glucose-50* UreaN-52* Creat-1.9* Na-141
K-4.5 Cl-104 HCO3-24 AnGap-18
[**2118-12-27**] 06:00AM BLOOD Glucose-110* UreaN-51* Creat-1.7* Na-137
K-5.0 Cl-105 HCO3-23 AnGap-14
[**2118-12-24**] 07:05PM BLOOD CK(CPK)-93
[**2118-12-25**] 06:11AM BLOOD CK(CPK)-83
[**2118-12-25**] 01:13PM BLOOD CK(CPK)-89
[**2118-12-24**] 07:05PM BLOOD cTropnT-0.04*
[**2118-12-25**] 06:11AM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2118-12-25**] 01:13PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2118-12-24**] 07:05PM BLOOD Calcium-8.6 Phos-5.6*# Mg-2.0
[**2118-12-25**] 06:11AM BLOOD Calcium-8.4 Phos-4.5 Mg-1.9
[**2118-12-25**] 01:13PM BLOOD Calcium-8.5 Phos-4.0 Mg-1.9
[**2118-12-26**] 05:22AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.1
[**2118-12-27**] 06:00AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.0
[**2118-12-26**] 05:22AM BLOOD Carbamz-5.6
.
Imaging/Studies:
EKG demonstrated SR (atrial bigemeny) 72, nl axis, nl LVH, 1st
degree AV block. No ST/TW changes
.
TELEMETRY demonstrated: atrial bigemeny
.
ECHO [**12-26**]: The left atrium is moderately dilated. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction with hypokinesis of the
inferior wall, inferior septum and apex. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2046-12-23**],
there is now a wire seen in the right atrium and right
ventricle. The other findings are similar.
.
Exercise stress: IMPRESSION: No anginal type symptoms or
ischemic EKG changes. Nuclear report sent separately.
.
p-MIBI: IMPRESSION:
1. Unchanged moderate, fixed perfusion defect involving the
distal anterior
wall, apex and distal inferior wall. 2. Moderately dilated LV.
Prominent RV. 3. Global hypokinesis most significant at the
apex. 4. LVEF = 33%.
.
Rib film: INDICATION: Cardiac arrest, status post CPR. Evaluate
for rib fractures.
No acute, displaced anterior rib fractures are identified, but
these radiographs are relatively insensitive for detecting
anterior fractures. Slight deformity of the sixth posterolateral
rib may be due to normal variation or old injury. There is no
evidence of pneumothorax.
Heart is mildly enlarged, and there is slight vascular
redistribution and perivascular indistinctness consistent with
mild CHF, with improvement from the recent radiograph. ICD
pacing device remains in standard position.
IMPRESSION:
1. No evidence of acute anterior displaced rib fracture or
pneumothorax, but anterior fractures can be difficult to detect
radiographically.
2. Improving CHF.
.
NON-CONTRAST HEAD CT
FINDINGS: There is no evidence of hemorrhage, mass effect, shift
of midline structures, hydrocephalus, or recent infarction.
Encephalomalacia involving the right and left occipital lobes is
consistent with old PCA distribution infarcts and there is
evidence of old lacunar infarcts involving the right caudate
nucleus as noted on prior exams. Atherosclerotic disease within
the anterior and posterior circulation. Soft tissues and osseous
structures appear unremarkable. Paranasal sinuses and mastoid
air cells are well aerated.
IMPRESSION:
No evidence of recent infarction. Unchanged sequelae of old
infarctions as described above.
.
BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale and Doppler
son[**Name (NI) 1417**] of the right common femoral, superficial femoral, and
popliteal veins demonstrate normal flow, compressibility,
augmentation, and waveforms. No intraluminal thrombus is
identified.
IMPRESSION: No evidence of bilateral lower extremity DVT.
.
EKG: Sinus rhythm with what appears to be ventricular pacer
activity in the form of pseudofusion complexes. First degree A-V
delay. Left atrial abnormality. Probable prior anterolateral
myocardial infarction. Non-specific ST-T wave changes. Clinical
correlation is suggested. Since the previous tracing of [**2118-12-25**]
pacer activity is less evident.
Brief Hospital Course:
# S/p Arrest versus syncope: Patient was reported to be
pulseless by bystander at the time of his event who then
initiated CPR. Once EMS arrived, patient was found to be have
narrow complex tachycardia with hypertension. Patient ruled out
for MI. EP interogated pacer/ICD and found no evidence of
arrythmia or shocks that could have resulted in syncopal event.
D-dimer elevated, however, V/Q scan with low probability for PE
and bilateral LENIs negative for DVT. Also, patient with stable
oxygen saturation, and no other signs of symptoms of PE. Head
CT showing evidence of old PCA stroke, no active bleed. P-Mibi
unchanged from prior. Still unknown etiology of event as it is
unclear as to whether patient was in fact pulseless. patient
had no events while inpatient and no arrythmias on telemetry
other than atrial bigeminy on his first day of admission. He was
discharged on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts events monitor with follow up
with Dr. [**First Name (STitle) 437**].
.
# CAD/Ischemia: CAD status post CABG ([**2107**]; LIMA to LAD, SVGs to
OM1 and PDA). No current ischemic symptoms and no chest pain
prior. Patient has a mild troponin leak, but does have renal
insufficiency and appears at his baseline. He will continue on
aspirin 325, Lipitor 40 mg, Toprol XL 25 [**Hospital1 **]. Given his
increased creatinine, we have held his lisinopril. He will
follow up with renal transplant team in one week to have his
labs checked to determine when to restart this medication as an
outpatient. Patient was instructed to weigh himself daily and to
call Dr. [**Last Name (STitle) **] if his weight increases by more than 3 pounds
or if he has increased LE edema.
.
# Pump: Systolic heart failure, Chronic. EF 40-45% on ECHO, 33%
on p-MIBI. Per renal transplant, we have held his lasix. He
should restart this as an outpatient as per renal transplant's
recommendations.
.
# Hypoxia: Noted to be 90-92% on RA and on ambulation. Was 93%
on RA during last admission. There is a question of COPD which
he denies although he does have a smoking history. He will
follow up on his pulmonary function with his PCP as an
outpatient with possible PFT evaluation.
.
# Rhythm: Atrial bigemeny resolved. History of complete heart
block and inducible VT for which he has a dual chamber
pacer/ICD. Pacer interogated by EP as above with no evidence of
arrythmia or heart block.
.
# Valves: No significant valvular disease.
.
# HTN: BP well-controlled on Metoprolol. Holding lisinopril in
the setting of acute renal failure as above.
.
# DM: Diabetes type 1 complicated by neuropathy, retinopathy,
nephropathy (HgbA1c 7.3 in [**5-16**]). Continued on home regimen of
NPH 16 units in the morning and 9 units at bedtime w/ Humalog
per sliding scale.
.
# ESRD: Status post cadaveric renal transplant (1/[**2117**]).
Baseline Cr 1.4, up to 1.9 during admission, trending down at
the time of discharge. Likely ATN, non-oliguric hemodynamically
mediated in the setting of hypotension. As per renal transplant
recommendations, holding ACEI and Lasix as above. Patient will
continue on his home regimen of Bactrim, CellCept [**Pager number **] mg four
times a day, Prograf 2 mg twice a day.
.
# Hypothyroidism: Synthroid 137 mcg daily
.
# Anemia: Appears to be at patient's baseline.
.
# Peripheral neuropathy: Patient will continue on Tegretol-XR
400 mg twice a day. Tegretol levels within normal limits.
.
# H/o arterial embolism to finger: On coumadin at home. Was
subtherapeutic at the time of admission so was intiated on
heparin drip. INR therapeutic at the time of discharge.
.
# BPH: Continued on home dose of Flomax.
.
# Code: Full but would not want prolonged intubation or feeding
tube
.
# Communication: HCP [**Name (NI) **] [**Name (NI) 4587**] ([**Telephone/Fax (1) 19769**]
Medications on Admission:
Aspirin 81 mg daily
Lipitor 60 mg daily
Tegretol-XR 400 mg twice a day
Lasix 60 mg daily
NPH 16 units in the morning and 9 units at bedtime
Humalog per sliding scale
Synthroid 137 mcg daily
lisinopril 5 mg daily
Toprol-XL 50 mg daily
CellCept [**Pager number **] mg four times a day
Prograf 2 mg twice a day
Flomax daily
Bactrim daily
warfarin as directed
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Carbamazepine 200 mg Tablet Sustained Release 12 hr Sig: Two
(2) Tablet Sustained Release 12 hr PO BID (2 times a day).
3. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
4. Atorvastatin 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
5. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
7. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
8. Warfarin 2 mg Tablet Sig: Four (4) Tablet PO DAILY16 (Once
Daily at 16).
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
10. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: As
directed Subcutaneous As directed: Take 16 units in the morning
and 9 units in the evening.
12. Insulin Lispro 100 unit/mL Cartridge Subcutaneous
13. Outpatient Lab Work
Please have labwork drawn on [**2119-1-4**] at Dr. [**Last Name (STitle) 6729**] office
including BUN/Cr and PT/INR levels. This will determine you
coumadin dosing and whether or not you need to restart your
lasix and lisinopril medications.
Please have your INR level faxed to the [**Company 191**] [**Hospital 3052**]. Their phone number is [**Telephone/Fax (1) 2173**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Syncope
.
Secondary diagnoses:
Coronary artery disease
Chronic systolic CHF
ESRD s/p cadaveric transplant
Type I DM
Hypertension
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
While you were here, the electrophysiologists determined that
you did not have an arrythmia and your ICD did not shock you. In
addition, it was determined that you did not likely have a
pulmonary embolism or a heart attack that lead to your syncopal
event. You heart was evaluated by ultrasound, and you do not
appear to have any significant disease of the valves of your
heart.
It is very important that you take all medications as prescribed
and keep all of your follow up appointments. We are currently
holding two of your medications: Lasix and Lisinopril as
requested by the renal transplant service. You should restart
lisinopril at a lower dose (2.5mg daily) after you are
discharged. You should not take the Lasix until you follow up
with the transplant service to determine when you should restart
this medication.
If you have another similar event, or if you experience any
chest pain, increased shortness of breath, significant weakness
or any other symptom that concerns you, you should call your
doctor [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the nearest emergency room as soon as
possible.
Followup Instructions:
Please keep the follow appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2119-1-17**] 9:45
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2119-1-17**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5377**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2119-1-31**] 10:00
|
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"357.2",
"250.41",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14584, 14642
|
8834, 12665
|
305, 312
|
14815, 14824
|
3693, 8811
|
16104, 16601
|
2725, 2807
|
13072, 14561
|
14663, 14673
|
12691, 13049
|
14848, 16081
|
2822, 3674
|
14694, 14794
|
258, 267
|
340, 1445
|
1467, 2558
|
2574, 2709
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,584
| 195,420
|
47683
|
Discharge summary
|
report
|
Admission Date: [**2113-12-27**] Discharge Date: [**2114-1-2**]
Date of Birth: [**2045-10-2**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
hypothermia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness: 68 yo man with h/o alcoholism,
glaucoma (legally blind) was out drinking last night and found
down in the snow since 3:30am and found to be hypothermic to
88-93F at 7:30am. Apparently he was out walking in the snow
intoxicated last night trying to find his friend who owed him
money. He then dropped his cane and his pants started to fall
down and in the effort to pull up his pants fell in the snow and
was down for likely approximately 4 hours. He thinks he landed
on his hip but does not remember which one. He tried to yell for
help without success. He thinks he lost consciousness for
periods at a time. He then recalls waking up again and yelling
for help after which someone shoveling snow luckily found him
and called EMS. EMS found his temp on the field to be 88F. They
warmed him with blankets and brought him to the ED.
In the ED, initial vs were: 96.8 95 134/84 20 100% NRB. He only
made 250cc of urine throughout his Tmin was 33.5C. He warmed
nicely with a warming blanket. His labs were notable for an
anion gap of 20, bicarb of 12, lactate of 5.5 after 3LNS, Cr of
1.9, CK of 549. The patient was given 5L of NS, and 1 L of D5
1/2NS after BS of 50. His last set of vitals prior to transfer
were 36.3 (98F) 102/59 14 98%2LNC.
On the floor, the patient denied any symptoms and wanted to eat
a meal.
Review of systems:
(+) Per HPI, does report new mild sore throat and cough with
sputum.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies orthopnea, weight changes. Denies nausea, vomiting,
diarrhea, constipation, abdominal pain, or changes in bowel
habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
1) Glaucoma - legally blind
2) Alcoholism
3) Lost to medical care for 4 years
Social History:
Family lives in [**Location 3320**], he does not want them notified.
- Tobacco: [**11-26**] PPD
- Alcohol: 1 pint of alcohol/day
- Illicits: None ("because I can't afford them")
Family History:
Brother died of alcoholic cirrhosis. Two sisters died of breast
cancer at unknown age.
Physical Exam:
On Admission to the MICU:
Vitals: T: 99.6 BP: P: R: 18 O2:
General: Alert, oriented, thin elderly man in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, surgical pupils
Neck: supple, JVP midway up neck at 45 degrees, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi, diffusely reduced breath sounds
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley with clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN 2-12 intact, [**3-29**] UE flexion/extension bilaterally, [**2-27**]
RLE flexion/extension of hips/calves [**12-27**] pain per patient all
[**3-29**] on LLE. Light touch intact throughout. Patellar reflexes 1+
bilaterally. Downgoing toes bilaterally. Pt answering questions
normally.
Pertinent Results:
Admission Labs:
[**2113-12-27**] 07:50AM BLOOD WBC-12.4* RBC-4.13* Hgb-14.1 Hct-41.5
MCV-101* MCH-34.1* MCHC-34.0 RDW-14.6 Plt Ct-128*
[**2113-12-27**] 07:50AM BLOOD Neuts-75* Bands-8* Lymphs-11* Monos-6
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2113-12-27**] 07:50AM BLOOD PT-12.9 PTT-30.7 INR(PT)-1.1
[**2113-12-27**] 07:50AM BLOOD Glucose-79 UreaN-20 Creat-1.9* Na-137
K-3.9 Cl-102 HCO3-12* AnGap-27*
[**2113-12-27**] 07:50AM BLOOD ALT-47* AST-85* CK(CPK)-549* AlkPhos-95
TotBili-0.5
[**2113-12-27**] 07:50AM BLOOD Calcium-10.2 Phos-7.6* Mg-2.5
[**2113-12-27**] 02:14PM BLOOD calTIBC-300 VitB12-205* Folate-8.5
Hapto-101 Ferritn-213 TRF-231
Tox:
[**2113-12-27**] 07:50AM BLOOD Acetone-NEGATIVE
[**2113-12-27**] 09:30AM BLOOD Osmolal-314*
[**2113-12-27**] 07:50AM BLOOD ASA-4.1 Ethanol-128* Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
ABG:
[**2113-12-27**] 02:39PM BLOOD Type-[**Last Name (un) **] pO2-64* pCO2-28* pH-7.33*
calTCO2-15* Base XS--9 Comment-ROOM AIR
Lactate:
[**2113-12-27**] 09:36AM BLOOD Lactate-5.5*
[**2113-12-27**] 02:39PM BLOOD Lactate-1.4
Surveillance labs:
[**2113-12-30**] 06:00AM BLOOD WBC-4.8 RBC-3.44* Hgb-11.2* Hct-32.7*
MCV-95 MCH-32.6* MCHC-34.3 RDW-15.1 Plt Ct-83*
[**2113-12-30**] 06:00AM BLOOD Glucose-95 UreaN-9 Creat-0.7 Na-139
K-3.0* Cl-110* HCO3-22 AnGap-10
[**2113-12-30**] 06:00AM BLOOD ALT-32 AST-58*
[**2113-12-30**] 06:00AM BLOOD Calcium-8.6 Phos-2.6* Mg-1.6
Studies:
ECG Study Date of [**2113-12-27**] 8:01:06 AM
Sinus rhythm with borderline sinus tachycardia. Prominent T
waves are
non-specific and may be within normal limits but clinical
correlation is
suggested. No previous tracing available for comparison.
TRACING #1
BILAT HIPS (AP,LAT & AP PELVIS) Study Date of [**2113-12-27**] 8:46 AM
IMPRESSION: No evidence of fracture or dislocation. Radiopaque
amorphous
bodies measuring up to 1.1 cm overlie the lateral aspect of the
femoral neck and proximal shaft.
Radiopaque amorphous bodies measuring up to 1.1 cm overlie the
soft tissue
lateral to the left femoral neck and proximal femoral shaft,
difficult to
discern whether external to the patient or foreign bodies.
Clinical
correlation advised.
CHEST (PORTABLE AP) Study Date of [**2113-12-27**] 4:06 PM
IMPRESSION: Opacities at the left and right base. These could be
further
characterized by a PA and lateral radiograph as they could
represent early
pneumonia or aspiration.
Micro biology:
[**2113-12-29**] 2:02 am URINE Source: CVS.
URINE CULTURE (Preliminary):
PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Brief Hospital Course:
# Hypothermia: The most likely etiology is exposure to the
elements in a blizzard for four hours. Patient remained
euthermic after rewarming and has no signs or sx of frostbite
damage to his extremities. His glucose and electrolytes have
remained stable. His EKG and telemetry reveal no arrythmias. No
e/o coaggulopathy with normal INR and normal fibrinogen.
# Anion gap metabolic acidosis: Patient initially presented with
an anion gap acidosis without a concominant nongap acidosis most
likely from a combination of lactic acidosis and alcoholic
ketoacidosis that has come down after feeding and rehydration.
His lactate was likely elevated secondary to hypothermia and
peripheral vasoconstriction and has now resolved to 1.4 after
rewarming and rehydration. He has subsequently developed a
concominant hyperchloremic nongap acidosis after 5L of NS. His
VBG confirmed this metabolic acidosis of 7.33 (which is
reassuring level) with appropriate respiratory compensation.
# Oliguric acute kidney injury: Most likely secondary to
rhabdomyelysis and possibly dehydration. Improved markedly after
fluid rescucitation. Currently making adequate urine.
# Rhabdomyelysis: Likely from being down overnight and possibly
from shivering/hypothermia. His CK trended downward and his
creatinine improved to 0.7. His UA showed blood without RBCs,
making myoglobinuria likely.
# Megaloblastic anemia: Most likely secondary to chronic
alcoholism. His MCV improved with nutritional supplementation.
His B12 was low, so we started B12 supplementation.
# Fall: Most likely a combinaion of deconditioning, blindness
leading to poor co-ordination, alcoholic neuropathy and
low-level neurological irritability from etoh withdrawl.
Physical therapy evaluated him and recommended a [**Hospital1 1501**] for rehab.
# Thrombocytopenia: Likely from myelosuppression from alcohol
abuse. Other possibilities include chronic liver dysfunction
such as cirrhosis. He has a palpable liver tip, but does not
have splenomegaly. Would benefit from abstinence of alcohol.
# Alcoholism: Patient arrived intoxicated with elevated alcohol
levels and alcohol on his breath. He was monitored with a CIWA
scale, but did not score, and he was started on supplementation
with thiamine, folate, multivitamin, and vitamin B12.
# Transfer of care: He was transferred to rehab for strength and
stability training. He will need PCP [**Name9 (PRE) 702**] upon discharge
from his rehab facility.
Medications on Admission:
None
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet
PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hypothermia
Lactic acidosis
Alcohol ketoacidosis
Myoglobinuria
Acute renal failure
Megaloblastic anemia
Thrombocytopenia
Alcohol abuse
Secondary:
Glaucoma, legally blind
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:
Mr. [**Known lastname **],
It was a pleasure taking part in your care. You were admitted
after being found in the snow and your temperature was low. You
were taken warmed up and monitored in the ICU overnight.
During your stay, you had multiple lab abnormalities that were
likely because of your alcohol intake as well as falling and
being out in the cold for multiple hours.
You were given IV fluids to help your kidney function, and
antibiotics for a urinary tract infection. We started you on a
lot of nutrition supplements (vitamins) to help supplement your
diet.
Physical therapy worked with you, and because you were unsteady
they recommended a short stay at a rehab facility to help get
you strong enough to go home.
We made the following changes to your medications:
-START thiamine 100mg daily
-START folic acid 1mg daily
-START multivitamin 1 tab daily
-START Vitamin B12 50mcg daily
-START Ciprofloxacin 500mg twice a day for 7 days (until
[**2114-1-5**])
Please choose a primary care physician to follow you as an
outpatient
Followup Instructions:
Please schedule an appointment to follow-up with a primary care
physician [**Name Initial (PRE) 176**] 2 weeks of discharge from rehab
Completed by:[**2114-1-3**]
|
[
"E885.9",
"303.01",
"276.51",
"E001.0",
"305.1",
"266.2",
"276.2",
"728.88",
"287.49",
"E901.0",
"584.9",
"263.9",
"781.3",
"041.6",
"357.5",
"365.9",
"276.8",
"791.3",
"599.0",
"369.4",
"285.8",
"251.1",
"991.6"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9011, 9017
|
6195, 8650
|
315, 322
|
9240, 9240
|
3616, 3616
|
10490, 10655
|
2565, 2653
|
8705, 8988
|
9038, 9219
|
8676, 8682
|
9423, 10174
|
2668, 3597
|
10203, 10467
|
1712, 2251
|
264, 277
|
6090, 6172
|
378, 1693
|
3632, 6061
|
9255, 9399
|
2273, 2353
|
2369, 2549
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,830
| 102,862
|
21367
|
Discharge summary
|
report
|
Admission Date: [**2103-4-24**] Discharge Date: [**2103-5-2**]
Date of Birth: [**2061-2-9**] Sex: F
Service: SURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 16769**]
Chief Complaint:
Presents with long standing diabetes for elective renal
transplant wi
Major Surgical or Invasive Procedure:
Living unrelated kidney transplant [**2103-4-24**]
History of Present Illness:
She has had no recent changes in her medical condition. Preop EF
60% and cardiac imaging shows no reversible defects. Preop labs
revealed recent hct 36.1. CMV status is negative to negative.
Past Medical History:
Type I DM
Hypothyroid
ESRD on peritoneal dialysis
Retinopathy
Left tib-fib fracture with internal fixation
Left breast lumpectomy
restless leg syndrome
Social History:
Lives with spouse. She works as office manager. Has two children
Family History:
Pertinent Results:
[**2103-4-24**] 09:21PM GLUCOSE-257* UREA N-70* CREAT-10.5*
SODIUM-134 POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-15* ANION GAP-20
[**2103-4-24**] 09:21PM HCT-33.1*
[**2103-4-24**] 02:53PM GLUCOSE-121* UREA N-68* CREAT-11.4*#
SODIUM-137 POTASSIUM-3.3 CHLORIDE-106 TOTAL CO2-17* ANION GAP-17
[**2103-4-24**] 02:53PM CALCIUM-8.2* PHOSPHATE-3.0 MAGNESIUM-1.9
[**2103-4-24**] 02:53PM WBC-8.4 RBC-3.44* HGB-10.8* HCT-33.0* MCV-96
MCH-31.5 MCHC-32.8 RDW-15.6*
[**2103-4-24**] 02:53PM PLT COUNT-223
[**2103-4-24**] 01:23PM GLUCOSE-63* K+-3.1*
[**2103-4-24**] 01:23PM HGB-9.7* calcHCT-29
[**2103-4-24**] 12:22PM TYPE-[**Last Name (un) **] PH-7.16*
[**2103-4-24**] 12:22PM GLUCOSE-152* K+-3.1*
[**2103-4-24**] 12:22PM HGB-10.2* calcHCT-31
[**2103-4-24**] 12:22PM freeCa-1.25
[**2103-4-24**] 11:30AM TYPE-[**Last Name (un) **] PH-7.14*
[**2103-4-24**] 11:30AM HGB-11.3* calcHCT-34
[**2103-4-24**] 11:30AM freeCa-1.28
[**2103-4-24**] 10:40AM TYPE-[**Last Name (un) **] PO2-85 PCO2-47* PH-7.19* TOTAL
CO2-19* BASE XS--10
[**2103-4-24**] 10:40AM GLUCOSE-365* K+-4.3
[**2103-4-24**] 10:40AM HGB-11.2* calcHCT-34
[**2103-4-24**] 10:40AM freeCa-1.25
Brief Hospital Course:
Taken to OR on [**2103-4-24**] for Left iliac fossa living unrelated
renal transplant. See operative note for details. Induction
immunosuppression was initiated intraoperatively using ATG,
Solumedrol and Cellcept. There was minimal EBL with good
perfusion intra op. BP ran 110/40-80/30 with heart rate of 80.
Neo and dopamine were initiated to keep SBP greater than 120.
Urine output was low postoperatively. She was transferred to the
SICU for administration of neosynephrine and dopamine. Urine
output picked up to 100cc/hour with pressor support keeping sbp
>120. Renal ultrasound on [**4-26**] revealed "no evidence of
perinephric fluid collections or hydronephrosis. There is flow
in the main renal artery and vein. There is no detectable
diastolic flow within the upper, mid, or lower poles." Prograf
was initiated on POD 1. One unit of PRBC was given for hct of
27.5 on POD 2. Repeat hct was 33.8. Urine output decreased to
36-40cc/hour. She was medicated with morphine sulfate pca for
pain with fair relief. Creatinine dropped from 11.8
preoperatively to 8.8 on POD 2.
Nephrology followed the patient closely and recommended IV
hydration with 1/2 saline and d/c of neosynephrine as urine
output was ~30ml/hour. Glucoses ran in the 300 range. This was
managed with an insulin drip. Glucoses improved to the low 100s.
The [**Last Name (un) **] attending was consulted and Lantus insulin was
initiated in addition to sliding scale humalog when the insulin
drip was stopped. She will follow up with [**Last Name (un) **] as an
outpatient for diabetes management.
She was transferred to the transplant unit on POD 3 after
neosynephrine and dopamine were stopped. BP was stable at
115-125/60. She was started on po bicarb for level of 15. WBC
dropped to 1.5 on POD 4. This was felt to be partially related
to cellcept. She received six doses of ATG. A repeat ultrasound
was done on [**2103-4-29**]. This demonstrated "a slight increase in
diastolic flow within the mid upper and mid pole compared to
[**2103-4-26**]. No diastolic flow is seen within the lower pole. A
normal venous waveform is seen within the renal vein. Resistive
indices in the upper pole and mid pole measure 0.82 in both
locations. Flow velocities appear similar to those on [**4-26**]".
Delayed graft function occurred for the remainder of the
hospital stay. Urine output averaged 1200-945ml/24 hours. She
was started on Lasix on [**4-29**] for significant edema. She denied
shortness of breath, nausea and vomiting. Peritoneal dialysis
was initiated via tenckhoff catheter at low volume dwells 1.5
liter 1.5% on [**4-30**] (POD 6). She did not tolerated these dwells
very well due to abdominal fullness and pain over LLQ. She was
unable to pull off fluid and was actually positive 250cc on POD
7. Leg edema decreased a small amount, but weight remained above
dry weight.
Physical therapy was consulted as she experienced difficulty
ambulating secondary to fluid retention. PT did not recommend
need for rehab and felt that she would be able to manage at home
with PT.
The wbc dropped on POD 6 to 1.7. She received neupogen 480mg sc
once and valcyte was decreased to every other day. WBC increased
to 12.9 after neupogen.
On POD 8 it was decided that patient could be discharged home
without peritoneal dialysis as she was not short of breath,
nauseated or so edematous that she couldn't ambulate. She was
tolerating a regular diet and moving her bowels. Pain was
moderately well controlled with oral dilaudid. Percocet were
ineffective. Dialysis was stopped secondary to leaking of clear
fluid from tenckhoff site and discomfort. JP was removed on pod
7.
In conjunction with nephrology, it was decided to discharge
[**Known firstname **] with follow up labs in 2 days. PT, PTT and INR was
ordered in anticipation of biopsy to rule out rejection versus
delayed graft function. A tranplant kidney biopsy was scheduled
for Monday [**5-7**] with labs ordered for Friday [**5-4**]. Labs on
discharge were as follows:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2103-5-2**] 06:00AM 11.5* 2.81* 8.5* 26.7* 95 30.5 32.0 16.1*
141*
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2103-5-2**] 06:00AM 141*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2103-5-2**] 06:00AM 102 92* 6.6*#1 139 3.2* 102 22 18
ADDED TSH [**2103-5-2**] 4:00PM
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2103-5-2**] 06:00AM 8.0* 5.6* 2.1
ADDED TSH [**2103-5-2**] 4:00PM
PITUITARY TSH
[**2103-5-2**] 06:00AM PND
ADDED TSH [**2103-5-2**] 4:00PM
TOXICOLOGY, SERUM AND OTHER DRUGS FK506
[**2103-5-2**] 06:00AM 9.51
1 TARGET 12-HR TROUGH (EARLY POST-TX): [**4-27**] [24-HR TROUGH 33-50%
LOWER]
She was discharged on lasix 100mg, prograf 4mg [**Hospital1 **] and cellcept
1 gram [**Hospital1 **]. She was set up to have VNA services as glargine
insulin was new and a home safety eval was recommended. She will
follow up with Dr. [**Last Name (STitle) 15473**] as an outpatient.
Medications on Admission:
levoxyl 137mcg po qam, renagel 1800mg with meals and snacks,
hecterol daily Monday thru Friday, zantac prn, Insulin Humulin
regular in dialysate 32-46 units, 4x/day. Humalog sliding scale.
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed: tylenol.
5. Levothyroxine Sodium 137 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed.
7. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-10**] Sprays Nasal
QID (4 times a day) as needed.
8. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
9. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO every [**3-14**]
hours as needed.
Disp:*30 Tablet(s)* Refills:*0*
10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12
hours).
11. Clotrimazole-Betamethasone 1-0.05 % Cream Sig: One (1) Appl
Topical HS (at bedtime) for 5 days.
Disp:*1 * Refills:*0*
12. Valganciclovir HCl 450 mg Tablet Sig: One (1) Tablet PO QOD
().
13. Insulin Glargine 100 unit/mL Solution Sig: Fourteen (14)
units Subcutaneous at bedtime.
14. Insulin Lispro (Human) 100 unit/mL Solution Sig: sliding
scale Subcutaneous every four (4) hours: follow sliding scale.
15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
16. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO BID (2
times a day).
17. Lasix 20mg tab: take 5 tabs every am for dose of 100mg qam.
Discharge Disposition:
Home With Service
Facility:
Community VNA, [**Location (un) 8545**]
Discharge Diagnosis:
Living unrelated kidney transplant [**2103-4-24**]
end stage renal failure [**1-10**] Type I Diabetes
Type I DM
Retinopathy
Hypothyroidism
Gerd
Discharge Condition:
stable
Discharge Instructions:
Call if fevers, chills, nausea, vomiting, inability to take
medications, increased abdominal pain, decreased urine output,
increased incisional or PD catheter site leaking. [**Telephone/Fax (1) 673**]
Labs on Friday [**5-4**] CBC, chem 7, calcium, phosphorus, ast,
t.bili, PT, PTT, INR, urinalysis and trough prograf level with
results fax'd to transplant office. THEN LABS as follows:
Labs every Monday & Thursday for cbc, chem 7, calcium,
phosphorus, ast, t.bili, urinalysis, and trough prograf level.
Labs to be fax'd immediately to transplant office [**Telephone/Fax (1) 697**]
No Peritoneal dialysis until notified by MD
No heavy lifting
No driving while taking pain medication
[**Month (only) 116**] shower
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15475**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2103-5-8**] 11:20
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2103-5-18**] 11:10
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK Where:
TRANSPLANT SOCIAL WORK Date/Time:[**2103-5-18**] 12:00
Follow up with [**Name8 (MD) **] MD: Walzcek. Call to schedule appointment
Completed by:[**2103-5-2**]
|
[
"585",
"250.41",
"276.2",
"996.81",
"276.1",
"285.9",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.92",
"54.98",
"55.69"
] |
icd9pcs
|
[
[
[]
]
] |
9005, 9075
|
2093, 7144
|
336, 389
|
9263, 9271
|
903, 2070
|
10032, 10676
|
884, 884
|
7383, 8982
|
9096, 9242
|
7170, 7360
|
9295, 10009
|
227, 298
|
417, 609
|
631, 785
|
801, 867
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,635
| 190,582
|
50072
|
Discharge summary
|
report
|
Admission Date: [**2126-1-25**] Discharge Date: [**2126-1-30**]
Date of Birth: [**2068-11-10**] Sex: F
Service: MEDICINE
Allergies:
Azmacort / Clindamycin / Versed / Fentanyl / Morphine / Optiray
300 / Ceftriaxone / Clarithromycin
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Hypotension, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
57 y/o f with h/o dyemyelinating syndrome, restrictive lung
defect FVC 52%, h/o recurrent aspiration pneumonias, s/p G tube
placement c/b gastrocutaneous fistula, s/p J tube placement [**4-19**]
but removed due to intolerance, who was recently admitted and
discharged [**2126-1-9**] after treatment for aspiration pneumonia, now
p/w fever, nausea, RLQ pain, and RL back pain x 4 days. The pt
states that her RLQ pain is sharp, [**9-24**], intermittent, without
alleviating or exacerbating factors, unrelated to position or
eating. She does not think her back pain is necessarily related
to her RLQ pain. Her nausea has not been accompanied by
emesis. The pt states she had a day of watery diarrhea 2 weeks
ago accompanied by lower abdominal pain and alleviated with
defecation. Over the past 4 days the pt has had a fever up to
107 and up to 103/104 after purchasing a new thermometer. She
has had a persistent cough ever since her last discharge,
productive of green sputum starting the day PTA. She also c/o
nasal congestion starting over the past several days; also she
has had decreased po intake x 4 days. Two weeks ago the pt also
had an episode of vaginal and rectal bleeding; she is followed
by OBGYN Dr. [**First Name (STitle) **] for her h/o vaginal bleeding. Of note, pt
states she completed her full course of prednisone and
levofloxacin after her last discharge.
.
In the ED initially she was febrile to 102.6, BP 113/60, then
became hypotensive to BP 64/39, not responsive to 4L NS (bp up
to only 86/38), unsuccessful IJ attempt, so R femoral line was
placed, and levophed at 0.15 was started. With levophed her BP
rose to 130/79, so it was titrated down to 0.1. She was also
given Levofloxacin, Vancomycin, and Flagyl, as well as combivent
nebs and Decadron 10 mg IV x1.
Past Medical History:
-Mod to severe aspiration per S and S eval [**1-20**]
-Asthma.
-Restrictive lung disease [**1-17**] neuromusc disorder (FEV1 63% of
pred, FVC 52% of pred, FEV/FVC 121 of pred)
-Demyelinating syndrome (L leg paresis, bilateral arm
weakness, demyelination on brain MRI, neurogenic bladder)
-History of Adrenal insufficiency though not chronically
maintained on prednisone
-Osteoporosis.
-Hypothyroidism.
-History of chest nodules.
-Dyslipidemia.
-History of breast papilloma with nipple discharge.
-Anxiety.
-Labile hypertension.
-History of right IJ thrombus in [**2112**].
-IgG deficiency.
-Anemia.
-Status post cholecystectomy in [**2112**].
-Dysfunctional uterine bleeding by history.
-Atypical pap smears.
-Common bile duct stenosis s/p sphincterotomy.
-Gastritis and prepyloric ulcers per EGD.
-Bilateral hearing loss.
-G-tube placement leading to gastrocutaneous fistula --> removal
of G-tube and placement of J-tube in [**4-19**]
-MRI [**1-20**]: multiple T2 hyperintense lesions in the cerebral
white matter are to some extent visible on prior CTs and may be
related to the history of post-infectious encephalomyelitis vs
MS
[**Name13 (STitle) **] [**8-19**]: nl systolic function, EF 55%, no diastolic
dysfunction
Social History:
Quit tobacco 20 years ago, occ ETOH, no illicits; lives in S.
[**Location (un) 86**] with husband and daughter, does not work but does
volunteer
Family History:
CAD. Father had [**Name2 (NI) 499**] cancer, her mother had breast cancer, and
her sister had brain cancer.
Physical Exam:
PE: T 96.8 HR 81 BP 109/51 R 16-26 Sat 94%2LNC
HEENT:ROMI PERRL, face symmetric, MMM, BL maxillary sinus ttp
Neck: +HJR, no cervical or supraclavicular LAD
CHEST: hyperresonant to percussion throughout, diffuse
expiratory wheezing, 1:3 I:E ratio, poor inspiratory effort,
decreased breath sounds throughout, diffuse rales
CV: RRR, Grade 3/6 SEM LLSB, nl S1/S2
ABD: soft, NABS, voluntary guarding to palpation of epigastrium
and RL quadrant, no rebound tenderness, no palpable masses,
unable to assess for HSM due to vol. guarding
EXT: No edema or rash, extrem warm
Neuro: CN II-XII grossly intact, [**3-20**] strenght throughout R arm
and R leg, 3/5 L biceps, triceps, and grip strength, 0/5
strength in L leg, a and o x3
Pertinent Results:
IMAGING:
.
CXR on admission:
INDICATION: Dyspnea and abdominal pain.
There is no free air seen under the diaphragm. Some mild
increased interstitial markings are visualized with Kerley B
lines noted. There is some blunting at the left costophrenic
sulcus and increased retrocardiac density suggesting either
atelectasis or pneumonia. Pulmonary vascular markings within
normal limits.
IMPRESSION:
No free air under the diaphragm. Possible left atelectasis
versus pneumonia in the retrocardiac region.
.
Transvaginal U/S:
1. No evidence of an endometrial abnormality on limited
evaluation.
2. Ovaries not visualized. No adnexal abnormalities identified.
3. Small amount of free fluid.
.
CXR:
chest findings have deteriorated during the last short time
interval now presenting bilateral basal parenchymal infiltrates
most of them located in the posterior segments as seen on the
lateral view. Comparison is also made with a previous chest
examination of [**1-10**] at which time these infiltrates on the
bases were already noted more marked on the left than on the
right side. On a more remote examination of [**2125-11-15**],
these basal infiltrates were suspicious for representing
aspiration pneumonias. Similar cause for the now new developed
basal infiltrates is reasonable. It is noted that the patient
has been scheduled for chest CT. IMPRESSION: New bilateral
basal infiltrates consistent with aspiration pneumonitis.
.
CT abdomen:
1. No focal abscess is identified.
2. Small amount of free fluid around the liver, without
definite etiology identified.
3. Stable low attenuations within the liver, too small to
characterize.
4. Stable low attenuations within both kidneys, too small to
characterize.
.
ADMIT LABS:
[**2126-1-25**] 01:40AM BLOOD WBC-9.4 RBC-3.64* Hgb-12.5 Hct-36.2
MCV-100* MCH-34.3* MCHC-34.5 RDW-13.4 Plt Ct-309
[**2126-1-25**] 11:45PM BLOOD WBC-11.1* RBC-2.74* Hgb-9.2*# Hct-27.7*
MCV-101* MCH-33.6* MCHC-33.3 RDW-13.7 Plt Ct-272
[**2126-1-25**] 01:40AM BLOOD Neuts-81.9* Lymphs-11.2* Monos-4.2
Eos-0.3 Baso-2.4*
[**2126-1-25**] 01:40AM BLOOD Macrocy-1+
[**2126-1-25**] 01:40AM BLOOD PT-12.3 PTT-26.7 INR(PT)-1.1
[**2126-1-25**] 01:40AM BLOOD Plt Ct-309
[**2126-1-26**] 06:15AM BLOOD Ret Aut-1.2
[**2126-1-25**] 01:40AM BLOOD Glucose-111* UreaN-14 Creat-1.0 Na-138
K-3.1* Cl-103 HCO3-21* AnGap-17
[**2126-1-25**] 01:40AM BLOOD ALT-15 AST-17 CK(CPK)-48 AlkPhos-72
Amylase-38 TotBili-0.1
[**2126-1-25**] 01:40AM BLOOD Lipase-16
[**2126-1-25**] 11:45PM BLOOD Lipase-18
[**2126-1-26**] 06:15AM BLOOD Lipase-18
[**2126-1-25**] 01:40AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2126-1-25**] 01:40AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.6
[**2126-1-28**] 03:44AM BLOOD calTIBC-247* Ferritn-161* TRF-190*
[**2126-1-25**] 11:45PM BLOOD TSH-0.15*
[**2126-1-25**] 06:57PM BLOOD Cortsol-26.5*
[**2126-1-25**] 06:19PM BLOOD Cortsol-20.4*
[**2126-1-25**] 05:20PM BLOOD Cortsol-2.7
[**2126-1-26**] 06:16PM BLOOD Vanco-12.3*
[**2126-1-25**] 08:15PM BLOOD Type-ART Temp-36.7 pO2-43* pCO2-53*
pH-7.16* calHCO3-20* Base XS--10 Intubat-NOT INTUBA
[**2126-1-25**] 09:23PM BLOOD Type-ART Temp-36.7 pO2-53* pCO2-61*
pH-7.15* calHCO3-22 Base XS--8 Intubat-NOT INTUBA
[**2126-1-25**] 01:48AM BLOOD Lactate-1.0
[**2126-1-25**] 08:15PM BLOOD Lactate-4.7*
.
DISCHARGE LABS:
[**2126-1-30**] 06:15AM BLOOD WBC-8.7 RBC-3.76* Hgb-11.9* Hct-35.8*
MCV-95 MCH-31.7 MCHC-33.3 RDW-14.9 Plt Ct-259
[**2126-1-27**] 05:07AM BLOOD Neuts-82.4* Lymphs-14.2* Monos-3.2
Eos-0.1 Baso-0.2
[**2126-1-27**] 05:07AM BLOOD WBC-5.8 RBC-3.41* Hgb-11.3* Hct-32.9*
MCV-97 MCH-33.1* MCHC-34.3 RDW-16.1* Plt Ct-222
[**2126-1-27**] 05:07AM BLOOD Anisocy-1+ Poiklo-1+ Macrocy-1+
[**2126-1-30**] 06:15AM BLOOD Plt Ct-259
[**2126-1-30**] 06:15AM BLOOD Glucose-77 UreaN-18 Creat-0.6 Na-149*
K-3.2* Cl-107 HCO3-32 AnGap-13
[**2126-1-30**] 06:15AM BLOOD ALT-33 AST-14 AlkPhos-129* TotBili-0.2
[**2126-1-30**] 06:15AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.7
Brief Hospital Course:
On admission the pt was placed on continuous albuterol nebs.
Levophed was weaned off within several hrs and her SBP initally
held in the 90s. Given rales on lung exam and elevated JVP, the
pt was given Lasix 10 mg IV x1. She diuresed 1 L, however her
BP dropped back into the 70s. The pt was restarted on levophed
with a 1L NS bolus. ABG: 7.23, 49, 41 with lacate up to 4.9.
Hct dropped from 36.2 to 27.7. Stat AXR and CT chest/abdomen
was unrevealing for hemorrhage, obstruction, ischemia, or other
acute process to explain the lactate, hypotension, and RLQ pain.
Wet read on CT abdomen showed no ileus, collapsed SB, dilated
large bowel at 3 cm, and small amt of increased free fluid in
the pelvis. The pts LFTs also increased that night, likely due
to hepatic congestion. The pts [**Last Name (un) 104**] stim test was normal,
however given that no etiology of the pts hypotension could be
identified, the pt was started on hydrocort/fludrocort on the
night of admission. She was also transfused 2 units of PRBC for
her hct drop. Following 2units PRBC and 1 L NS bolus, the pts
lactate dropped to 1.0. Repeat CT abdomen/pelvis/chest was
unrevealing for a source of bleed. The pts levophed gtt was
quickly titrated off the day following admission and the pts BP
was stable. She required lasix 20 mg IVx1 on HD3 for mild
volume overload. The etiology of the pts fever and hypotension
remained unclear.
.
A/P: 57 y/o f with h/o demylinating syndrome, restrictive lung
defect FVC 52%, h/o recurrent aspiration pneumonias p/w c/o RLQ
pain and fever, found to be hypotensive with fever in the ED.
.
#Hypotension/ID: SIRS vs dehydration vs blood loss. Pt was
noted to be febrile in the ED, with tachycardia, and hypotension
resistant to fluids. Source of infection is unclear. WBC was
not initially elevated but has risen to 11 with L shift.
Lactate also rose up to 4.9. UA negative. CT of the abdomen is
negative for infectious process or etiology to explain RLQ pain;
repeat CT negative for acute pathology as well. Overnight pt had
10 pt hct drop and SBP dropped back to the 70s requiring
reinitiation of levophed gtt and 1 L NS. Treated with broad
spectrum antibiotics. Cultures did not grow anything. Switched
to prednisone from hydrocort/fludricort and discharged with plan
to taper off over 3 days with plan for endocrine followup. HD
stable on discharge.
.
#O2 requirement/Hypercarbia: Asthma vs. volume overload vs.
aspiration. Pt likely has reactive airway component given
wheezing on exam, however she seemed initially to be volume
overloaded s/p 4 L NS in ED. She had elevated JVD, signs of
overload on CXR. Pt was s/p Lasix 10 mg IV x1 with 1 L diuresis
prior to hypotension, requiring fluids again. ABG: 7.23/49/41 on
2LNC, but after placed on BIPAP with 40%FIo2, ABG: 7.37/43/140.
Oxygenation improved while on the floor; on discharge was
using O2 by N/C; she has this at home
.
#Elevated lactate: Pts lactate rose on admission from 1 up to
4.9. Given concern for ab pathology, AXR and CT abdomen were
ordered, but neither revealed a source for infection/ischemia.
CT lungs also negative for gross infiltrate. Lactate down to 1.1
this am after 1 L NS bolus and 1 unit PRBC. Lactate resolved
and etiology of rise remained unclear.
.
#Acidosis: Pt had both resp and metabolic acidosis. Resp
component likely due to reactive airway, metabolic component
likely due to lactic acidosis. Pt also has a non-gap acidosis,
likely related to receiving NS. On d/c acidosis resolved.
.
#Anemia/Hct drop: Pt hct dropped from 36 to 27 on DOA. Given no
clear etiology, it is possible pt was initially hemoconcentrated
on admission and pts hct dropped s/p aggressive fluid
resuscitation. CT abdomen negative for acute hemorrhage. T
Bili and LDH wnl (aka no hemolysis). Coags wnl. s/p 2 units
PRBC transfusion. On d/c HCT stable. Guiaic negative.
.
#RLQ pain: Unclear etiology. CT negative for pathology but does
show distended loops of large bowel. Pt reports no BM for 7
days. Had BM on floor prior to d/c. Also had TV ultrasound not
demonstrating clear pathology.
.
#Elevated LFTs: LFTs and alk phos rose during the night of
admission, felt to be due to hepatic congestion s/p fluid
resuscitation. Should be followed up as an outpatient.
.
# NMD: Continued her on her outpatient medications/muscle
relaxants of tizanidine and baclofen
.
# Anxiety: Continued her outpatient medications of buspar and
klonopin
.
#Aspiration: Pt has mod-severe dysphagia and aspiration per
video eval. Asp precautions; pt referred to another GI for eval
for PEG (as Dr. [**Last Name (STitle) 2161**] feels that PEG is not warranted and does
not decreased asp risk), pt was intolerant of J tube. Pt. kept
on aspiration precautions. Also kept on regular diet as she
refused thickened liquids/dysphagia diet. She was aware of the
risks of aspiration.
Medications on Admission:
ADVAIR DISKUS 500-50MCG--Use one puff by mouth twice a day
ALBUTEROL 90GM--Take 2 puffs four times a day
ALBUTEROL SO4 0.083 %--One neb q 4-6 hrs as needed
[**Doctor First Name **] 60MG [**Hospital1 **]
BACLOFEN 20 mg TID
BUSPIRONE HCL 10MG TID
CLONAZEPAM 2 mg TID
IPRATROPIUM BROMIDE 14 GM--2-3 puffs inh four times a day
LEVOXYL 50MCG qd
LIPITOR 10MG--One by mouth every day
Ativan 2 mg TID
Protonix 40 mg
Vit B12
Folate
ASA 325
Vit D
[**Hospital1 **] 8 mg TID
.
MEDS on TRANSFER:
Vancomycin HCl 1000 mg IV Q 12H
Fexofenadine 60 mg PO BID
Baclofen 10 mg PO TID
Aspirin 325 mg PO DAILY
Levothyroxine Sodium 50 mcg PO DAILY
BusPIRone 10 mg PO TID
Tizanidine HCl 8 mg PO TID
Atorvastatin 10 mg PO DAILY
Lorazepam 0.5-2 mg PO Q4-6H:PRN
Pantoprazole 40 mg PO Q24H
Cyanocobalamin 50 mcg PO DAILY
Folic Acid 1 mg PO DAILY
Vitamin D 400 UNIT PO DAILY
Senna 1 TAB PO BID:PRN
Docusate Sodium 100 mg PO BID
Acetaminophen 325-650 mg PO Q4-6H:PRN
Heparin 5000 UNIT SC TID
Levofloxacin 500 mg PO Q24H
Metronidazole 500 mg PO TID
Clonazepam 2 mg PO TID
Orabase w/ Benzocaine Paste 1 Appl TP PRN
traMADOL 50-100 mg PO Q4-6H:PRN
RISS
Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN
Prednisone 40 mg PO DAILY
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: see below for taper Tablet PO see
below for taper for 2 days: [**1-31**] - 5 mg [**Hospital1 **]
[**2-1**] - 5 mg qd
[**2-2**] - off.
Disp:*3 Tablet(s)* Refills:*0*
2. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Buspirone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. Tizanidine 2 mg Tablet Sig: Four (4) Tablet PO TID (3 times a
day).
8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Lorazepam 2 mg Tablet Sig: One (1) Tablet PO three times a
day.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
17. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
18. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
19. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Inhalation
four times a day.
20. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: [**1-18**]
Inhalation four times a day.
21. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
22. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
1. Hypotension
2. Possible Adrenal insufficiency
Secondary
1. Hypothyroidism
2. Demyelinating disease
3. Restrictive lung disease
Discharge Condition:
Good
Discharge Instructions:
You should return to the ER if you have further light
headedness, dizziness, chest pain, nausea, vomiting, abdominal
pain, shortness of breath. You should take all your medications
as directed. You should follow up at [**Hospital 191**] clinic on [**2-7**] as
below. You should finish a prednisone taper over the next two
days as directed.
Followup Instructions:
You have an appointment on [**2-7**] in [**Hospital 191**] clinic (see below). You
should be seen by the endocrine clinic in two months as well.
You have an appointment for this on [**2126-3-18**] as below.
You have the following appointment:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15101**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2126-2-7**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3031**], M.D. Date/Time:[**2126-4-22**] 12:00
Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 3972**] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2126-3-18**] 1:00
|
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"787.2",
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"300.00",
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"401.9",
"341.9",
"507.0",
"244.9",
"V16.0",
"279.03",
"458.9",
"V16.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
16488, 16494
|
8439, 13310
|
378, 385
|
16676, 16683
|
4506, 4521
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3636, 3745
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14548, 16465
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16515, 16655
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13336, 13801
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16707, 17051
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7774, 8416
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3760, 4487
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320, 340
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413, 2211
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4535, 7758
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2233, 3457
|
3473, 3620
|
13819, 14525
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,006
| 156,373
|
54671
|
Discharge summary
|
report
|
Admission Date: [**2127-5-27**] Discharge Date: [**2127-6-7**]
Date of Birth: [**2048-6-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
Abdominal distention, confusion
Major Surgical or Invasive Procedure:
EGD
paracentesis
History of Present Illness:
78M with cirrhosis [**12-26**] hemochromatosis, prior GI bleed who is
transferred to [**Hospital1 18**] with hypotension and for evaluation for
possible liver transplant. The patient was admitted to [**Hospital **]
Hospital on [**2127-5-24**] after his son brought him to the [**Name (NI) **] stating
that the patient had increasing abdominal distention and
confusion, worsening anorexia and lethargy over the prior [**11-25**]
months. Of note, abdomen noted to be protuberant at 5/23 PCP
visit and he was apparently admitted to [**Hospital 3278**] Medical Center one
month ago and had therapeutic 2L paracentesis (neg for SBP)
performed and was discharged a few days later with plan for GI
follow up as an outpatient. Cr in [**Month (only) **] at that time was noted to
be 1.6-1.8, had been 1.3 in [**Month (only) 547**] with normal bilirubin. Labs
at presentation this admission notable for WBC 6.2, Hct 43, PLT
212, Na 132, BUN 34, Cr 2.06, albumin 3.2, Tbili 1.2, AST 35,
ALT 6, ammonia 58. He was admitted to [**Hospital **] Hospital for
decompensated liver disease. CXR unremarkable. CT scan of the
A/P showed massive ascites, shrunken liver suggesting cirrhosis,
abdominal varices noted and esophageal varices suspected, GB
with hyperdense material and nonobstructive stone in GB neck.
Abdominal ultrasound showed GB sludge without evidence of acute
cholecystitis.
On day prior to transfer, patient underwent diagnostic and
therapeutic paracentesis with removal of 16L clear yellow fluid,
counts were 88 WBC, 462 RBC, 3% PMNs, albumin 1.6, protein 3.2,
cholesterol 45, glucose 85. He was noted to be hypotensive to
the 70s systolic post-paracentesis and he was given volume
resuscitation with crystalloid and albumin. He was also noted to
be nauseous on day of transfer, lipase normal. A R IJ CVL was
placed under sterile conditions, confirmed on CXR, and he was
given a dose of albumin 25g 25% before he was transferred to
[**Hospital1 18**] for possible liver transplant evaluation in the setting of
HRS. Labs on day of transfer notable for Cr 2.00, BUN 29, Tbili
0.5, albumin 2.6. VS at transfer: 97.7 50 90/61 18 97% RA.
Pt was admitted to the MICU and had EGD showing varices, but
couldn't be banded due to intolerance of procedure. Also noted
candidiasis so started fluc. He eceived 5% 500ml albumin and his
hypotension resolved. His renal function and encephalopathy
appeared to be improving. He was called out to the floor. On the
floor, he was pleasant, alert, oriented to place only, and had
no complaints.
Review of systems: (+) Per HPI, otherwise negative
Past Medical History:
Cirrhosis diagnosed 1 year ago, due to hemochromatosis, c/b
grade 3 esophageal varices, poral gastropathy, ascites
Hemochromatosis
prior (variceal) GI bleed in [**6-/2126**] s/p banding
Social History:
Lives in [**Hospital3 4634**] independently, divorced, girlfriend
lives in apt. above his. Retired painter. He does not, nor has
he ever, drank alcohol with any regularity and he does not
smoke.
Family History:
Mother died of cirrhosis, father died at 88 of old age, sister
with liver cancer, brother with diabetes.
Physical Exam:
Admission Exam:
General: Alert, oriented to person, [**2126**], home address, thinks
he is at [**Hospital **] Hospital on [**5-10**], no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
upper and lower denture plates noted
Skin: Spider angiomata noted on upper chest, ecchymoses on upper
extremities, no jaundice
Neck: supple, JVP not elevated, no LAD, R IJ CVL in place
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, distended with fluid wave, bowel sounds present,
no hepatosplenomegaly, non-tender throughout, no rebound or
guarding
GU: foley with clear yellow urine
Ext: slightly cool, 1+ pulses, no clubbing, cyanosis, R hand
with 1+ pitting edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred, mild asterixis
Discharge Exam:
VS: 97.6, 100s/50s-60s, 50s, 18 100% 3L
GENERAL: Elderly male, Appears comfortable
HEENT: Sclera anicteric. MM dry. Right CVL c/d/i
CARDIAC: rrr, no m/r/g
LUNGS: Decreased BS bilaterally anteriorly .
ABDOMEN: Distended, non tender, dull to percussion at the
flanks.
EXTREMITIES: 2+ pulses, no edema
NEUROLOGY: A/O 1, not cooperating with asterixis exam
SKIN: Multiple bruises on arms
Pertinent Results:
Admission labs:
[**2127-5-27**] 10:00PM BLOOD WBC-5.8 RBC-4.07* Hgb-13.1* Hct-39.9*
MCV-98 MCH-32.1* MCHC-32.8 RDW-14.9 Plt Ct-180
[**2127-5-27**] 10:00PM BLOOD PT-14.5* PTT-30.2 INR(PT)-1.4*
[**2127-5-27**] 10:00PM BLOOD Glucose-88 UreaN-28* Creat-1.7* Na-139
K-3.1* Cl-100 HCO3-30 AnGap-12
[**2127-5-28**] 03:47AM BLOOD ALT-6 AST-19 LD(LDH)-126 AlkPhos-35*
TotBili-0.9
[**2127-5-28**] 03:47AM BLOOD proBNP-3524*
[**2127-5-27**] 10:00PM BLOOD Calcium-8.3* Phos-1.9* Mg-2.1
[**2127-5-28**] 03:47AM BLOOD calTIBC-98* Ferritn-218 TRF-75*
[**2127-5-28**] 03:47AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2127-5-28**] 03:47AM BLOOD Smooth-POSITIVE *
[**2127-5-28**] 03:47AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2127-5-28**] 03:47AM BLOOD IgG-861
[**2127-5-28**] 03:47AM BLOOD HCV Ab-NEGATIVE
Pertinent Labs:
[**2127-6-5**] 12:18PM BLOOD WBC-5.6 RBC-3.21* Hgb-10.1* Hct-32.1*
MCV-100* MCH-31.4 MCHC-31.5 RDW-15.9* Plt Ct-81*
[**2127-6-5**] 05:04AM BLOOD PT-19.0* INR(PT)-1.8*
[**2127-6-3**] 04:53AM BLOOD Glucose-102* UreaN-41* Creat-3.9* Na-142
K-3.8 Cl-106 HCO3-24 AnGap-16
[**2127-6-4**] 06:11AM BLOOD Glucose-105* UreaN-50* Creat-4.2* Na-141
K-3.8 Cl-104 HCO3-24 AnGap-17
[**2127-6-5**] 05:04AM BLOOD Glucose-111* UreaN-57* Creat-4.3* Na-139
K-3.4 Cl-104 HCO3-22 AnGap-16
[**2127-6-5**] 05:04AM BLOOD ALT-4 AST-11 AlkPhos-33* TotBili-0.9
[**2127-5-28**] 03:47AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2127-5-28**] 03:47AM BLOOD calTIBC-98* Ferritn-218 TRF-75*
[**2127-5-28**] 03:47AM BLOOD Smooth-POSITIVE *
[**2127-5-28**] 03:47AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2127-5-28**] 03:47AM BLOOD IgG-861
[**2127-5-28**] 03:47AM BLOOD HCV Ab-NEGATIVE
Pertinent micro/path:
[**2127-5-27**] 9:50 pm URINE CULTURE (Final [**2127-5-29**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
[**2127-5-31**] 2:26 pm PERITONEAL FLUID
GRAM STAIN (Final [**2127-5-31**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2127-6-3**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
[**2127-6-2**] 12:43 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2127-6-3**]**
C. difficile DNA amplification assay (Final [**2127-6-3**]):
Reported to and read back by DR. [**Known firstname 1575**] [**Last Name (NamePattern1) 49355**], [**2127-6-3**],
9:43AM.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
[**2127-6-2**] 12:43 pm STOOL
C. difficile DNA amplification assay (Final [**2127-6-3**]):
Reported to and read back by DR. [**Known firstname 1575**] [**Last Name (NamePattern1) 49355**], [**2127-6-3**],
9:43AM.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
Blood cultures pending.
Pertinent imaging:
RUQ U/S with dopplers:
1. Limited study. Possible cavernous transformation of the
main portal vein which may be secondary to a chronic thrombosis.
There is flow within the left main portal vein.
2. Large amount of ascites.
3. Nodular and echogenic liver consistent with underlying
cirrhosis.
4. Gallstones and sludge within the gallbladder.
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 valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global biventricular systolic
function. No valvular pathology or pathologic flow identified.
CXR: There has been placement of a right IJ central line with
distal
lead tip at the cavoatrial junction. The heart size is within
normal limits. There are no pneumothoraces. Lungs are grossly
clear. Bony structures are intact.
Brief Hospital Course:
This is a preliminary discharge summary. Full to be written.
78M with hemochromatosis leading to cirrhosis complicated by
variceal bleed, portal gastropathy, and ascites who is
transferred with hypotension, elevated creatinine, concern for
HRS, and evaluation for liver transplant. Patient's condition
worsened and decision was made to pursue hospice/CMO.
.
# Hypotension:
The pt was afebrile and infectious workup was negative. We
believed this was most likely related to fluid shifts and
intravascular volume loss s/p 16L removal during paracentesis.
He was aggressively hydrated with fluid and albumin, and his BP
improved before he was called out to the floor. On the floor, he
received an additional unit of albumin and was then stable. He
appeared euvolemic on exam. His blood pressure remained stable
on the floor w/ sbps in 80s-100s range.
# C.Diff colitis: Patient was found to have positive C. diff
test in setting of diarrhea. He was started on flagyl (Day 1 =
[**6-3**], end date [**6-17**]) with PO Metronidazole. Diarrhea
improving. Will continue for 14day course.
# Cirrhosis: known previously to be due to hemochromatosis. RUQ
U/S did not visualize main portal vein but noted patent right
portal vein. Multiple serologies and antibodies were sent for
cirrhosis workup. Lactulose was started PO with improvement in
mild encephalopathy within first 24-48h. Though the patient
eventually refused to take PO and was not taking his lactulose
with worsening encephalopathy. Of note, he had a 3L
paracentesis on [**5-31**] given recurrence of tense ascites. The
fluid was negative for SBP. A family meeting was held and it
was determined that he was not a transplant candidate. The
patient's nutrition was extremely poor and he was not taking PO.
Discussion about a feeding tube was held and the family
determined that this measure was not within the patient's goals
of care.
.
# Acute kidney injury: Likely HRS, with Cr increasing despite
albumin resuscitation. Cr had improved to 1.7, then increased
to 4.3. Urine lytes showed a prerenal picture. He was placed on
midodrine and octreotide and daily albumin to no effect. The pt
was placed on maximum dosing of both of these medications and
his kidney failure continued to progress. The decision was made
by the pt and his family to stop this therapy as it was causing
bradycardia and urinary retention.
# Coffee ground emesis: Noted on [**5-28**] without signs of active
bleeding. He had EGD on [**5-30**] and was found to have 3 cords of
grade II varices. Could not be banded as pt did not tolerate
procedure long enough. He was maintained on infectious ppx with
CTX for 7 days and a daily PPI
# Goals of care: palliative was consulted given the poor
prognosis and decision made to pursue hospice and comfort
measures only from this juncture forward. The pt was discharged
to an extended care facility in order to provide hospice care.
The pt, the family and the medical team came to this decision
collectively.
# Bradycardia: HR noted to be in 50s at OSH, now in 50s here as
well. Could be related to nadolol, unclear when last dose
received. Nadolol held, HR remained 50s-60s.
# Coagulopathy: INR 1.4, most likely related to liver disease,
given PO Vitamin K. As his liver failure progressed his
synthetic function has decreased and his INR continued to rise
to 1.8 prior to discharge.
# Vitamin deficiencies: noted at OSH. Continued folate,
thiamine, started MVI.
# Transitional:
1. Pt was discharged to extended care facility for hospice care
2. Continue flagyl for 14 day course
3. Aspiration precautions as had mild aspiration event in
hospital
Medications on Admission:
Medications HOME:
Nadolol 20mg daily
Colace 100mg [**Hospital1 **]
Pantoprazole 40mg daily
KCl 20 mEq daily
Spironolactone 100mg daily
Furosemide 20mg daily
.
Medications TRANSFER:
Lactulose 30mL PO TID (on hold presently)
Folic acid 1 mg daily
Prilosec 20mg daily
Thiamine 100mg daily
Zofran 4mg IV Q6H:PRN nausea
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
hold for loose stools
2. Pantoprazole 40 mg PO Q24H
3. HYDROmorphone (Dilaudid) 1-2 mg PO Q3H:PRN pain, respiratory
distress
4. Lactulose 15 mL PO BID
5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
d1 [**6-3**]
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 57733**] at [**Location (un) 2203**] Nursing Center - [**Location (un) 2203**]
Discharge Diagnosis:
Liver Cirrhosis
Kidney failure
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Mr. [**Known lastname 2643**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital with low blood
pressure and abdominal discomfort from your underlying liver
disease. Unfortunately as your liver disease has progressed your
kidneys started to fail. We attempted rescue therapy for your
kidneys but unfortunately we were unsuccessful. We determined
that no further medical therapy was available to help reverse
the kidney disease. You, your family and the medical team have
decided that leaving the hospital with hospice care was the most
appropriate plan moving forward.
The following changes have been made to your medications:
STOP:
Nadolol
Furosemide
Spironolactone
CHANGE:
Lactulose 15ml twice per day
NEW:
Metronidazole every 8 hours to complete a 14 day course which
will end on [**2127-6-17**]
Hydromorphone for pain
Followup Instructions:
no further follow up is required
|
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66,014
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7956
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Discharge summary
|
report
|
Admission Date: [**2170-6-12**] Discharge Date: [**2170-6-15**]
Date of Birth: [**2105-8-24**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
left heart catheterization
History of Present Illness:
Mr. [**Known lastname 5066**] is a 54 y/o M with a history of CAD s/p BMS to
LAD in [**2158**], HTN, DM2 who presented with sudden onset chest
pain/indigestion approximately 1 hour prior to presentation to
the ED. Patient reports burning chest pain that felt like
indigestion radiating to his left arm and up his neck. He was
watching television during the onset of his symptoms. He took
his home omeprazole with no relief. He called EMS and who noted
STE in anterolateral leads. He was brought to the ambulance and
had an episode of V-fib, which responded to one shock. He
reverted to NSR after and was loaded with 150mg of amiodarone.
He was also given a aspirin 81mg.
.
When he arrived to the ED initial vitals were Pulse: 106 RR:
25, BP: 130/76, O2Sat: 95%, O2Flow: RA. A code STEMI was called
and he was taken to the cath lab which revealed significant LAD
disease primarily in-stent restenosis of his previous BMS and a
more distal occlusion that was felt to be the culprit lesion. In
the ED he was given aspirin 325mg, plavix 600mg, and started on
a heparin and amiodarone drip. EKG showed STE in V1-V4 and
pathological q waves in II, III and aVF.
.
On arrival to the floor, patient the patient was comfortable and
in no acute distress. He did note having continued indigestion
however he states that the sensation was different than what he
was experiencing previously. 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: N/A
-PERCUTANEOUS CORONARY INTERVENTIONS: BMS to LAD [**2158**]
-PACING/ICD: N/A
3. OTHER PAST MEDICAL HISTORY:
Ulcerative Colitis
PUD
OSA not on CPAP
Asthma
Social History:
He is a retired Navy consultant.
-Tobacco history: denies
-ETOH: denies
-Illicit drugs: denies
Family History:
He states that his mother has angina but had never had an
intervention. His sister has struggled with arthritis and
multiple cancers.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission exam:
GENERAL: comfortbale and in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 7 cm.
CARDIAC: RR, 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+
Left: DP 2+ PT 2+
Discharge exam:
98-99.5 74-98 109-162/57-82 RR 18 93-98% RA
Gen: comfortable, NAD, NT/ND
HEENT: sclera anicteric, PERRLA. COnjunctive pink without
cyanosis or pallor. No xanthelasma.
Neck: supple, JVP of 7
Cardiac: normal S1, S2. No murmurs, rubs, or gallops, difficult
due to adiposity.
Lungs: good air entry bilaterally, no rales, rhonchi, or
wheezes.
Abdomen: soft, non-tender, non-distended, normal bowel sounds.
no organomegaly.
Extremities: edema present to one hands-breadth below knee
Skin: no stasis ulcers, dermatitis, scars. Abundant skin lesions
on back.
Pulses: right and left DPs and PTs 2+
Pertinent Results:
[**2170-6-15**] 06:57AM BLOOD WBC-7.5 RBC-3.39* Hgb-9.9* Hct-30.4*
MCV-90 MCH-29.2 MCHC-32.6 RDW-14.8 Plt Ct-244
[**2170-6-12**] 03:30AM BLOOD WBC-12.4* RBC-4.10* Hgb-11.9* Hct-36.6*
MCV-89 MCH-29.0 MCHC-32.4 RDW-15.1 Plt Ct-225
[**2170-6-15**] 06:57AM BLOOD Plt Ct-244
[**2170-6-15**] 06:57AM BLOOD PT-14.3* PTT-73.5* INR(PT)-1.3*
[**2170-6-12**] 03:30AM BLOOD PT-12.2 PTT-150* INR(PT)-1.1
[**2170-6-12**] 03:30AM BLOOD Plt Ct-225
[**2170-6-12**] 03:30AM BLOOD Fibrino-426*
[**2170-6-15**] 06:57AM BLOOD Glucose-166* UreaN-10 Creat-0.7 Na-142
K-4.1 Cl-105 HCO3-28 AnGap-13
[**2170-6-12**] 09:08AM BLOOD Glucose-221* UreaN-18 Creat-0.8 Na-139
K-3.5 Cl-99 HCO3-28 AnGap-16
[**2170-6-13**] 02:45AM BLOOD ALT-28 AST-59* LD(LDH)-472* AlkPhos-79
TotBili-0.2
[**2170-6-14**] 06:59AM BLOOD ALT-22 AST-29
[**2170-6-14**] 09:24PM BLOOD CK(CPK)-172
[**2170-6-14**] 09:24PM BLOOD CK-MB-3 cTropnT-1.32*
[**2170-6-12**] 09:08AM BLOOD CK-MB-53*
[**2170-6-12**] 03:30AM BLOOD CK-MB-11* MB Indx-2.9 cTropnT-0.90*
[**2170-6-15**] 06:57AM BLOOD Calcium-8.3* Phos-2.0* Mg-2.2
[**2170-6-12**] 09:08AM BLOOD Calcium-7.6* Phos-2.0* Mg-1.1*
[**2170-6-12**] 03:30AM BLOOD %HbA1c-7.1* eAG-157*
[**2170-6-12**] 03:30AM BLOOD Triglyc-102 HDL-35 CHOL/HD-2.8 LDLcalc-44
[**2170-6-12**] 03:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2170-6-12**] 03:46AM BLOOD Glucose-246* Lactate-4.2* Na-140 K-2.9*
Cl-99 calHCO3-27
[**2170-6-12**] 03:46AM BLOOD Hgb-11.6* calcHCT-35 O2 Sat-94 COHgb-2
MetHgb-0
[**2170-6-12**] 03:21PM BLOOD freeCa-1.03*
[**2170-6-13**] 02:09PM BLOOD ALDOSTERONE-PND
[**2170-6-13**] 02:09PM BLOOD RENIN-PND
INDICATIONS FOR CATHETERIZATION:
Coronary artery disease, Canadian Heart Class IV, unstable.
Prior PTCA
[**2158-12-4**].
PROCEDURE:
Percutaneous coronary revascularization was performed using
placement of
drug-eluting stent(s).
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 2.58 m2
HEMOGLOBIN: 11.9 gms %
ENTRY
**PRESSURES
AORTA {s/d/m} 112/74/86
**CARDIAC OUTPUT
HEART RATE {beats/min} 103
RHYTHM SINUS
**PTCA RESULTS
LAD
PTCA COMMENTS:
Primary PCI was delayed because of severe torutosity in the
right upper
extremity and inability to seat the guide appropriately. We
initially
gained access via the right radial artery. However, because of
severe
tortuosity in the right axilla and because of a short ascending
aorta,
we were unable to engage the left main coronary artery. Because
of this,
we then gained access in the right femoral artery. A 6F sheath
was
inserted. Initial angiography revealed a 70% stenosis in the
proximal
LAD, a 70% stenosis in the proximal portion of the prior mid LAd
stents
and a 95% stenosis in the mid to distal edge of the prior mid
LAD
stents. We planned to treat all of these lesions with PTCA and
stenting.
Bivalirudin was administered for anticoagulation, and a
therapeutic ACT
was confirmed. A 6F XBLAD 3.5 guide provided adequate support. A
Prowater wire crossed the lesions with mdoerate difficulty. We
then
predilated the distal lesion with a 2.25 x 12 mm Sprinter Legend
RX
balloon at 10 atm three times. This led to a short dissection
and no
reflow in the distal LAD. We therefore attempted to rapidly
deliver a
2.25 x 18 mm Resolute RX stent, but we were not able to deliver
due to
tortuosity. We therefore elected to change for a stiffer wire. A
2.25 x
15 mm Sprinter balloon was advanced to the distal LAD, and the
Prowater
wire was removed. A Choice PT Extra Support wire was advanced to
the
distal LAD, and the distal LAd was again predilated with the
2.25 x 15
mm Sprinter balloon at 12 atm. We were then able to deliver a
2.25 x 14
mm resolute stent to the distal lesion and deployed it at 13
atm. We
then delivered a 2.75 x 22 mm Resolute to the more proximal
portion of
the prior stents and deployed it at 16 atm. The proximal portion
of
the new stents was postdilated with a 3.0 x 15 mm NC Quantum
Apex MR
balloon at 16 atm. The mid portion of the newly deployed stents
was
postdilated with a 2.75 x 12 mm NC Quantum Apex balloon at 18
atm. We
then direct stented the more proximal LAD lesion with a 3.5 x 15
mm
Resolute stent at 16 atm. Final angiography revealed no residual
stenosis, no evidence of dissection and TIMI 3 flow. Right
femoral
angigoraphy revealed an arteriotomy site appropriate for
closure, and a
6F Perclose was deployed with adequate hemostasis.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 1 hour 54 minutes.
Arterial time = 1 hour 53 minutes.
Fluoro time = 35 minutes.
Effective Equivalent Dose Index (mGy) = 6634 mGy.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 440 ml
Premedications:
Midazolam 0.5 mg IV
Fentanyl 25 mcg IV
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Other medication:
Diltiazem (ia) 500mcg
Nitroglycerine (ia) 200mcg
potassium 40meq
Amiodarone (iv) 1mg/min
Bivalrudin 100mg IVB f/b 238mg/hr
Fentanyl 100mcg
Midazolam 1.5mg
Nicardipine 1000mcg
Cardiac Cath Supplies Used:
- [**Doctor Last Name **], PROWATER 300CM
- [**Company **], MAGIC TORQUE 260CM
- [**Company **], CHOICE PT EXTRA SUPPORT 300CM
2.25MM [**Company **], SPRINTER 12MM
2.25MM [**Company **], SPRINTER 15MM
- [**Company **], NC APEX 15/3.0
- [**Company **], NC APEX 12/2.75
6FR CORDIS, XBLAD 3.5
6FR [**Doctor Last Name **], PERCLOSE PROGLIDE
- [**Company **], RESOLUTE 15/3.5
- [**Company **], RESOLUTE 15/3.5
- ALLEGIANCE, CUSTOM STERILE PACK
- MERIT, LEFT HEART KIT
6FR TERUMO, GLIDESHEATH
- [**Doctor Last Name **], PRIORITY PACK 20/30
- TERUMO, TR BAND LARGE
COMMENTS:
1. Selective coronary angiography of this right-dominant system
demonstrated severe 2 vessel CAD. The LMCA had no
angiographically-apparent disease. The LAD had 70% proximal
stenosis
prior to the old mid-LAD stent. There was also 95% stenosis at
the
distal end of the old mid-LAD stent. The LCX had 80% stenosis in
the OM1
branch. The dominant RCA had no angiographically apparent
disease.
2. Limited resting hemodynamics revealed normal systemic
arterial
pressures with a measured central aortic pressure of 112/67/84.
3. Left ventriculography was deferred.
4. Successful PTCA and stenting of the mid to distal LAd with
overlapping 2.25 x 14 mm (distal) and 2.75 x 22 mm Resolute DESs
postdilated to 2.75 mm in the mid portion and 3.0 mm proximally
(see
PTCA comments).
5. Successful direct stenting of the more proximal LAD with a
3.5 x 15
mm Resolute DES (see PTCA comments).
6. Successful RFA Perclose (see PTCA comments).
FINAL DIAGNOSIS:
1. Two vessel CAD with LAD stenosis (culprit).
2. Successful PCI of the mid to distal LAD with overlapping 2.25
x 14 mm
(distal) and 2.75 x 22 mm (proximal) Resolute DESs postdilated
to 2.75
mm in the overlapping segment and 3.0 mm in the proximal
segment.
3. Successful PCI of the proximal LAD with a 3.5 x 15 mm
Resolute DES.
4. Successful RFA Perclose.
.
I, DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **],
was physically present during the entire procedure and in
compliance with the CMS regulations.
.
[**Hospital1 18**] ATTENDING OF RECORD: [**Last Name (LF) **],[**First Name3 (LF) **] E.
REFERRING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
FELLOW: [**Last Name (LF) **],[**First Name3 (LF) **]
[**Last Name (LF) **],[**First Name3 (LF) **] B.
INVASIVE ATTENDING STAFF: [**Last Name (LF) **],[**First Name3 (LF) **] E.
Electronically signed by: [**Last Name (LF) **],[**First Name3 (LF) **] on FRI [**2170-6-15**] 10:23
AM
[**Medical Record Number 28546**] M 64 [**2105-8-24**]
.
Cardiovascular Report ECG Study Date of [**2170-6-12**] 3:14:42 AM
.
Sinus tachycardia. Left axis deviation. Acute anterolateral wall
myocardial infarction. Possible inferior wall myocardial
infarction. Compared to the previous tracing of [**2159-6-21**] the
acute infarction is new.
.
Echo [**2170-6-12**]
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is severe regional
left ventricular systolic dysfunction with akinesis of the
anterior wall, septum and apex. The remaining segments contract
normally (LVEF = 25%). No masses or thrombi are seen in the left
ventricle. Right ventricular chamber size is normal with focal
hypokinesis of the apical free wall. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
.
IMPRESSION: Extensive regional left ventricular systolic
dysfunction, c/w proximal LAD disease. No LV thrombus seen.
.
Compared with the report of the resting portion of the prior
stress study (images unavailable for review) of [**2162-11-16**],
regional LV wall motion abnormalities are new.
.
Findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 1120 hours
on the day of the study.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2170-6-12**] 11:22
.
.
EKG Study Date of [**2170-6-12**] 7:54:28 PM
.
Sinus rhythm. Left axis deviation. There are Q waves in the
anterior leads
with ST segment elevation and terminal T wave inversion
extending into the
anterolateral leads. There are tiny R waves in the inferior
leads consistent
with probable infarction. There are additional non-specific ST-T
wave changes.
Compared to the previous tracing of the same day ST segment
elevation in the
anterior leads has increased. Clinical correlation is suggested.
TRACING #3
Brief Hospital Course:
Active Issues:
# STEMI with reduced EF:
Mr. [**Known lastname 5066**] presented to the ED one hour after the onset of
sudden, severe, burning chest pain that radiated up his neck and
to his left arm. He perceived the chest pain to be indigestion
and took an antacid to no relief. He called EMS, who documented
ST elevation inthe anterolateral leads. During transport, Mr.
[**Known lastname 5066**] had an episode of ventricular fibrillation, which
responded to one shock. He reverted to normal sinus rhythm and
was administered amiodarone and aspirin.
In the ED, ECG demonstrated STE in V1-V4 and pathological q
waves in II, III and aVF. Mr. [**Known lastname 5066**] was taken straight for
cardiac catheterization, which revealed significant LAD disease
- primarily in-stent restenosis of his in situ bare metal stent
and a more distal 95% stenosis. Three drug-eluting stents were
placed in the proximal and distal LAD with good angiographic
results.
Post-STEMI echocardiography demonstrated an ejection fraction of
25%, which is a marked deterioration from previous studies
(EF=60%). Moreover, there was newly diagnosed apical, anterior,
and septal akinesis. Based on these findings, the team decided
that Mr. [**Known lastname 5066**] would benefit from the initiation of
coumadin therapy for thrombus prevention.
During Mr. [**Known lastname 28547**] stay, an Electrophysiology consult
advised us to schedule Mr. [**Known lastname 5066**] for electrophysiology
follow-up as an outpatient in 40 days' time to assess his need
for an ICD. They felt that he would not benefit from
anti-arrhythmic therapy or an external defibrillating device in
the interim.
Recovery, first in the CCU and subsequently on the Cardiology
[**Hospital1 **], was speedy. Mr. [**Known lastname 5066**] required some potassium
supplementation, and several changes were made to his
medications. During his hospitalization, Mr. [**Known lastname 5066**] [**Last Name (Titles) 28548**]d nifedipine 30mg once daily, irbesartan 150mg once
daily, metoprolol tartrate 100mg twice daily, and
hydrochlorothiazide 25mg once daily, and was commenced on
coumadin 3mg once daily, clopidogrel 75mg once daily, losartan
25mg once daily, metoprolol succinate 200mg once daily,
eplerenone 25mg once daily. His other medications remain
unchanged.
#Inactive Issues
1. Ulcerative Colitis: Appears to be doing well with no recent
flares. Continue dicyclomine as needed and sulfazaline 1000mg
TID
2. Diabetes mellitus: The patient was switched from his oral
medications to insulin while in house with good results.
#Transitional Issues
1. Mr. [**Known lastname 5066**] has commenced coumadin prophylaxis. He
received his first dose (5mg) on [**2170-6-13**], and was discharged on
3mg once daily. His INR is to be checked by a visiting nurse on
[**2170-6-16**], and he is scheduled to attend your clinic on [**2170-6-19**].
He has been instructed to take 3mg once daily at 4pm until he
attends your clinic or is linked in with your coumadin service.
We defer any dose adjustments that he may require to you. I have
already contact[**Name (NI) **] a nurse in your office with this information.
(2) Given the fact that Mr. [**Known lastname 5066**] required potassium
supplementation a few times during his hospital stay, we
recommend that his serum electrolytes be checked in the short
term, possibly alongside his INR. We commenced him on
eplerenone, which may help in avoiding hypokalemia.
(3) Outpatient appointments have been arranged with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] (Cardiac services [**2170-6-18**]) and Dr. [**Last Name (STitle) **] [**Name (STitle) 1911**]
(Cardiac services, electrophysiology [**2170-7-26**]).
(4) Mr. [**Known lastname 5066**] has expressed interest in cardiac rehab
services in [**Location (un) 745**]. I informed him that he should contact the
center of his choice, which would correspond with your office to
arrange for an official referral. He also expressed concern at
having missed a recent appointment with a dietician, which he
would like to have rescheduled through your office.
Medications on Admission:
1. Omeprazole 20 mg Oral Capsule, Delayed Release(E.C.) Take 1
capsule 30 min before first meal of day
2. Sitagliptin (JANUVIA) 100 mg Oral Tablet TAKE ONE TABLET
DAILY
3. Metformin 750 mg Oral Tablet Extended Release 24 hr TAKE 1
TABLET THREE TIMES A DAY
4. Sitagliptin (JANUVIA) 100 mg Oral Tablet 1 tab PO QD
5. Fluticasone (FLONASE) 50 mcg/actuation Nasal Spray,
Suspension 1 spray in each nostril twice a day
6. Glipizide 10 mg Oral Tablet Extended Rel 24 hr TAKE 1 TABLET
TWICE DAILY
7. Sulfasalazine 500 mg Oral Tablet 2 tablets (1000mg) three
times daily
8. Atorvastatin 80 mg Oral Tablet Take one tablet daily
9. Irbesartan (AVAPRO) 150 mg Oral Tablet Take 1 tablet daily
10. Loratadine 10 mg Oral Tablet 1 tablet daily as needed.
11. Epinephrine (EPIPEN) 0.3 mg/0.3 mL Intramuscular Pen
Injector use AS NEEDED and seek medical advice
12. Hydrochlorothiazide 25 mg Oral Tablet 1 tablet daily
13. NIFEDIPINE ER 30 MG 24 HR TAB 30 mg Oral TR24 Take 1 tablet
daily
14. DICYCLOMINE 20 MG TAB take 1 tablet by mouth 4 times a day
as needed
15. ONE TOUCH ULTRA TEST STRIPS (BLOOD SUGAR DIAGNOSTIC) Use as
directed 2 times daily
16. LANCETS use [**Hospital1 **] prn
17. METOPROLOL 100 MG TAB (METOPROLOL TARTRATE) 1 tablet twice
daily
18. BABY ASPIRIN ORAL (ASPIRIN) None Entered
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
2. Losartan Potassium 25 mg PO DAILY
please hold for SBP<100
please start [**2170-6-15**]
RX *losartan 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
3. Nitroglycerin SL 0.3 mg SL PRN chest pain
RX *Nitrostat 0.3 mg 1 tablet sublingually every 15 minutes as
needed for chest pain NOT TO EXCEED three pills Disp #*30 Tablet
Refills:*3
4. Eplerenone 25 mg PO DAILY
RX *eplerenone 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
5. Metoprolol Succinate XL 200 mg PO DAILY
Start in AM on [**6-15**]
RX *metoprolol succinate 200 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
6. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
7. Atorvastatin 80 mg PO DAILY
Please stop this drug if you develop muscle weakness or pain or
if your urine gets very dark.
8. Aspirin 81 mg PO DAILY
9. SulfaSALAzine_ 1000 mg PO TID
10. Januvia *NF* (sitaGLIPtin) 100 mg Oral daily
11. MetFORMIN XR (Glucophage XR) 750 mg PO TID
Do Not Crush
12. fluticasone *NF* 50 mcg/actuation NU [**Hospital1 **]
1 spray each nostril twice daily
13. GlipiZIDE XL 10 mg PO BID
14. Loratadine *NF* 10 mg Oral qday:prn asthma
15. EpiPen *NF* (EPINEPHrine) 0.3 mg/0.3 mL Injection once:prn
anaphylaxis
use as needed and seek medical advice IMMEDIATELY
16. DiCYCLOmine 20 mg PO TID:PRN bowel irritation
Please do not take this medication until you see your physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 28549**], on [**6-19**].
17. One Touch Ultra Test *NF* (blood sugar diagnostic)
Miscellaneous [**Hospital1 **]
Use as directed two times daily
18. lancets *NF* Miscellaneous [**Hospital1 **]
use as directed twice daily
19. Warfarin 3 mg PO DAILY16
RX *warfarin 1 mg 3 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
20. Outpatient Lab Work
Please draw blood for an INR on [**2170-6-16**] and fax the result to
Dr. [**Last Name (STitle) 28549**] at [**Telephone/Fax (1) 6808**]
21. Outpatient Lab Work
Please draw blood on [**2170-6-22**] and send it for serum sodium,
potassium, chloride, bicarbonate/CO2, BUN, creatinine, calcium,
magnesium, and phosphate. Please fax the results to Dr. [**Last Name (STitle) 28549**]
at [**Telephone/Fax (1) 6808**]
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary diagnosis: anterolateral ST segment myocardial
infarction (heart attack to the front wall of your heart)
Secondary diagnosis: apical akinesis of the left ventricle
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 5066**],
It was a pleasure taking care of you while you were hospitalized
at the [**Hospital1 **]. As you know, you were admitted to
the hospital because of your chest pain. On the way, the
emergency medical technicians had to shock you because of an
irregular heart rhythm, which reverted to normal subsequently.
When you got to the hospital, we confirmed that you indeed had a
heart attack and performed a procedure called a left heart
catheterization where a wire was threaded into the arteries that
supply your heart. We found that the area where you already had
a stent placed in [**2158**] was narrowed and there was a very severe
narrowing farther along the artery. The newly diagnosed
narrowing was fixed with a drug-eluting stent. This should help
prevent the re-narrowing that occurred at the site of the bare
metal stent you received in [**2158**].
Please keep in mind two important points:
1. You must take Plavix for at least 6 months to one year based
on the placement of your drug-eluting stent. You must not miss
ANY doses because if you do, you will run the risk of having a
sudden and severe blockage of the new stent that could give you
another severe heart attack.
2. Because of the location of your heart attack, part of your
heart is not moving properly. This can cause blood to be
stagnant inside of the heart and clot, which can lead to strokes
or other adverse events. As a result, you will need to start a
blood thinner called coumadin for at least a few months. If your
heart regains some of its lost function, you may be able to stop
blood thinners, but this is a discussion that needs to be
undertaken in several months in conjunction with your
cardiologist. Until you see Dr. [**Last Name (STitle) 28549**], you should take 3mg of
coumadin by mouth each afternoon at 4pm.
You were brought to the cardiac care unit after your procedure
where you did well. You were transferred to the non-intensive
care cardiology floor shortly thereafter where your course
continued to be unremarkable.
You have several follow-up appointments listed below. Please
keep all of them; each is extremely important. Also, please
discuss cardiac rehabilitation with your cardiologist and
primary care provider next [**Name9 (PRE) 766**] and Tuesday, respectively.
START:
coumadin 3mg by mouth once daily (on [**8-16**], and [**6-17**]). You
will have blood tests drawn on the 14th and 15th that will
dictate your dose on [**6-18**] and thereafter. You must go to [**Hospital1 2292**] in [**Location (un) **], [**University/College **], or [**Location (un) 38**] to have these labs
drawn. They will be submitted electronically to Dr.[**Name (NI) 28550**]
office, where he and his team can decide the appropriate
coumadin dose.
Plavix 75mg by mouth once daily
Losartan 25mg by mouth once daily
metoprolol succinate (XL) 200mg by mouth once daily
Eplerenone 25mg by mouth once daily
STOP:
nifedipine ER 30 daily
irbesartan 150 daily
metoprolol tartrate 100mg twice daily
hydrochlorothiazide 25mg daily
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2170-6-18**] at 4:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) **],[**First Name3 (LF) **] J
Location: [**Location (un) 2274**]-[**Location **]
Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 28551**]
Appt: [**6-19**] at 2:20pm
Department: CARDIAC SERVICES
When: FRIDAY [**2170-7-13**] at 10:00 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 6738**], 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: THURSDAY [**2170-7-26**] at 1 PM
With: [**Name6 (MD) 1918**] [**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
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,970
| 113,253
|
36490
|
Discharge summary
|
report
|
Admission Date: [**2168-12-29**] Discharge Date: [**2169-1-9**]
Date of Birth: [**2085-12-3**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness: Mr. [**Known lastname 76901**] is an 83 y/o M with a
h/o AF not on coumadin, CHF with an EF of 20%, severe AS, RA
(chronic prednisone 5), CKD (baseline Cr around 1.3) and ? COPD
on adviar with who initially presented to [**Hospital1 **] [**Location (un) 620**] on
[**2168-12-26**] after having episodes of painless BRBPR at home. On
[**2168-12-26**] he was admitted to the ICU at [**Hospital1 **] [**Location (un) 620**] and underwent
a colonoscopy that day which showed diverticuli but did not
reveal any active bleeding. On [**12-26**] his HCT dropped from 31.3
to 27.7 and he was give PRBCs. The night of [**12-27**] he had more
BRBPR and his HCT drifted down to 26, but he remained
hemodynamically stable. On [**12-28**] he underwent another
colonoscopy with no localized source of bleeding but did show a
large amount of blood in the colon. Also in the course of the
work up of his GI bleed he underwent a CTA of his abdomen on
[**12-28**] with no active GI bleeding seen. Got total of 7 units PRBC
to maintain Hct ~ 27 throughout his stay at [**Hospital1 18**], Surgery was
also consulted who agreed with the CTA and recommended a
transfer to [**Hospital1 18**] if the family wished to pursue a further work
up or aggressive treatment such as angio for embolization or
surgical resection. Prior to transfer he past 400 mL BRBPR with
associated clots. He reports [**2-7**] bowel movements per day.
.
Also during his stay at [**Hospital1 **] [**Location (un) 620**] given his history of
systolic heart failure and murmur heard on exam he had an
echocardiogram which showed an improvement in his EF to 55%, but
significantly worsening of his aortic stenosis. He notes some
shortness of breath with exertion at baseline but notes he
mobility is limited by his RA and not breathing. His AS was
previously characterized as mild but was found to be severe with
a valve area of 0.8 to 1.0 cm2.
.
On the floor patient comfortable denying any chest pain,
shortness of breath, fever, chills, night sweats, diarrhea,
constipation or vomiting. Does not chronic arthralgias due to
RA.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies rashes or skin changes.
Past Medical History:
Severe AS (valve area 0.8 to 1.0)
Chronic Systolic CHF EF of 55%
Atrial Fibrillation off coumadin
Rheumatoid Arthritis
Chronic Kidney Disease
Social History:
Lives at home with his wife, denies any tobacco, drinks [**2-7**]
bottle of whiskey per week
Family History:
Maternal aunt with [**Name2 (NI) **], father with DM, no family history of
heart or valvular disease
Physical Exam:
ADMISSION EXAM
Vitals: T: 96 BP:123/67 P: 97 R: 18 O2: 99% 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: irregularilty irregular, normal S1 + S2, III/VI systolic
murmur heard best at RUSB with radiation to the carotids
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, brisk capillary refill. Joint swelling in the MCPs, PIPs
bilaterally as well as bilateral feet consistent with RA. +
Rheumatoid nodules.
DISCHARGE EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, mmm, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB
CV: irregular rate and rhythm, normal S1 + S2, [**4-10**] mid peaking
systolic murmur heard best at RUSB, no rubs or gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses. Joint swelling in the MCPs,
PIPs bilaterally as well as bilateral feet consistent with RA. +
Rheumatoid nodules. Left shoulder has dressing covering it,
incision C/D/I. Edema and bruising in left arm improved. Good
passive ROM of upper extremity joints with minimal pain, active
ROM improving.
Neuro: A&Ox3
Pertinent Results:
ADMISSION LABS
[**2168-12-29**] 03:30PM BLOOD WBC-11.8* RBC-3.81* Hgb-11.9* Hct-32.8*
MCV-86 MCH-31.2 MCHC-36.2* RDW-15.5 Plt Ct-145*
[**2168-12-29**] 03:30PM BLOOD Neuts-85.0* Lymphs-9.2* Monos-5.3 Eos-0.3
Baso-0.2
[**2168-12-29**] 03:30PM BLOOD PT-14.0* PTT-33.1 INR(PT)-1.2*
[**2168-12-29**] 03:30PM BLOOD Glucose-85 UreaN-20 Creat-1.1 Na-133
K-4.1 Cl-102 HCO3-21* AnGap-14
[**2168-12-29**] 03:30PM BLOOD ALT-10 AST-14 LD(LDH)-139 AlkPhos-62
TotBili-4.4*
DISCHARGE LABS
[**2169-1-9**] 06:07AM BLOOD WBC-6.7 RBC-3.29* Hgb-10.0* Hct-30.4*
MCV-92 MCH-30.5 MCHC-33.0 RDW-14.9 Plt Ct-322
[**2169-1-9**] 06:07AM BLOOD Glucose-81 UreaN-16 Creat-0.9 Na-138
K-3.7 Cl-104 HCO3-26 AnGap-12
[**2169-1-9**] 06:07AM BLOOD Calcium-8.2* Phos-3.3 Mg-1.4*
.
CARDIAC ENZYMES
[**2168-12-29**] 03:30PM BLOOD CK-MB-2 cTropnT-<0.01
[**2168-12-30**] 04:04AM BLOOD CK-MB-2 cTropnT-0.02*
.
Digoxin level
[**2168-12-29**] 03:30PM BLOOD Digoxin-1.2
[**2168-12-31**] 03:07AM BLOOD Digoxin-0.9
[**2169-1-9**] 06:07AM BLOOD Digoxin-0.9
.
Vancomycin level
[**2169-1-4**] 09:10PM BLOOD Vanco-26.3*
[**2169-1-6**] 07:35PM BLOOD Vanco-23.9*
[**2169-1-7**] 06:23PM BLOOD Vanco-21.1*
Misc
[**2169-1-6**] 05:51AM BLOOD CRP-81.6*
[**2169-1-6**] 05:51AM BLOOD ESR-45*
IMAGING:
[**12-29**] TTE:
The left atrium is dilated. The right atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy
with normal cavity size. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are severely thickened/deformed. There is
severe aortic valve stenosis (valve area 0.8-1.0cm2). Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
[**1-2**] CXR:
Lungs are clear. Heart size is normal, although the
configuration suggests
right atrial enlargement. Lungs are clear and there is no
pleural effusion.
[**1-2**] Left shoulder xray:
IMPRESSION: Degenerative changes in the AC and glenohumeral
joints but no
evidence of dislocation or fracture.
[**1-3**] CT abd/pelvis:
1. Small right pleural effusion with adjacent atelectasis.
2. Distal pancreatic ductal dilitation concerning for stricture.
Recommend
ERCP for further evaluation.
3. Colonic diverticulosis without diverticulitis.
4. Ectasia of the infrarenal abdominal aorta.
5. Near complete loss of L1 vertebral body height, new since
[**2162**] with
associated disc extrusion. No evidence of discitis.
6. Bilateral renal cysts.
[**1-4**] CXR:
FINDINGS: As compared to the previous radiograph, there is a
very subtle
newly appeared parenchymal opacity at the right lung base.
Simultaneously,
there is persistent peribronchial thickening at the left lung
base. Overall, the changes could reflect chronic aspiration or
early pneumonia
[**1-7**] ECHO:
The left atrium is dilated. The right atrium is moderately
dilated. The estimated right atrial pressure is 0-5 mmHg. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF 70%). Right ventricular chamber size
and free wall motion are normal. The aortic arch is mildly
dilated. There are focal calcifications in the aortic arch. The
aortic valve leaflets are severely thickened/deformed. There is
severe aortic valve stenosis. The mitral valve leaflets are
mildly thickened. Moderate (2+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion. .
.
MICRO:
[**1-2**] blood cultures negative
[**1-3**] shoulder joint culture - 4+ PMNs, no growth on culture.
Brief Hospital Course:
PRIMARY REASON for ADMISSION
83 y/o M with a h/o AF not on coumadin, CHF with an EF of 20%,
severe AS, RA (chronic prednisone 5), CKD (baseline Cr around
1.3) and ? COPD on advair who initially presented to [**Hospital1 **] [**Location (un) 620**]
with BRBPR 7 likely [**3-9**] to a sigmoid diverticular bleed,
transferred to [**Hospital1 18**] for further management. Diverticular
bleed self-resolved, however course was complicated by septic
arthritis of the shoulder.
ACTIVE ISSUES BY PROBLEM:
# Lower GI bleed: Patient transferred from BIDN with a continued
GI Bleed without localized source. Colonoscopy at [**Location (un) 620**] were
suggestive of bleeding from sigmiod diverticuli. CTA did not
show active bleeding. Patient was transferred for potential IR
vs surgical intervention. On admission to the [**Hospital Unit Name 153**] patient was
noted to be hemodynamically stable. HCT was monitored and
remained statble between 28 and 30. He had received a total of
7 units of PRBCs at [**Location (un) 620**] and did not require further
transfusion while in the ICU. GI was consulted and recommended
IR procedure should bleeding recur. Patient was noted to be
intermittently hypotensive with SBPs
in the 70s which responded to bolus IVFs with improvement to the
90s-100s. He had no further episodes of bloody bowel movements
while in the ICU and was transferred to the medicine floor. His
bleeding then self-resolved with no further interventions.
Transfused a total of 2 units PRBCs during his stay.
# Septic arthritis: Patient triggered on [**1-2**] for fever to
103.7 axillary, WBCs rising, developed hypotension requiring
transfer to the MICU. Began complaining of shoulder pain, so
joint was aspirated by orthopedic surgery. Found to have likely
septic arthritis of left shoulder joint-- 122K WBCs on joint
aspiration and frank pus on washout, however no organisms on
gram stain and no growth yet on cultures. Cannot completely
rule out crystal disease because there was not enough specimen
for crystal analysis. Taken to OR on [**1-3**] for washout with no
complications, started on ceftriaxone and vancomycin. His
shoulder began to improve clinically at this point. ID was
consulted, recommended repeat TTE to rule out vegetations
(negative) and course of 4 weeks ceftriaxone 1g q24hours
(through [**1-31**]). A PICC was placed for outpatient abx
administration, and he will have weekly safety labs during his
abx therapy.
#Afib- Patient has a known history of afib on digoxin qod at
home, however level noted to be low on admission so digoxin
increased to [**Month/Year (2) 24018**]. He was noted to be intermittently
tachycardic with RVR to 170s when OOB, though he remained
asymptomatic at these times. He was started on metoprolol for
his frequent RVR, to be continued at rehab with close
monitoring.
# Diastolic CHF: Echo at OSH with EF of 55%, LVEF confirmed on
echo here with evidence of grade 1 diastolic dysfunction. Was
taking PRN lasix at home, however this was held initially given
transient hypotension. He had no evidence of fluid retention,
so this medication was not restarted and is not being continued
on discharge.
# Aortic stenosis: Last echo in [**2166**] showed mild AS, however
echo on this admission shiwed EF 55%, severe AS (valve area
0.8-1.O cm2), LVH, 1+ MR/TR. Notes he has some dyspnea on
exertion, but he denies any syncope or angina. Fluid status was
carefully monitored throughout his stay, given his AS.
# Acute renal failure: Creatinine at [**Location (un) 620**] was 1.4 on
admission. This was felt to likely be pre-renal in nature.
Creatinine improved to 1.1 with admistration of blood products
and remained stable throughout the remainder of his hospital
course.
# Elevated troponin and EKG changes: Patient was noted to have
elevated troponin elevation at OSH felt to be possibly [**3-9**]
demand ischemia with non specific EKG changes. ACS was felt to
be unlikely given patient remained symptom free with negative
troponin x 2 and normal CK MB.
.
# Rheumatoid arthritis: Patient was continued on home
prednisone. He was given tylenol for pain in place of his home
aleve.
.
TRANSITIONAL ISSUES
- Digoxin: changed dosing to [**Last Name (LF) 24018**], [**First Name3 (LF) **] need to have level
checked at next PCP visit
[**Name Initial (PRE) **] Septic shoulder: follow up appt made with surgeon on [**1-19**]
for follow up of I&D
- Will need to have weekly safety labs (CBCw/diff, CMP, ESR/CRP)
drawn while taking ceftriaxone, fax results to [**Hospital **] clinic at
[**Telephone/Fax (1) 1419**]. First due: [**1-16**]
- Pancreatic mass: incidentally found on CT, will need further
evaluation with if more work up is desired. Pt aware, family not
currently interested in pursuing.
Patient was DNR/DNI throughout this hospitalization
.
Pending results:
acid fast culture from shoulder joint.
Medications on Admission:
Home Medications (confirmed w/wife [**2168-12-31**]):
Lasix [**2-7**] 20 mg tablets QD
Prednisone 5 mg 1 tablet PRN (QD recently)
Digoxin 0.125 mg QOD
Advair 250-50 1 puff [**Hospital1 **]
ASA 81 mg QD
Aleve 2 tabs qAM PRN
Omeprazole 20 mg PRN
Potassium 20 mEq PO QD
Acidophilus 1 tab QD
(metoprolol stopped 2 years ago)
.
Medications on Transfer:
Magnesium Sulfate 2g IV daily
Advair 1 puff [**Hospital1 **]
Prednisone 5mg daily
Nexium 40mg daily
Digoxin 0.125mg daily
Vitamin B12 1000mcg daily
Colace prn
Zofran prn
Acetaminophen prn
Discharge Medications:
1. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Please hold for SBP <100, HR <60.
7. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
9. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours) for 22 days:
Please continue through [**2169-1-31**].
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
13. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Lower GI bleed
Septic arthritis
Atrial fibrillation with rapid ventricular response
Rheumatoid arthritis
Aortic stenosis
Pancreatic mass
Acute renal failure
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 76901**],
You were transferred to [**Hospital1 18**] due to rectal bleeding. You
stayed briefly in the ICU, but your bleeding slowed down
significantly and you were transferred to the medicine floor.
We believe your bleeding was due to diverticuli (small
out-pouchings) in your colon, many of which will stop bleeding
on their own like yours.
While you were here, you developed severe left shoulder pain and
fevers and were found to have an infection of the joint. You
were taken to the operating room for the surgeons to open up
your shoulder and clean it out. You will need to keep taking
intravenous antibiotics until [**1-31**] to fully treat this
infection. Physical therapy to improve your shoulder mobility
will also be important.
Changes to your medications:
STOP furosemide 20-40 mg daily
STOP potassium
INCREASE digoxin 125 mcg to daily (instead of every other day)
START ceftriaxone 1g every 24 hours through [**1-31**]
START metoprolol 12.5 mg twice daily
START oxycodone 2.5 mg tabe every 4 hours as needed for pain
START acetaminophen 650mg three times a day
START senna 8.6mg tab twice daily
START docusate 100mg twice daily
START bisacodyl 10mg daily as needed for constipation
Followup Instructions:
Department: ORTHOPEDICS
When: THURSDAY [**2169-1-19**] at 12:20 PM
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: THURSDAY [**2169-1-19**] at 12:40 PM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2169-1-25**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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49,446
| 161,452
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43914
|
Discharge summary
|
report
|
Admission Date: [**2115-1-3**] Discharge Date: [**2115-1-8**]
Date of Birth: [**2046-6-2**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Atorvastatin / alprazolam / oxytocin / Demerol /
Codeine
Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
epigastric pain and dyspnea
Major Surgical or Invasive Procedure:
Cardioversion and transesophageal echocardiogram
History of Present Illness:
This is a 68 year-old Female with a PMH history significant for
CAD (s/p CABG in [**2102**]; LIMA-LAD, SVG-D1, SVG-OM1 and s/p
multiple PCIs with most recent cardiac catheterization in [**1-/2114**]
showing widely patent grafts), systolic CHF (EF 20-25% in [**2106**]),
HTN, HLD, diabetes mellitus type 2, PVD who presented to [**Hospital1 **] with 1-week of abdominal pain associated with some
dyspnea and chest discomfort.
.
The patient notes that she had the acute onset of progressive
hypogastric discomfort that heightened to a [**10-29**] in intensity
and was dull and achy in character; exacerbated by movement and
positional. She also associated this with some nausea, two
episodes of vomiting this AM (non-bilious, particulate,
non-bloody) and some chest discomfort for the past week. The
chest pain is a tightness that does not radiate, is a [**5-29**] in
intensity and is relieved with reclination and worsened when she
roles to the right side. She denies fevers or chills, no
diaphoresis but some mild palpitations. She denies headaches or
vision changes. No lightheadedness or dizziness. She denies
dysyuria or hematuria. She has no leg swelling or clot history.
She denies sick contacts or URI symptoms recently.
.
At [**Hospital3 **], where she received Aspirin 162 mg PO x 1,
Metoprolol tartrate 25 mg PO, Morphine 6 mg IV, Zofran 4 mg IV,
Pantoprazole 40 mg IV and Lovenox 70 mg SC x 1. Her laboratory
studies were remarkable for a WBC 8.9, HCT 38.8, PLT 182. Sodium
132, potassium 3.9, creatinine 1.9 (baseline 1.1-1.4), normal
LFTs, INR 1.3 with lactate of 1.6 and a negative U/A. An EKG
showed A.fib @ 113, LAD/NI, TWI in leads aVL, I and TWI in
lateral leads (V5-6). A CXR showed a top-normal heart size, with
no pleural effusion or consolidation. Troponin-I was 0.12. BNP
was 220. The atrial fibrillation was of unknown timing and thus
cardioverted was deferred and rate control was employed. She
subsequently became hypotensive and an urgent bedside 2D-Echo
showed an EF estimated at 10%. A right IJ-CVC was placed.
Levophed gtt was started given her hypotension. She was
transferred to [**Hospital1 18**] for further management.
.
In the [**Hospital1 18**] ED, initial VS 96.2 94 117/80 16 98%6L. Exam was
notable for mild epigastric tenderness, guaiac negative brown
stool. Laboratory studies demonstrated WBC 11.2, HCT 41.9, INR
1.2. Her bicarbonate was 21 (AG-metabolic acidosis of 14),
creatinine of 2.2 and lactate of 2.1. Repeat Troponin was 0.04.
Repeat U/A was unremarkable. An EKG showed A.fib @ 98, TWI in I,
aVL worse compared to prior. A CXR showed mild pulmonary edema.
Bedside 2D-Echo showed no pericardial effusion and sub-optimal
squeeze. FAST was negative. A CT of the abdomen and pelvis was
obtained showing right greater than left-sided pleural effusion,
mild ascites with fat stranding centered around the omentum with
concern for infarct, diverticulosis, normal appendix and a 2-mm
non-obstructing left nephrolith. She received Vancomycin 1 g x
1, Flagyl 500 mg IV x 1, Metoclopramide, Zofran and Morphine.
Cardiology and ACS-Surgery were consulted. She was admitted to
the CCU for further management on Levaphed gtt at 0.2.
.
On arrival to the CCU, she denies chest pain or trouble
breathing. Her abdominal pain is mild and improved.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, syncope or
presyncope.
Past Medical History:
* CARDIAC RISK FACTORS: Dyslipidemia, Hypertension, Diabetes,
tobacco use
* CARDIAC HISTORY:
- CABG: [**2102**]; LIMA-LAD, SVG-D1, SVG-OM1
.
- PCI: multiple PCIs, mostly to LAD - most recent cardiac
catheterization in [**1-/2114**] showing widely patent grafts
* [**2102**]: NSTEMI s/p coronary atherectomies to LAD/D1 bifurcation
lesion with placment of 2 stents and PTCA to jailed D1
* [**2102**]: Elective cath revealed in-stent restenosis and 90%D1
restenosis; PTCRA was performed for in-stent restenosis as
well as kissing balloons to LAD/D1 with residual 20% D1 lesion
* [**2106**]: UA with cath/no intervention but LVEDP 38
* [**2114**]: Chest pain with diagnostic cath showing widely patent
LIMA-LAD and SVG-D1-OM1. LMCA with 50% stenosis, LAD with 80%
proximal and mid, LCx with 70-80% proximal, and RCA with 80%
ostial lesion. LVEDP severely elevated to 36 mmHg.
.
- PACING/ICD: history of non-sustained VT on telemetry in the
setting of MI, sustained T-wave alternans on stress testing (was
worked up
for ICD in [**2106**] but did not receive one)
.
PAST MEDICAL & SURGICAL HISTORY:
1. Systolic congestive heart failure (2D-Echo in [**2106**] showing
LVEF 20-25%)
2. Hypertension
3. Hyperlipidemia
4. Diabetes mellitus, type 2
5. Peripheral vascular disease
6. Hypothyroidism
7. Nephrolithiasis (s/p right nephrectomy with chronic renal
insufficiency, creatinine 1.1-1.4 at baseline)
8. Peptic ulcer disease
9. Plantar fasciitis
10. Reflux esophagitis, GERD
11. Peripheral neuropathy
12. s/p right inguinal hernia operations x 4
13. s/p laparoscopic cholecystectomy [**6-/2113**] ([**Hospital3 **])
14. s/p hysterectomy
Social History:
Patient is divorced and has 6 children. Long-time smoking
history (4-cigarettes a day for 50-years) and quit 1-3 months
prior; denies alcohol use or recreational substance use. Retired
911-operator and works part-time as a crossing gaurd at a
school.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 96.6 / 96.6 85-96 109/66 14-16 96-100% 6L NC
CVP: 19-21
GENERAL: Appears in no acute distress. Alert and interactive,
somnolent at times, but responds to verbal commands.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD 2-3 cm above the
clavicle while laying flat.
CVS: PMI located in the 5th intercostal space, mid-clavicular
line. Irregularly irregular, with a [**3-25**] holosystolic murmur
heard best at the apex, without rubs or gallops. S1 and S2
normal. No S3 or S4.
RESP: Respirations unlabored, no accessory muscle use. Decreased
breath sounds bilaterally. No wheezing or rhonchi. Bilateral
inspiratory crackles at bases.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs. Abdominal aorta
not enlarged to palpation, no bruit.
EXTR: no cyanosis, clubbing, 2+ peripheral pulses; [**1-21**]+
peripheral edema noted to the mid-shins
DERM: No stasis dermatitis, ulcers, scars.
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Strength 5/5 bilaterally, sensation grossly intact. Gait
deferred.
PULSE EXAM:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
.
[**2115-1-3**] 06:10PM BLOOD WBC-11.2* RBC-4.26 Hgb-13.7 Hct-41.9
MCV-99*# MCH-32.2* MCHC-32.7 RDW-13.5 Plt Ct-245
[**2115-1-3**] 06:10PM BLOOD Neuts-81.9* Lymphs-13.6* Monos-2.8
Eos-1.2 Baso-0.4
[**2115-1-3**] 06:10PM BLOOD PT-13.1* PTT-32.7 INR(PT)-1.2*
[**2115-1-3**] 06:10PM BLOOD Glucose-268* UreaN-40* Creat-2.2* Na-137
K-4.5 Cl-102 HCO3-21* AnGap-19
[**2115-1-3**] 06:10PM BLOOD Calcium-9.3 Phos-5.3* Mg-1.9
.
PERTINENT LABS AND STUDIES:
[**2115-1-4**] 01:35AM BLOOD CK(CPK)-67
[**2115-1-3**] 06:10PM BLOOD cTropnT-0.04*
[**2115-1-4**] 01:35AM BLOOD CK-MB-4 cTropnT-0.06*
[**2115-1-4**] 09:49AM BLOOD CK-MB-3 cTropnT-0.07*
[**2115-1-4**] 03:25PM BLOOD CK-MB-3 cTropnT-0.08*
[**2115-1-4**] 03:35AM BLOOD TSH-6.0*
[**2115-1-4**] 09:49AM BLOOD Free T4-1.3
[**2115-1-3**] 06:17PM BLOOD Lactate-2.1*
[**2115-1-4**] 01:55AM BLOOD Lactate-1.5
[**2115-1-3**] BLOOD CULTURE staph coag negative preliminary
[**2115-1-3**] BLOOD CULTURE negative
[**2115-1-3**] urine culture negative
[**2115-1-3**] MRSA negative
[**2115-1-5**] blood culture negative x2
[**2115-1-6**] urine culture negative
.
[**2115-1-3**] CXR 1. Appropriate positioning of right internal
jugular central venous catheter without evidence for
pneumothorax. 2. Mild pulmonary edema.
.
[**2115-1-3**] CT ABDOMEN AND PELVIS 1. Inflammatory changes in the
infrahepatic region of uncertain etiology characterized by fat
stranding and ascites, centered primarily near the colon but
without diverticulosis or wall thickening to confirm a colonic
etiology. The degree of stranding seems greater than might be
expected for post-operative changes after prior nephrectomy and
would also probably not explain regional ascites in most cases.
A small part of the fluid tracks medially up to the duodenum,
which may be significant. Fat necrosis, trauma, or duodenal
ulcer perforation could be considered and colonic etiologies are
not excluded. Correlation with clinical features is important in
interpreting the findings. This was called to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1255**]
on [**2115-1-3**] at 11:00p.m.
2. Basilar opacities which are non-specific.
3. Suspected nephrolithiasis.
.
[**2115-1-4**] ECHOCARDIOGRAM The left atrium is mildly dilated. The
estimated right atrial pressure is at least 15 mmHg. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity is moderately dilated. There is severe global
left ventricular hypokinesis (LVEF = 20%), with regional
variation, most c/w multivessel CAD. A left ventricular
mass/thrombus cannot be excluded. Right ventricular chamber size
is normal. with mild global free wall hypokinesis. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. There is no mitral
valve prolapse. Severe (4+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is an anterior
space which most likely represents a prominent fat pad.
IMPRESSION: Dilated left ventricle with severe global systolic
dysfunction, most c/w multivessel CAD. Severe mitral
regurgitation. Moderate tricuspid regurgitation. Moderate
pulmonary hypertension.
.
RENAL US [**2115-1-6**]
1. Non-obstructing nephrolithiasis.
2. Mild hydronephrosis, but not necessarily due to an
obstructive process; it may be secondary to mild renal atrophy
or subclinical ureteropelvic junction obstruction. However, if
renal failure were to worsen, then short-term follow-up
ultrasound could be considered.
3. Echogenic liver suggesting fatty infiltration; however, other
forms of
liver disease including more advanced forms of liver disease
such as
significant hepatic fibrosis/cirrhosis cannot be excluded by
this study.
.
TEE [**2115-1-7**] 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. The left ventricular
cavity is dilated with severe global hypokinesis (LVEF <20 %).
Right ventricular free wall motion is depressed. There are
simple atheroma in the ascending aorta. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. Trace aortic regurgitation is seen. The mitral
leaflets are mildy thickened. Severe (4+) posteriorly directed
mitral regurgitation is seen. There is moderate [2+] tricuspid
regurgitation. There is no pericardial effusion. IMPRESSION: No
spontaneous echo contrast or thrombus in LA/LAA/RA/RAA. Left
ventricular cavity dilation with severe global left ventricular
hyopkinesis. Right ventricular free wall hypokinesis. Severe
mitral regurgitation.
Brief Hospital Course:
68F with a PMH significant for CAD (s/p CABG in [**2102**]; LIMA-LAD,
SVG-D1, SVG-OM1 and s/p multiple PCIs with most recent cardiac
catheterization in [**1-/2114**] showing widely patent grafts),
systolic CHF (EF 20-25% in [**2106**]), HTN, HLD, diabetes mellitus
type 2, PVD who presented to [**Hospital3 **] with 1-week of
abdominal pain associated with some dyspnea and chest discomfort
found to have possible omental infarction vs. perforated peptic
ulcer found to be in atrial fibrillation with evidence of acute
systolic congestive heart failure exacerbation.
.
ACUTE CARE
# HYPOGASTRIC ABDOMINAL PAIN ?????? The patient initially presented
with hypogastric abdominal pain and she experienced this pain
intermittently throughout her hospitalization. Her physical exam
remained benign and non-surgical, with a soft, non-tender
abdomen, no distention and normo-hypoactive bowel sounds. CT
read suggestive of potential omental infarct with lesser concern
for peptic ulcer perforation. Given she has newly recognized
atrial fibrillation, there is some concern for embolization from
an atrial thrombus which may have caused an omental infarct.
GERD is also a likely etiology given that it is quick in onset
and often occurs after eating. ACS was consulted and there is
no surgical intervention indicated. Lactate normalized soon
after arrival to the floor. Received Metronidazole and
Ceftriaxone on [**1-5**] but was discontinued due to low concern for
intra-abdominal infection.
.
# HYPOTENSION - Patient presented with hypotension in the
setting of acute abdominal complaints and concern for worsening
systolic CHF - started on Levophed gtt at outside institution;
etiologies that were initially considered included poor forward
flow vs sepsis from intraabdominalpathology. Levophed gtt was
successfully weaned [**1-4**] and her MAPs improved with better
control of her heart rate after being dig loaded. Central venous
catheter removed on [**1-5**]. She did have one out of four bottles
positive for coagulase negative Staphylococcus but a septic
cause of hypotension was thought to be unlikely and this was
considered a contaminant.
.
# ATRIAL FIBRILLATION - no documented prior atrial fibrillation
of note. Patient presented with evidence of atrial fibrillation
with rapid ventricular response to 130-140s at [**Hospital3 **]
with hypotension. Etiologies would include: worsening heart
failure vs. thyroid dysfunction vs. hypertension vs.
catecholingeric surge in the setting of abdominal issues -
CHADS2 score is 3. It is also possible that she went into Afib
which worsened her CHF and caused her current exacerbation. HR
is now well controlled after dig loading. Also treated with
metoprolol. The patient had TEE/CV which was successful and she
remained in NSR after the cardioversion on [**1-7**]. Digoxin was
discontinued after her cardioversion and she was started on
Amiodarone therapy. The patient was also started on Coumadin for
anticoagulation.
.
# ACUTE ON CHRONIC RENAL INSUFFICIENCY ?????? Creatinine remains
elevated at 2.5, by report Cr is 1.1-1.4 at baseline. She is
s/p right nephrectomy in the [**2073**] for recurrent
nephrolithiasis. The etiology of the acute worsening of her
renal function may be poor forward flow from her depressed EF
and volume overload and decreased perfusion to her single
kidney. Arguing against this is that her FEUrea was >35%,
suggesting that she is not pre-renal and may have progressed to
ATN. Also consider obstruction given single kidney and mild
hydro on US.
.
# ACUTE SYSTOLIC CONGESTIVE HEART FAILURE - 2D-Echo from [**2106**]
demonstrating severe global hypokinesis and inferior wall
akinesis with LVEF of 20-25% and moderate-severe mitral
regurgitation was noted. Repeat TTE here showed EF of 20% with
worsening mitral regurgitation, from 2+ to 4+. She presented
with evidence of volume overload (elevated JVP, peripheral edema
and inspiratory crackles) with CXR imaging showing pulmonary
edema. Acute decompensation considerations: medication
non-compliance vs. dietary indiscretion vs. ACS/MI or ischemia
(unlikely given reassuring serial cardiac biomarkers) vs.
valvular disease (worsening mitral regurgitation noted) vs.
tachycardia-inudced cardiomyopathy given her atrial fibrillation
(although it appears recent and her HR has not exceeded 130s,
TSH 6.0 with normal free T4 of 1.3). On exam, her volume status
improved prior to admission, with resolution of crackles and
edema. We held her ACEI in setting of hypotension and acute
renal insufficiency. She was dosed Lasix and a beta-blocker.
.
# GRAM POSITIVE COCCI BACTEREMIA, LIKELY CONTAMINANT- 1 of 4
bottles of admission blood culture was positive for coagulase
negative Staphylococcus. She has been afebrile since admission
and her WBC was normal. Most likely cause was a contaminant,
especially given the speciation and subsequent blood cultures
had been negative.
.
CHRONIC CARE:
# CORONARY ARTERY DISEASE - Patient has substantial coronary
artery disease history with CABG in [**2102**] (LIMA-LAD, SVG-D1,
SVG-OM1) and s/p multiple PCIs with most recent cardiac
catheterization in [**1-/2114**] showing widely patent grafts. She
presents with atypical and vague chest complaints this
admission, with some exertional dyspnea. Troponin trend and
CK-MB have been flat and no evidence of AMI causing her
symptoms. We continued her home Aspirin 81 mg PO daily and
Pravastatin.
.
# HYPERTENSION - home regimen includes ACEI, beta-blocker and
K-sparring diuretic with thiazide diuretic combination. She
reports controlled blood pressure as an outpatient, currently
hypotensive. These were held in setting of hypotension.
.
# HYPERLIPIDEMIA - will continue on Pravastatin 20 mg PO daily.
Developed myalgias in the past to Atorvastatin.
.
# DIABETES MELLITUS, TYPE 2 - history of diet-controlled
diabetes with insulin use only remotely - she did not tolerate
Levemir therapy and discontinued this months ago for GI
complaints; she rarely checks her blood sugars - no record of an
HbA1c in our system. She was maintained on ISS during her
hospitalization.
.
TRANSITIONS OF CARE ISSUES:
1. At the time of discharge, the patient's blood cultures from
[**1-3**] and [**1-5**] were pending without growth and her Abdominal
X-ray imaging from [**2115-1-6**] was pending a final read, but was
overall reassuring.
2. Patient was discharged with supratherapeutic INR of 5.9 and
will hold Coumadin anticoagulation until primary care follow-up.
3. If her non-specific abdominal pain continues, she will be
seen by a gastroenterologist for further evaluation to determine
the need for endoscopy.
4. Patient was started on Amiodarone therapy given her atrial
fibrillation; which she tolerated well.
5. We held her Lisinopril, Amelioride-Hydrochlorothiazide and
Metformin until her renal function improves; can be resumed at
her primary care physician's and cardiologist's discretion.
Medications on Admission:
1. Pravastatin 20 mg PO daily
2. Synthroid 100 mcg PO daily (5-days a week, weekdays only)
3. Aspirin 81 mg PO daily
4. Zantac 75 mg (10 mL) PO BID
5. Lisinopril 2.5 mg PO daily
6. Metoprolol succinate XL 25 mg PO daily
7. Amiloride-HCTZ 5/50 mg PO daily
8. Coenzyme Q-10 100 mg PO daily
9. Lasix 20 mg PO daily (recently started)
10. Metformin 500 mg PO daily
Discharge Medications:
1. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO 5X/WEEK
(MO,TU,WE,TH,FR).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
5. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. coenzyme Q10 100 mg Capsule Sig: One (1) Capsule PO once a
day.
9. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
Disp:*120 Tablet, Chewable(s)* Refills:*2*
10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 12 days: On [**2115-1-21**], decrease dose to one tablet once
a day.
Disp:*24 Tablet(s)* Refills:*0*
11. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Start on [**2115-1-21**].
Disp:*30 Tablet(s)* Refills:*2*
12. Outpatient Lab Work
Please check Chem-7 and INR on Thursday [**1-10**] with results to
Dr. [**Last Name (STitle) 10543**] at Phone: [**Telephone/Fax (1) 4475**]
Fax: [**Telephone/Fax (1) 29683**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Atrial fibrillation with rapid ventricular response
Abdominal pain
Acute on Chronic systolic congestive heart failure
Secondary diagnosis:
Diabetes mellitus
Hypertension
Acute on chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had some abdominal pain and vomiting that brought you to
[**Hospital3 **]. It is unclear why you are having pain with
eating and you will need to see Dr. [**First Name (STitle) 15532**] again for more
testing.
At the same time, it was found that you were in an irregular
heart rhythm called atrial fibrillation that was very rapid. You
received some medicine to help slow the rhythm and was
treansferred to [**Hospital1 18**] for care. Your heart was shocked back into
a regular rhythm and you were started on amiodarone to help keep
it in a regular rhythm. You will take warfarin (coumadin) from
now on to prevent strokes caused by the atrial fibrillation. You
will need to get your warfarin level checked regularly and Dr. [**Name (NI) 94281**] office.
As your heart rate was very fast, you had some fluid backup in
your lungs. Your weight this morning is 177 pounds. Weigh
yourself every morning, call Dr. [**Last Name (STitle) 10543**] if weight goes up more
than 3 lbs in 1 day or 5 pounds in 3 days. You also should avoid
salt in your diet.
.
We made the following changes to your medicines:
1. Increase ranitidine to 150 mg to take at night
2. START taking Amiodarone to prevent atrial fibrillation and
control the heart rate
3. Increase metoprolol to 100 mg daily
4. START Pantroprazole and Simethicone to help with your stomach
pain and gas
5. STOP taking lisinopril, Amelioride/Hydrochlorothiazide and
metformin until your kidney function improves.
Followup Instructions:
Primary Care:
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: INTERNAL MEDICINE
Address: [**Street Address(2) 4472**],[**Apartment Address(1) 24519**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 18325**]
Appointment: THURSDAY [**1-17**] AT 3:30PM
Gastroenterology:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) 1955**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Specialty: GASTROENTEROLOGY
Address: [**Street Address(2) 4472**]. [**Apartment Address(1) 31103**], [**Hospital1 **],[**Numeric Identifier 4474**]
Phone: [**Pager number **]
Appointment: TUESDAY [**1-15**] AT 2:45PM
.
Cardiology:
Department: CARDIAC SERVICES
When: TUESDAY [**2115-2-12**] at 1:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"414.00",
"V45.73",
"443.9",
"584.9",
"428.23",
"V45.81",
"585.9",
"789.00",
"428.0",
"403.90",
"412",
"244.9",
"V45.82",
"427.31",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.62",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
21110, 21167
|
12299, 19200
|
353, 404
|
21413, 21413
|
7587, 7587
|
23051, 24090
|
6138, 6253
|
19611, 21087
|
21188, 21306
|
19226, 19588
|
21564, 23028
|
6293, 7568
|
286, 315
|
432, 4198
|
21327, 21392
|
7603, 12276
|
21428, 21540
|
4220, 5854
|
5870, 6122
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,007
| 128,952
|
7211
|
Discharge summary
|
report
|
Admission Date: [**2157-4-25**] Discharge Date: [**2157-4-28**]
Service:
ADMITTING DIAGNOSIS: Cholangitis.
HISTORY OF PRESENT ILLNESS: The patient is a 79 year old
female with a history of metastatic cholangiocarcinoma,
status post multiple stones for biliary stasis, cholangitis,
admitted with nausea, vomiting and fever to 103. She went to
the Emergency Department where her temperature was 100, blood
pressure systolic 67, and she was given intravenous fluids,
started on Dopamine for thirty minutes. She was then given
Ampicillin, Gentamicin and Flagyl and transferred to the
endoscopic retrograde cholangiopancreatography suite where a
double pigtail stent was replaced. She was then transferred
to the Medical Intensive Care Unit for observation.
PAST MEDICAL HISTORY:
1. Metastatic cholangiocarcinoma diagnosed in [**2149**], status
post Taxol and liver resection in [**2150**]. Diaphragmatic lesion
resected in 03/99. She had stents placed in [**2155-5-2**], [**2156-5-1**], [**2156-1-2**], [**2157-1-29**], and [**2157-3-1**].
2. Breast cyst removed in [**2113**].
3. Thyroid nodule.
4. Diastolic dysfunction.
ALLERGIES: The patient has listed allergies to Penicillin
and Vancomycin, however, she received Ampicillin and
Vancomycin on this hospitalization without incident.
MEDICATIONS ON ADMISSION:
1. Multivitamins.
2. Xeloda.
SOCIAL HISTORY: The patient is a retired college
administrator.
PHYSICAL EXAMINATION: Upon transfer to the floor,
temperature was 98, blood pressure 122/54, heart rate 65,
respiratory rate 20, oxygen saturation 98% on two liters
nasal cannula. In general, she is an elderly female,
pleasant, in no acute distress. Head, eyes, ears, nose and
throat was anicteric. Heart - regular rate and rhythm,
distant S1 and S2. Pulmonary - slight rales, decreased at
the left base, but right clear. Abdomen - surgical scar in
the right upper quadrant, positive bowel sounds, soft,
nontender, nondistended, no masses appreciated. Extremities
- no cyanosis, clubbing or edema.
LABORATORY DATA: On transfer, white blood cell count 9.5,
hematocrit 35.6. Chem7 significant for bicarbonate of 14.
Coagulation studies significant for INR of 2.1, up from 1.5.
Liver function tests significant for alkaline phosphatase of
149, down from 206 and total bilirubin of 1.9, down from 2.1.
The patient had right upper quadrant ultrasound which showed
no ductal dilatation but did show a mass in the right hepatic
lobe in the past. The patient had endoscopic retrograde
cholangiopancreatography performed which was significant for
a tumor causing stricture from the bile duct extending to the
bifurcation all the way down to the distal third of the
common bile duct. She had a successful extraction of sludge
and tumor debris and placement of a double pigtail stent in
the common bile duct.
HOSPITAL COURSE:
1. Gastrointestinal - The patient was transferred to the
endoscopic retrograde cholangiopancreatography suite from the
Emergency Department after getting intravenous fluids and
Dopamine briefly. In the Emergency Department, she received
a restenting of her biliary duct and removal of prior stent
and removal of sludge. She was then continued on intravenous
antibiotics and was stable. She was changed to Vancomycin,
Levofloxacin and Flagyl on the floor and on discharge was
placed on Levofloxacin.
2. Cholangiocarcinoma - She was on Xeloda. Lessen scar
tissue. Follow-up with Dr. [**Last Name (STitle) 19**] as an outpatient. She had a
slight drop in her hematocrit which stabilized. She had
normal anemia workup. Metabolic acidosis which was stable.
She had an elevated INR which resolved with Vitamin K .
3. Prophylaxis - She was continued on proton pump inhibitor.
She did not get subcutaneous Heparin during this admission
with her elevated INR.
4. Code - Her code was full throughout.
MEDICATIONS ON DISCHARGE:
1. Levofloxacin 500 mg p.o. once daily times six days.
2. Multivitamin.
FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) 19**] and her
primary care physician.
DISCHARGE DIAGNOSES:
1. Cholangitis.
2. Cholangiocarcinoma.
DISCHARGE STATUS: To home with home safety evaluation.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern1) 6834**]
MEDQUIST36
D: [**2157-4-28**] 14:18
T: [**2157-4-30**] 09:21
JOB#: [**Job Number 26723**]
|
[
"197.0",
"197.7",
"V10.07",
"576.1",
"197.6",
"576.2",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.05",
"51.10"
] |
icd9pcs
|
[
[
[]
]
] |
4099, 4443
|
3893, 4078
|
1334, 1366
|
2860, 3867
|
1455, 2843
|
147, 769
|
104, 118
|
791, 1308
|
1383, 1432
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,593
| 192,553
|
40431
|
Discharge summary
|
report
|
Admission Date: [**2200-4-9**] Discharge Date: [**2200-4-21**]
Date of Birth: [**2132-8-1**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents / Penicillins / Sulfa (Sulfonamide Antibiotics) /
Nitrofurantoin / Carbonic Anhydrase Inhibitors
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
Intubation
Central Lines
History of Present Illness:
67 yo female rehab resident h/o CKD, PMR currently on a long
steroid taper, recent MRSA HD line infection on Vancomycin
presented to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital today with AMS since Tuesday,
and a UTI. Per her son, she was recently admitted to [**Name (NI) **]
[**Last Name (NamePattern1) **] [**Date range (1) 88611**] ago and was placed on temporary HD for large
volume diuresis. Volume overload at that time was felt secondary
to high dose steroids. On admission, her Cr was 1.1 and prior to
d/c her cr was 1.9. She was discharged on lasix 80 [**Hospital1 **] as she
was still felt to be volume overloaded. She developed a MRSA
blood stream infection from her HD line. Line was discontinued
and completed a 2 week course of vancomycin. HD was stopped. She
regained renal function after continuing lasix 80 [**Hospital1 **] and was
reportedly euvolemic. On the Tuesday prior to admission, the
family and rehab staff noted that the patient was becoming
increasingly paranoid and yelling at staff members. She was
taken to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and found to have ARF. The family decided
to transfer to [**Hospital1 18**] for further management.
.
In the ED, initial vs were: 98.2 90 85/43 18 92% on 4L. Exam
notable for oriented x 0 and uncooperative with questions. Found
to be hypoxic to 86% on 5L NC and improved to 100% on NRB. Also,
notably had decreased sbp's in the 70s transiently that
recovered without intervention. A right IJ was placed.
.
She was found to have a diffuse rash in her medial thighs. She
was given 125 methlypredisone and 50 IV benadryl. There was
concern for necrotizing fasciatis and an abdominal CT was
performed with cuts down to her thighs that did not show
evidence of this, however she was given 150 mg of clindamycin.
.
Also, EKG showed sinus tach with mild depressions in lateral
leads. She was given 600 mg PR ASA. She was notably guaiac
negative.
.
Other labs notable for a wbc of 12.9 with a left shift, proBNP:
[**Numeric Identifier 88612**], elevated ALT: 597, AST: 282, Cr of 3.1 (baseline ?1.1),
and a grossly positive UA. CXR significant for a left pleural
effusion and increased peri-hilar fullness consistent with
volume overload. She was given a dose of 750 mg of levofloxacin
for presumed PNA and her UTI. VS prior to transfer: 80 105/43
14 100% NRB, CVP: [**11-12**].
Upon arrival to the MICU, patient is yelling at nursing to stop
hurting her and not oriented. Her NRB was weaned down to a 70%
shovel mask
Past Medical History:
- CKD, baseline Cr 1-1.2. Prior to d/c from OSH [**3-25**]: Cr 1.9.
- Recent admission to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] where she was placed on
temporary HD for volume overload, subsequently developed a MRSA
HD line infection/bacteremia and treated with line removal and 2
weeks of vancomycin. TEE negative for vegetations.
PMR on slow steroid taper
Diabetes
Morbid Obesity
Osteoporosis
Depression
h/o nephrolithiasis
Chronic nonhealing skin lesions of the foot and ankle
Fibromyalgia
Compression fracture of T10 noted in prior OSH stay in [**3-10**].
causing severe pain and radicular symptoms with abdominal pain
and ileus.
Chronic LE edema
Glaucoma
OSA on home oxygen
CHF (8456 pro-BNP on [**2200-3-27**])
Social History:
Lantus 15 units QHS
HISS
Nephrocaps daily
dulcolax 5 mg [**Hospital1 **]
colace 100 [**Hospital1 **]
Lactulose prn
ASA 81
Simvastatin 20 qhs
Citalopram 20 qhs
Allopurinol 200 mg daily
Synthroid 50 mcg daily
Metoprolol succinate 200 mg daily
Zofran prn
lasix 80 mg [**Hospital1 **]
Vitamin C 500 mg [**Hospital1 **]
folic acid 1 mg daily
fosamax 70 mg q tuesday
Calcium Carbonate 400 mg TID
Mycostatin powder daily
Duragesic 12 mcg/hr patch q 72 hours (started [**4-6**])
MS Contin 15 mg [**Hospital1 **]
Vitamin C 1000 mg daily
Vancomycin 1500 mg daily
Epogent 20,000 unit/mL sq q Monday
potassium chloride 20 meq daily
Morphine IR 5 mg q 4 hours prn pain
Acidophilus [**Hospital1 **]
Zinc sulfate 220 daily until [**4-11**]
Prednisone taper 15 mg po x 5 days (starting [**4-8**]), then 12.5
daily x 5 days, then 10 mg daily x 5 days, 7.5 mg x 10 days then
5 mg daily
Family History:
NC
Physical Exam:
On Admission:
Vitals: T: 97.8 A, 92 132/79 19 98% on 70% shovel mask, CVP: 11
General: Not oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: Obese, unable to appreciate JVP, right IJ in place
Lungs: Rales at bases bilaterally
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic murmur
heard best at base
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 1+ pulses peripherally, right/left
feet wrapped. 2+ pitting edema bilaterally in LE
Skin: diffuse blanching erythematous rash diffusely throughout
skin.
Pertinent Results:
[**2200-4-9**] 03:53PM PT-13.1 PTT-25.0 INR(PT)-1.1
[**2200-4-9**] 03:53PM PLT COUNT-175
[**2200-4-9**] 03:53PM NEUTS-83.7* LYMPHS-10.0* MONOS-2.6 EOS-3.0
BASOS-0.6
[**2200-4-9**] 03:53PM WBC-12.9* RBC-3.45* HGB-11.0* HCT-33.2*
MCV-96 MCH-31.9 MCHC-33.1 RDW-19.1*
[**2200-4-9**] 03:53PM VANCO-19.6
[**2200-4-9**] 03:53PM TSH-3.4
[**2200-4-9**] 03:53PM CALCIUM-8.2* PHOSPHATE-4.6* MAGNESIUM-1.9
[**2200-4-9**] 03:53PM CK-MB-3 proBNP-[**Numeric Identifier 88612**]*
[**2200-4-9**] 03:53PM cTropnT-0.30*
[**2200-4-9**] 03:53PM LIPASE-15
[**2200-4-9**] 03:53PM LIPASE-15
[**2200-4-9**] 03:53PM estGFR-Using this
[**2200-4-9**] 03:53PM GLUCOSE-143* UREA N-70* CREAT-3.1*
SODIUM-129* POTASSIUM-5.5* CHLORIDE-86* TOTAL CO2-32 ANION
GAP-17
[**2200-4-9**] 03:55PM LACTATE-1.2
[**2200-4-9**] 08:00PM URINE EOS-POSITIVE
[**2200-4-9**] 08:00PM URINE WBCCLUMP-MANY
[**2200-4-9**] 08:00PM URINE RBC->182* WBC->182* BACTERIA-MOD
YEAST-MANY EPI-0 TRANS EPI-2
[**2200-4-9**] 08:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
[**2200-4-9**] 08:00PM URINE COLOR-AMB APPEAR-Cloudy SP [**Last Name (un) 155**]->1.030
[**2200-4-9**] 11:30PM CALCIUM-8.1* PHOSPHATE-5.4* MAGNESIUM-1.9
[**2200-4-9**] 11:30PM CK(CPK)-17*
[**2200-4-9**] 11:30PM GLUCOSE-186* UREA N-75* CREAT-3.2*
SODIUM-130* POTASSIUM-6.3* CHLORIDE-86* TOTAL CO2-34* ANION
GAP-16
Brief Hospital Course:
Death: The patient presented to the hospital with altered mental
status secondary to bacteremia. The patient on hospital day 3
was intubated for airway protection as she was tachypneic and
tiring out. Subsequently she continued to develop hypotension
with multiple repeat blood cultures, urine cultures and sputum
cultures that grew out multiple organisms including pseudomonas,
MRSA and yeast. The patient was started on a myriad of
antibiotics including vanco, zosyn, linezolid, dapto,
amphotercin, cefteraline. She also developed hypotension during
the admission that required a central line to be started. She
was at time of CMO status on 3 pressors to support a MAP of 50s.
The patient also became acutely fluid overloaded and was started
on CVVH for ultrafiltration and pulling fluid off. This was
successful in returning the patient to her dry weight however
subseuqently the patient became severely hypotensive. During the
admission the patient also became neutropenic with an ANC of 0.
Otherwise also became thrombocytopenic with a negative DIC
panel. A family meeting with the patient resulted in CMO status.
The patient was extubated and all pressors were discontinued.
The patient died within minutes of this occuring. She was
pronounced at 0043 on [**2200-4-21**]. NEOB was notified prior to time
of death and was refused. PCP was [**Name (NI) 653**]. Admitting office
was [**Name (NI) 653**]. Medical examiner not [**Name (NI) 653**] as no indication.
Family refused autopsy. Patient was transferred to the morgue.
Medications on Admission:
Lantus 15 units QHS
HISS
Nephrocaps daily
dulcolax 5 mg [**Hospital1 **]
colace 100 [**Hospital1 **]
Lactulose prn
ASA 81
Simvastatin 20 qhs
Citalopram 20 qhs
Allopurinol 200 mg daily
Synthroid 50 mcg daily
Metoprolol succinate 200 mg daily
Zofran prn
lasix 80 mg [**Hospital1 **]
Vitamin C 500 mg [**Hospital1 **]
folic acid 1 mg daily
fosamax 70 mg q tuesday
Calcium Carbonate 400 mg TID
Mycostatin powder daily
Duragesic 12 mcg/hr patch q 72 hours (started [**4-6**])
MS Contin 15 mg [**Hospital1 **]
Vitamin C 1000 mg daily
Vancomycin 1500 mg daily
Epogent 20,000 unit/mL sq q Monday
potassium chloride 20 meq daily
Morphine IR 5 mg q 4 hours prn pain
Acidophilus [**Hospital1 **]
Zinc sulfate 220 daily until [**4-11**]
Prednisone taper 15 mg po x 5 days (starting [**4-8**]), then 12.5
daily x 5 days, then 10 mg daily x 5 days, 7.5 mg x 10 days then
5 mg daily
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiopulmonary Arrest secondary to Bacteremia
Discharge Condition:
Expired
|
[
"112.2",
"V85.43",
"730.28",
"707.22",
"707.03",
"288.03",
"038.43",
"276.7",
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"293.0",
"287.5",
"695.89",
"707.05",
"725",
"428.0",
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"038.12",
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"421.0",
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"428.31",
"518.81",
"362.01",
"995.92",
"311",
"327.23",
"482.42",
"411.89",
"427.31",
"585.9",
"278.01",
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"276.1",
"733.00",
"276.4",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"88.72",
"38.91",
"00.14",
"38.93",
"96.72",
"39.95",
"96.04",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
9272, 9281
|
6795, 8325
|
374, 400
|
9371, 9381
|
5348, 6772
|
4649, 4654
|
9244, 9249
|
9302, 9350
|
8351, 9221
|
4669, 4669
|
331, 336
|
428, 2978
|
4683, 5329
|
3000, 3747
|
3763, 4633
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,812
| 137,750
|
24559
|
Discharge summary
|
report
|
Admission Date: [**2119-10-3**] Discharge Date: [**2119-10-17**]
Date of Birth: [**2055-11-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Zosyn / Demerol
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Nausea and food intolerance.
Major Surgical or Invasive Procedure:
[**2119-10-12**]
1. Redo laparotomy, lysis of adhesions.
2. Substernal colon interposition with creation of
coloesophageal and cologastric anastomosis.
3. Partial resection of manubrium, clavicle, and first rib.
4. Feeding jejunostomy.
History of Present Illness:
Mr [**Known lastname **] is a 63 year old Caucasian well known to the Thoracic
Surgery Service. He has had multiple repairs of his hiatal
hernia and now has a stricture which has been dilated and
stented multiple times. Most recently
an esophageal stent was placed by Dr.[**Last Name (STitle) **] on [**2119-9-1**]. Most
recent CXR on [**2119-9-5**] showed Esophageal stent noted in the
expected location of the GE junction.
Past Medical History:
Gastroesophageal Reflux disease for 20 years.
Benign Prostatic hypertrophy
Asthma
GERD
Laparascopic Nissen fundoplication in [**2110**]
Thoracic repair of hiatal hernia in [**2111**]
Nissen fundoplication with repair of hiatal hernia with mesh via
a midline laparotomy approach 4/[**2117**].
Social History:
He denies tobacco or alcohol use and he works as a plumber. He
is married with children.
Family History:
He has no family history of GERD. No other relevant family
history.
Physical Exam:
VS: T: 98.8 HR: 80 SR BP: 144/94 Sats: 97 RA
General: no apparent distress
Neck: incision healing with slight redness, but no purulence or
drainage.
Card: RRR, S1, S2 no MRG
Resp: clear bilaterally t/o to ausc
GI: bowel sounds positive. JP drain intact.
Ext: 2+ pedal edema bilaterally.
Pertinent Results:
[**2119-10-14**] WBC-9.5 RBC-3.69* Hgb-9.6* Hct-29.1* MCV-79* MCH-25.9*
MCHC-32.8 RDW-16.7* Plt Ct-238
[**2119-10-16**] 06:28AM BLOOD Glucose-109* UreaN-12 Creat-0.9 Na-139
K-3.9 Cl-105 HCO3-27 AnGap-11
Barium swallow study on [**2119-10-13**]
IMPRESSION: Patent coloesophageal and cologastric anastomoses
without
evidence of leak. Prompt distal passage of contrast into the
small bowel with minimal contrast retention in the neoesophagus.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
Mr. [**Known firstname **] [**Known lastname **] was admitted to [**Hospital1 18**] for complaints of
dysphagia and intolerance to certain foods, and was found to
have a migrated esophageal stent, with esophageal stricture. He
was taken to the operating room on [**2119-10-9**] where Dr. [**First Name (STitle) **] and
Dr. [**Last Name (STitle) **] performed a redo laparotomy, with lysis of
adhesions, substernal colon interposition with creation of
coloesophageal and cologastric anastomosis, partial resection of
manubrium, clavicle, and first rib, and a feeding jejunostomy.
The patient recovered in the intensive care unit, and was
transfered to the floor on [**2119-10-12**].
He underwent swallow evaluation [**2119-10-13**] revealing patent
coloesophageal and cologastric anastomoses without evidence of
leak. Prompt distal passage of contrast into the small bowel
with minimal contrast retention in the neoesophagus. The patient
is tolerating tube feedings, along with full liquid diet.
Pain management has been a big issue, along with anxiety. The
patient was transitioned to oxycontin on Monday [**2119-10-16**] and has
had anxiety mostly controlled with lorazepam.
PT evaluated the patient and deemed him safe to transfer home.
The patients wife is aware of these recommendations. The patient
and wife were given written and verbal DC instructions, and
showed repeat demonstration on JP management, as abdominal JP's
remained in the patient given its continued drainage.
Discharge Medications:
1. Singulair 10 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.
2. Docusate Sodium 100 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO BID (2
times a day).
3. OxyContin 40 mg Tablet Sustained Release 12 hr [**Month/Day/Year **]: One (1)
Tablet Sustained Release 12 hr PO twice a day.
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*0*
4. Lorazepam 0.5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO every six (6)
hours as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
5. Prevacid SoluTab 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day).
7. Lopressor 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
8. Oxycodone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every 6-8 hours
as needed for pain: breakthrough pain.
Disp:*60 Tablet(s)* Refills:*0*
9. Ventolin HFA 90 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]: One
(1) Inhalation four times a day as needed for shortness of
breath or wheezing.
Disp:*1 inhaler* Refills:*3*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 486**]
Discharge Diagnosis:
Esophageal Stricture
Discharge Condition:
stable
Discharge Instructions:
-Call Dr.[**Name (NI) 5067**] office at [**Telephone/Fax (1) 2348**] if you have fevers
>101.5, chills, nightsweats, cough, chest pains, difficulties
swallowing, nausea, vomiting, diarrhea or major weight loss.
-Check and record your weights daily.
If your feeding tube sutures become loose or break, please tape
tube securely and call the office [**Telephone/Fax (1) 2348**]. If your feeding
tube falls out, save the tube, call the office immediately
[**Telephone/Fax (1) 170**]. The tube needs to be replaced in a timely manner
because the tract will close within a few hours.
-Do not put any medication down the tube unless they are in
liquid form.
-Flush your feeding tube with 50cc every 8 hours if not in use
and before and after every feeding.
-Please empty the abd drain and neck drain daily and record the
ouput. Bring a record of the drainage to your clinic
appointment. Any questions reguarding the drain, please call
[**Telephone/Fax (1) 2348**].
-Do not drive while taking narcotics.
Followup Instructions:
Dr. [**First Name (STitle) **] [**2119-10-24**] at 1030 am on [**Hospital Ward Name 23**] 9
Get a chest xray [**Location (un) **] 30 minutes before your appointment.
Completed by:[**2119-10-18**]
|
[
"V85.1",
"562.10",
"493.90",
"276.51",
"E879.8",
"530.81",
"996.59",
"568.0",
"458.29",
"600.00",
"530.87",
"787.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"45.13",
"44.39",
"45.23",
"97.59",
"38.93",
"96.6",
"88.47",
"42.55",
"45.93",
"46.39",
"54.59",
"77.81",
"47.19",
"45.52"
] |
icd9pcs
|
[
[
[]
]
] |
5191, 5241
|
2375, 3865
|
312, 553
|
5306, 5315
|
1842, 2352
|
6363, 6561
|
1446, 1516
|
3888, 5168
|
5262, 5285
|
5339, 6340
|
1531, 1823
|
244, 274
|
581, 1008
|
1030, 1323
|
1339, 1430
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,416
| 116,117
|
33870
|
Discharge summary
|
report
|
Admission Date: [**2107-9-21**] Discharge Date: [**2107-9-27**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
left chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient speaks minimal English. Most of history obtained from
chart. He arrived via ems from day care program with report s/p
fall - report pt slid off of chair and hit back of head - no
LOC.
Complains of pain L chest and L knee
Past Medical History:
COPD
CAD (severe LAD disease, ?no stent per UMG but on plavix)
Chronic diastolic heart failure
DM (followed by [**Last Name (un) **])
HTN
Arthritis
s/p compression fx L1
Spinal stenosis L4-5
presumed Gout, on colchicin
Stage II chronic renal failure
Social History:
Lives at [**Location 78275**] living ([**Telephone/Fax (1) 78276**]). Uses cane at baseline.
No EtOH, smoking, drugs per patient
Family History:
No sudden death or early CAD
Physical Exam:
Time Pain Temp HR BP RR Pox
+ 10:12 5 98.5 64 162/68 22 96
Looks well, in pain.
Alert and oriented.
No scalp injury.
Pupils equal and reactive;
Neck: No tenderness
Lungs: Clear bilateral;Decreased air entry bilateral bases
Tenderness L chest
Heart: Regular rate and rhythm
Abdomen: soft nondistended. Some tenderness RLQ
Rectal: Sphincter tone present. No occult blood
Spine: Tenderness in lower thoracic spine and lumbar spine
Pertinent Results:
[**2107-9-21**] 11:45AM WBC-5.4 RBC-4.50* HGB-13.1* HCT-39.6* MCV-88
MCH-29.1 MCHC-33.0 RDW-14.7
[**2107-9-21**] 11:45AM NEUTS-72.8* LYMPHS-19.6 MONOS-4.8 EOS-2.2
BASOS-0.6
[**2107-9-21**] 11:45AM PLT COUNT-129*
[**2107-9-21**] 11:45AM GLUCOSE-328* UREA N-34* CREAT-2.0* SODIUM-135
POTASSIUM-5.0 CHLORIDE-100 TOTAL CO2-26 ANION GAP-14
[**2107-9-21**] CT Chest/Abd/pelvis : 1. L1 vertebral body compression
fracture with an 8-mm retropulsion of indeterminate age,
although no surround hematoma or soft tissue swelling.
Retropulsion causes severe spinal canal narrowing at this level,
which increases risk of spinal cord injury. If clinical concern,
MRI is more sensitive in evaluation of spinal cord injury.
2. Multiple bilateral rib fractures as above, with underlying
left chest
wall/mediastinal contusion/hematoma. Multiple old-healing
fractures, as
detailed above.
3. Cholelithiasis.
[**2107-9-21**] C Spine CT :
1. No acute fracture or subluxation.
2. Multilevel degenerative changes including osteophytes with
mild spinal
canal narrowing at C3-C4, increasing risk of spinal cord injury.
If clinical concern for spinal cord or ligamentous injury, MRI
is more sensitive.
[**2107-9-21**] Head CT :
Fracture of nasal spine of the maxilla, age indeterminate.
Lucency in the anterior left maxilla, of indeterminate age.
Findings may be periapical and dental related, although while
felt less likely, traumatic injury is not excluded
[**2107-9-21**] Right hip and knee :
No evidence of acute fracture involving the right hip, right
femur, or right knee.
[**2107-9-22**] Carotid studies : On the right,likely carotid occlsuion
with recanalization. On the left, there has been progression in
the plaque, now with 70-79% carotid stenosis. Clinical
correlation MRA or CTA evaluation is warranted.
[**2107-9-22**] Cardiac echo : The left atrium is dilated. There is
mild symmetric left ventricular hypertrophy with normal cavity
size. There is mild regional left ventricular systolic
dysfunction with hypokinesis of the basal inferior and
inferolateral segments. Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
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. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is an anterior space which most
likely represents a fat pad.
Compared with the report of the prior study (images unavailable
for review) of [**2106-5-5**], a focal wall motion abnormality can be
seen on the current study. This may have been present on the
prior but image quality precluded certainty. Mild symmetric LVH
is seen on the current study.
[**2107-9-24**] CXR : Left lower lobe opacity has minimally increased;
this could be due to atelectasis, pneumonia cannot be totally
excluded but less likely. There are low lung volumes.
Cardiomegaly is unchanged. Atelectasis in the right base is
stable. There are no enlarging pleural effusions or
pneumothorax.
[**2107-9-24**] KUB :
The ascending colon has a large amount of stool. The
transverse colon is
slightly distended measuring 8.5 cm in maximal diameter. There
are no air-
fluid levels. The visualized sigmoid colon is of normal caliber.
Haziness of the abdomen could be due to patient body habitus
and/or ascites. There are degenerative changes in the lumbar
spine.
[**2107-9-26**] Video swallow :
There is penetration and aspiration with thin consistency. There
is also penetration with nectar consistency, but no evidence of
aspiration. For further details, please refer to full speech
and swallow division note in OMR.
FINDINGS: Penetration with thin and nectar consistencies.
Aspiration with thin consistency.
Brief Hospital Course:
Mr. [**Known lastname 78277**] was evaluated in the ER by the Trauma Service and
Ct scans of the C Spine, Chest, Abdomen and Pelvis were notable
for multiple rib fractures and an old L1 compression fracture.
He was admitted to the Trauma floor for pain control, pulmonary
toilet and a syncopal work up. It was difficult to fully
explain the mechanism of his fall despite the help of the
Italian interpreter and on exam he seemed to have no vision in
the left eye. Eventually his daughter explained that his visual
problems were old secondary to a detached retina.
He had carotid studies which showed a string sign on the right
and 70-79% occlusion of the left internal carotid artery. The
vascular surgery service was consulted and recommended an MRA of
the neck however this was not obtained as the family felt that
surgery was not an option due to his age and comorbidities.
His pain was partially controlled with a PCA but language
barrier limited more instruction therefore he was changed to
Tylenol around the clock and prn oxycodone.
Unfortunately despite resuming his pre admission inhalers and
pulmonary toilet he desaturated to the mid 80's on 2 liters and
was tachypneic prompting transfer to the ICU. A chest Xray
revealed a left lower lobe density and he was placed on IV
Vancomycin and Zosyn. After a 48 hour stay in the ICU for
pulmonary toilet he was transferred back to the Trauma floor and
was evaluated by the Physical Therapy service. Due to his age
and deconditioned state as well as his pulmonary compromise he
was transferred to rehab to further help increase his mobility
and contine pulmonary toilet.
He remained afebrile with a normal WBC and was changed to oral
Cipro in [**2107-9-27**] which will continue thru [**2107-10-1**]. His
cultures were negative but the antibiotic was for Xray findings.
His main complaint of left sided rib pain was controlled with
Tylenol and prn Oxycodone.
Medications on Admission:
Vitamin D 1,000 unit Cap; Plavix 75 mg Tab
Advair Diskus 100 mcg-50 mcg/Dose for Inhalation
Aspir-81 81 mg Tab; Omeprazole 10 mg Cap, Isosorbide Mononitrate
10 mg Tab Glipizide SR 2.5 mg 24 hr Tab
Sertraline 25 mg Tab; Atrovent HFA 17 mcg/Actuation Aerosol
Inhaler; *flaxseed oil 1000mg Once Daily
Lasix 20', Colace 100 "
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: 2.5 mg Inhalation Q6H (every 6 hours).
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
250/50 mcg/Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for SBP < 100 HR < 60.
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
14. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12
hours on / 12 hours off.
15. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
16. Oxycodone 5 mg/5 mL Solution Sig: 5-10 mls PO Q6H (every 6
hours) as needed for pain.
17. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): Hold for SBP < 100.
18. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours): Thru [**2107-10-1**].
19. Insulin Regular Human 100 unit/mL Solution Sig: 2-8 units
Injection four times a day as needed for elevated blood sugars
per sliding scale: Check blood sugars Pre meal and HS.
20. Glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO BID (2 times a day).
21. Brimonidine 0.2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day): Both eyes.
22. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime): Both eyes.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
S/P fall with :
Left anterior [**5-15**] rib fracture
Right anterior 7th rib fractuer
Left lateral 6th rib fracture
Old L1 compression fracture with stenosis
Bilateral carotid stenoses
COPD
CAD
DM2
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) 600**] for a follow up appointment in 2
weeks
Call Dr. [**Last Name (STitle) 4321**] at [**Telephone/Fax (1) 608**] for a follow up appointment in
[**12-10**] weeks
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2107-9-27**]
|
[
"486",
"E884.2",
"403.90",
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"585.2",
"862.29",
"414.01",
"433.30",
"E849.6",
"361.07",
"496",
"428.32",
"250.00",
"428.0",
"724.02",
"807.02"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9898, 9969
|
5343, 7269
|
276, 283
|
10211, 10220
|
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|
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221, 238
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|
831, 962
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,377
| 188,974
|
54568
|
Discharge summary
|
report
|
Admission Date: [**2161-11-4**] Discharge Date: [**2161-11-6**]
Date of Birth: [**2109-7-1**] Sex: F
Service: MEDICINE
Allergies:
Nsaids / Aspirin / Influenza Virus Vaccine
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Right foot and calf pain, hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
52 yo F with history of pulmonary hypertension (prescribed 3L
home oxygen) presented with right foot pain, mild right calf
pain and redness. At presentation to ED denied chest pain,
dyspnea, fevers, chills, no new numbness or weakness.
.
In the emergency department, patient presented at approximately
2330 on [**2161-11-3**]. Initial vitals were T 97.8, HR 80, BP
143/100, RR 17, O2Sat 98% 2L NC. Her complaint of right calf
pain and tenderness prompted LENIS, which were negative. She was
started on Vancomycin for empiric cellultits treatment. CBC,
Chem 7, and troponin at presentation including were normal. Only
abnormal lab was slight INR elevation to 1.3. She received her
home medications in the ED overnight including omeprazole,
metoprolol, albuterol, and gabapentin. Also received two rounds
of 4 mg IV morphine for pain. On morning of [**11-4**] patient was
noted to have oxygen sat of 85% on 3L NC. She was additionally
complaining of chest pain. The chest pain resolved with
administration of nebulizers. She was awake at that time and
appearing compfortable and then was placed on NRB for
supplemental oxygen. Due to concern for PE, a CTA was obtained
and on prelim read showed no PE, but was consistent with CHF
showing cardiomegaly and pulmonary edema. Given unknown etiology
of hypoxemia, ED started levofloxacin and drew troponin and CK
again. Vitals immediately prior to transfer to the ICU were T
afebrile, HR 86, BP 127/87, RR 21, O2Sat 94% on NRB.
.
Upon arrival to the ICU, the patient denies chest pain or
dyspnea, though notes they were present transiently in the ED.
Her predominant complaint continues to be right foot and calf
pain. She denies fevers.
.
REVIEW OF SYSTEMS:
(+)ve: chest pain, dyspnea, wheezing, prurtic lesions on right
inner thigh, right foot pain, right calf pain
(-)ve: fever, chills, night sweats, loss of appetite, fatigue,
palpitations, cough, sputum production, hemoptysis, orthopnea,
paroxysmal nocturnal dyspnea, nausea, vomiting, diarrhea,
constipation, hematochezia, melena, dysuria, urinary frequency,
urinary urgency, focal numbness, focal weakness, myalgias
Past Medical History:
1) Pulmonary hypertension: Thought to be attributed to cocaine
abuse. R heart cath [**7-9**] with PA pressure mean 60, failed a
vasoactive trial with NO. L heart cath demonstrated no L-sided
etiology
2) Restrictive lung disease: TLC 2.59, 55% predicted on
[**2161-7-30**]
3) Asthma: ? given FEV1/FVC 120% predicted on [**2161-9-28**]
4) Hepatic fibrosis, stage 2 without cirrhosis by biopsy [**12-9**].
Thought to be secondary to history of EtOH.
5) Hypertension
6) Perforated duodenal ulcer [**12/2159**], attributed to NSAID use
7) History of Guillane-[**Location (un) **]
8) Polysubstance abuse, smoked cocaine
9) Depression
10) Rheumatoid arthritis, seronegative
11) Chronic severe back pain
12) 4 C-sections
13) History of secondary syphilis, treated
14) Seizures in childhood
Social History:
Lives with boyfriend. Four children, and several grandchildren.
Mother is HCP. She currently smokes [**1-3**] cigarettes per week.
Has glass of wine several times per week. Has h/o cocaine use,
and has used as recently as [**9-/2161**] based on urine toxicology
testing. Denies h/o IVDU.
Family History:
Father with COPD. Sister with diabetes.
Physical Exam:
On admission:
VITALS: 98.6 114/77 85 23 96%venti mask
GENERAL: awake, alert, resting in bed, tearful when discussing
social situation, NAD
HEENT: NCAT. PERRL, EOMI. MMM.
NECK: supple, no LAD, no appreciable JVD
CARDIAC: RRR, split second heart sound with loud P2, no r/m/g,
RV heave
LUNGS: crackles at bases bilaterally, R>L, no wheezing
appreciated
ABDOMEN: normoactive bowel sounds, soft, NT, ND, no
hepatosplenomegaly appreciated, midline scar and lower
transverse scar
EXTREMITIES: lower extremities cool to touch, but DPs faintly
palpable, trace edema, RLE mildly tender to palpation but
without eyrthema
NEURO: AAOx3
Pertinent Results:
Admission Labs:
[**2161-11-4**] 02:45AM BLOOD WBC-6.8 RBC-4.99 Hgb-15.1 Hct-45.2 MCV-91
MCH-30.3 MCHC-33.5 RDW-14.6 Plt Ct-206
[**2161-11-4**] 02:45AM BLOOD Neuts-45.6* Lymphs-41.5 Monos-5.8
Eos-4.4* Baso-2.8*
[**2161-11-4**] 06:35PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2161-11-4**] 02:45AM BLOOD PT-15.3* PTT-33.5 INR(PT)-1.3*
[**2161-11-4**] 02:45AM BLOOD Glucose-75 UreaN-11 Creat-0.8 Na-136
K-3.6 Cl-97 HCO3-24 AnGap-19
[**2161-11-4**] 09:30AM BLOOD Calcium-9.6 Phos-4.2 Mg-1.5*
[**2161-11-4**] 02:52AM BLOOD Lactate-1.1 K-3.5
[**2161-11-4**] 12:19PM BLOOD freeCa-1.16
[**2161-11-4**] 12:19PM BLOOD Type-ART pO2-68* pCO2-40 pH-7.40
calTCO2-26 Base XS-0
.
Cardiac Enzymes:
[**2161-11-4**] 02:45AM BLOOD cTropnT-<0.01
[**2161-11-4**] 09:30AM BLOOD cTropnT-<0.01
[**2161-11-4**] 06:35PM BLOOD CK-MB-2 cTropnT-<0.01
[**2161-11-4**] 09:30AM BLOOD CK(CPK)-70
[**2161-11-4**] 06:35PM BLOOD CK(CPK)-68
.
Discharge Labs:
[**2161-11-6**] 06:53AM BLOOD WBC-5.3 RBC-4.65 Hgb-14.3 Hct-42.2 MCV-91
MCH-30.7 MCHC-33.9 RDW-14.7 Plt Ct-144*
[**2161-11-6**] 06:53AM BLOOD PT-14.8* PTT-32.4 INR(PT)-1.3*
[**2161-11-6**] 06:53AM BLOOD Calcium-9.1 Phos-3.7 Mg-1.9
[**2161-11-6**] 06:53AM BLOOD Glucose-98 UreaN-14 Creat-1.0 Na-139
K-3.7 Cl-105 HCO3-24 AnGap-14
.
Microbiology:
[**2161-11-4**] Blood cultures: pending, no growth to date at time of
discharge
[**2161-11-5**] Urine culture: final, no growth
.
Imaging:
[**2161-11-4**] EKG: Sinus rhythm. Left atrial abnormality. Marked
right axis deviation. Right ventricular hypertrophy. Compared to
the previous tracing of [**2161-11-4**] no diagnostic interim change.
Clinical correlation is suggested.
.
[**2161-11-4**] Bilateral LENIS: No evidence of DVT. Limited assessment
of the right peroneal veins.
.
[**2161-11-4**] Right foot x-ray: There is no fracture or osseous
malalignment. There are no focal sclerotic or lytic lesions.
Slight generalized
demiineralization. There is fragmentation sugging old fracture
of distal
dorsal suirface of tarsal navicular. No acute fracture. An
incidental plantar calcaneal spur is noted. IMPRESSION: No
evidence of osteomyelitis.
.
[**2161-11-4**] CXR: Lungs are grossly clear. There is no pleural
abnormality or good evidence for central adenopathy.
Moderate-to-severe cardiomegaly with particular enlargement of
central pulmonary artery is longstanding.
.
[**2161-11-4**] CTA Chest:
1. No evidence of pulmonary embolism.
2. Marked cardiomegaly, and interstitial prominence without
frank edema,
consistent with congestive heart failure.
3. Right lower lobe 8 mm pulmonary nodule. Recommend three-month
followup.
.
[**2161-11-5**] TTE: The left atrium is elongated. The right atrium is
markedly dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is very small, with
reduced diastolic filling secondary to the reverse Bernheim
effect. Overall left ventricular systolic function is normal
(LVEF 75%). There is no ventricular septal defect. The right
ventricular free wall is hypertrophied. The right ventricular
cavity is markedly dilated with depressed free wall
contractility. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. The tricuspid valve leaflets are mildly thickened.
Moderate [2+] tricuspid regurgitation is seen. There is severe
pulmonary artery systolic hypertension. The main pulmonary
artery is dilated. The branch pulmonary arteries are dilated.
There is a trivial/physiologic pericardial effusion. There are
no echocardiographic signs of tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2161-6-30**], multiple major abnormalities as previously
described persist without major change.
Brief Hospital Course:
52yo F with history of pulmonary hypertension (prescribed 3L
home oxygen) presented with right foot pain, mild right calf
pain and redness then had acute oxygen desaturation in ED with
associated chest pain, transferred to the ICU for further
management.
.
#. Hypoxemia: During ED observation prior to admission, patient
had acute worsening of hypoxemia. Concurrent chest pain caused
concern for pulmonary embolism; however, CTA without evidence of
PE. Has known history of pulmonary hypertension thought to be
attributed to history of cocaine abuse. Most recent urine
toxicology in [**2161-9-28**] was positive for cocaine metabolites. On
RHC in [**7-/2159**], had minimal change in CI and pulm vasc resistance
with 100% FiO2 and no additional change with inhaled NO.
Outpatient pulmonary physician has been reluctant to further
test or treat PH given suspected ongoing cocaine use. Possible
that current hypoxemia is just a worsening of pulmonary
hypertension. Was given standing albuterol and ipratropium to
assure that reactive airway disease was not contributing. Trial
of diuresis with 20 mg IV furosemide was given, but patient's
fluid balance was net positive. The patient also did not
clinically respond well to this diuresis, with brief hypotension
of SBP's into the 60's. Hypotension improved with two 500cc NS
fluid boluses. The patient's oxygen saturation remained stable
in the upper 80's to low 90's on nasal cannula. The patient was
weaned off NRB, and was back to baseline oxygen requirement of
3L NC. Of note, urine toxicology to assess for ongoing cocaine
use was positive for cocaine and opiates. An echo was repeated,
and showed no significant change from prior study with chronic
pulmonary hypertension. Once stable, the patient was
transferred from the ICU to the medicine floor. At time of
discharge she was satting in the high 90s on baseline oxygen
requirement of 3L NC, and her SOB had resolved.
.
#Hypotension: While in ICU, the patient had hypotensive episode
with SBP in the 60s. Decreased SBP occurred in the setting of
diuresis with IV furosemide. The patient had positional
lightheadedness, but was mentating well and otherwise
asymptomatic. She received 2 IVF boluses of 500cc NS, with
improvement in SBP to 80s. Her blood pressure remained stable,
and had improved to 110s/80s on morning of discharge. She was
afebrile, without leukocytosis, and had no signs of bleeding or
infection. Given hypotension and cocaine use, her metoprolol
tartrate was stopped, and this was not resumed on discharge.
The patient should discuss resuming this medication with her PCP
during [**Name9 (PRE) 702**] the week after discharge.
.
#[**Last Name (un) **]: Cr increased from 0.8 to 1.3 on [**2161-11-5**], in setting of
attempted diuresis.
[**Last Name (un) **] was believed to be multifactorial in setting of probable
hypovolemia and perhaps a component of contrast nephropathy
given recent CT w/ contrast of chest, though it had only been 2
days since the study. Urine output was stable. Monitored
creatinine daily, and Cr was trending down at time of discharge
at 1.0.
.
#. Chest pain: Atypical for cardiac pain, and patient ruled out
for MI with 3 negative sets of cardiac enzymes. CTA chest also
negative for PE. Pain may have been secondary to
bronchospasm/reactive airway disease, given correlation of pain
with periods of wheezing and resolution of pain with nebulizers.
.
#. Right foot/calf pain: Etiology unclear, but most likely
secondary to either muscle cramps or neuropathic pain. DVT was
ruled out with negative LENIs in ED. No evidence of foot
fracture seen on x-ray. Exam not consistent with cellulitis.
While in ICU, patient's pain was periodic and more consistent
with muscle cramps, given palpable contractions during worst
pain. Calcium and magnesium were monitored, and the patient did
have magnesium repleted on one occasion. Electrolytes were
within normal limits at time of discharge. The patient was
continued on home dose gabapentin, as well as
hydrocodone-acetaminophen prn pain.
.
#. Chronic pain: Continued gabapentin, hydrocodone-acetaminophen
prn pain.
.
#. Cocaine abuse history: Patient denied recent use, though
urine tox screen was positive for cocaine. Ongoing cocaine use
likely contributing to worsening of pulmonary hypertension. The
patient was seen by social work during this admission, and
patient was amenable to counseling for coping with current
illness, feeling of isolation, and to address cocaine use.
Social work contact[**Name (NI) **] patient's PCP to request social work
referral [**Location **]clinic.
.
#. Left ear pain: Continued Auralgan, started as outpatient.
.
#. Code Status: The patient's code status was full code during
this admission.
Medications on Admission:
1) Auralgan (w/ acetic acid) 5.4 %-1.4 % [**1-3**] gtts TID
2) Albuterol sulfate 90 mcg Inhaler Q4-6H PRN
3) Clobetasol 0.05 % Foam apply affected areas QD to [**Hospital1 **]
4) Fluticasone 110 mcg/Actuation Aerosol 2 puffs [**Hospital1 **]
5) Gabapentin 1200 mg TID
6) Hydrocodone-acetaminophen 5 mg-500 mg Tablet Q8H:PRN pain
7) Metoprolol tartrate 37.5 mg [**Hospital1 **]
8) Omeprazole 40 mg [**Hospital1 **]
9) Trazodone 50 mg QHS
10) Docusate sodium 100 mg DAILY
11) Multivitamin once DAILY
12) Ranitidine HCl 150 mg DAILY
Discharge Medications:
1. Auralgan (w/ acetic acid) 5.4-1.4 % Drops Sig: 1-2 drops Otic
three times a day.
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
3. clobetasol 0.05 % Foam Sig: One (1) application Topical once
a day.
4. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. gabapentin 400 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
6. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q8H (every 8 hours) as needed for pain.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
8. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a
day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Pulmonary Hypertension
Hypoxia
Hypotension
Right foot pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. [**Known lastname 3646**],
You were initially seen in the emergency room at [**Hospital1 18**] for right
foot and calf pain. An ultrasound showed you do not have a
blood clot in your leg, and an x-ray did not show any evidence
of a new fracture. Your pain may be related to muscle cramps,
or it may be neuropathic pain (nerve pain). You should continue
to take gabapentin as you have been doing, and you should
discuss this pain with your primary care doctor.
While you were here, your oxygen levels became very low, and you
were admitted the to ICU to improve your breathing. You were
placed on a mask that helps increase your oxygen levels, and you
improved. We did tests that showed you did not have a heart
attack or a blood clot in your lungs. The low oxygen levels
were likely related to your pulmonary hypertension and extra
fluid on your lungs. You will need to follow-up with Dr. [**Last Name (STitle) **]
after you leave the hospital.
You also had some low blood pressures while you were here, and
we held your metoprolol. You should discuss restarting this
medication with your primary care doctor next week.
We made the following changes to your medications:
1. STOPPED metoprolol tartrate 37.5mg twic daily
We did not make any other changes to your medications. Please
continue to take them as directed.
Please follow-up [**Hospital1 **]Clinic next week on
Wednesday, [**2161-11-11**] at 3pm.
If you need to return to the hospital, please bring your home
oxygen with you.
Followup Instructions:
Department: [**Hospital 7975**] [**Hospital **] HEALTH CENTER
When: WEDNESDAY [**2161-11-11**] at 3:00 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 8268**], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
We are working on a follow up appointment in Sleep Medicine with
Dr. [**Last Name (NamePattern1) 4512**]within 1-2 weeks. The office will contact you
at home with an appointment. If you have not heard within 2
business days or have any questions please call [**Telephone/Fax (1) 6856**].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
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"458.9",
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"311",
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] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
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14640, 14698
|
8306, 13045
|
335, 342
|
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|
4322, 4322
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,815
| 199,344
|
9709
|
Discharge summary
|
report
|
Admission Date: [**2191-3-2**] Discharge Date: [**2191-3-6**]
Date of Birth: [**2148-6-7**] Sex: M
Service: TRRANSPLANT SURGERY
CHIEF COMPLAINT: Living related renal transplant.
HISTORY OF PRESENT ILLNESS: This is a 42 year-old male with
a longstanding history of insulin dependent diabetes mellitus
who presents for a living related kidney transplant.
PAST MEDICAL HISTORY: Positive for 1) coronary artery
disease, 2) hypertension, 3) insulin dependent diabetes
mellitus, 4) end stage renal disease, 5)
hypercholesterolemia, 6) neuropathy, 7) retinopathy, 8)
gastroparesis. He had cardiac catheterization in [**10/2190**]
which showed ejection fraction of 25%.
PAST SURGICAL HISTORY: Previous surgeries include 1)
coronary artery bypass graft [**10-9**] and 2) amputation of left
toe.
PHYSICAL EXAMINATION: Blood pressure 134/82, pulse 82,
weight 134 pounds. General is alert, oriented, in no acute
distress. Head, eyes, ears, nose and throat is negative
lymphadenopathy. Chest clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm. Abdomen soft,
nontender, nondistended, positive bowel sounds. Extremities:
multiple scars on the lower extremities, negative peripheral
edema.
MEDICATIONS ON ADMISSION: Lopressor 100 mg p.o. q.d.,
Zestril 10 mg p.o. q.d., Lipitor 10 mg p.o. q.d., Nephrocaps
1 cap q.d., Reglan 10 mg p.o. q. A.M., Phoslo 1 pill t.i.d.,
insulin Lantis 20 mg p.o. with dinner, Prevacid 20 mg p.o.
q.d., Lasix 80 mg p.o. b.i.d.
HOSPITAL COURSE: The patient was admitted on [**3-2**] and was
brought to the operating room with the diagnosis of end stage
renal disease. The patient had a living related renal
transplant. The patient tolerated the procedure well and was
transported to the postoperative area in stable condition.
Patient was then transferred to the Intensive Care Unit for
close monitoring due to his cardiac history. Postoperative
day one the patient did well, was transfused one unit of
packed red blood cells for hematocrit of 25. On
postoperative day two the patient continued to do well and
had urine output of 7,470 liters. On the [**10-2**] the
patient was transferred to the nursing floor. His urine
output over the previous day totalled 24 liters. His
intravenous fluids totalled 19 liters and the patient's
replacement fluid was discontinued and his maintenance dose
was increased to 100 cc per hour. On postoperative day four
the patient continued to do well and it was decided that most
likely patient be discharged the following day. On discharge
physical hematocrit is 96.6, heart rate 64, blood pressure
130/90, respiratory rate 18, 100 percent on room air. P.o.
2200, intravenous 1800, urine output 4400, JP 115. Discharge
physical - general - alert and oriented in no acute distress.
Cardiovascular - regular rate and rhythm. Respiratory -
clear to auscultation bilaterally. Abdomen soft, nontender,
nondistended, positive bowel sounds. Graft was nontender.
Extremities negative peripheral edema, negative swelling.
Incision was intact, clean and dry.
DISCHARGE LABORATORIES: White cell count 2.5, hematocrit
29.2, platelets 97. Chem-7: 139/3.6, 107/25, 24/1.1 and
glucose of 239. Calcium 7.9, magnesium of 1.3.
DISCHARGE DIAGNOSIS:
1. Status post living related kidney transplant.
2. History of coronary artery disease.
3. History of hypertension.
4. History of insulin dependent diabetes mellitus.
5. Status post coronary artery bypass graft in [**10-9**].
DISCHARGE INSTRUCTIONS: Patient will be discharged home in
stable condition and will follow up per his preplanned
schedule. Patient will also be discharged on 2 mg of
Prograft b.i.d. His level will be checked later today and if
there is a change in medication we will call his home and he
will adjust his medications as stated. Discharge medications
will include Reglan 10 mg p.o. q.A.M., Bactrim SS 1 tablet
p.o. q.d., Mycelex troche q.i.d., prednisone 80 mg on [**3-7**] mg on [**3-8**] and 20 mg thereafter. Prograft 2 mg p.o.
b.i.d., Lopressor 150 mg p.o. b.i.d., Lipitor 10 mg p.o.
q.d., Prevacid 20 mg p.o. q.d., Colace 100 mg p.o. q.d.,
Ganciclovir 500 mg p.o. t.i.d. and Percocet 5 one to two tabs
p.o. q. 4 to 6 hours, Lantis 20 units subcutaneously with
dinner, Humulog insulin sliding scale 200 to 250 2 units; 250
to 300 4 units; 301 to 350 6 units; 350 to 400 8 units.
DISCHARGE CONDITION: Stable/good to home.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15475**], M.D. [**MD Number(1) 15476**]
Dictated By:[**Last Name (NamePattern4) 959**]
MEDQUIST36
D: [**2191-3-6**] 10:25
T: [**2191-3-6**] 12:05
JOB#: [**Job Number **]
|
[
"250.61",
"362.01",
"250.51",
"401.9",
"583.81",
"536.3",
"585",
"414.01",
"250.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.69"
] |
icd9pcs
|
[
[
[]
]
] |
4420, 4715
|
3258, 3510
|
1262, 1502
|
1520, 3237
|
3535, 4398
|
714, 816
|
839, 1235
|
167, 201
|
230, 378
|
401, 690
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,240
| 116,129
|
45227
|
Discharge summary
|
report
|
Admission Date: [**2148-2-26**] Discharge Date: [**2148-3-7**]
Date of Birth: [**2077-7-1**] Sex: M
Service: MEDICINE
Allergies:
Quinolones / Morphine
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
CC: Unresponsive, hypotensive
Major Surgical or Invasive Procedure:
Intubation/Extubation
Central Line placement
Arterial Line placement
PICC line placment.
History of Present Illness:
HPI: 70yo male w/hx of Multiple Sclerosis and chronic indwelling
foley who was brought to ED via EMS after having a witnessed
syncopal event on [**2-26**]. While eating dinner, he lost
conciousness and his head fell back and his arms went up. He was
noted by his wife and son to be gurgling. His family denies any
prodromal complaints aside from fatigue a few days prior. The
EMS team found him to be unresponsive with some emesis in his
mouth. Pt brought to ED, intubated for airway protection.
Received Vanco/Cefepime/Clinda initially and an additional
2Liters of NS. MICU course notable for hypotension unresponsive
to IVF requiring intermittient Levophed gtt.
Additionally a CT head postive for L post/temp intraparenchymal
bleed which was then re-read as an AVM. CT Angiogram of the
Chest was performed and revealed a R subsegmental non-occlusive
thrombi with a chronic appearance. While in the MICU the pt
failed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test, developed aspiration pneumonia, had
labile blood pressures requiring Nitroprusside gtt, and [**11-21**]
positive bld cx for Staph Epi. Pt ruled out for MI, Echo was
nml, and EKG with old AV delay and type I 2nd degree AV block
(Wenkebach)with a normal rate.
Past Medical History:
1. Multiple Sclerosis
2. Hypertension
3. Neurogenic Bladder (chronic indwelling catheter)
4. Hyperlipidemia
5. GERD
7. s/p L foot 1st, 3rd and 4th metatarsal fractures
8. s/p L knee arthroscopy, resection of plica [**2-/2139**]
9. Bradycardia with first deg AV block
10. BPH
Social History:
occasional EtOH use; no tobacco or an IV recreational drug use;
worked as a judge, currently lives at home with good social
support
Family History:
Non contributory
Physical Exam:
T99.6, Tc 98.6, 140-170/55-72, 72-80, 12, 95% 3LNC
GEN: NAD, A & O x 3
HEENT: PERRL, EOMI, OP: clear
CV:Reg rate, S2, S2
PULM:Bilat course BS, crackles at bases
ABD:Distended, soft +BS
EXT:+1 Bilat lower ext edema
Neuro: grossly intact, strength 4/5, able to get to edge of bed
but difficulty ambulating.
Pertinent Results:
[**2148-2-26**] 11:00PM TYPE-ART TEMP-37.8 RATES-/14 TIDAL VOL-650
PEEP-5 O2-40 PO2-185* PCO2-40 PH-7.41 TOTAL CO2-26 BASE XS-1
INTUBATED-INTUBATED VENT-SPONTANEOU
[**2148-2-26**] 03:49PM WBC-9.9 RBC-3.24* HGB-10.1* HCT-29.2* MCV-90
MCH-31.0 MCHC-34.4 RDW-13.8
[**2148-2-26**] 03:49PM GLUCOSE-202* UREA N-33* CREAT-1.0 SODIUM-147*
POTASSIUM-3.5 CHLORIDE-113* TOTAL CO2-23 ANION GAP-15
[**2148-2-26**] 03:53PM LACTATE-3.4*
[**2148-2-26**] 05:03AM CORTISOL-23.3*
[**2148-2-26**] 05:30AM CORTISOL-24.7*
[**2148-2-26**] 03:13AM ALT(SGPT)-20 AST(SGOT)-21 LD(LDH)-197
CK(CPK)-67 ALK PHOS-67 AMYLASE-368* TOT BILI-0.3
[**2148-2-26**] 03:13AM LIPASE-32
[**2148-2-26**] 03:13AM CK-MB-NotDone cTropnT-0.01
[**2148-2-26**] 03:13AM CALCIUM-7.6* PHOSPHATE-3.5 MAGNESIUM-2.1
[**2148-2-26**] 03:13AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2148-2-25**] 10:15PM FIBRINOGE-525*
[**2148-2-25**] 10:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2148-2-26**] 03:49PM PLT COUNT-130*
Brief Hospital Course:
70yo male with hx of Multiple Sclerosis and chronic indwelling
foley catheter a/w syncope, aspiration pneumonia, and possible
intraparenchymal CNS bleed.
1. Hypotension/Syncope: Hypotension resolved while in MICU. [**Month (only) 116**]
have been related to septic physiology on presentation. CTA with
non-occlusive segmental thrombi in R pulm art. which was thought
to be chronic and not related to primary event. Echo w/ nml EF
and wall motion, and valves, CT head with AVM stable on repeat
imaging and confirmed by MRI/MRA, EEG w/o epileptiform activity.
Pt has h/o vaso-vagal symptoms and was eating at the time of the
event which is the most likely cause. 1st degree AV block with
Wenckebach intermittently would not be a cause of syncope since
his heart rate was always normal. Neurosurgery consultation
recommended anticoagulation with Hep gtt while in house given
the PE and pt is immobile, but no long term anticoagulation is
recommended (pt is a fall risk, risk of CNS bleed, and PE is an
incidental finding)Bilateral LENIS were negative. We
specifically discussed with the patient about all the risks and
benefits of being anticoagulated and also not being
anticoagulated. He understood everything and agreed with the
plan. His outpt neurologist at [**Hospital1 2025**] was also contact[**Name (NI) **] and is
aware of his hospitalization.
2. ARF: Likely due to hypotension/ATN vs UTI. Normalized with
fluids.
3. ID: Bilateral aspiration PNA, + MRSA, and possible
bacteremia. Intubated for two days. Blood cultures only [**11-21**] grew
Coag neg staph, thought to be a contaminant. MRSA grew in
sputum. Total body macular rash developed while pt was on Zosyn
and Ceftriaxone.
-initially covered w/Vanco/Zosyn Dced upon transfer to floor.
Was on Clinda for two days but spiked through it to 103. Started
Flagyl/Aztreonam/Vanc [**3-1**] given allergy to quinolone and ? rash
to cephalosporins.
-DC A-line and DC Central Line [**2-28**], sent tip for culture.
-Surveillance cultures were all negative. Repeat CXR with slight
improvement.
-Pt has chronic indwelling foley but U/A has been negative.
4. Neuro: Multiple Sclerosis, and h/o CNS AVM. Pt seen by
neurology and neurosurgery early in hospital course. Pt was
deconditioned, weak, and fatigued for most of his stay with
limited mobility. Will need aggressive PT and cont treatment for
MS. [**Name13 (STitle) **] been on Cytoxan in the past and is followed by [**Hospital1 2025**]
Neurologist.
5. Code: Full
6. Dispo: to rehab
7. Communication: Wife = (o)[**Telephone/Fax (1) 96660**] or (h)[**Telephone/Fax (1) 96661**]
PCP([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1728**])[**Telephone/Fax (1) 96662**]. (call between 6A and 6P)-
Neurologists: Dr. [**First Name4 (NamePattern1) 401**] [**Last Name (NamePattern1) 45435**] [**Hospital1 2025**] [**Telephone/Fax (1) 88304**] and Dr. [**Last Name (STitle) **] at
[**Hospital1 112**].
Medications on Admission:
ASA 81 qd
Colace
Senna
Nexium 40 qd
Enalapril 10 qd
Lipitor 10 qd
HCTZ 25 qd
Baclofen 20 [**Hospital1 **]
Ativan prn
Neurontin
Detrol
Cytoxan
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Dorzolamide-Timolol 2-0.5 % Drops Sig: Two (2) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
5. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): Regular Sliding scale.
8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Baclofen 10 mg Tablet Sig: Three (3) Tablet PO QAM (once a
day (in the morning)).
10. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Baclofen 10 mg Tablet Sig: Four (4) Tablet PO QPM (once a
day (in the evening)).
12. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
13. Baclofen 10 mg Tablet Sig: Three (3) Tablet PO Q NOON ().
14. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 9 days.
16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
17. Oxycodone HCl 5 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
18. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at
bedtime) as needed.
19. Vancomycin HCl 10 g Recon Soln Sig: One (1) gm Intravenous
Q24H (every 24 hours) for 9 days.
20. Aztreonam in Dextrose(IsoOsm) 1 g/50 mL Piggyback Sig: One
(1) gm Intravenous three times a day for 9 days.
21. Heparin Sodium 5,000 unit/0.5 mL Syringe Sig: One (1)
Injection three times a day: For DVT prophylaxis.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 100**] Rehab-MACU
Discharge Diagnosis:
1. Aspiration Pneumonia
2. MRSA Pneumonia
3. Syncope
4. Stable CNS AVM
5. Subacute Pulmonary Embolus
6. Multiple Sclerosis
7. 1st degree AV block, without bradycardia
Discharge Condition:
Stable to Rehab
Discharge Instructions:
Please see your PCP [**Name Initial (PRE) 176**] 1-2 weeks of discharge.
Followup Instructions:
1. Please see your PCP [**Name Initial (PRE) 176**] 1-2 weeks
2. Provider: [**Name10 (NameIs) 8741**] [**Name11 (NameIs) **], MD Where: [**Hospital6 29**]
ORTHOPEDICS Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2148-3-13**] 3:00
3. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11642**], MD Where: [**Hospital6 29**]
ORTHOPEDICS Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2148-3-14**] 2:20
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"507.0",
"426.11",
"431",
"340",
"482.41",
"780.2",
"584.9",
"V09.0",
"415.19",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.04",
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
8651, 8707
|
3623, 6550
|
310, 401
|
8918, 8935
|
2507, 3600
|
9056, 9580
|
2149, 2167
|
6743, 8628
|
8728, 8897
|
6576, 6720
|
8959, 9033
|
2182, 2488
|
240, 272
|
429, 1685
|
1707, 1984
|
2000, 2133
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,804
| 141,001
|
32459
|
Discharge summary
|
report
|
Admission Date: [**2196-12-18**] Discharge Date: [**2197-1-9**]
Date of Birth: [**2117-4-23**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Obstructive Uropathy/transfer from [**Hospital3 26615**]
Major Surgical or Invasive Procedure:
1. Bilateral percutaneous nephrotomy tubes (bilaterally)
2. Cystoscopy with biopsy
3. PICC line placement
History of Present Illness:
79 year old M with chronic urinary retention secondary to
prostate cancer (diagnosed in [**2186**], grade 7, stage t-3, r
seminal vessicle involvement at diagnosis). Treated with xrt and
hormonal rx at diagnosis. Had TURP [**2193**], did well following this
and self-cathed for urinary retention. (See urology OSH note in
back of chart for detail on urethral problems). In [**9-16**] had
foley placement complicated by false passage. Since then
difficultly cathing himself. Saw his urologist prior to his
admission to [**Hospital3 26615**] [**12-15**] and was noted to have fecal
material in his urine after a foley was passed. Due to
suspicion of enterovesical fistula the patient was admitted.
Upon admission his creatinine was noted to be 6.4 up from a
baseline of 1.0. A gastrograffin enema and a cystogram was done
showing a large filling defect involving the bladder, but no
frank fistula. Due to hyperkalemia is was ultimately admitted to
the ICU. A temporary dialysis line was placed and he was
dialyzed for hyperkalemia.
.
Of note, the patient was also noted to have lytic lesions of the
spine and has been recieving radation to his lumbar spine. A
biopsy has shown squamous cell carcinoma.
.
Pt is a vague historian, but accurate with most details.
Past Medical History:
-CAD
-ICD
-hypercholestorlemia
-prostate cancer w/ chronic urniary retention requiring self
cath
-treated with xrt, hormones in [**2187**]. grade 7, T3 at diagnosis)
-Known to have bone mets in R hip/pelvix and is currently
undergoing XRT 13/15 treatments done)
-DVT R leg [**1-14**]
-[**9-16**] foley placement complicated by false passage
Social History:
denies tob/etoh. Ret. math teacher
Family History:
No ESRD
Physical Exam:
Tmax: Temp: 98.6 BP: 110/60 HR:100 RR:12
.
General Appearance: elderly, pleasant, comfortable, NAD,
Eyes: anicteric
ENT: MMM, op without exudate or lesions, no supraclavicular or
cervical lymphadenopathy, JVP to 12 cm, no carotid bruits, no
thyromegaly or thyroid nodules
Respiratory: CTA b/l with good air movement throughout.
bibasilar rales
Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops
appreciated. Tachycardic. ICD in place over L subclavian
Gastrointestinal: nd, +b/s, soft, nt,
Eextremities: no cyanosis, clubbing. 2+ edema
Skin/nails: warm, no rashes/no jaundice/no splinters
Heme/Lymph: no cervical or supraclavicular lymphadenopathy
GU: Foley catheter in place draining scant amounts feculent
urine
Pertinent Results:
ADMIT LABS
----------
[**2196-12-18**] 11:20PM WBC-14.0* RBC-3.24* HGB-9.6* HCT-28.8* MCV-89
MCH-29.6 MCHC-33.3 RDW-13.2
[**2196-12-18**] 11:20PM PLT COUNT-142*
[**2196-12-18**] 11:20PM NEUTS-90.9* LYMPHS-4.8* MONOS-3.8 EOS-0.5
BASOS-0.1
[**2196-12-18**] 11:20PM PT-18.8* PTT-31.8 INR(PT)-1.7*
[**2196-12-18**] 11:20PM GLUCOSE-119* UREA N-41* CREAT-4.4* SODIUM-135
POTASSIUM-3.8 CHLORIDE-95* TOTAL CO2-28 ANION GAP-16
[**2196-12-18**] 11:20PM ALT(SGPT)-14 AST(SGOT)-21 LD(LDH)-219 ALK
PHOS-76 AMYLASE-21 TOT BILI-0.6
[**2196-12-18**] 11:20PM LIPASE-10
[**2196-12-18**] 11:20PM ALBUMIN-2.5* CALCIUM-7.2* PHOSPHATE-3.7
MAGNESIUM-1.7
.
DISCHARGE LABS
--------------
.
STUDIES
-------
[**2196-12-19**] Renal ultrasound
The right kidney measures 12.6 cm. The left kidney measures 11.9
cm. Moderate hydronephrosis is seen within bilateral kidneys. No
definite renal stone or mass is identified.
Bladder measures 11.3 x 7.7 x 7.5 cm and contains a large
heterogeneous mass with internal vascularity consistent with
tumor. A Foley balloon is identified within the bladder.
Attempts were made to fill the bladder with saline to better
evaluate the mass; however, patient could not tolerate more than
5 cc.
IMPRESSION: Bilateral moderate hydronephrosis. Large
heterogeneous mass filling the bladder lumen consistent with
tumor.
.
[**2196-12-21**] CT abdomen and pelvis
Study is compared with outside ([**Hospital3 26615**] Hospital) _____ CT,
dated [**12-15**], as well as interval renal [**Name (NI) 75758**], dated [**2196-12-19**].
Evaluation of the urinary tract, in particular, the bladder, is
limited by the lack of intravenous contrast material. However,
the bladder is markedly abnormal in overall appearance: It is
quite distended, despite the presence of _____ heterogeneous,
predominantly attenuation (40 [**Doctor Last Name **]) material corresponding to the
apparently known mass, demonstrated by [**Name (NI) 13416**], whose margins
cannot be defined. The bladder also contains numerous small gas
pockets, likely related to either the Foley catheter placement,
biopsy or other reasons; GI tract is not excluded, though none
is demonstrated. There is ill-defined haziness in the adjacent
fat of the prevesicular space of Retzius, superficial to the air
pockets, no definite extravesical extension is demonstrated.
There is no adenopathy, and no other pelvic adenopathy is seen.
Since the previous studies, bilateral nephrostomy tubes have
been placed, with pigtail loops in both renal pelves, draining
externally and the previously-demonstrated hydronephrosis is no
longer seen; there is persistent right more than left
hydroureter, incompletely characterized. There is relatively
slight perinephric soft tissue stranding, unchanged, and no
significant air is identified in the upper urinary tract, though
there is a small pocket of air in the left posterior pararenal
space, likely related to the recent tube placement. There is no
free retro- or peritoneal _____ air, and the small and large
bowel loops are relatively well-opacified and not distended,
with transit of contrast material into normal-appearing large
bowel, and no extraluminal contrast to suggest bowel
perforation. There is extensive, circumferential calcification
of the thoracoabdominal aorta and its branches; the abdominal
aorta measures some 2.9 cm in maximal diameter (2:46), without
frank aneurysmal dilatation. There is no intramural hematoma or
discrete peri-aortic fat-stranding to suggest "leak" limited
evaluation of the _____. There is no free fluid in the abdomen.
There is marked _____ cardiomegaly with multi-chamber
enlargement. There is extensive diffuse coronary arterial
calcification. Dual-chamber cardiac pacemaker in situ, with
apparently intact leads. There are small-moderate bilateral
pleural effusions with associated passive atelectasis. There is
also some interlobular septal thickening with patchy
ground-glass opacity, as well as prominence of the more-anterior
vessels, all consistent with underlying CHF. A focal
consolidation at the _____ aspect of the left lung base cannot
be excluded. No pericardial effusion is seen. Destructive
process involving the right L5 vertebral body, extending into
and largely replacing the cortex and right posterior elements
_____ a large soft tissue component, displacing the thecal sac
to the left, and deforming it. ______ the right neural foramen,
inseparable from the exiting right L5 nerve root, likely
preexistent. Though there are multilevel degenerative changes
elsewhere, no other destructive lesion is identified. There is
anterior wedging of the T7 vertebral body, with a mixed
sclerotic appearance which may represent a previously-treated
metastasis or, alternatively, ______ hemangioma. No similar
appearance is seen elsewhere.
IMPRESSION:
1. Markedly abnormal appearance to the bladder, which is
distended and may be largely filled with apparently-known soft
tissue mass. This is incompletely characterized, due to lack of
contrast enhancement. Numerous air pockets in the bladder may
relate to recent interventions, including biopsy, but should be
correlated clinically.
2. Status post interval placement of bilateral nephrostomy tubes
with external drainage, and virtual complete resolution of
hydronephrosis.
3. Unremarkable large and small bowel, with no evidence of
perforation, and no free fluid in the abdomen or pelvis.
4. Extensive destructive lesion involving right lateral aspect
of the L5 vertebral body and its posterior elements, with large
epidural soft tissue component thecal sac in exiting right L5
nerve root. This could be further characterized by MR
examination.
5. Abnormal appearance of the T7 vertebral body, which could
represent previously-treated metastasis and should be correlated
with other clinical information.
6. Multi-chamber cardiomegaly with dual-chamber cardiac
pacemaker, and evidence of CHF with bilateral pleural effusions
and passive atelectasis.
7. ____ medial aspect of the left lung base.
.
[**2196-12-21**] Echocardiogram
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated. Overall left ventricular systolic function is
moderately depressed (LVEF= 30-40 %) secondary to severe
hypokinesis of the inferior and posterior (inferolateral) walls.
Tissue Doppler imaging suggests a normal left ventricular
filling pressure (PCWP<12mmHg). There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The number of aortic valve leaflets cannot be
determined. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (area 1.2-1.9cm2). No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
.
Brief Hospital Course:
1. Obstructive nephropathy with acute renal failure. The patient
was transferred for [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital after initiation of
hemodialysis. After re-evaluation of his obstruction, bilateral
percutaneous nephrostomies were placed with very rapid
resolution of his ARF to a serum creatinine at his baseline. A
number of electrolyte abnormalities developed during his
post-obstruction diuresis, such as hypocalcemia, hypokalemia,
hypophosphatemia, and hypomagnesemia, which were corrected as
needed. Urology has recommended permanently leaving percutaneous
nephrostomies and bladder catheter in place. Bladder to be
irrigated twice daily with 500 cc of normal saline via three way
catheter. He was instructed to follow up with his long term
Urologist (Dr. [**Last Name (STitle) 75759**] within one month, as his urinary
catheters will likely need to be changed under cystoscopic
guidance.
2. Poorly differentiated maligancy in the bladder. Urology and
Oncology consultation was obtained, and re-imaging by ultrasound
and CT were done of the bladder mass. Subsequently, a rigid
cystoscopy was performed by Urology which demonstrated fibrinous
material in the urethra and large fibrinous mass adherent to the
bladder wall, consistent with old clot material. The material
was partially cleared, and a clean bladder wall was observed.
Biopsies were performed of the material. Continuous bladder
irrigation was started to help clear the mass. Initial gram
stains and studies demonstrated gram positive and gram negative
bacteria and antibiotics were continued, and later tailored
based on sensitivities. Pathology demonstrated a poorly
differentiated malignancy. Oncology then requested the pathology
slides of his spine biopsy to compare to the pathology from the
cystoscopy. Outpatient follow up with GU Oncology was arranged
pending pathology review for [**2196-1-13**] with Dr. [**Last Name (STitle) 10777**].
3. Paroxysmal atrial fibrillation. The patient developed bursts
of atrial fibrillation with rapid ventricular response. He was
rate controlled with a titration of metoprolol tartrate, later
converted to metoprolol succinate, and diltiazem. During his
invasive studies, warfarin anticoagulation was held, with the
plan to resume later; at the time of discharge this was being
resumed at 10 mg daily with a heparin bridge, to be completed at
the rehabilitation hospital.
4. Thrombocytopenia. The patient developed a 30% drop in his
platelets upon transfer, after significant exposure to heparin
during dialysis and for DVT prophylaxis. Preliminary heparin
dependent antibodies were positive, and confirmation serotonin
release studies were negative. Heparin was later used as a
bridge when initiating warfarin anticoagulation, without
recurrence of thrombocytopenia.
5. Left basilic vein deep venous thrombosis. The patient was
restarted on warfarin anticoagulation with a goal INR [**2-13**], and
covered with unfractionated heparin infusion on a weight based
protocol with PTT monitoring.
6. Possible enterovesicular fistula. Numerous studies done at
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], and direct cystoscopy by Urology here at [**Hospital1 18**]
failed to demonstrate a fistula; however, the enteric organism
leading to his urinary tract infection argued for a fistula. A
charcoal study was positive with the third urinary fraction (out
of 4) positive; General surgery and Urology were consulted
again, and it was determined that the patient was not a suitable
surgical candidate for fistula repair.
7. Pseudomonal urinary tract infection. The patient was started
on an initial fluroquinolone regimen and then changed to
meropenem, before finally settling on imipenem regimen. A PICC
catheter was placed, and the patient is to complete a total 4
weeks of imipenem therapy.
8. Diarrhea. C diff negative times 4 stool assays. Attributed
to mult stool softeners as well as charcoal given for
enterovesicular fistula evaluation (twice). Stool softeners
held.
Medications on Admission:
On transfer from OSH:
Atenolol 50 qd
Isordil 40 [**Hospital1 **]
MScontin 15 q12
MSIR 15 q6 prn pain
oxycontin 10 po q6 prn pain
protonix 40 qd
leviquin 250 q48 iv
1/2 ns w/ 2 amps nahc03 at 60 cc/hr
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. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
6. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Powder in Packet
Sig: One (1) Powder in Packet PO BID (2 times a day).
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
10. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
11. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO DAILY16 (Once
Daily at 16).
12. Imipenem-Cilastatin 500 mg Recon Soln Sig: Five Hundred
(500) mg Intravenous Q6H (every 6 hours) for 17 days.
13. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed.
14. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: 1100 (1100) Units Intravenous once a day: 1100 units per
hour continuous parenteral infusion; check PTT every 6 hours,
adjust heparin dose according to sliding scale (included) until
stable dose determined. Heparin drip should be continued until
INR has been therapeutic (between 2 and 3) for at least 48
hours.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
. Upper extremity deep venous thrombosis
. Poorly differentiad cancer in the bladder
. Urinary obstruction with acute renal failure, status bilateral
percutaneous nephrostromy tubes
. Locally invasive grade 7, T3 prostate cancer s/p radiation and
TURP on hormone therapy
. Squamous cell carcinoma of the bone
. History of squamous cell carcinoma of the skin
. Coronary artery disease history of myocardial infarction
. Chronic systolic congestive heart failure status post AICD
placement
. Paroxysmal atrial fibrillation
. Hyperlipidemia
. History of lower extremity deep venous thrombosis
Discharge Condition:
Fair, unable to ambulate with assistance.
Discharge Instructions:
Please contact your primary care physician or report to the
Emergency Department if you develop fevers, sweats, chills,
nausea, vomiting, blood in your urine, or decreasing amount of
urine.
Please contact your radiation oncologist to determine if you
need to continue radiation treatments.
Followup Instructions:
Call your primary doctor for a follow up appointment for within
one month of leaving the hospital: [**Last Name (un) **],[**Last Name (un) 75760**] A [**Telephone/Fax (1) 75761**]
Call your Urologist, Dr. [**Last Name (STitle) 75759**], for a follow up appointment
for within one month of leaving the hospital.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2503**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2197-1-12**] 2:00
Provider: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2197-1-12**] 2:00
|
[
"276.7",
"787.91",
"599.0",
"V10.46",
"428.0",
"272.4",
"V12.51",
"427.31",
"453.8",
"188.8",
"041.7",
"287.4",
"198.5",
"599.69",
"593.5",
"584.9",
"286.9",
"428.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"39.95",
"57.32",
"57.33",
"55.03"
] |
icd9pcs
|
[
[
[]
]
] |
15842, 15922
|
9857, 13916
|
329, 437
|
16556, 16600
|
2943, 9834
|
16939, 17560
|
2162, 2171
|
14167, 15819
|
15943, 16535
|
13942, 14144
|
16624, 16916
|
2186, 2924
|
233, 291
|
465, 1729
|
1751, 2094
|
2110, 2146
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,431
| 188,867
|
51320
|
Discharge summary
|
report
|
Admission Date: [**2142-5-28**] Discharge Date: [**2142-6-1**]
Date of Birth: [**2083-6-22**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Prograf / Phenergan / Haldol
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
hypogylcemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
58 year old male nursing home resident, MMP incl in brittle DM
[**1-25**] pancreatic insufficiency, ESRD on HD, others, BIBA from
[**Location (un) **] NH with chief complaint of low BS a/w increased
somnolence, diaphoresis, shaking, and confusion. Patient is a
resident at [**Hospital **] Nursing Home. Per report, yesterday pt had
FSBS = 41 yesterday, given dextrose and food with stabilization
of BS. This morning the patient was found to be diaphoretic and
not speaking, and glucometer at 910am read "low" - he was given
juice with increase in his BS to 61. He was given glucagon 1mg
IM x 1, and EMS called. On arrival to ED FSBS was 64. The
patient's repeat FSBS was 29. IV access was difficult, and a L
femoral line was placed. He was given 1 amp D50, and his sugars
increased to 89. 1.5 hours later, his BS was 19, he was given
1amp D50 and started on D10 drip. Prior to transfer to the MICU,
his FSBS was 86.
.
Pt states his dose of insulin (? lantus) was recently increased
during the 1 week prior to admission, but he is a difficult
historian and unclear on the details. He does not know which MD
is in charge of his diabetes. He states he has had diminished po
intake this week because he does not like the food at the NH. He
did not eat breakfast this AM, but reportedly was given his
lantus.
Past Medical History:
ESRD on HD (T, Th, Sat)
R AV graft
alcoholic pancreatitis
Brittle DM ([**1-25**] chronic pancreatitis) c/b neuropathy,
nephropathy, DKA and hypoglycemic seizure
s/p failed LRD renal txplt ([**2133**])
HTN
PVD s/p left 5th toe and right all 5 toes amputation
hx DVT with PE
Right tib-fib fx nonunion s/p external fixation
GERD
idiopathic meningoencephalitis
Anemia
R shoulder arthroplasty [**8-27**] and I&D in [**12-28**]
chronic diarrhea
dementia
h/o VTE
penile prosthesis
Social History:
Patient lives in [**Location **]. He has a wife named [**Name (NI) **]. [**Name2 (NI) **] was a heavy
drinker but quit several years ago. [**10-12**] pack year smoker.
Reportedly has been victim of domestic violence at hands of his
teenage daughter.
Family History:
noncontributory
Physical Exam:
93.7 (rectal T unobtainable) HR 50 BP 143/83 R 11 O2sat 93% on
RA
GEN: thin elderly male lying in stretcher in NAD, answering
questions appropriately
HEENT: NC AT, PERRL, MM dry, OP clear, no JVD
Heart: nl rate, S1S2, no mrg
Lungs: decreased BS at bases
Abd: flat, firm, mild epigastric tenderness, no r/g
Ext: s/p R midfoot amputation, L 5th toe amputation, no edema,
+PT b/l
Neuro: A&0X3, CN II-XII grossly intact
Pertinent Results:
ADMISSION LABS:
141 | 102 | 15 AGap=12
----------------<55
4.1 | 31 | 3.4 D
Ca: 7.6 Mg: 1.8 P: 2.5
.
MCV 92
4.6 >---< 140
.....34.4
.
Iron: 63
calTIBC: 120
Ferritn: 355
TRF: 92
.
Imaging:
CXR [**2142-5-28**] - Moderate Bilateral pleural effusions, improved on
the left, responsible for chronic basal atelectasis.
Brief Hospital Course:
The patient was initially admitted to the MICU for further
management of his hypoglycemia. His hospital course, by problem,
is as follows.
.
1) Hypoglycemia - Attributed to recent increase in Lantus dose
(6U qAM -> 15UqAM) with poor renal function (decreased
clearance) and compromised liver gluconeogenesis. He was placed
on a D10 drip, and his lantus dose was initially held, then
decreased to 7U. He was weaned off the D10 drip, but had
reccurent symptomatic hypoglycemia to FSBS 34. [**Last Name (un) **] consult
was obtained, and the patient was then put on 4 U lantus with a
sliding scale. He persistently had relatively low blood glucose
levels each morning, and therefore, his nighttime sliding scale
was made less aggressive. His FSBS were fairly stable on
transfer to the floor. On transfer to the floor he had normal to
high blood sugars without any evidence of hypoglycemia
overnight, but than had one episode of hypoglycemia to 39 in the
setting of not eating after getting prandial humulog coverage.
he was counciled to not allow administration of any kind of
insulin unless he had food available and he was planning on
eating a meal. All changes in insulin dosing should be made with
extreme caution. Do not cover with humulog at dinner until FS
>150 and no not cover with humulog at bedtime until FS >200.
.
2) End Stage Renal Disease - Stable throughout his admission. He
was dialyzed by the renal service as per his outpatient schedule
(Tues, Thurs, Sat).
.
3) Pancreatic insufficieny/chronic diarrhea - The patient
continued with his chronic diarrhea. He should take pancrease w/
meals due to ongoing malabsorption.
.
4)Rectal prolapse - The patient had 2 episodes of rectal
prolapse while in the MICU. One episode required manunal
reduction (stage III), the other spontaneously reduced (Stage
II). A curbside surgery consult was obtained, and they
recomended that the patient be referred for outpatient surgical
management unless his prolapsed rectum becomes irreducible.
.
5) Hypothermia - the patient was hypothermic on presentation to
the ED, with a rectal temperature too low to be recorded by the
rectal thermometer (<96 degrees). TSh/fT4 were checked which
were normal. He showed no evidence of sepsis. This was therfore
attributed to his hypoglycemia. He was normothermic for the rest
of his hospital stay.
He has a right arm AV graft for Dialysis and should have
dialysis on Tues/Thurs/Sat.
Medications on Admission:
MVI
amlodipine 5qd
folate
synthroid 100qd
cholestyramine
zinc
vitamin C
pancrease
dilt 120'
clonidine 0.2patch qWED
celexa 10qd
oxycontin 10bid
oxycodone prn
senna
colace
dulcolax
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO BID
(2 times a day).
5. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: [**12-25**] Caps PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
7. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
8. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
14. Lantus 100 unit/mL Solution Sig: Four (4) units Subcutaneous
QAM.
15. Humalog 100 unit/mL Solution Sig: As Directed by Sliding
Scale Subcutaneous As Directed by Sliding Scale: Please see
insulin sliding scale.
16. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] health care
Discharge Diagnosis:
Principal:
Hypoglycemia
Secondary:
Multi-infarct Dementia with Impaired executive functioning
Chronic Kidney Disease Stage V on Hemodialysis
Status Post Failed Renal Transplant [**2133**].
Poorly controlled IDDM with recurrent DKA and Hypoglycemic
Seizures
Deep Venous Thrombosis with Pulmonary Embolism
Recurrent Line Sepsis and Bacteremia
Systolic Heart Failure/Dilated Cardiomyopathy NOS
ETOH abuse in Remission
ETOH related Pancreatitis c/b Pancreatic Insufficiency
Lymphocytice Meningoencephalitis NOS - CN Palsy and Coma [**9-/2140**]
Gastro-esophageal Reflux Disease
Left Ophthalmoplegia
Dietary and Medication non-compliance
Chronic Diarrhea
Ano-sphincter dysfunction c/b intermittent incontinence
Hypertension
Hyperlipidemia
Hypothyroidism
Depression
Intermittent Delirium
Peripheral Neuropathy
Penile Prosthesis
PVD status post bilateral toe amputations
Status Post RUE arteriovenous graft thrombectomy
Right Proximal Humeral Joint Fracture c/b nonunion
Right Shoulder Hemiarthroplasty
Right Shoulder Prosthetic Joint Infection s/p Washout
Status Post Right Tib-Fib Fracture c/b non-[**Hospital1 **] and
Osteomyelitis
Status Post Right Tib-Fib OREF
Discharge Condition:
Improved, stable.
Discharge Instructions:
Please be sure to have food available when getting insulin to
avoid low blood sugars.
If you notice sweating, shaking, dizziness, headache, nausea, or
any other signs of low blood sugar, please eat something with
sugar and let your healthcare providers know.
Please follow up at the [**Hospital **] Clinic
Followup Instructions:
Primary Care Doctor
Name: [**Last Name (LF) 3134**],[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Location: [**Hospital3 **] HOSPITAL
Address: [**Street Address(1) 106458**], [**Location (un) **],[**Numeric Identifier 11562**]
Phone: [**Telephone/Fax (1) 3135**]
.
Please follow up at the [**Hospital **] Clinic ([**Telephone/Fax (1) 3537**] for your
diabetes care.
.
Dialysis per usual outpatient schedule.
Completed by:[**2142-6-5**]
|
[
"403.91",
"428.22",
"E932.3",
"250.60",
"443.9",
"357.2",
"250.40",
"569.1",
"250.80",
"585.6",
"425.4",
"530.81",
"577.8",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7337, 7391
|
3241, 5662
|
312, 318
|
8595, 8614
|
2903, 2903
|
8970, 9459
|
2434, 2451
|
5893, 7314
|
7412, 8574
|
5688, 5870
|
8638, 8947
|
2466, 2884
|
259, 274
|
346, 1652
|
2919, 3218
|
1674, 2149
|
2165, 2418
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,787
| 157,546
|
545+55218
|
Discharge summary
|
report+addendum
|
Admission Date: [**2175-1-28**] Discharge Date: [**2175-3-4**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
aspiration pneumonia
Major Surgical or Invasive Procedure:
G-J tube replacement
PICC line placement
History of Present Illness:
Patient is a [**Age over 90 **] year old man with a long history of a persistent
vegetative state recently admitted to [**Hospital1 112**] with an aspiration
pneumonia. He required intubation and was maintained on TPN and
tube feedings until he was able to be extubated and discharged
to rehab. He returns after only a few days after a presumed
episode of reaspiration again requiring intubation and pressor
support.
Past Medical History:
-Alzheimer disease
-persistent vegetative state
-GERD
-h/o aspiration PNA
-osteopenia
-atrial fibrillation
-myoclonus
Social History:
Has been cared for by his daughter for the past three years.
Family History:
Noncontributory
Physical Exam:
Gen unresponsive, resting comfortably
Neck flexed with no masses
CV RRR no m/r/g
Resp coarse BS bilaterally
Abd mildly distended, slightly firm, GJ tube in place
Ext [**12-19**]+ LE edema
Sacral decub w/dressing in place
Neuro unresponsive
Pertinent Results:
[**2175-3-2**] 02:43AM BLOOD WBC-10.9 RBC-3.50* Hgb-10.4* Hct-31.8*
MCV-91 MCH-29.6 MCHC-32.7 RDW-19.9* Plt Ct-339
[**2175-2-24**] 02:58AM BLOOD Neuts-71* Bands-2 Lymphs-11* Monos-6
Eos-3 Baso-1 Atyps-1* Metas-3* Myelos-2*
[**2175-2-24**] 02:58AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-2+ Microcy-1+ Polychr-1+ Schisto-1+ Tear Dr[**Last Name (STitle) **]1+
[**2175-3-2**] 02:43AM BLOOD Plt Ct-339
[**2175-2-22**] 03:31AM BLOOD PT-16.1* PTT-28.1 INR(PT)-1.5*
[**2175-3-2**] 02:43AM BLOOD Glucose-97 UreaN-35* Creat-1.0 Na-138
K-3.7 Cl-97 HCO3-30 AnGap-15
[**2175-2-11**] 04:24PM BLOOD ALT-24 AST-36 AlkPhos-150* Amylase-64
TotBili-0.4
[**2175-2-11**] 04:24PM BLOOD Lipase-72*
[**2175-3-2**] 02:43AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.6
[**2175-2-27**] 02:17AM BLOOD calTIBC-256* Ferritn-215 TRF-197*
[**2175-3-2**] 08:28AM BLOOD Vanco-20.6*
[**2175-3-4**] 07:25AM BLOOD Vanco-PND
[**2175-2-18**] 02:13AM BLOOD HoldBLu-HOLD
[**2175-2-18**] 10:23PM BLOOD Glucose-110* K-3.8
[**2175-2-8**] 05:44PM BLOOD O2 Sat-97
[**2175-2-27**] 02:49AM BLOOD freeCa-1.18
Brief Hospital Course:
Neuro-patient is in a persistent vegetative state and remained
unresponsive and at his baseline throughout his hospital stay.
Cardiovascular-patient was weaned off of pressor support shortly
after admission, he was maintained on iv metoprolol with
adequate control of his blood pressure. However, the pt. does
not tolerate being turned on his right side - his pressures will
decrease somewhat. If this occurs - place pt. back to supine
position and blood pressure should correct.
Respiratory-patient was intubated on admission. A series of
discussions were had with the [**Hospital 228**] health care proxy, his
daughter, regarding the need for tracheostomy. Both the primary
general surgery team and the thoracic team were consulted
regarding the need for tracheostomy. Eventually, a second
opinion was requested by the daughter and obtained from general
surgery. The daughter was told that the patient would likely
benefit from tracheostomy and that extubation could very well
lead to reintubation considering the patient's poor functional
status. The daughter decided to attempt extubation, the pt. was
extubated and has been doing very well for the past several days
off of the vent. He has been maintaining O2 saturations in the
high 90s with minimal oxygen from the face tent.
GI-the patient was started on TPN for nutritional support. He
was also given tube feedings. He is currently being maintained
on tube feeds and no TPN. His albumin has been stable with this
regimen and he should be continued on this: Nepro 45% strength
for Osm of 280 at a goal rate of 70cc/hour.
GU-Pt. has been getting Lasix throughout his stay for help
w/diuresis. He was initially quite volume overloaded and need
this to get fluid off so he could be extubated. He is no longer
requiring lasix and is making adequate uring on his own. His
renal function has also returned to [**Location 213**].
[**Name (NI) **] The pt. received a few transfusions of PRBCs during his
and for the past week his hematocrit has been stable. We do not
anticipate that he will need any further transfusions.
[**Name (NI) **] Pt. was initially being treated for aspiration pneumonia and
is requiring two more day of antibiotics to complete his course.
His WBCs have been stable.
Endo- stable
Medications on Admission:
vancomycin/ceftriaxone/flagyl, colace, lasix, reglan, enoxaparin
Discharge Medications:
1. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gm
Intravenous Q 24H (Every 24 Hours): - for 2 days [**3-4**] and [**3-5**].
2. Zosyn 2.25 g Recon Soln Sig: 2.25 gm Intravenous every eight
(8) hours for 2 days: - for [**3-4**] and [**3-5**].
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-19**]
Drops Ophthalmic PRN (as needed).
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Fifteen (15)
ML PO DAILY (Daily).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection [**Hospital1 **] (2 times a day).
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
neb Inhalation Q6H (every 6 hours).
10. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) mg PO once a day: via j-tube.
11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
12. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
-persistent vegetative state
-pneumonia
-bacteremia
Discharge Condition:
stable
Discharge Instructions:
-please return to the emergency department if the patient has
shortness of breath, inability to tolerate tube feedings, fever
>101.4F or any other problems
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 957**] as necessary. Call
[**Telephone/Fax (1) 673**] for an appointment.
Name: [**Known lastname 481**],[**Known firstname 482**] Unit No: [**Numeric Identifier 483**]
Admission Date: [**2175-1-28**] Discharge Date: [**2175-3-4**]
Date of Birth: [**2079-2-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 484**]
Addendum:
Adjustments were made to the pt. medications and it was decided
that he should continue Lasix at 20mg by J tube twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 485**] MD [**MD Number(1) 486**]
Completed by:[**2175-3-4**]
|
[
"507.0",
"438.82",
"427.31",
"707.04",
"783.7",
"285.29",
"707.11",
"294.10",
"428.0",
"041.11",
"518.84",
"780.03",
"331.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"44.32",
"33.24",
"99.15",
"96.72",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6994, 7229
|
2377, 4650
|
281, 324
|
6125, 6134
|
1297, 2354
|
6339, 6971
|
1005, 1022
|
4765, 5927
|
6050, 6104
|
4676, 4742
|
6158, 6316
|
1037, 1278
|
221, 243
|
352, 770
|
792, 911
|
927, 989
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,053
| 127,133
|
37105
|
Discharge summary
|
report
|
Admission Date: [**2153-1-7**] Discharge Date: [**2153-2-6**]
Date of Birth: [**2089-8-13**] Sex: M
Service: SURGERY
Allergies:
Iodine
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p Self inflicted gunshot wound to head
Major Surgical or Invasive Procedure:
[**2153-1-23**] EGD
History of Present Illness:
63yoM w/ h/o depression presents s/p self-inflicted gun shot
wound to face. Per report injury occurred 5-7days ago and
patient called EMS to his home today. He was conversant on their
arrival but was intubated at the scene for combativeness and
refusal to have care. He was taken to an area hospital and
transferred to [**Hospital1 18**] because of his injuries.
Past Medical History:
PVD, Venous stasis ulcers, chronic back pain, Clotting disorder,
Depression with h/o previous multiple suicide attempts
Social History:
Health care proxy - [**Name (NI) **] [**Name (NI) 78098**] , his mother and daughter are
very involved in his care.
ETOH none
Tobacco none
Family History:
non contributory
Physical Exam:
Upon admission:
98.8 86ST-189AF 107/69 (78) CMV TV 600 PEEP 5 RR 29 FiO2 100%
Sat 99%
Neuro: Intubated sedated, unable to completely assess facial
nerve, pt moves eyebrows on Lt
Face: face encrusted w/ old blood, there is a 4x3cm wound over
the Rt cheek immediately inferior to the lobule at the level of
the parotid, midface slightly mobile
Eyes: Lt pupil 6->5mm sluggish, Lt subconjunctival hemorrhage
and
edema, infraorbital rim intact bilaterally, Rt pupil 4->2mm and
reactive Rt conjuctival edema, no obvious injuries
Ears: no otorrhea
Nose: full of thin bloody secretions unable to assess septum
Mouth: limited exam given ETT unable to adequately assess Rt
side
of jaw, no obvious injury to dentition on Lt
Neck right jaw 1cm laceration, clean
Chest clear, no deformity
COR RRR
Abd large, softly distended
Ext No edema, calves soft
Pulses 2+ throughout
Pertinent Results:
[**2153-1-7**] 10:55PM WBC-19.6* RBC-3.03* HGB-9.1* HCT-27.2* MCV-90
MCH-30.0 MCHC-33.4 RDW-15.3
[**2153-1-7**] 10:55PM PLT COUNT-374
[**2153-1-7**] 09:31PM TYPE-ART PO2-65* PCO2-35 PH-7.48* TOTAL
CO2-27 BASE XS-2
[**2153-1-7**] 09:24PM GLUCOSE-139* UREA N-20 CREAT-0.8 SODIUM-142
POTASSIUM-3.1* CHLORIDE-105 TOTAL CO2-29 ANION GAP-11
[**2153-1-7**] 09:24PM ALT(SGPT)-29 AST(SGOT)-30 LD(LDH)-471*
CK(CPK)-527* ALK PHOS-162* TOT BILI-0.4
[**2153-1-7**] 09:24PM CK-MB-5 cTropnT-0.04*
[**2153-1-7**] 09:24PM ALBUMIN-2.5* CALCIUM-8.0* PHOSPHATE-0.8*
MAGNESIUM-2.1 IRON-55
[**2153-1-7**] 09:24PM calTIBC-196* FERRITIN-130 TRF-151*
[**2153-1-7**] 09:24PM TRIGLYCER-115
[**2153-1-7**] 09:24PM TSH-0.36
[**2153-1-7**] 02:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
Cardiology Report ECG Study Date of [**2153-1-7**] 3:56:08 PM
Atrial fibrillation with rapid ventricular response. Low limb
lead
voltage. Delayed precordial R wave transition. Baseline
artifact.
Repeat tracing of diagnostic quality is suggested. No previous
tracing
available for comparison.
Head CT scan [**2153-1-7**]
IMPRESSION:
1. No intracranial hemorrhage. Complex maxillofacial fractures
described in detail in the concurrent CT sinus. Lodged bullet in
the left retroorbital soft tissues again described in the
concurrent CT. Please refer to the CT sinus for details.
2. Opacification of bilateral paranasal sinuses with air-fluid
levels in the sphenoid sinuses and hemorrhagic opacification of
bilateral maxillary sinuses.
CT Sinus/mandible [**2153-1-7**]
IMPRESSION:
1. Complex maxillofacial mandibular fracture as described above,
involving
the right medial and lateral pterygoid plates, walls of
bilateral maxillary sinuses including the inferior wall of the
left orbit with a large bullet lodged in the left retroorbital
soft tissues, distorting the intraconal fat and limiting
evaluation of optic nerve and ophthalmic artery. No large
retroorbital hematoma was however appreciated.
CT Cervical Spine [**2153-1-7**]
IMPRESSION:
1. No evidence of C-spine traumatic injury, no fractures or
traumatic
malalignment.
2. Mild multilevel degenerative disease, worst at C5-C6 and
C6-C7. Biapical patchy opacities, right greater than left.
Document resolution on followup chest CT after stabilization of
patient's current clinical state.
3. The moderately distended esophagus is partly visualized.
4. Maxillofacial fractures partly imaged, better described in
concurrent
sinus CT.
CT Chest/Abdomen/Pelvis [**2153-1-8**]
IMPRESSION:
1. No evidence of hematoma of the chest, abdomen or pelvis.
2. Moderate bilateral pleural effusions with underlying
atelectasis/consolidation. Multifocal bilateral airspace
opacities concerning for infection, including opportunistic
infection. Tree-in-[**Male First Name (un) 239**] pattern and ground-glass opacity of the
lingula concerning for aspiration.
3. Distended stomach with fluid and air. Consider NG tube for
decompression.
4. Non-specific peritoneal stranding/thickening, may reflect
inflammation or a chronic/ongoing intra-abdominal process.
5. L1 compression deformity, age indeterminate.
Repeat head CT scan [**2153-1-19**]
IMPRESSIONS:
1. Extensive streak artifact from bullet and dental hardware
limits evaluation of the left frontotemporal region and the
posterior fossa, as before. Allowing for this, no large
intracranial hemorrhage, cerebral edema or mass effect seen.
2. Interval opacification of middle ear cavities and mastoid air
cells,
bilaterally.
Brief Hospital Course:
He was admitted to the Trauma service and transferred to the
Trauma ICU where he remained sedated and intubated. His hospital
course by systems is as follows:
Neurologic: There was no intracranial hemorrhage noted on
initial and on repeat head CT imaging. He initially required
sedation while in the ICU while ventilated; eventually his
sedation was weaned off. His current mental status at time of
this dictation is awake, alert; very interactive. He is
ambulating with a rolling walker and walking all around the
Trauma floor without any complaints.
ENT: His hearing is somewhat decreased though he seems to be
able to hear everyone speaking in normal tones. On exam his
right ear outer canal had some old blood visible and Cerumenex
was started to soften it up.
Respiratory: Once weaned and extubated he remained in the ICU
for close monitoring; his saturations remained stable throughout
his ICU stay. He no longer requires any supplemental oxygen.
Cardiac: He was noted with runs of atrial fibrillation during
his initial ICU stay and received beta blockade. He remained on
Lopressor for a short period and this has since been stopped.
There have been no other cardiovascular issues.
Gastrointestinal: He was noted with a hematocrit drop and melena
requiring intermittent blood transfusions with packed cells.
Because of this he was transferred back to the ICU for several
days. GI was consulted; he underwent an EGD which showed pyloric
ulcer and esophagitis. He was started on a PPI. Serial
hematocrits were followed. His current hematocrit at time of
this dictation is 29.9 He is currently tolerating a regular
diet.
Genitourinary: There are currently no active issues. He is
voiding without difficulty.
Musculoskeletal: There are no active issues currently. He
continues to work with Physical therapy and is making progress
toward becoming independent with ambulation.
His chronic back pain is controlled.
Heme: A Hematology consult was obtained early on while in the
ICU due to an eosinophilia. It was felt by Heme that it was most
likely his eosinophilia was secondary to medications. It was
further noted by Heme that medication-induced eosinophilia is
usually asymptomatic and doesn't necessarily require stopping
the offending medication. And that regardless of the cause of
his eosinophilia, its diagnosis is unlikely to affect his
short-term prognosis and can be further
worked up if it doesn't resolve once his antibiotic course is
finished.
Pain: Has a history of chronic pain related to his spine. Was
evaluated by the Pain Service while in the ICU and initially
placed on Methadone. This was stopped at some point and he is
currently taking Percocet prn with adequate pain control. He has
been followed closely by the Chronic Pain Service and they have
determined that it is effective based on exam and conversations
with Mr. [**Known lastname 75403**].
Psychiatric/Mental Health: He has been followed closely by
Psychiatry during his inpatient stay. He was started on Cymbalta
and Trazodone and is tolerating both without any difficulties.
There have been no behavioral issues.
Medications on Admission:
coumadin, fioricet, imitrex, pepcid
Discharge Medications:
1. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Ophthalmic Q6H (every 6 hours): apply to left eye.
2. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day): apply to left eye.
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime): apply to left eye.
4. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours): apply to left eye.
5. Artificial Tear Ointment Ointment Sig: One (1) Appl
Ophthalmic QID (4 times a day): apply to both eyes. Alternate
use between Polymixin.
6. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
10. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30)
ML's PO twice a day as needed for constipation.
11. Dulcolax 10 mg Suppository Sig: One (1) supp Rectal once a
day as needed for constipation.
12. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain, fever.
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
16. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
18. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
19. Sumatriptan Succinate 25 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily) as needed for headache.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Location (un) 10059**]
Discharge Diagnosis:
s/p Self inflicted gunshot wound to head
Complex maxillofacial fractures
LeForte II fractures
Bullet fragment left orbit
Traumatic optic neuropathy
Gastrointestinal bleeding
Pyloric ulcer
Esophagitis
Depression
Suicidal ideation
Acute blood loss anemia
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Flat affect, intermittently interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
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.
?????? Do NOT take any anti-inflammatory medicines such as Motrin,
Aspirin, Advil, or Naprosyn
CALL YOUR DOCTOR IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow up with Ophthamology/Neuro-ophthamology in [**2-22**] weeks:
call [**Telephone/Fax (1) 253**] for an appointment.
Follow up with Plastics in 3 weeks, call [**Telephone/Fax (1) 5343**] for an
appointment.
Follow up in [**Hospital 40530**] clinic in the next 3-4 weeks with Dr. [**First Name (STitle) **] to
discuss further if repair of your jaw is needed. call
[**Telephone/Fax (1) 55393**] for an appointment.
Follow up with Psychiatry after discharge as instructed
following your inpatient stay.
Completed by:[**2153-2-6**]
|
[
"288.3",
"377.39",
"578.1",
"728.88",
"276.52",
"427.31",
"E955.0",
"802.7",
"801.50",
"507.0",
"338.4",
"518.5",
"289.81",
"802.34",
"E849.0",
"276.0",
"459.81",
"707.12",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.6",
"86.28",
"38.91",
"38.93",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
10702, 10781
|
5514, 8626
|
305, 326
|
11078, 11078
|
1948, 5491
|
12182, 12719
|
1034, 1052
|
8712, 10679
|
10802, 11057
|
8652, 8689
|
11272, 12159
|
1067, 1069
|
224, 267
|
354, 718
|
1083, 1929
|
11092, 11248
|
740, 861
|
877, 1018
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,168
| 106,944
|
46888
|
Discharge summary
|
report
|
Admission Date: [**2149-2-28**] Discharge Date: [**2149-3-3**]
Service:
CHIEF COMPLAINT: Bright red blood per rectum.
HISTORY OF PRESENT ILLNESS: This is a 79-year-old male with
a history of diverticulosis, hypertension, thalassemia and
prostate cancer who presents with bright red blood per rectum
starting at approximately 4:30 AM on the day of admission.
He was up at 4 AM, had some [**Last Name (un) **] water, then had a loose
yellow bowel movement with no blood. About one-half hour
later he had bright red blood per rectum then came
immediately to the emergency room where he reports three more
episodes of bright red blood per rectum. Usually the patient
has one brown bowel movement per day, no melena or bright red
blood per rectum usually. He ate four handfuls of popcorn
last night and watermelon with seeds. He denies chest pain,
shortness of breath, abdominal pain, nausea, vomiting, or
diarrhea. He was dizzy only when an nasogastric tube was
attempted to be placed. In the emergency room the patient
received fluids and Protonix and had a stable blood pressure.
Gastrointestinal saw the patient and recommended a
colonoscopy but not urgently. No nasogastric lavage was done
as the tube could not be passed.
PAST MEDICAL HISTORY: Hypertension, thalassemia, prostate
cancer not being treated, history of a diverticular bleed ten
years ago. He reports having a normal colonoscopy here at
that time though it is not in our computer system. The
patient states he has a history of a heart murmur, history of
gout.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS: Atenolol 50 mg p.o. q.d.; Accupril dose
uncertain q.d.; allopurinol q.d.
SOCIAL HISTORY: He lives with his wife. [**Name (NI) **] worked in the
heating business. He has two sons, one is deceased. No
tobacco. He drinks a quart of wine per day. He has never
withdrawn. He has no primary care physician at present, as
his primary care physician [**Name Initial (PRE) **].
FAMILY HISTORY: Diabetes and coronary artery disease in his
mother.
PHYSICAL EXAMINATION: On admission his vital signs were
temperature 98.8, pulse 62, respiratory rate 18, blood
pressure 144/54 and 100% on room air. Generally, he was
alert and oriented x 3 in no apparent distress. HEENT showed
pupils were equal, round, and reactive to light, extraocular
movements intact, no lymphadenopathy. Cardiac examination
was regular rate and rhythm, a [**3-6**] murmur at the left lower
sternal border that radiated to the axilla not to the neck.
Lungs were clear to auscultation bilaterally; no wheezes, no
rales. Abdomen was soft, nontender, and nondistended,
positive bowel sounds. Genitourinary examination showed
bright red blood per rectum per the emergency room.
Extremities had no edema. Neurological examination showed
cranial nerves two through 12 were intact. Strength was [**6-2**]
throughout.
He had an EKG that was normal sinus rhythm at 67, left axis
deviation with normal intervals, no ST elevation or T wave
inversion. He did have mild upsloping of the T wave in V2
through V4 which could be called J point elevation. There is
no old film to compare.
LABORATORY STUDIES: His admission hematocrit was 36.7.
Discharge hematocrit was 30.4. White count 10.7, MCV 67,
58.2 neutrophils, 35.8 lymphocytes, 3.0 monocytes, 2.3
eosinophils, 0.6 basophils. Platelet count was 133. PT
12.8, PTT 28.3, INR 1.1. Glucose 131, BUN 9, creatinine 0.8,
sodium 138, K 5.1, hemolyzed, chloride 105, bicarbonate 22,
ALT 16, AST 41, amylase 45. CKs x 3 were 59, 30 and 36.
Lipase was 34, troponin less than 0.3 x 3. Calcium 8.9,
phosphorous 4.4, magnesium 1.9, iron 84, TIBC 324, ferritin
364, TRF 249, hemoglobin A1c 6.1.
HOSPITAL COURSE: This was a very pleasant 79-year-old man
with a lower gastrointestinal bleed.
1. Gastrointestinal: The patient received a total of four
units of packed red blood cells with only one more episode of
bright red blood when he reached the intensive care unit.
The patient had a colonoscopy which showed multiple
diverticula and internal hemorrhoids. The patient did
receive p.o. Protonix during his course here, though he was
not discharged on that. The patient was discharged and
advised to avoid seeds, nuts and popcorn.
2. Hypertension: The patient had a history of hypertension.
His medications were held here and he was advised to restart
them as an outpatient on the day after discharge.
3. Thalassemia: Stable with his low MCV.
4. Endocrine: The patient had an elevated blood glucose when
he arrived. We did q.i.d. fingersticks x 1 day and
hemoglobin A1c was sent. On further information the patient
said he has had some glucose intolerance in the past and
actually sees a doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) **].
5. Cardiovascular: The patient had a murmur that he states
was worked up in the past with echocardiogram. He stated he
has not had a recent stress test. Due to the J point
elevation and repeat EKG showing some T wave flattening,
would recommend and outpatient stress and an outpatient
echocardiogram to work-up the patient's murmur.
DISPOSITION: The patient was discharged to home in stable
condition. He was given the phone number for Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1058**] and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Associates to follow up for his
primary care physician.
DISCHARGE MEDICATIONS: He was to return to his regular
outpatient regimen of atenolol, Accupril and allopurinol.
The patient was to follow up with his new primary care
physician in two weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5587**]
Dictated By:[**Last Name (NamePattern1) 22309**]
MEDQUIST36
D: [**2149-3-4**] 01:12
T: [**2149-3-5**] 08:07
JOB#: [**Job Number 99469**]
|
[
"185",
"562.12",
"455.0",
"282.4",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
2011, 2064
|
5469, 5945
|
3745, 5445
|
2087, 3727
|
99, 129
|
158, 1243
|
1266, 1690
|
1707, 1994
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,715
| 184,419
|
38970
|
Discharge summary
|
report
|
Admission Date: [**2118-6-16**] Discharge Date: [**2118-6-21**]
Date of Birth: [**2045-5-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Zestril
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
mitral regurgitation/coronary artery disease
Major Surgical or Invasive Procedure:
mitral valve repair (25mm [**Company 1543**] 3D ring), coronary artery
bypass graft x 1(SVG-PDA) [**2118-6-17**]
History of Present Illness:
This 73 year old white male has known mitral regurgitation and
previously has undergone catheterization to reveal distal right
coronary disease. He underwent full mouth extractions recently
and is readmitted now for cardiac surgery rescheduled after his
need for dental surgery was addressed.
Past Medical History:
Congestive Heart Failure(Chronic, Systolic)
Mitral Regurgitation
coronary artery diseasee
Hypertension
Chronic Atrial Fibrillation
Chronic obstructive pulmonary disease
Chronic Renal Insufficiency
Obesity
Dyslipidemia
Anxiety
History of gastrointestinal bleed
s/p colonic polyp removal
s/p Left Total Hip replacement
s/p Eye Surgery as child
Social History:
Race: Caucasian
Last Dental Exam: many yrs ago
Lives alone
Occupation: retired businessman
Tobacco: Quit [**2086**]-started at age 21yo-smoked ~2PPD, 40 pack
year
history
ETOH: Denies
Family History:
non- contributory
Physical Exam:
admission:
Pulse: 100 Resp: 18 O2 sat: 100%
B/P Right: 120/80 Left:
Height: 5'7" Weight: 200 lbs
General: well-developed male in no acute distress
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X] poor dentition
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X] slight decrease BS
Heart: RRR [] Irregular [X] Murmur 2/6 systolic-[**6-2**] over 6th
ICS
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema LLE > RLE with
chronic venous stasis changes
Neuro: Grossly intact [X]
Pulses:
Femoral Right: Left:
DP Right: 2+ Left: 1+
PT [**Name (NI) 167**]: Left:
Radial Right: 2+ Left: 2+
Carotid Bruit-none appreciated Pulses Right/Left: -2+(B)
Pertinent Results:
[**2118-6-20**] 05:00AM BLOOD WBC-7.8 RBC-3.51* Hgb-11.1* Hct-32.6*
MCV-93 MCH-31.6 MCHC-34.1 RDW-14.6 Plt Ct-125*
[**2118-6-16**] 04:15PM BLOOD WBC-6.7 RBC-4.58* Hgb-14.8 Hct-43.0
MCV-94 MCH-32.3* MCHC-34.4 RDW-15.2 Plt Ct-219
[**2118-6-20**] 05:00AM BLOOD PT-13.1 INR(PT)-1.1
[**2118-6-19**] 11:08AM BLOOD PT-13.0 INR(PT)-1.1
[**2118-6-18**] 08:16AM BLOOD PT-13.2 PTT-25.7 INR(PT)-1.1
[**2118-6-17**] 12:16PM BLOOD PT-13.7* PTT-26.9 INR(PT)-1.2*
[**2118-6-20**] 05:00AM BLOOD Glucose-101* UreaN-22* Creat-1.0 Na-138
K-3.7 Cl-101 HCO3-29 AnGap-12
[**2118-6-16**] 04:15PM BLOOD Glucose-102* UreaN-45* Creat-1.5* Na-135
K-4.7 Cl-99 HCO3-22 AnGap-19
[**2118-6-16**] 04:15PM BLOOD ALT-28 AST-39 LD(LDH)-256* AlkPhos-42
Amylase-30 TotBili-0.9
[**2118-6-21**] 05:20AM BLOOD PT-14.0* INR(PT)-1.2*
[**2118-6-17**]:
PRE-BYPASS: The left atrium is markedly dilated. No spontaneous
[**Month/Day/Year 113**] contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. Overall left ventricular systolic
function is severely depressed (LVEF=30 %). The right
ventricular cavity is moderately dilated with moderate global
free wall hypokinesis. There are simple atheroma in the
ascending aorta. The descending thoracic aorta is mildly
dilated. There are complex (>4mm) atheroma in the descending
thoracic aorta. There are three aortic valve leaflets. The
aortic valve leaflets are moderately thickened. There is mild
aortic valve stenosis (valve area 1.2-1.9cm2). Trace aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is mild mitral valve prolapse. An eccentric,
anteriorly directed jet of Severe (4+) mitral regurgitation is
seen. There is no pericardial effusion.
POST CPB:
1. Imprpoved [**Hospital1 **]-ventricular systolc function, EF = 30-35%.
(Milrinone and Epinephrine)
2. Saddle shaped complete annuloplasty ring seen in the
mitralposition. Well seated and good leaflet excursion.
Peak gradient = 10 mm HG and a mean gradiet of 4 mm HG (Cardiac
output 5 lit/min)
3. Trace TR and intact aorta
[**2118-6-21**] 05:20AM BLOOD PT-14.0* INR(PT)-1.2*
Brief Hospital Course:
Following admission Heparin was started and he underwent mitral
repair and single coronary graft as noted. See operative note
for details. He weaned fom pressors onNeo Synephrine,
Epinephrine and Propofol infusions. His ejection fraction post
bypass was still 30-40 %.
He transferred to the ICU where he awakened intact, was weaned
and extubated and pressors were weaned off. His CTs were
removed per protocol as were temporary pacing wires.
Coumadin was begun for his chronic atrial fibrillation. He was
diuresed towards his preoperative weiht and Physical Therapy
worked with him for mobility and strength.
Arrangements were made for Coumadin follow up at [**Hospital **] Medical
[**Hospital 197**] Clinic as preop. He will be staying at his daughter's
home after discharge until he returns to his own home. VNA will
see him as well. He was discharged home with VNA services on
post operative day 4 in stable condition. All follow up
appointments were arranged.
Medications on Admission:
**Warfarin**-2.5mg T,Th,Fri. 5mg Sun/Wed->***last dose [**2118-5-31**]
**Lovenox- last dose 5/17
Aspirin 81 qd
Co-Enzyme Q10
Lasix 40 [**Hospital1 **]
Lopressor 25mg [**Hospital1 **]
Omega 3 Fatty Acids
Spiriva 18mcg INH daily
Spironolactone 25 qd
Zocor 40 qhs
MVI
Advair 250-50 1P [**Hospital1 **]
? Albuterol Nebs qid prn
Discharge Medications:
1. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain/temp.
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*30 Disk with Device(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
10. Warfarin 2.5 mg Tablet Sig: as directed Tablet PO once a
day: INR 2-2.5.
Disp:*100 Tablet(s)* Refills:*2*
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
mitral regurgitation
coronary artery disease
s/p coronary artery bypass graft/mitral valve repair
chronic heart failure
hypertension
chronic atrial fibrillation
chronic renal insufficiency
chronic obstructive pulmonary disease
s/p left total hip arthroplasty
hyperlipidemia
anxiety disorder
s/p full mouth dental extractions
h/o gastrointestinal bleed
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 Left - healing well, no erythema or drainage. Edema trace LT
Discharge Instructions:
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.
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 of sternal wound.
**Please call cardiac surgery office with any questions or
concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call
person during off hours.**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon:Dr. [**Last Name (STitle) **] on Thursday, [**7-21**] at 1:15pm
please call to schedule appointments with:
primary Care: Dr. [**First Name (STitle) **] [**Last Name (NamePattern4) 86446**] ([**Telephone/Fax (1) 86447**]) in [**1-29**] weeks
Cardiologist: Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 83686**] in [**1-29**] weeks
[**Last Name (un) **] call cardiac surgery office with any questions or concerns
([**Telephone/Fax (1) 170**]). Answering service will contact on call person
during off hours.**
Labs: PT/INR for Coumadin ?????? for chronic atrial fibrillation
Goal INR: 2-2.5
First draw: [**2118-6-22**]
Results to: [**Hospital **] Medical [**Hospital 197**] Clinic
phone: [**Telephone/Fax (1) 85180**] fax: [**Telephone/Fax (1) 7165**]
Pt instructed to take 5 mg Coumadin on [**2118-6-21**] with VNA to draw
INR [**2118-6-22**]
Completed by:[**2118-6-21**]
|
[
"496",
"V15.82",
"272.4",
"428.0",
"428.22",
"278.00",
"424.0",
"585.9",
"403.90",
"414.01",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"39.61",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
7010, 7069
|
4299, 5272
|
319, 434
|
7465, 7701
|
2171, 3889
|
8560, 9532
|
1341, 1360
|
5647, 6987
|
7090, 7444
|
5298, 5624
|
7725, 8537
|
1375, 2152
|
235, 281
|
462, 757
|
779, 1123
|
1139, 1325
|
3899, 4276
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,667
| 142,978
|
7890
|
Discharge summary
|
report
|
Admission Date: [**2182-8-30**] Discharge Date: [**2182-9-7**]
Date of Birth: [**2111-9-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor / Crestor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
exertional angina
Major Surgical or Invasive Procedure:
[**2182-8-30**] Redo sternotomy/ AVR ( [**Street Address(2) 6158**]. [**Male First Name (un) 923**] porcine)
History of Present Illness:
This is a 70yo male with known
coronary artery disease, prior CABG in [**2170**] and subsquent
PCI/stenting who now presents with recurrent chest discomfort
for
the last 18 months. Angina mostly occurs with exertional and
also
with emotional stress. He experiences angina almost daily, even
occasionally at rest. Nitro does not improve his chest pain.
Chest pain is relieved with rest and/or Vicodin. Myoview EST in
[**2182-6-26**] showed a dilated, diffusely hypokinetic LV with
asynchrony and apical dyskinesis. When compared to the EST from
[**2179**], it also demonstrated a more marked perfusion defect in the
anterior septal and lateral apical regions. Further workup
included a cardiac catheterization which showed patent stents
and
LIMA, along with progression of his aortic stenosis. Based upon
the above results, he was referred for evaluation for possible
redo operation.
Past Medical History:
aortic stenosis /coronary artery disease (s/p redo
sternotomy/AVR)
post-op seizure
- Coronary Artery Disease, History of NSTEMI [**2175**]
- s/p Cypher DES of the LMCA into the proximal LCX in [**2175**]
- s/p Cypher DES of mid RCA in [**2176**]
- Aortic Stenosis
- Hypertension
- Hyperlipidemia
- Type II Diabetes, on no meds(previously on Metformin)
- Obesity
- History of renal calculus
- Gout
- Chronic low back pain, s/p epidural injections
- Severe Neck Arthritis, Mild Right Shoulder Arthritis
- GERD
- ?Pulmonary Nodule? - stable per patient
Past Surgical History
- s/p CABG (LIMA to LAD) [**2170**] @ [**Hospital1 18**]
- s/p Bilateral carpal tunnel release
- Pilonidal cyst
- Vasectomy
- Left Heel Surgery secondary to MVA
Social History:
Retired heavy machinary operator.
Divorced
Tob: 5ppd x5-6years quit 25years ago
EtOh: occassional [**2-28**] drinks/wk
Family History:
Father - CVA @ 60 [**Name2 (NI) **]
Mother - Gastric CA
Physical Exam:
Pulse: 62 Resp: 18 O2 sat: 95%
B/P Right: 145/81 Left: 147/72
Height: 69" Weight: 118kg
General: Obese male in no acute distress
Skin: Dry [x] intact [x] - well healed sternotomy
HEENT: PERRLA [x] EOMI [x]
Neck: +kyphosis with severe limitation of neck extension
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [] Murmur [x] grade 3/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x]
bowel sounds + [x] + ventral hernia noted
Extremities: Warm [x], well-perfused [x]
Edema: 1+ bilaterally Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2 Left: 2
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Carotid Bruit: transmitted murmurs bilaterally
Pertinent Results:
[**2182-9-7**] 06:50AM BLOOD WBC-6.6 RBC-3.48* Hgb-10.7* Hct-32.6*
MCV-94 MCH-30.6 MCHC-32.6 RDW-16.1* Plt Ct-356
[**2182-9-6**] 06:15AM BLOOD WBC-6.9 RBC-3.17* Hgb-9.9* Hct-30.2*
MCV-96 MCH-31.2 MCHC-32.7 RDW-16.4* Plt Ct-326
[**2182-9-7**] 06:50AM BLOOD Glucose-151* UreaN-21* Creat-0.8 Na-141
K-4.3 Cl-105 HCO3-31 AnGap-9
[**2182-9-6**] 06:15AM BLOOD Glucose-124* UreaN-27* Creat-0.9 Na-143
K-4.5 Cl-110* HCO3-26 AnGap-12
[**2182-9-6**] 06:15AM BLOOD Mg-2.4
.
[**Known lastname 28393**],[**Known firstname 177**] [**Medical Record Number 28394**] M 70 [**2111-9-19**]
Neurophysiology Report EEG Study Date of [**2182-9-3**]
OBJECT: bedside LTM, video, EKG, [**Date range (1) 12519**]/11.
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
FINDINGS:
BACKGROUND: Showed symmetric, [**7-2**] Hz theta waveform and reached
[**9-3**] Hz
alpha frequency waveforms with an anterior posterior gradient.
Occasionally, the background appeared asymmetric with slower
frequencies
in the theta range on the left hemispheric leads while it was at
low
alpha frequency on the right. There were no epileptic discharges
or
electrographic seizures. The background appeared more organized
and of
longer duration of faster frequencies, at times 10 Hz alpha,
towards the
end of this recording.
PUSHBUTTON ACTIVATIONS: There were no pushbutton activations.
SPIKE DETECTION PROGRAMS: There were no entries in this file.
SEIZURE DETECTION PROGRAMS: There were 24 entries in this file
all due
to movement or electrode artifact.
SLEEP: There was no normal sleep morphology.
CARDIAC MONITOR: Showed a regular rhythm with an average rate of
90-95
bpm.
IMPRESSION: This is an abnormal extended routine EEG monitoring
study
due to diffuse symmetric background slowing consistent with a
mild
diffuse encephalopathy. The etiology is non-specific but could
be
related to several contributing factors including cerebral
hypoxic/
ischemic injury, metabolic abnormalities ,and effect of sedating
medications. Periods of background asymmetry with slower
frequencies on
the left may represent an underlying structural or functional
abnormality in the left hemisphere. No epileptiform discharges
or
electrographic seizures were present. This study was unchanged
compared
to prior day's recording.
INTERPRETED BY: [**Last Name (LF) **],[**First Name3 (LF) **] L.
([**11/3111**]S)
.
MRI [**2182-9-2**]
IMPRESSION:
1. Acute lacunar infarct in the right subinsular white matter.
2. Acute sinus disease with air-fluid levels in the frontal and
maxillary
sinus.
3. Normal MRI/MRA of the head, specifically without evidence of
hemodynamically significant stenosis of the intra- and
extracranial
vasculature.
4. Prominent lymphoid tissue of the adenoid that should be
correlated
clinically.
The report was communicated to Dr. [**Last Name (STitle) 28395**] via telephone at 2
pm.
The study and the report were reviewed by the staff radiologist.
DR. [**Last Name (STitle) 28396**] [**Name (STitle) 28397**]
DR. [**First Name (STitle) **] [**Name (STitle) 12563**]
Approved: WED [**2182-9-4**] 9:58 AM
Imaging Lab
.
[**2182-8-31**] Head CT
IMPRESSION:
1. No evidence of an acute intracranial process. MRI would be
more sensitive
for an acute infarction or other source of seizures, if
clinically warranted.
2. Air-fluid levels in the paranasal sinuses are most likely
related to
endotracheal intubation.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 28398**]
DR. [**First Name11 (Name Pattern1) 95**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 96**]
Approved: SUN [**2182-9-1**] 8:36 AM
Imaging Lab
.
Brief Hospital Course:
Admitted [**8-30**] and underwent surgery with Dr. [**Last Name (STitle) **]. Transferred
to the CVICU in stable condition on a titrated propofol drip.
Seizure activity noted when sedation weaned. Dilantin started
and neurology was consulted. EEG monitored. Pancultured for
fever- all cultures would return negative. Mental status
improved after successful weaning of propofol. Head MRI did not
show an acute event. Extubated early morning of POD #4. He was
hemodynamically stable, weaned from inotropic and vasopressor
support. Beta blocker was initiated and the patient was gently
diuresed toward the preoperative weight. Speech and swallow
cleared the patient for a regular diet of solids and thin
liquids. CPAP was implemented for sleep. This should be
followed up with his PCP for [**Name Initial (PRE) **] sleep study. Nystatin was
started for oral [**Female First Name (un) 564**].
The patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued
without complication. The patient was evaluated by the physical
therapy service for assistance with strength and mobility. By
the time of discharge on POD 8 the patient was max-assist with
movement- requiring [**Doctor Last Name 2598**] lift from bed to chair. The wound was
healing and pain was controlled with oral analgesics. The
patient was discharged to [**Hospital6 **], [**Location (un) 4047**] for further
conditioning and physical therapy.
Medications on Admission:
Isosorbide Mononitrate 120mg qd, Lovastatin
20mg daily, Metoprolol 100mg twice daily, Furosemide 20mg daily,
Nexium 40mg daily, Allopurinol 300mg daily, Lisinopril 30mg
daily, Aspirin 81mg daily, Vitamin D, Testosterone every four
weeks, Lorazepam 1mg prn, Vicodin 5-500 prn
Discharge Medications:
1. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
2. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. lovastatin 20 mg Tablet Sig: One (1) Tablet PO Daily ().
6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
11. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
13. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): per attached sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] @ [**Location (un) 4047**]
Discharge Diagnosis:
aortic stenosis /coronary artery disease (s/p redo
sternotomy/AVR)
post-op seizure
- Coronary Artery Disease, History of NSTEMI [**2175**]
- s/p Cypher DES of the LMCA into the proximal LCX in [**2175**]
- s/p Cypher DES of mid RCA in [**2176**]
- Aortic Stenosis
- Hypertension
- Hyperlipidemia
- Type II Diabetes, on no meds(previously on Metformin)
- Obesity
- History of renal calculus
- Gout
- Chronic low back pain, s/p epidural injections
- Severe Neck Arthritis, Mild Right Shoulder Arthritis
- GERD
- ?Pulmonary Nodule? - stable per patient
Past Surgical History
- s/p CABG (LIMA to LAD) [**2170**] @ [**Hospital1 18**]
- s/p Bilateral carpal tunnel release
- Pilonidal cyst
- Vasectomy
- Left Heel Surgery secondary to MVA
Discharge Condition:
Alert and oriented x2 nonfocal
Max assist/[**Doctor Last Name 2598**] Lift
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema - trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2182-10-9**] 1:00
Please call to schedule appointments with your
Neurology: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 5285**] in 1 month
Primary Care Dr.[**Last Name (STitle) **] [**Telephone/Fax (1) 28399**] in [**4-30**] weeks- please evaluate
need for sleep study/CPAP
Cardiologist:Dr. [**Last Name (STitle) 28400**] office will call with appointment
**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:[**2182-9-7**]
|
[
"250.00",
"E878.2",
"V45.82",
"780.62",
"518.89",
"V45.81",
"412",
"724.2",
"272.4",
"413.9",
"424.1",
"274.9",
"997.00",
"414.01",
"401.9",
"716.98",
"780.39",
"530.81",
"786.09",
"280.0",
"V15.82",
"434.11",
"V02.53",
"997.02",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"89.19",
"39.61",
"35.21",
"96.71",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
9851, 9921
|
6816, 8286
|
301, 412
|
10698, 10893
|
3087, 6793
|
11816, 12545
|
2235, 2292
|
8612, 9828
|
9942, 10677
|
8312, 8589
|
10917, 11793
|
2307, 3068
|
244, 263
|
440, 1325
|
1347, 2082
|
2098, 2219
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,096
| 148,775
|
20782
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 55434**]
Admission Date: [**2111-5-17**]
Discharge Date: [**2111-5-24**]
Date of Birth: [**2066-3-10**]
Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old
woman who was transferred from [**Hospital3 **]. The patient
originally presented to her PCP approximately one week prior
to admission here with increasing cough, dyspnea and fatigue.
She was given a Z-Pak for treatment along with albuterol.
Despite this, she continued to worsen and became febrile.
So, she was admitted to [**Hospital3 **] on [**2111-5-15**]. At the
hospital, she was started on Rocephin and Levaquin for a
right lower lobe pneumonia seen on chest x-ray. She
continued to have increasing respiratory distress with
hypoxia. She was also significantly tachypneic. At this
time, repeat chest x-ray showed bilateral diffuse infiltrates
consistent with ARDS. The patient was intubated and then
transferred to [**Hospital1 18**] MICU.
PAST MEDICAL HISTORY: Hypothyroidism.
Depression.
Anxiety disorder.
MEDICATIONS:
1. Levoxyl 112 mcg q.d.
2. Prozac.
3. Codeine for cough.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is unemployed. She smokes
approximately one pack per day. She drinks alcohol socially.
PHYSICAL EXAMINATION: On admission, vital signs:
Temperature 101.4, blood pressure 101/62, pulse 80,
respiratory rate 19 on a ventilator with settings of assist
control at 500/12 and a PEEP of 5. General: The patient is
intubated and sedated, but easily arousable. HEENT: Pupils
equally round and reactive to light. Sclerae are anicteric.
ET tube is in place. Neck: Soft and supple.
Cardiovascular: Normal. Chest: Faint scattered wheezes
bilaterally. Abdomen: Benign. Extremities: Warm with good
distal pulses. There is no edema. Neurologic: Able to
follow simple commands.
LABORATORY DATA: Labs on admission from outside hospital,
CBC notable for a white count of 21.9 with hematocrit of 36.3
and normal platelets. Chem-7 notable for potassium of 3.2
and bicarbonate of 30. LFTs show an elevated ALT of 52 and
AST of 101 with normal alkaline phosphatase and total
bilirubin.
Latest arterial blood gas with pH of 7.45, pCO2 43 and pO2
155 on 100 percent oxygen via ventilator.
RADIOGRAPHIC STUDIES: Chest x-ray shows right middle lobe,
right lower lobe, and left lower lobe infiltrates. EKG shows
normal sinus rhythm at 70 beats per minute with normal axis
and intervals, borderline LVH.
SUMMARY OF HOSPITAL COURSE: Respiratory: On admission, the
patient had what appeared to be acute respiratory distress
syndrome secondary to community-acquired pneumonia. She was
maintained on a ventilator and ventilated according to
ARDSNet protocol. For antibiotic coverage of her pneumonia,
she was started on Levaquin, ceftriaxone, and vancomycin.
Over the next two days after admission, the patient's vent
settings were gradually weaned, and she was extubated two
days after being transferred to this hospital. After
extubation, the patient was oxygenating well on face mask.
She did continue to have a persistent fairly severe cough;
however, her cough was weak due to abdominal muscle pain from
repeated coughing. The cough was mostly nonproductive. The
patient was breathing comfortably. As there was no
identified bacterial pathogen on any cultures, the patient
was continued on the triple antibiotics for first several
days of the hospitalization. She was also on round-the-clock
Atrovent and albuterol nebulizers. Once the patient was
transferred out of the ICU and after extubation, the
antibiotics were gradually narrowed. The vancomycin and
Levaquin were discontinued after approximately four days in
the hospital. The ceftriaxone was discontinued after four
days in the hospital, and the patient was to continue on
Levaquin. The patient had gradual improvement in her
oxygenation.
Pain control: The patient had fairly significant abdominal
pain secondary to persistent cough. She was started on a
regimen of MS Contin with oxycodone for breakthrough pain.
This helped her somewhat though she has continued to have
difficulty coughing due to the pain. Tylenol and ibuprofen
were also added for better control.
Transaminitis: The patient was noted to have mild
transaminitis on admission. However, this was felt to be due
to her significant infection. This should continue to be
followed as an outpatient to assure that it returns back to
normal.
Anemia: The patient's reticulocyte count showed inadequate
production. Iron studies showed a mixed picture with
decreased iron and decreased iron to TIBC ratio suggestive of
iron-deficiency anemia, but also normal to high MCV. B12 was
noted to be low and the patient was given an injection of IM
B12 while in the hospital. She was also started on iron
supplementation.
Hypothyroidism: The patient was continued on Synthroid for
her chronic hypothyroidism.
DISCHARGE STATUS: The patient was discharged home with
services.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSES: Community-acquired pneumonia.
Acute respiratory distress syndrome.
Iron-deficiency anemia.
Hypothyroidism.
DISCHARGE MEDICATIONS:
1. Levothyroxine 75 mcg q.d.
2. Prozac 40 mg q.d.
3. Levaquin 500 mg q.d. for 7 days after discharge.
4. Guaifenesin syrup p.r.n. cough.
5. Oxycodone 10 mg q.4 h. p.r.n. for pain.
6. Colace 100 mg b.i.d.
7. MS Contin 30 mg b.i.d.
8. Ibuprofen 800 mg q.8 h.
9. Albuterol 1 to 2 puffs q.6 h. p.r.n.
10. Atrovent 1 puff q.6 h. p.r.n.
DISCHARGE INSTRUCTIONS: Follow-up Plans: The patient was
instructed to call her PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4702**], to follow up the
week of discharge. She is also to call her PCP if she has
increasing shortness of breath or fevers.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5704**], [**MD Number(1) 5705**]
Dictated By:[**Doctor Last Name 7255**]
MEDQUIST36
D: [**2111-7-20**] 17:19:48
T: [**2111-7-21**] 00:27:21
Job#: [**Job Number 55435**]
|
[
"V15.82",
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icd9cm
|
[
[
[]
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] |
[
"38.93",
"96.6",
"38.91",
"96.71"
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icd9pcs
|
[
[
[]
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5017, 5024
|
5046, 5157
|
5180, 5518
|
5543, 5543
|
2513, 4995
|
1292, 2484
|
5561, 6094
|
185, 968
|
991, 1150
|
1167, 1269
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,931
| 169,190
|
38490
|
Discharge summary
|
report
|
Admission Date: [**2186-5-25**] Discharge Date: [**2186-5-26**]
Date of Birth: [**2109-3-21**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
stridor, SOB
Major Surgical or Invasive Procedure:
Mechanical Ventilation
Bronchoscopy
History of Present Illness:
Mr. [**Known lastname **] is a 77 yo M w/ h/o prostate ca, HTN and
rheumatoid arthritis (although per report he hasn't seen a
physician in years)who presented to [**Hospital **] hospital on [**2186-5-24**]
with SOB and stridor. Apparently he had been having stridor for
1 mo at home (PCP [**Name9 (PRE) 85642**] told him he had allergies) and
also endorsed nausea, swelling, weight loss, pallor, sweats and
sore throat. At the OSH, he was found to have an esophageal mass
with tracheal obstruction, right supraclavicular mass and likely
liver metastases. CT scan of neck and chest showed large mass
compressing and invading post wall of trachea likely eso tumor
stretching from 14 mm below vocal cords to 2-3 cm above [**Female First Name (un) 5309**].
Apparently, Dr. [**Last Name (STitle) 59152**] ([**Telephone/Fax (1) 85643**]) at the OSH, who requested
his transfer here for IP stenting, also scoped the pt and found
an exophytic surface at lvl carina c/w tumor. Also of note, he
had a Ca at OSH of 12. The pt expressed a desire for transport
to [**Hospital1 18**] for palliative treatment of his mass.
.
In the ED at the OSH, he was found to be retaining CO2 with ABG
pH 7.23/ pCO2 76/ pO2 78. He was placed on heliox 70/30 (30% O2)
with subsequent ABG pH 7.34/ PCO2 57/ p02 106/ HCO3 30. He was
intubated with fiberoptic bronchoscope at the OSH with ETT 6.5
which was 2cm above the lvl of the carina at the OSH. Initial
post intubation ABG was 7.47/44/132/31. Ativan was given for
sedation post intubation and pt also reportedly recieved
decadron there as well. PIVs were placed for access prior to
transport. At time of d/c from OSH, his vitals were T 98.6
184/72 P 88 (reported to be NSR) RR 26 O2 sat 99%. Vent settings
were AC RR 12, TV 500, PEEP 5 FiO2 50%. He was on a versed gtt
at 3mg/hr.
.
On arrival to the ICU the pt is intubated and sedated and unable
to give a history.
.
Review of systems: unable to obtain at this time.
Past Medical History:
HTN
Appendectomy
h/o prostate ca
rheumatoid arthritis
Social History:
tree surgeon/ arborist
- Tobacco: + hx- cigars currently
- Alcohol: none in 30 years- heavy drinker in past
- Illicits: none per family
Family History:
Non-contributory
Physical Exam:
Gen: intubated patient
Neck: stridor
Lungs: CTA bilaterrally
CV: RRR
Abd: soft, NT, ND. + BS
Ext: No c/c/e
Pertinent Results:
Admission laboratories:
[**2186-5-25**] 06:31AM BLOOD WBC-13.8* RBC-4.40* Hgb-12.0* Hct-38.5*
MCV-88 MCH-27.3 MCHC-31.1 RDW-13.1 Plt Ct-431
[**2186-5-25**] 06:31AM BLOOD PT-12.7 PTT-28.7 INR(PT)-1.1
[**2186-5-25**] 06:31AM BLOOD Glucose-234* UreaN-23* Creat-1.0 Na-134
K-6.1* Cl-97 HCO3-28 AnGap-15
[**2186-5-25**] 06:31AM BLOOD ALT-26 AST-53* LD(LDH)-462* AlkPhos-84
TotBili-0.2
[**2186-5-25**] 06:31AM BLOOD Albumin-3.9 Calcium-10.9* Phos-5.3*
Mg-2.0
Brief Hospital Course:
Mr. [**Known lastname **] is a 77 yo male with a history of prostate ca, HTN
and rheumatoid arthritis (although per report he hasn't seen a
physician in years) who presented to OSH with stridor found to
have esophageal mass compressing trachea, intubated there and
transferred here for possible IP stenting. IP was unable to
provide any further interventions. The esophagus was biopsied
which showed an undifferentiated carcinoma. Radiation oncology
was consulted for palliative options, though the family did not
believe that the patient would want radiation treatment.
Palliative care was consulted and provided support to the
family. Per the family's request, the patient was weaned off of
his sedation and was able to answer that he no longer wanted
intubation. The patient was terminally extubated with the family
at his bedside. He received midazolam and morphine for comfort
measures.
Medications on Admission:
Atenolol 25 [**Hospital1 **]
Lisinopril 20 daily
Prednisone 5 daily
Claritin 10 daily
HCTZ
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired due to respiratory distress secondary to
esophageal mass.
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
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[
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[
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icd9pcs
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[
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4246, 4255
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3182, 4075
|
285, 323
|
4372, 4381
|
2704, 3159
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4437, 4447
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2544, 2562
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4217, 4223
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4276, 4351
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4405, 4414
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2577, 2685
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233, 247
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351, 2244
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2318, 2374
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2390, 2528
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,065
| 168,800
|
39859
|
Discharge summary
|
report
|
Admission Date: [**2126-1-29**] Discharge Date: [**2126-2-6**]
Date of Birth: [**2085-1-5**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
dyspnea, chest pain
Major Surgical or Invasive Procedure:
endotracheal intubation with mechanical ventilation
History of Present Illness:
Mr. [**Known lastname 87697**] is a 41M with CAD s/p prior LAD and LCx, s/p Right MCA
ischemic stroke with hemorrhagic transformation, s/p
hemicranitomy and cranioplasty [**6-3**], s/p peg/trach now removed,
type 1 dm, htn, hyperlipidemia, etoh and cocaine abuse,
depression, and acute cholecystitis now transferred to [**Hospital1 18**] s/p
PEA arrest for possible cardiac catherization.
.
The patient was in his usual state of health until today when he
presented to OSH with fever of 101 from his rehab. Prior to
this, he was being treated for a UTI with macrobid but had no
other recent illness or medication change. At the OSH, concern
was for aspiration PNA (CXR demonstrated large right basal lobe
and left lower lobe PNA), so he was started on antibiotics
(vancomycin, zosyn, azithromycin). He was desatting to the 70s
and was satting 89% on 10L NC so he was started on BiPAP. When
placed on BiPAP he vomited and went into hypoxia respiratory
failure with subsequent PEA arrest. He was urgently intubated
and underwent CPR with ROSC. After event, patient complained of
chest pain and EKG showed STE's in III, aVF, aVR, V1-V3. There
was concern for ACS and cardiogenic shock so he was started on
pressors and transferred to [**Hospital1 18**] for possible catheterization.
Of note, the patient was recently hospitalized 3 months ago for
inferior NSTEMI, has been discharged to a nursing home since
then. He has had multiple episodes of aspiration pneumonia since
then.
.
Upon transfer, patient was sent to cath lab, where it was found
that his STEs were resolving. His INR was 5, so no cardiac cath
was performed. TTE showed global hypokinesis consistent with
recent arrest. Given resolving EKG changes and ECHO findings
inconsistent with ACS, he did not undergo cardiac
catheterization.
.
Of note, patient was in CCU in [**Month (only) 404**] for an inferior NSTEMI.
He initially underwent cardiac cath where he was found to have
severe diffuse 3VD and had BMS to LAD and Cx lesions. This was
complicated by worsening cardiogenic shock requiring
intra-aortic balloon pump and after, when no improvement was
seen in cardiac function, a Tandem Heart LVAD was placed. He was
paralyzed while on the Tandem Heart and when taken off
paralysis, it was noted he left sided weakness. CT head [**12-11**]
showed a large R MCA infarct w/ 3mm midline shift. TTE done at
that time showed large LV thrombus and an EF of 35%. Neurology
was consulted and it was decided to continue anticoagulation.
Serial head CTs the next 2 days showed that the infarct was
stable and no evidence of hemorrhagic conversion but on [**12-15**] CT
head showed worsening midline shift and uncal herniation. He
then underwent R hemicraniectomy for urgent decompression [**12-15**].
He remained on heparin gtt given high risk for thromboembolism.
His course was also complicated by NSTEMI (up-trending CE's on
[**12-20**]), chronic renal failure, and persistent fevers with
unclear source for which he was covered broadly with vanco,
meropenem, and tobramycin.
Past Medical History:
CAD with 3vd with stents in LAD, Cx
Right MCA ischemic stroke with hemorrhagic transformation s/p
hemicraniectomy
s/p tracheostomy & PEG
Acalculous cholecystitis s/p perc chole tube
Diabetes mellitus type I
HLD
HTN
ETOH abuse
Cocaine abuse
Depression
Social History:
Patient currently living at [**Hospital3 **].
-Tobacco history: quit 10 years ago
-ETOH: 7 beers/drinks per day
-Illicit drugs: recent marijuana use, cocaine quit 5 years ago
Family History:
Mother has diabetes. Father is deceased, had diabetes, renal
failure and CAD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL: intubated, sedated,
HEENT: Pupils 3mm and sluggish to light, EOMI. right sided
craniotomy incision C/D/I with notably soft to palpation on
right side of scalp
CARDIAC: distant heart sounds, nl s1/s2, difficult to appreciate
any murmurs. unable to note any JVP secondary to obese neck
LUNGS: bilateral crackles, coarse breath sounds bl.
ABDOMEN: distended, obese, soft, NTND.
EXTREMITIES: 1+ pitting edema bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
.
DISCHARGE PHYSICAL EXAM:
Vitals - Tm/Tc:98.7/98.3 HR:70s BP:126-141/70-93 RR:18 02 sat:
98(RA)
GENERAL: somnolent but arousable, no acute distress
HEENT: PERRL, no pharyngeal erythemia, mucous membs moist, no
lymphadenopathy, JVP not elevated
CHEST: bibasilar crackles much improved from before
CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or
gallops
ABD: soft, non-tender, non-distended, BS normoactive.
EXT: WWP, no edema. DPs, PTs 2+.
NEURO: CNs II-XII intact. 5/5 strength in U/L extremities.
Pertinent Results:
ADMISSION LABS:
WBC-12.6*# RBC-2.64*# Hgb-8.4*# Hct-25.3*# MCV-96 MCH-31.9
MCHC-33.3 RDW-14.3 Plt Ct-191
PT-61.9* PTT-59.1* INR(PT)-6.2*
Glucose-478* UreaN-57* Creat-3.2*# Na-135 K-5.7* Cl-103 HCO3-21*
AnGap-17
Calcium-8.5 Phos-5.4*# Mg-2.1
ALT-15 AST-23 CK(CPK)-140 AlkPhos-52 TotBili-0.3
CK(CPK)-140, CK-MB-7, cTropnT-0.84*
TTE [**2126-1-29**]:
The estimated right atrial pressure is at least 15 mmHg. Overall
left ventricular systolic function is severely depressed (LVEF=
25-30 %). The right ventricle is mildly dilated with global free
wall hypokinesis. There is no ventricular septal defect. 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 no pericardial effusion.
Renal US [**1-31**]:
IMPRESSION: Normal size kidneys. No evidence of hydronephrosis.
TTE [**2126-2-2**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
to moderate regional left ventricular systolic dysfunction with
basal inferior akinesis and severe hypokinesis/akinesis of the
distal septum and anterior walls and the apex. There is a small
apical left ventricular aneurysm. The estimated cardiac index is
normal (>=2.5L/min/m2). No masses or thrombi are seen in the
left ventricle. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction most c/w multivessel CAD (PDA and
distal LAD distribution). Pulmonary artery hypertension. Mild
mitral regurgitation.
Compared with the prior study (images reviewed) of [**2126-1-29**],
global left ventricular systolic function has improved and PA
hypertension is now identified.
TTE [**2126-2-4**]:
Mild regional left ventricular systolic dysfunction with
hypokinesis of the distal septum and anterior wall. The apex is
mildly aneurysmal and akinetic. No masses or thrombi are seen in
the left ventricle.
IMPRESSION: Regional left ventricular wall motion abnormality
with small apical aneurysm without echo evidence for
intraventricular thrombus.
Cardiac Enzymes:
[**2126-1-29**] 11:02PM BLOOD CK-MB-7 cTropnT-0.84*
[**2126-1-30**] 05:33AM BLOOD CK-MB-7 cTropnT-1.07*
[**2126-1-30**] 02:27PM BLOOD CK-MB-5 cTropnT-1.36*
Labs on Discharge:
[**2126-2-6**] 05:00AM BLOOD WBC-8.1 RBC-2.71* Hgb-8.4* Hct-25.0*
MCV-92 MCH-31.0 MCHC-33.7 RDW-14.1 Plt Ct-233
[**2126-2-6**] 05:00AM BLOOD PT-15.7* PTT-33.7 INR(PT)-1.5*
[**2126-2-6**] 05:00AM BLOOD Glucose-152* UreaN-61* Creat-3.2* Na-143
K-3.8 Cl-105 HCO3-29 AnGap-13
[**2126-1-31**] 03:00AM BLOOD ALT-14 AST-15 LD(LDH)-240 AlkPhos-54
TotBili-0.4
[**2126-2-6**] 05:00AM BLOOD Calcium-8.9 Phos-5.4* Mg-2.4
[**2126-1-30**] 05:33AM BLOOD Hapto-370*
Brief Hospital Course:
40 yo male with history of IDDM, HTN, HLD, admitted with
inferior distribution STEMI second to hypoxia-inducted PEA
arrest, did not receive cardiac cath secondary to resolving STE
and elevated INR.
.
#s/p PEA arrest/STEMI: ST elevations noted in II, III, V4R,
V1-V3 that were resolving on transfer. In addition INR 5.1on
presentation. Given history of aspiration with subsequent PEA
arrest, makes ACS less likely. Patient did not undergo
catheterization on arrival to [**Hospital1 18**] due resolving ST elevations
and elevated INR. He is on aspirin, plavix. Based on previous
cath data, he has known RCA and LAD disease. Globally depressed
systolic function could also be secondary to known PEA arrest.
Patient was thought to be in cardiogenic shock at OSH and was
started on levophed but it was weaned by the time he arrived to
[**Hospital1 18**]. TTE showed globally depressed EF inconsistent with new
infarction. Based on previous cath data, he has known RCA and
LAD disease. Globally depressed systolic function could also be
secondary to known PEA arrest. Patient was thought to be in
cardiogenic shock at OSH and was started on levophed but it was
weaned by the time he arrived at [**Hospital1 18**]. He was cooled,
intubated and intermittently on dopmaine pressor support.
Eventually, he was warmed, liberated from the vent, and taken
off of dopamine. Repeat TTE showed return of cardiac function
post-arrest with EF 40%, and another TTE ruled out LV thrombus.
For this reason, warfarin and heparin gtt (bridging patient
while he was subtherapeutic) were both stopped. Patient was
continued on aspirin 325, plavix 75mg in AM, carvedilol 37.5mg
[**Hospital1 **], lipitor 10. He is not on an ace secondary to renal
failure.
.
# Hypoxic respiratory distress- likely secondary to aspiration
PNA. The patient was febrile at OSH with shortness of breath
that acutely worsened when he was placed on BiPAP. He has
extensive history of aspiration PNA. He was intubated and
underwent CPR for PEA arrest with ROSC. As mentioned, EKG was
concerning for ACS but changes are resolving. Patient was
initially intubated and sedated, but was eventually liberated
from the vent. He was diuresed 1-2L daily, as his renal
function would tolerate. PICC line was placed and patient
received 8 days of IV antibiotics (vanc, zosyn, levofloxacin)for
HCAP. At the time of discharge, he had one remaining day of
antibiotics and was breathing well on room air. He also
received nebs and pulmonary toilet.
.
#.Aspiration PNA: Patient treated with 8 day course of
vancomycin/levoquin/zosyn. Given his h/o frequent aspiration
pneumonias, pt had video swallow eval with OT, who recommended
[**2-24**] month trial of nectar thick liquids and regular solids,
followed by repeat video swallow, to attempt to decrease risk of
aspiration events.
.
#DM- Patient was hyperglycemic continuously throughout
admission, originally with blood sugars in the 500s, then with
adjustments to insulin, blood sugars downt o 300s-400s. In the
ICU, he was intermittently placed on an insulin drip to
maintaing euglycemic levels. Insulin sliding scale was
readjusted when patient came off tube feeds and began a regular,
soft diet. Patient will need outpatient f/u with a dibetes
provider.
.
#[**Last Name (un) **]- Creatine was 0.9 in [**5-/2125**] and was found to be 2.3 on
arrival to OSH. Patient's family reports he was "dehydrated"
prior to admission making prerenal azotemia a likely etiolgy.
Pre-renal etiology was confirmed by urine lytes/ Foley catheter
currently in place with good UOP. His Cr was trended and
nephrotoxic agents were avoided.
.
#Blood Pressure - Patient was hypotensive on presentation
secondary to cardiac arrest, and was maintained on dopamine. As
the dopamine was weaned off, patient became hypertensive. Home
blood pressure medications were slowly introduced and his bp
monitored. At the time of discharge, patient was taking imdur
60 daily, carvedilol 37.5 [**Hospital1 **] and amlodipine 10 daily.
.
# Normocytic Anemia: Hct somewhat lower than baseline on
admission. Has history of tranfusion dependant anemia during
prior admission. Hemolysis labs indicate no hemolysis; no
evidence of blood loss. Hct was stable throughout admission wit
range 21-25. Hemolysis labs were negative, patient was guaiac
negative. He was continued on omeprazole 20mg PO daily.
.
#Depression. He was continued on home celexa 20mg daily.
.
#Seizure prophylaxis. He was continue home depakote 1000mg [**Hospital1 **],
started for seizure prophylaxis after large stroke last
admission.
.
#Hyperlipidemia. Continue lipitor 80mg daily (home dose was
lipitor 10).
.
#Right MCA infarct: Patient with residual left sided weakness
after CVA in [**2124**], which was complicated by hemorrhagic
conversion and now s/p cranial decompression.
He was continued on seizure prophylaxis as above and was seen by
PT/OT.
.
# GERD: He was continued on protonix 40mg daily.
.
==========================================
TRANSITION OF CARE:
****Aspiration risk: pt should have [**2-24**] month trial of nectar
thick liquids and regular solids while at rehab, followed by
repeat video swallow (not modified) in attempt to decrease risk
of aspiration events. [**Hospital1 18**] OT is contacting PCP to determine
whether f/u should occur via [**Hospital1 18**] OT or elsewhere****
Patient's PICC is technically in midline position. It needs to
be advaned 6.5cm, per IV team, and has been in similar position
for several days. He has only one remaining day of antibiotics.
PICC can be pulled on [**2-7**].
Patient should follow-up with outpatient nephrologist regarding
Stage III CKD.
Medications on Admission:
HOME MEDICATIONS: (per OSH transfer note)
-Norvasc
-Aspirin
-Lisinopril 40mg PO daily
-Toprol XL 175mg PO daily
-Imdur 60mg PO daily
-Clonidine 0.1mg PO TID
-Lipitor 10mg PO daily
-Coumadin 8.5mg PO daily (last dose [**2126-1-26**])
-Celexa 20mg PO daily
-Depakote 1000mg PO BID
-Gabapentin 400mg PO TID
-Lidocaine 5% patch q12 hrs
-Lantus 22 units 22 [**Hospital1 **]
-Lispro 12 units TID with meals
-Lispro sliding scale
-DuoNeb inh via nebulizer QID
-Macrobid 100mg PO BID
-Omeprazole 20mg PO daily
-Ergocalciferol 50,000 IU monthly
-Ferrous sulfate 325mg PO daily
-Multivitamin PO daily
-Lactobacillus 1 cap PO BID
PRN meds:
-Tylenol prn
-Dulcolax prn
-Colace prn
-Vicodin prn
-DuoNeb prn
-Nitroglycerin prn
-Prochlorperazine suppository prn
-Senna prn
-Simethicone prn
-Sodium phosphate prn
-Fleet enema prn
-Zolpidem prn
.
MEDICATIONS ON TRANSFER:
-Vancomycin 1000mg IV q12 hrs
-Zosyn 2.25mg IV q6 hrs
-Azithromycin 500mg/250mL q24 hrs
-Macrobid 100mg [**Hospital1 **]
-Hydralazine 20mg PO q6 hrs
-ASA 325mg PO daily
-Clonidine 0.1mg PO TID
-Coumadin 8.5 mg
-Crestor 5mg PO daily
-Imdur 60mg PO daily
-Metoprolol succinate 175mg daily
-Metoprolol tartrate 4mg q4 hrs
-Amlodipine 10mg daily
-Lisinopril 40mg PO daily
-Ambien 5mg PO qHS PRN
-Celexa 20mg PO daily
-Valproate sodium 1000mg/100mL [**Hospital1 **](?)
-Depakote 1000mg PO BID
-Lidoderm 5% patch
-Neurontin 400mg TID
-Vicodin 1 tab PO q6 hrs PRN
-Humalog 12 units TID with meals,
-Lantus 22 units [**Hospital1 **]
-Propofol 100mL IV q24 hrs
-Dopamine 400mg/250mL q24 hrs
-Combivent inh 8 puffs QID
-Duoneb inh 3mL QID + q4hrs PRN
-Albuterol 2.5mg inh q2 hrs PRN
-Compazine 25mg PO BID PRN
-Zofran 4mg q4hrs PRN
-Protonix 40mg daily
-Ferrous sulfate 325mg PO daily
-Fleet enema
-Colace
-Senna
-Multivitamin
-Vitamin D 50,000 IU q30 days
Discharge Medications:
1. aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
2. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. docusate sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
4. clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
5. citalopram 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
6. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
7. multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
8. valproic acid 250 mg Capsule [**Hospital1 **]: Two (2) Capsule PO Q6H
(every 6 hours).
9. levofloxacin 250 mg Tablet [**Hospital1 **]: Three (3) Tablet PO Q48H
(every 48 hours): Last dose [**2126-2-7**].
10. ferrous sulfate 300 mg (60 mg iron) Tablet [**Month/Day/Year **]: One (1)
Tablet PO DAILY (Daily).
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day/Year **]: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheezing/sob.
12. ipratropium bromide 0.02 % Solution [**Month/Day/Year **]: One (1) neb
Inhalation Q6H (every 6 hours).
13. guaifenesin 100 mg/5 mL Syrup [**Month/Day/Year **]: 5-10 MLs PO Q6H (every 6
hours) as needed for congestion/secretions.
14. gabapentin 400 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO DAILY
(Daily).
15. amlodipine 5 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO DAILY (Daily).
16. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
[**Month/Day/Year **]: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
17. carvedilol 12.5 mg Tablet [**Month/Day/Year **]: Three (3) Tablet PO BID (2
times a day).
18. heparin (porcine) 5,000 unit/mL Solution [**Month/Day/Year **]: One (1)
injection Injection TID (3 times a day).
19. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Month/Day/Year **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
20. atorvastatin 10 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
21. sevelamer carbonate 800 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
22. furosemide 40 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
23. 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.
24. Vancomycin 1000 mg IV Q48H
25. insulin glargine 100 unit/mL Solution [**Month/Day/Year **]: Thirty Two (32)
units Subcutaneous twice a day.
26. Humalog 100 unit/mL Solution [**Month/Day/Year **]: Twelve (12) units
Subcutaneous with meals.
27. Piperacillin-Tazobactam 2.25 g IV Q6H
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] health care center
Discharge Diagnosis:
Aspiration pneumonia
Recent NSTEMI in [**Month (only) 404**]
MCA ischemic stroke with hemmorhagic transformation
S/p hemicraniectomy
Hypertension
Dyslipidemia
Diabetes
History of ETOH and cocaine abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure to care for you during your hospitalization at
[**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **].
You were admitted here with a heart attack following a hypoxia
induced (PEA) cardiac arrest. You likely had an aspiration
pneumonia from being placed on bipap.
You have been on IV antibiotics during your hospital stay. You
should continue your Vancomycin/ Levaquin and Zosyn to complete
an 8 day course (tomorrow [**2-7**] is last day).
Your blood sugars have been uncontrolled while you were in the
hospital, you were seen by the [**Last Name (un) **] team. You should continue
on your current regimen of 32 units Glargine [**Hospital1 **] and 12 units of
Humalog with meals plus Humalog SS if needed with meals
(depending on blood sugars).
Your kidneys were not functioning properly while you were in the
hospital, you had a foley catheter placed with good urine
output. The catheter was removed on [**2-6**] 1:20 pm, you will be
due to void in 6 hours (by 7:20pm).
For your heart failure diagnosis: Weigh yourself every morning,
[**Name8 (MD) 138**] MD if weight goes up more than 3 lbs in 3 days or 5 lbs in
2 days, follow a low salt diet and restrict your fluids to
1500ml/ day.
Followup Instructions:
**It is recommended you schedule an appointment with a Primary
Care Provider. [**Name10 (NameIs) **] you need help obtaining a PCP, [**Name10 (NameIs) **] call our
Find a Doctor line at [**Telephone/Fax (1) 70946**]. They can help you Monday -
Friday between the hours of 8:30AM and 5:00PM.**
Department: WEST [**Hospital 2002**] CLINIC/NEPHROLOGY
When: WEDNESDAY [**2126-2-13**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 21927**], MD [**Telephone/Fax (1) 87700**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Completed by:[**2126-2-6**]
|
[
"311",
"272.4",
"V45.82",
"250.93",
"518.81",
"414.01",
"V44.1",
"403.90",
"285.9",
"507.0",
"728.87",
"530.81",
"V12.53",
"V44.0",
"V58.61",
"585.3",
"410.41",
"584.9",
"790.92",
"787.22",
"438.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
18580, 18641
|
8295, 13956
|
322, 375
|
18887, 18887
|
5062, 5062
|
20401, 21101
|
3923, 4003
|
15808, 18557
|
18662, 18866
|
13982, 13982
|
19065, 20378
|
4043, 4528
|
14000, 14811
|
7645, 7802
|
263, 284
|
7821, 8272
|
403, 3437
|
5078, 7628
|
18902, 19041
|
14836, 15785
|
3459, 3712
|
3728, 3907
|
4553, 5043
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,726
| 153,720
|
24033
|
Discharge summary
|
report
|
Admission Date: [**2191-9-19**] Discharge Date: [**2191-10-1**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is an 89 year old male with CHF on home O2 (unknown amount)
and HTN with chief complaint of shortness of breath. He reports
worsening of his baseline SOB in the evening of the night of
admission. This was associated with palpitations and was
similar to his recent CHF exacerbation in [**Month (only) **]. He reports
that he has been taking all of the medications that he was
discharged on from his last admission in [**Month (only) **], and he
denies recent salt load. He denies noticeable changes in
chronic LE lymphedema, and he denies CP, arm/jaw/back pain, N/V,
dizziness, or changes in his weight. At the nursing home,
patient desaturated to 71% on 3 Liters despite 100mg po lasix
and 40 IM 2hr prior. He was placed on nonrebreather 100% with no
improvement. He was given zaroxolyn 5mg po, bp dropped to 98/60,
HR remained 112, no significant improvement in saturation, high
70's to mid 80's.
.
In the ED, VS were T 92.9, BP 119/65, P 110, 97% on 100% NRB. In
the ED he received Furosemide 40mg IV x 3, Acetaminophen 325mg,
1 g ceftriaxone, azithromycin 500 mg. He was placed on bipap and
then nonrebreather. He was febrile to 101.4 and blood and urine
cx were sent.
.
Upon admission to the ICU, he was no longer significantly short
of breath and was satting well on 50% ventimask. He denied
other symptoms as outlined earlier.
.
Of note, during his recent admission on [**2191-8-9**] for CHF
exacerbation, he was responsive to lasix.
Past Medical History:
-CHF - diastolic dysfunction
-multiple falls
-HTN
-BPH
-Chronic Lymphedema
-Venous stasis (w/ LLE stasis ulcer)
-Peripheral Neuropathy
-h/o DVT
Social History:
Txferred from [**Hospital3 2558**]. He lives with a roomate. He
reports remote and limited tobacco and alcohol use.
Family History:
NA
Physical Exam:
vitals: 97.1 120/78 HR 85 RR 33 SpO2 94% 50% ventimask
gen: alert, nad though mildly tachypneic
heent: NCAT, adentilous, EOMI grossly, perrl
neck: no tmg, no lad, JVD 12cm
pulm: wet crackles 3/4 up lung fields bilaterally, no w/r
cv: hrrr, no m/r/g
abd: s/nt/nd/nabs/no hsm
extr: extensive bilateral LE lymphedema and 2+ bilateral pedal
edema. No c/c
neuro: AOx4
Pertinent Results:
Color
Yellow Appear
Clear SpecGr
1.008 pH
5.0 Urobil
Neg Bili
Neg
Leuk
Neg Bld
Tr Nitr
Neg Prot
Neg Glu
Neg Ket
Neg
RBC [**5-1**]
WBC [**1-24**]
Bact Few
Yeast None
Epi 0
.
Lactate:2.7
.
Trop-T: 0.13
CK: 194 MB: 3
.
145 102 53
-------------< 146
3.7 31 2.8
98
8.2 D 13.8 261
42.0
N:79.5 L:15.8 M:3.1 E:1.4 Bas:0.2
PT: 34.4 PTT: 31.2 INR: 3.7
.
Bld and urine cx pending
.
Imaging:
UPRIGHT PORTABLE CHEST: Cardiac size is mildly enlarged but
unchanged. A dilated calcified aorta is also unchanged allowing
for technique. Compared to [**8-16**], there are more
prominent interstitial markings bilaterally with evidence of
peribronchial cuffing observed. A left pleural effusion is again
noted. No pneumothorax. No definite focal consolidation.
.
echo [**2191-8-10**]
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is 11-15mmHg.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
There is no ventricular septal defect. The right ventricular
cavity is moderately dilated. Right ventricular systolic
function is borderline normal. Interventricular septal motion is
normal. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**11-23**]+) 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
trivial/physiologic pericardial effusion.
IMPRESSION: Normal LVEF. Dilated RV with borderline normal
systolic function. Moderate to severe pulmonary hypertension.
These findings suggest chronic pulmonary hypertension. No
findings of acute, massive pulmonary embolism are suggested.
.
[**2191-9-21**]
Brief Hospital Course:
MICU COURSE:
A/P: Patient is an 89yo male with pmhx dCHF, pulm HTN, potential
pulm fibrosis and HTN who presents with hypoxic respiratory
failure. Patient was intitially admitted to ICU with
heartfailure and improved with diuresis and was discharged to
floor where he developed hypoxic respiratory failure.
.
# Hypoxic respiratory failure: Per family discussion would like
to extubate as patient's original wishes were DNR/DNI. They are
aware that the patient may have continued respiratory failure
and death if extubated and have decided to continue with
extubation. Patient extubated on [**2191-9-29**]. Leading differential
would be for pulm edema vs aspiration secondary to
intra-abdominal pathology. Crackles and pink frothy sputum on
suction as well as hx CHF or more suggestive of pulmonary edema.
Flash pulmonary edema may have occured [**12-24**] afib vs mitral
reguritation with mild ischemia. However, recent suctioning
revealed thick, yellow material and patient's hx is c/w
aspiration. Tracheal sputum cultures are growin GPC's and he was
treated with Vanc which was stopped upon discharge. CE neg for
ischemia. Would think low prob for PE given INR >2. ABG shows
cont A-a gradient. Likely chronic Co2 retainer. Patient was
allowed to autodiurese. Patient was transfered to Hospice care
after family discussion given poor prognosis of his medical
condition.
.
# Adb pain/colonic dilation: Resolved with bowel movement.
Lactate trending down makes ischemic process less likely. No
evidence for infectious colitis or obtructive process on abd CT.
LFT's are also normal although slight elevated amylase/lipase.
Guiac negative. C diff neg. OGT was placed to decompress.
Flagyl/Zosyn was discontinued.
#Hypotension- Resolved with volume replacement on admission.
likely from peri-intubation medications following pre-intubation
diuresis.
.
# ARF- At baseline. Baseline creatinine is 1.7-1.9. Up to 2.8
upon admission. This is likely in the setting of CHF
exacerbation and poor perfusion of the kidneys, which improved
with diuresis.
.
# Hypokalemia- likely from diuresis. Repleted K prn during
hospital stay.
.
# Hypernatremia - Repleted free water deficit during hospital
stay.
.
# H/O DVT- Held anticoagulation with coumadin given elevated
INR. His INR should be followed to assess restarting his
coumadin.
.
# FEN- OGT for decompression, NPO except meds.
.
# PPX- PPI, elevated INR
.
# Access- RIJ
.
# Code- DNR, do not re-intubate.
.
# [**Name (NI) 2638**] brother [**Name (NI) **] [**Name (NI) 61152**] at [**Telephone/Fax (1) 61153**]
.
# Dispo- Family wanted DNR/DNI. Patient will be transfered to
Hospice care after discussing with family.
Medications on Admission:
1. Fluticasone 50 mcg/Actuation Aerosol, Spray [**Telephone/Fax (1) **]: One (1)
Spray Nasal DAILY (Daily).
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Telephone/Fax (1) **]:
One (1) Cap Inhalation DAILY (Daily).
3. Mirtazapine 15 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO HS (at
bedtime).
4. Acetaminophen 325 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO Q6H (every
6 hours) as needed.
5. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Telephone/Fax (1) **]: One (1)
Inhalation Q6H (every 6 hours) as needed.
6. Erythromycin 5 mg/g Ointment [**Telephone/Fax (1) **]: One (1) Ophthalmic QID (4
times a day).
7. Labetalol 100 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID (2 times a
day).
8. Ketorolac Tromethamine 0.5 % Drops [**Telephone/Fax (1) **]: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
9. Diltiazem HCl 30 mg Tablet [**Hospital1 **]: One (1) Tablet PO QID (4
times a day).
10. Famotidine 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H (every
24 hours).
11. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours).
13. Furosemide 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
14. Warfarin 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Six (6)
Puff Inhalation Q4H (every 4 hours).
3. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: 2-4 Puffs Inhalation
Q4H (every 4 hours).
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
6. Morphine Concentrate 10 mg/0.5 mL Solution [**Last Name (STitle) **]: [**11-23**] PO every
4-6 hours as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
. Acute diastolic heart failure
. Pulmonary hypertension
. Hypertension
. Atrial fibrillation
Secondary:
-CHF - diastolic dysfunction (EF 65%, mild sym LVH)
-multiple falls
- pulmonary hypertension (TR grad 52)
-BPH
-Chronic Lymphedema
-Venous stasis (w/ LLE stasis ulcer)
-Peripheral Neuropathy
-h/o DVT
- Chronic Kidney Disease (baseline Cr ~1.7-2)
Discharge Condition:
Fair
Discharge Instructions:
Mr. [**Known lastname 61152**] was seen at [**Hospital1 18**] for CHF exacerbation and
respiratory failure. He was briefly intubated and successfully
weaned and extubated. His respiratory status has been stable.
Please contact your primary care physician or go to the
emergency department if you develop worsening shortness of
breath, chest pain, palpitations, fever greater than 101.4
degrees F or any other symptoms that concern you.
Followup Instructions:
Please schedule a follow up appointment with your primary care
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 335**] [**Last Name (NamePattern1) 5351**] [**Telephone/Fax (1) 608**], within the next 7 to
10 days.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"403.90",
"518.81",
"428.0",
"459.81",
"600.00",
"356.9",
"507.0",
"276.8",
"585.3",
"428.33",
"584.9",
"276.0",
"416.8",
"427.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9317, 9387
|
4521, 7187
|
273, 280
|
9792, 9799
|
2486, 4498
|
10285, 10663
|
2079, 2083
|
8637, 9294
|
9408, 9771
|
7213, 8614
|
9823, 10262
|
2098, 2467
|
230, 235
|
308, 1759
|
1781, 1927
|
1943, 2063
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,800
| 111,764
|
688
|
Discharge summary
|
report
|
Admission Date: [**2139-10-17**] Discharge Date: [**2139-10-24**]
Date of Birth: [**2087-5-17**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5167**]
Chief Complaint:
increased [**First Name3 (LF) 862**]
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
The pt is a year-old woman with a PMH s/f MS [**First Name (Titles) **] [**Last Name (Titles) 862**] D/O
including a history of status epilepticus who presented to
[**Hospital6 5168**] on the evening of [**2139-10-16**] with chief
complaint of found unresponsive. History obtained from sister
and from OSH records. The patient was at home and had a fall,
which was not unusual. She seemed fine after the fall. She was
found unresponsive at 8:30pm and brought to the OSH. She was
noted to have seizures at the OSH by the sister. She was also
noted to be Febrile to 101. She had an elevated white count.
[**Date Range **] was managed with ativan (unknown how much)and
phosphenytoin 1000mg x1. An EEG on [**2139-10-17**] showed rare Left
temporal sharps but no seizures. The fever workup included
UA/UCx, BCx, chest x-ray, non contrast head CT, and an LP. None
of these was revealing. The patient was felt to be in a
protracted post-ictal state. A decision was made to transfer
the
patient to the [**Hospital1 18**] for further management. The patient was
put
on a propofol gtt, given fentanyl and intubated for airway
protection, given the concern that she might seize en route.
Past Medical History:
-Complex partial seizures (staring spells and arm extension).
She
had status 10 yrs ago
-Demyelinating disease by MRI and oligoclonal bands on LP in
[**2119**].
-Depression and h/o SI
-Restless legs
-h/o mumps
Social History:
Patient lives with her eldest sister and her 82 year old mother
in [**Name (NI) 5169**], MA where she was born. She is one of six children
having 4 sisters and 1 brother. She describes her family as
being extremely close and supportive of her. She is very close
to her mother and is upset about being away from her during this
hospitalization. She is unemployed at this time due to physical
and cognitive limitations related to her disease. She worked as
a horticulturist doing research in [**State 4565**] and [**State 5170**] in
the past. She is divorced, but remains on good terms with her
former husband who lives in CA. She has no children. She has
no history of IV drug use, tobacco use or alcohol consumption.
Family History:
Father died of a myocardial infarction. Mother is alive and at
82 years of age is in good health. One sister is 42 and also
suffers from a demyelinating disease, (suspected multiple
sclerosis) which has affected her cognition more than her motor
and sensory systems. This sister has responded well to
Solumedrol infusions and Rebif in the past with resolved speech
and swallowing problems. [**Name (NI) **] had one paternal uncle with
suspected multiple sclerosis (diagnosed at age 27, died at 42),
another paternal uncle with paranoid schizophrenia, another
paternal uncle who died of stroke in his 40??????s, and another
paternal uncle who died suddenly of suspected bacterial
meningitis. Many of her sisters are bothered by psoriasis. One
of her sisters has been diagnosed with [**Name (NI) 5171**]??????s thyroiditis
Physical Exam:
T:100.6 P:70-80 R:18 BP:104/50 SaO2:100% on RA
General: Intubated and sedated.
HEENT: NC/AT, no scleral icterus noted
Neck: no carotid bruits appreciated.
Pulmonary: Lungs CTA bilaterally anteriorly.
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Sedated and intubated at time of exam.
-Cranial Nerves: Pupils reactive. Gag reflex intact. Corneals
intact.
-Motor: With lightening of sedation patient moved all four
extremities to noxious stimuli.
-Sensory: to noxious in all four.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor bilaterally.
-Gait: NT
Pertinent Results:
[**2139-10-17**] 08:26PM LACTATE-0.9 K+-3.4*
[**2139-10-17**] 08:23PM GLUCOSE-93 UREA N-26* CREAT-0.8 SODIUM-142
POTASSIUM-3.5 CHLORIDE-112* TOTAL CO2-19* ANION GAP-15
[**2139-10-17**] 08:23PM ALT(SGPT)-26 AST(SGOT)-74* CK(CPK)-4468* ALK
PHOS-74 AMYLASE-45 TOT BILI-0.4
[**2139-10-17**] 08:23PM LIPASE-16
[**2139-10-17**] 08:23PM CK-MB-8 cTropnT-<0.01
[**2139-10-17**] 08:23PM CALCIUM-7.5* PHOSPHATE-2.3* MAGNESIUM-2.2
[**2139-10-17**] 08:23PM PHENYTOIN-10.2
[**2139-10-17**] 08:23PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2139-10-17**] 08:23PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2139-10-17**] 08:23PM WBC-11.6* RBC-3.26* HGB-9.6* HCT-27.4* MCV-84
MCH-29.4 MCHC-35.0 RDW-13.9
[**2139-10-17**] 08:23PM NEUTS-84.2* BANDS-0 LYMPHS-9.7* MONOS-5.7
EOS-0.3 BASOS-0.1
[**2139-10-17**] 08:23PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.025
Brief Hospital Course:
pt was admitted to the ICU where she did well. she continued to
have fevers in the ICU without obvious source.
Neuro:
Pt was loaded with dilantin with improvement in seizures.
EEG: This is an abnormal 24-hour video EEG telemetry in the
waking and sleeping states due to the slow and disorganized
background
rhythm suggestive of a mild to moderate encephalopathy. This may
be
seen with medication effect, toxic metabolic abnormalities, or
infections. There are no regions of focal slowing and no
epileptiform
discharges noted.
She was extubated without incident and repeat EEG without
evidence of electrographic seizures. pt without [**Last Name (un) 862**]
activity for the rest of her hospital stay. dilantin level was
low, but with possibility that dilantin was cause of fever,
dilantin was discontinued.
pt with improving encephalopathy during stay with return to
fairly baseline mental status, although with continued decreased
strength in her LE and decreased ability to ambulate.
ID: pt continued to have daily fevers. Abx stopped with
negative cultures. acyclovir CT torso without source. US of
gallbladder and LE were both negative for source. HSV PCR at
OSH was not resulted. Repeat LP was performed without CSF
pleiocytosis so acyclovir was stopped. Without source,
consideration of possible drug fever. dilantin level had been
low without [**Last Name (un) 862**] activity. dilantin was weaned off without
issue with resolution of fever.
PT/OT evaluated the patient and felt that she would benefit
significantly from acute rehabilitation placement.
GI: pt with some difficulty eating. Speech and swallow evaluated
her and found her to have difficulty with solids. patient's
diet was changed to softs which she tolerated well.
Discharge Medications:
1. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5172**] Rehabilitation Center at [**Hospital3 5173**] - [**Location (un) 5174**]
Discharge Diagnosis:
seizures
MS
depression
Discharge Condition:
stable. no seizures
Discharge Instructions:
please follow up with pcp/call primary neurologist if worsened
weakness, worsened gait, seizures, HA, decreased responsiveness,
or for any other patient concerns.
Followup Instructions:
follow up with primary neurologist in [**Location (un) 5169**] area.
please follow up with PCP
Completed by:[**2139-10-24**]
|
[
"345.90",
"780.6",
"340"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
7608, 7727
|
5268, 7022
|
355, 373
|
7793, 7815
|
4283, 5245
|
8026, 8154
|
2587, 3414
|
7045, 7585
|
7748, 7772
|
7839, 8003
|
3938, 4264
|
3429, 3866
|
279, 317
|
401, 1594
|
3881, 3921
|
1616, 1828
|
1844, 2571
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,820
| 148,882
|
23887
|
Discharge summary
|
report
|
Admission Date: [**2193-6-15**] Discharge Date: [**2193-6-19**]
Date of Birth: [**2143-12-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Transfer from OSH for complete heart block s/p septal alcohol
ablation
Major Surgical or Invasive Procedure:
DDD placement, ICD placement
History of Present Illness:
49 y/o male with htn, hyperlipidemia, resolved DM after L
kidney/pancreas transplant [**2183**], severe PVD s/p numerous
peripheral PCI's, "SVT" per chart and severe HOCM who was
referred to [**Hospital1 18**] for elective ethanol septal ablation on [**6-10**]
after a stress ECHO [**2193-3-23**] revealed resting gradient 18, with
valsalva 86 and post-exercise 191 (8 METS, lateral ST changes,
stopped [**2-20**] claudication, mild-mod AI). LVEDD 4.92, IV Septum
1.27. Pt has marked DOE, becoming winded after 5 minutes of
walking or going up 2 flights of stairs. Also c/o numerous
pre-syncopal events, last 3 nights ago. Does have palpitations
also.
In [**Hospital1 18**] cath lab, peak gradient was 118 with Valsalva and
post-PVC (Braunwald-Brockenbrough beat). His first septal
artery(which was quite a large artery) was ablated. In
addition, LHC revealed TO distal LCx w/ good collateral flow.
During last hospital stay, temporary wire placed x 3 d. Pt
never required pacing. No evidence heart block noted.
Post-procedure the patient did have two episodes of polymorphic
VT - one episode converted by defibrillation, second spontaneous
conversion. In addition, three episodes of NSVT. He was started
on amio load x 24 hours. Role of temp wire in causing VT
considered, however, not the VT was not monomorphic so it was
felt less likely. More likely, the patient had ischemic VT. An
AICD was discussed given that his brother recently passed. The
medical examiner confirmed that there was no evidence of HOCM or
sudden cardiac death in his brother. Therefore, EP made the
decision to forgo ICD placement. On discharge, the plan was for
the patient to have a holter monitor to observe for episodes of
VT. If episodes of VT were documented, then the patient would
have an ICD placed.
[**6-15**] patient re-pressentec to outside hospital with . Noted
to have complete heart block. Transferred to [**Hospital1 18**] as outside
hospital unable to place ICD as well as PM.
Past Medical History:
1. HOCM, s/p ethanol septal ablation
2. PVD: S/P stenting L common iliac x 2 in [**1-23**] c/b
retroperitoneal hemorrhage and RLE [**2192-9-27**] (6 x 29mm) initially
planned for PCI during [**2193-6-10**] admission but deferred secondary
to large MI post ETOH ablation.
3. OSA: Not on CPAP
4. Moderate AI: By ECHO [**3-23**]
5. SVT: Had holter in past that showed lots of APB's, but no SVT
or VT.
6. Diabetes: S/P combined L kidney/pancreas transplant. On
tacrolimus, cellcept and prednisone. No longer diabetic.
7. HTN: On BB, clonidine, norvasc and minoxidil
8. Dyslipidemia
9. CAD: no flow limiting lesions (cath [**3-/2193**])
Social History:
Married, works as a home and building inspector.
Family History:
(?) FHx CAD: Brother died suddenly a few weeks ago at age 52 hx
of ETOH abuse. Mother has a pacemaker.
Physical Exam:
T 99.6, HR 70, RR 12, BP 112/51, SaO2 100%
GENL: NAD
HEENT: +[**Doctor Last Name **] A waves
CV: Irregular, nl S1, paradoxical S2, 1+ DP pulses, 2+ carotid
pulses
ABD: soft, nt, nd
EXT: no edema
Nuero: A&Ox3
Pertinent Results:
[**2193-6-19**] 07:15AM BLOOD WBC-8.4 RBC-4.27* Hgb-12.2* Hct-36.7*
MCV-86 MCH-28.6 MCHC-33.2 RDW-14.5 Plt Ct-242
[**2193-6-16**] 01:31AM BLOOD WBC-9.7 RBC-4.92 Hgb-13.6* Hct-41.4
MCV-84 MCH-27.7 MCHC-32.9 RDW-14.5 Plt Ct-240
[**2193-6-16**] 01:31AM BLOOD Neuts-75.9* Lymphs-14.2* Monos-8.2
Eos-1.4 Baso-0.3
[**2193-6-19**] 07:15AM BLOOD Plt Ct-242
[**2193-6-19**] 07:15AM BLOOD PT-12.5 PTT-27.1 INR(PT)-1.0
[**2193-6-19**] 07:15AM BLOOD Glucose-100 UreaN-18 Creat-1.1 Na-141
K-4.6 Cl-104 HCO3-28 AnGap-14
[**2193-6-19**] 07:15AM BLOOD Calcium-9.5 Phos-3.4 Mg-1.7
[**2193-6-19**] 07:15AM BLOOD FK506-PND
[**2193-6-16**] 01:31AM BLOOD Glucose-128* UreaN-17 Creat-1.0 Na-140
K-3.9 Cl-103 HCO3-25 AnGap-16
EKG: Vpaced, Rate 64
Brief Hospital Course:
49 y/o male with HOCM s/p recent septal ethanol ablation on
[**2193-6-10**], complicated by post intervention VT requiring
defibrillation, who presents 2 days after discharge to [**Hospital 1514**]
Hospital with intermittent symptomatic complete heart block.
Rhythm: It is felt his complete heart block is a complication of
the septal ablation. The heart block was a phase 4 deplarization
block (at slower heart rates has more block, at faster heart
rates less block). He underwent dual chamber pacemaker and ICD
placement on [**2193-6-17**]. CXR showed leads to be in good place post
procedure. However, his atrial lead had suboptimal sensing. The
ventircular lead was sensing well. It was set to DDDR, rate of
70. He will follow up in device clinic in 1 week. He may need
replacement of the atrial lead if it continued to have
suboptimal sensing. He will complete a 96 hour course of
antibiotics. We restarted his beta blocker, lopressor 50 mg [**Hospital1 **].
He will need DFT (defibrillator threshold testing)in one month.
He did note some lightheadedness, but given his pacemaker was AV
paced, we felt this was unlikely pacemaker syndrome as his atria
should not be contracting against a contracting ventricle at
this setting.
Pump: S/P recent ethanol ablation w/ peak CKs 1800. He was
euvolemic throughout hospital course.
CAD: Cath on [**2193-6-10**], showed no flow limiting lesions. We
continued aspirin/statin/BB
HTN: We continued minoxidil, amlodipine, clonidine. His BP was
well controlled.
PVD: Needs bilateral peripheral interventions when he has
recovered from ethanol ablation procedure and pacemaker
placement. He will follow up with Dr. [**Last Name (STitle) **].
S/P Renal/Pancreas Transplant: We cont Cell cept, prednisone,
FK506. An FK 506 level was pending at time of discharge. He will
follow up with this level and with his transplant doctor.
Medications on Admission:
Outpt Meds:
Cellcept 1gm [**Hospital1 **]
Prograf 2mg [**Hospital1 **]
Prednisone 5mg daily
Metoprolol 50mg [**Hospital1 **]
Clonidine 0.10mg [**Hospital1 **]
Norvasc 10mg daily
Zocor 40mg daily
Minoxidil 0.5mg daily
Aspirin 325mg daily
Discharge Medications:
1. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
2. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Clonidine HCl 0.1 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Minoxidil 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain for 7 days.
Disp:*20 Tablet(s)* Refills:*0*
11. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 2 days.
Disp:*8 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1) complete heart block
2) s/p ethanol septal ablation
3) severe hypertrophic obstructive cardiomyopathy
4) S/P kidney and renal transplant, [**2183**]
5) Peripheral vascular disease, s/p stents x2.
6) CAD
7) Dyslipidemia
8) Hypertension
9) Moderate AI (echo [**3-23**])
10) OSA
Discharge Condition:
Good
Discharge Instructions:
1) Please take medications as directed.
2) Please attend your follow up appointments.
3) Return to medical care if you develop any chest pain,
dizziness, bleeding from the site or develop any concerning
symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2193-6-26**] 1:00
-
Follow up with Dr. [**Last Name (STitle) **] in 1 month for your vascular disease,
([**Telephone/Fax (1) 5909**]
You can call [**Telephone/Fax (1) 16116**] to follow up on your FK506 and urine
amylase levels. Please call these results to your transplant
doctor.
|
[
"V42.0",
"425.1",
"424.1",
"997.1",
"780.57",
"401.9",
"V42.83",
"443.9",
"426.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.94"
] |
icd9pcs
|
[
[
[]
]
] |
7413, 7419
|
4266, 6145
|
386, 417
|
7742, 7748
|
3517, 4243
|
8009, 8428
|
3169, 3274
|
6432, 7390
|
7440, 7721
|
6171, 6409
|
7772, 7986
|
3289, 3498
|
276, 348
|
445, 2428
|
2450, 3086
|
3102, 3153
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,101
| 111,770
|
17682
|
Discharge summary
|
report
|
Admission Date: [**2131-5-31**] Discharge Date: [**2131-6-7**]
Date of Birth: [**2074-12-8**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10223**]
Chief Complaint:
Abdominal pain and emesis x 2days
Major Surgical or Invasive Procedure:
History of Present Illness:
Pt awoke 2 days PTA w/ abdominal pain (epigastric, sharp,
non-radiating, not associateed with food intake). He had a
bowel movement (non-bloody, non-mucoid) that did not relieve his
pain. He then ate a boiled egg and had a cup of coffee. Within
a half-hour he vomited the food contents (non-bloody,
non-bilious). His emesis was proceded and followed by nausea.
He denies F/C/SOB/palpitations/urinary sx(frequency, urgency,
dysuria) or changes in bowel movements (frequency, consistency,
color).
Past Medical History:
--pancreatitis (secondary to ETOH)
--HTN
--cirrhosis (h/o ascites, h/o encephalopathy, esophageal
varicies, spenomegaly)
--ETOH abuse
--left foot injury - pins placed
Social History:
ETOH abuse [**12-1**] gallon of vodka/day, stopped one year ago. 1 [**12-1**]
ppd cigarette smoker x 40 yrs, down to 2-3 cigarettes/day over
last year.
Physical Exam:
T96, BP150/80, HR68, R18, O297%
HEENT: no lymphadenopathy, no JVD, no elevated JVP, MMM, EOMI,
PERRL, NCAT
CHEST: CTAB
CV: RRR, NL s1/s2
ABD: soft, BS+, epigastric tenderness, ND, no guarding, no
rebound
EXT: warm, no C/C/E, venous stasis changes in left leg, scars
from old trauma to left lower leg/foot
NEURO: AxOx3
Pertinent Results:
[**2131-5-31**] 06:45AM PLT COUNT-88*
[**2131-5-31**] 06:45AM NEUTS-64.7 LYMPHS-20.3 MONOS-8.3 EOS-6.3*
BASOS-0.3
[**2131-5-31**] 06:45AM WBC-6.7 RBC-4.12* HGB-13.2* HCT-39.4* MCV-96
MCH-32.1* MCHC-33.6 RDW-15.5
[**2131-5-31**] 06:45AM ALBUMIN-3.3* CALCIUM-9.3 PHOSPHATE-3.4
MAGNESIUM-1.6
[**2131-5-31**] 06:45AM LIPASE-105*
[**2131-5-31**] 06:45AM ALT(SGPT)-33 AST(SGOT)-57* ALK PHOS-144*
AMYLASE-96 TOT BILI-1.8*
[**2131-5-31**] 06:45AM GLUCOSE-98 UREA N-16 CREAT-1.0 SODIUM-138
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-22 ANION GAP-13
[**2131-5-31**] CT ABD:No evidence of acute pancreatitis or any sequela
of pancreatitis. Cirrhosis and evidence of portal hypertension.
Stable appearance of enlarged lesser curvature iliac and portal
lymph nodes.
[**2131-6-3**] RENAL U/S:No evidence of stones, masses or
hydronephrosis.
[**2131-6-3**] CXR:There are increased interstitial markings which
suggest some mild failure.07/04&[**4-3**] BLOOD CULTURE: negative
[**2131-6-4**] FECES NEGATIVE FOR C. DIFFICILE TOXIN
[**2131-6-5**] FECAL CULTURE: NO CAMPYLOBACTER FOUND
[**2131-6-6**] FECAL CULTURE: NO SALMONELLA OR SHIGELLA FOUND.
Brief Hospital Course:
Pt was made NPO, given IVF, analgesics and antiemetics. His
symptoms resolved overnight and was feeling much better the
following day. He was caught smoking a cigarette in the
hospital and was then allowed to continue to smoke outside. He
returned and stated that his abdominal pain, N/V had returned.
Pt was continued one NPO, IVF, analgesics and antiemetics. On
the third day of hospitalization he had diarrhea w/ frank blood
and an episode of dizziness w/ orthostatic changes. He was
ruled-out for MI. GI consulted, colonoscopy was deferred. He
continued to have diarrhea and abdominal pain. On the next day
he experienced a marked drop in O2 sat into 80's while sleeping,
was hypotensive, tachycardic, somnolent, positive asterixis. An
ABG showed 7.22/47/96. His BP improved with a fluid bolus and
his O2sat went into the 90's while he was awake. Narcotics were
held, Pt was given Narcan with good response in mental status
and lactulose was contniued for possible encephalopathy. This
episode was also accompanied by an elevation in his WBCs, renal
failure, positive U/A. Pt was transferred to [**Hospital Unit Name 153**]. Renal
consulted, and agressive IVF for pre-renal ARF, and
ciprofloxacin added for possible UTI. Pt improved in [**Hospital Unit Name 153**]
secondary to hydration and narcotic wean. His amylase and
lipase levels rose to 157 and 211 respectively, consistent with
an acute on chronic pancreatitis. He spent two more days on the
medicine floor, his O2 sat on RA, BP, and creatinine levels
returned to his baseline levels, abdominal pain had resolved,
mental status improved, and he was tolerating PO intake.
Medications on Admission:
oxycodone
spironolactone
folate
multivitamins
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
2. Nadolol 80 mg Tablet Sig: One (1) Tablet PO QD (once a day).
Disp:*30 Tablet(s)* Refills:*2*
3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*qs 1 month* Refills:*2*
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*qs 1 month* Refills:*0*
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*21 Tablet(s)* Refills:*0*
8. Lidocaine 5 % Adhesive Patch, Medicated Sig: One (1) Adhesive
Patch, Medicated Topical 12 HRS ON 12 HRS OFF ().
Disp:*60 Adhesive Patch, Medicated(s)* Refills:*2*
9. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on Chronic Pancreatitis
HCV and EtOH Cirrhosis w/encephalopathy
Discharge Condition:
stable
Discharge Instructions:
Please notify your doctors [**First Name (Titles) **] [**Last Name (Titles) 2449**] of shortness of breath,
pain, palpitations, nausea, vomiting, weight loss, inability to
eat or drink or any other symptoms of concern. We recommend
that you have a cardiac stress test within 1 week of leaving the
hospital. DO NOT TAKE NARCOTICS OTHER THAN THE ONES PRESCRIBED
TO YOU.
Followup Instructions:
1) Please call to schedule an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
at [**Telephone/Fax (1) 250**] within 2 weeks of leaving the hospital. At this
time you should have your bloodwork (electrolytes) checked.
2)Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD Where: LM [**Hospital Unit Name 7129**]
CENTER Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2131-11-14**] 11:00
|
[
"571.5",
"577.0",
"578.1",
"572.2",
"070.51",
"577.1",
"276.2",
"535.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5613, 5619
|
2750, 4401
|
345, 345
|
5733, 5741
|
1587, 2727
|
6160, 6624
|
4497, 5590
|
5640, 5712
|
4427, 4474
|
5765, 6137
|
1248, 1568
|
271, 306
|
373, 873
|
895, 1063
|
1079, 1233
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,089
| 115,325
|
25760
|
Discharge summary
|
report
|
Admission Date: [**2139-5-25**] Discharge Date: [**2139-6-1**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
Transfer for possible placement of BiV pacer
Major Surgical or Invasive Procedure:
[**Hospital1 **]-ventricular pacer placement
History of Present Illness:
Patient is a 84 year old man with ischemic cardiomyopathy (EF in
the 30's, 2+ TR, 2+MR [**First Name (Titles) **] [**Last Name (Titles) **] on [**2138-10-22**])admitted [**2139-5-19**] to
[**Hospital3 3583**] with complaints of several weeks of generalized
fatigue. He was r/o for MI and was found to have a UTI for which
he was given ceftriaxone 1g IV yesterday ([**2139-5-24**]). His
creatinine was 1.7 on admission but has since improved to 1.2.
He was also found to be hyperglycemic with positive ketones
secondary to self dicontinuation of glyburide. During his
hospital stay he developed a right lower extremity DVT and is
now on heparin drip 900u/hour. During this admission he also had
a head CT which showed moderate atrophy. The reason for this
was not clarified as he was not reported to have any mental
status changes. They also did an abdominal u/s as his LFT's were
elevated which showed hepatic steatosis.
Upon admit to [**Hospital3 **] he was also found to have new
onset RAF to the 110's. While on telemetry he had a 13 beat run
of NSVT. They were trying to manage his rate but last Friday he
did have some pauses up to 3 seconds, therefore his digoxin
(level 1.2 on [**2139-5-19**] admission) and verapamil were held. He
has not had any pauses in 3 days. He was transferred for
possible placement of BiV pacer.
Past Medical History:
1. Ischemic cardiomyopathy, EF 30%
2. CAD s/p CABGx3
2. New onset AF
3. hypertension
4. hyperlipidemia
5. DM
6. Prostate cancer- dx mid-[**2123**]'s with urinary retention
7. CRI
8. glaucoma
9. right total hip replacement
10. LBBB
Social History:
Rarely uses alcohol, former smoker quit 55 years ago
Family History:
Father-Died of MI in 70's
Mother lived into her 90s and was healthy
Brother 87 with CAD and ICD placed a year ago
Brother 79-healthy
Sister in her 90's had stroke at age [**Age over 90 **]
Physical Exam:
General: Elderly gentleman lying supin in NAD.
Vitals:t. 96 BP 122/52 P 104 R 20 O2sats 99% on 2L Wt. 77.6 kg
CV: irreularly, irregular, no murmur
Pulm:CTA b/l
Abd: +BS, soft, NT/ND
Ext: 3+ pitting edema on right up to hip, 2+ pitting edema on
left up to knee
ROS: Denies N/V, abdominal pain, dysuria, fever, chills.
Pertinent Results:
[**2139-5-25**] 11:26PM PTT-131.1*
[**2139-5-25**] 03:34PM GLUCOSE-372* UREA N-52* CREAT-1.3* SODIUM-141
POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-26 ANION GAP-14
[**2139-5-25**] 03:34PM ALT(SGPT)-285* AST(SGOT)-211* ALK PHOS-190*
TOT BILI-0.4
[**2139-5-25**] 03:34PM CALCIUM-7.8* PHOSPHATE-3.0 MAGNESIUM-2.2
[**2139-5-25**] 03:34PM WBC-9.5 RBC-4.11* HGB-13.2* HCT-39.7* MCV-97
MCH-32.2* MCHC-33.3 RDW-14.9
[**2139-5-25**] 03:34PM PLT COUNT-119*
[**2139-5-25**] 03:34PM PT-17.4* PTT-150* INR(PT)-2.0
[**2139-5-28**] 01:16PM BLOOD Glucose-265* UreaN-68* Creat-1.7* Na-137
K-4.2 Cl-103 HCO3-25 AnGap-13
[**2139-5-28**] 05:05PM BLOOD Creat-1.7*
[**2139-5-28**] 01:16PM BLOOD ALT-235* AST-102* LD(LDH)-1065*
AlkPhos-158* TotBili-0.4
[**2139-5-28**] 01:16PM BLOOD Mg-2.2
[**2139-5-27**] 04:04PM BLOOD Smooth-NEGATIVE
[**2139-5-27**] 04:04PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2139-5-27**] 06:20AM BLOOD IgG-439* IgM-94
[**2139-5-27**] 06:20AM BLOOD HCV Ab-NEGATIVE
[**2139-5-25**] 03:34PM BLOOD WBC-9.5 RBC-4.11* Hgb-13.2* Hct-39.7*
MCV-97 MCH-32.2* MCHC-33.3 RDW-14.9 Plt Ct-119*
[**2139-5-27**] 06:20AM BLOOD WBC-8.4 RBC-3.86* Hgb-12.3* Hct-37.8*
MCV-98 MCH-31.9 MCHC-32.5 RDW-15.2 Plt Ct-104*
[**2139-5-30**] 06:15AM BLOOD WBC-13.3* RBC-3.38* Hgb-10.6* Hct-32.5*
MCV-96 MCH-31.5 MCHC-32.7 RDW-15.3 Plt Ct-166
[**2139-5-31**] 05:13AM BLOOD WBC-13.9* RBC-2.88* Hgb-9.0* Hct-27.0*
MCV-94 MCH-31.3 MCHC-33.3 RDW-15.2 Plt Ct-138*
[**2139-5-25**] 03:34PM BLOOD PT-17.4* PTT-150* INR(PT)-2.0
[**2139-5-27**] 03:12PM BLOOD PT-13.2 PTT-64.7* INR(PT)-1.2
[**2139-5-30**] 06:15AM BLOOD PT-26.2* PTT-58.7* INR(PT)-4.6
[**2139-5-31**] 05:13AM BLOOD PT-32.1* PTT-44.9* INR(PT)-6.8
[**2139-5-25**] 03:34PM BLOOD Glucose-372* UreaN-52* Creat-1.3* Na-141
K-4.4 Cl-105 HCO3-26 AnGap-14
[**2139-5-27**] 06:20AM BLOOD Glucose-274* UreaN-50* Creat-1.2 Na-141
K-4.1 Cl-105 HCO3-27 AnGap-13
[**2139-5-29**] 06:25AM BLOOD Glucose-127* UreaN-83* Creat-2.2* Na-139
K-4.5 Cl-103 HCO3-25 AnGap-16
[**2139-5-30**] 06:15AM BLOOD Glucose-151* UreaN-104* Creat-3.5* Na-136
K-4.9 Cl-103 HCO3-20* AnGap-18
[**2139-5-31**] 05:13AM BLOOD Glucose-106* UreaN-130* Creat-4.5* Na-137
K-5.2* Cl-106 HCO3-18* AnGap-18
[**2139-5-25**] 03:34PM BLOOD ALT-285* AST-211* AlkPhos-190*
TotBili-0.4
[**2139-5-28**] 01:16PM BLOOD ALT-235* AST-102* LD(LDH)-1065*
AlkPhos-158* TotBili-0.4
[**2139-5-30**] 06:15AM BLOOD ALT-174* AST-107* LD(LDH)-1132*
AlkPhos-125* TotBili-0.3
[**2139-5-28**] 01:16PM BLOOD GGT-417*
[**2139-5-30**] 06:15AM BLOOD TotProt-3.8* Albumin-2.0* Globuln-1.8*
Phos-6.5*# Mg-2.2 Iron-62
[**2139-5-30**] 06:15AM BLOOD Ammonia-49*
Brief Hospital Course:
84 y/o man with PMH significant for ischemic cardiomyopathy (EF
in the 30s, 2+ TR, 2+ MR) admitted on [**5-25**] for placement of BiV
pacer. Prior to admission, the pt had been admitted to [**Hospital1 3325**] on [**6-18**] with several weeks of generalized fatigue. He
was ruled out for MI. However, the pt was found to have new
onset rapid atrial fibriallation with a rate in the 110s. He
also had a 13 beat run of NSVT and up to three second pauses.
This prompted the transfer for possible BiV pacer. During the
OSH admission, the pt was also found to have a UTI and was
started on treatment with ceftriaxone. In addition, he developed
a right LE DVT and was started on treatment with a heparin drip.
.
Following admission at [**Hospital1 18**], the pt was seen by EP and
underwent placement of a BiV pacemaker on [**5-28**]. The procedure
was uncomplicated. However, the pt began to have dramatically
decreased urine output (less than 500 cc on [**5-28**]) and a rising
Hct. His creatinine went from 1.3 on admission --> 1.7 on [**5-28**]
--> 2.2 on [**5-29**] --> 3.5 on [**5-30**] --> 4.5 on [**5-31**]. A renal
consult was obtained on [**5-30**]. They felt that his ARF picture
was most consistent with ATN but extensive evaluation and
treatment (dialysis) was deferred as the pt decided to become
CMO. In addition to the repidly worsening renal failure, a
hepatology consult was obtained as the pt was found to have
elevated transaminitis and fatty infiltration of the liver.
Further evaluation of this will also be deferred at this time.
Pt also began to suffer from hypotension starting on [**5-28**]. This
has continued.
.
Prior to the pt becoming CMO, he was transferred to the CCU on
[**5-30**] when it was considered that more agressive treatments
might be benificial. It was thought that his multisystem failure
(severe ARF, hepatic failure, hypotension) was most likely [**12-31**]
poor forward flow from his CHF/CM. Upon transfer, the pt decided
that he wanted to be DNR/DNI. He was very clear about his wishes
not to have heroic measures, further treatment, or anything that
might cause him discomfort. His family was present and supported
him in his decision to be comfort measures only. Therefore, the
pt was transferred to the floor for CMO care. He was maintained
on morphine drip, and all other medications held.
At 5pm on [**6-1**], housestaff (Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 4154**]) was called to
bedside to pronounce Mr. [**Known lastname **] death. On exam, his pupils
were fixed and dilated, and he had no pulse, respirations, or
heart sounds. He was pronounced dead at 5:05pm. His family
declined a post-mortem examination.
Medications on Admission:
asa 81, KCL, insulin, alphagan eye gtts, lispro insulin,
ceftriaxone, avandia, aldactone, lasix 20, lisinopril 15, coreg
3.125 [**Hospital1 **], heparin 900u/hour. (recently decreased as PTT 128
this morning)- PTT due for 4pm.
Discharge Medications:
None
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Congestive heart failure
Acute renal failure
Hepatic failure
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
|
[
"V64.2",
"414.00",
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"414.8",
"428.0",
"E879.8",
"E849.7",
"250.92",
"570",
"427.1",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.50"
] |
icd9pcs
|
[
[
[]
]
] |
8231, 8250
|
5242, 7923
|
306, 352
|
8354, 8364
|
2603, 5219
|
8416, 8554
|
2058, 2249
|
8202, 8208
|
8271, 8333
|
7949, 8179
|
8388, 8393
|
2264, 2584
|
222, 268
|
380, 1717
|
1739, 1972
|
1988, 2042
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,619
| 102,359
|
14131
|
Discharge summary
|
report
|
Admission Date: [**2179-2-7**] Discharge Date: [**2179-2-10**]
Date of Birth: [**2097-1-18**] Sex: F
Service: MEDICINE
Allergies:
Ativan
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
[**Hospital Unit Name 196**]/[**Doctor Last Name **] TRANSFER FOR PREHYDRATION ON SUNDAY [**2-7**]
Major Surgical or Invasive Procedure:
Thoracic aorta and carotid (with cerebral) angiography,
PTA/stent x1 to left internal carotid artery. [**2179-2-8**] by Dr.
[**First Name (STitle) **]
History of Present Illness:
82 yo female with history of cellulitis, CAD, diabetes who
recently presented to [**Hospital 1474**] Hospital [**2178-1-19**] with right and
left sided tingling x 1-1.5hr. Dx as TIA. Carotid US
demonstrated critical 80-99% stenosis of the left internal
carotid artery. She declined MRI [**2-12**] claustrophobia, but head CT
was reportedly normal. As per neurology, the symptoms were
compatible with [**Doctor First Name 3098**] lesion. She was discharged to Life Center
Rehab/Nursing home where she is currently residing. She is now
referred for prehydration in preparation for a carotid angiogram
with Dr. [**First Name (STitle) **] tomorrow. She reports having difficulty walking
due to persistence of LE weakness and spends most of her time in
a wheelchair.
.
ROS:
(+) LE swelling unchanged, R LE weakness, tingling sensation
(-) 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:
1. PAD with recently documented TIA with the carotid duplex
suggesting the critical left ICA lesion.
2. Coronary artery disease: MI [**12/2173**] with stent to LCX. Also
with AMI [**2174**] with instent restenosis in LCx, s/p restenting and
brachytherapy. Also with residual 70% ostial stenosis of LAD,
70% mid vessel stenosis of the LAD with an 80% mid vessel
stenosis of the D1, medically managed. (note: only "baseline
ECG" available predates [**2174**] in-stent restenosis and PCI)
3. Hypertension.
4. Poor mobility due to multiple factors.
5. Recurrent urinary tract infections due to chronic
catheterization.
6. Chronic leg cellulitis/bilateral.
7. Bilateral pedal edema - multifactorial.
8. CRI - baseline Cr 2.0
9. Bipolar disease
10. COPD
11. DM
12. Psoriasis
13. CHF
Social History:
Nonsmoker, nondrinker, lives independently at senior high rise,
[**Doctor Last Name **] Towers.
Family History:
Unknown.
Physical Exam:
Vitals: T: 98.0 P: 70 BP: 154/61 R: SaO2:99% on RA
General: Obese talkative elderly female in no acute distress
HEENT: PERRL, cataracts, non elevated JVP. OP clear.
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted. Obese
Extremities: 2+ edema to knee. Warm, erythematous distally.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
though tangential in thought
-cranial nerves: II-XII intact
-motor: Normal grasp, Normal strength and tone bilaterally.
-sensory: reports altered sensation on right aspect of face
V2,V3 and R UE, RLE diffusely.
2+ DP and PT pulses.
Pertinent Results:
Admission Labs:
137 106 76
-----------<204
5.3 19 2.4
estGFR: 19/23 (click for details)
Ca: 8.8 Mg: 2.1 P: 4.6
.
10.4
6.7>--<207
31.4
.
PT: 12.7 PTT: 30.1 INR: 1.1
.
EKG: NSR, nl axis and intervals, Qs in II, III, AVF (not present
on [**5-12**] ECG, which was done prior to in-stent restenosis and
revascularization)
.
Radiologic Data:
[**2179-1-19**] Carotid U/S:
Grossly abnormal study: On the left side there is soft
heterogeneous plaque which is irregular. It is present in the
carotid bulb and extends into the proximal left internal carotid
artery. Spectrum analysis shows markely accelerated flow
velocities and spectral broadening consistent with an 80-99%
stenosis of the left internal carotid artery. Would strongly
recommend patient undergo CT angiography or MRA.
.
On the right side there is heterogeneous calcific plaque in the
bulb which involves the right internal carotid artery. Spectrum
analysis is wnl, not suggesting any evidence of hemodynamically
significant stenosis present in the right internal carotid
artery. There is antegrade flow present in both vertebral
arteries.
.
Conclusion: Grossly abnormal study
1) Evidence of critical 80-99% stenosis of the left internal
carotid artery. Would strongly recommend further imaging studies
as described above.
2) No evidence of hemodynamically significant stenosis present
in the right internal carotid artery.
3) Antegrade flow present in the vertebral artery bilaterally.
.
Thoracic aorta and carotid angiography [**2179-2-8**]: stent to [**Doctor First Name 3098**].
Brief Hospital Course:
Assessment and Plan:
Ms. [**Known lastname **] is a 82 year old female with severe carotid stenosis
and hx of recent TIA, suggesting [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**] lesion, who had a stent
placed in the [**Doctor First Name 3098**] with uncontrolled hypertension.
.
1) Carotid stenosis: She was admitted for pre cath hydration.
One episode of syncope 4 yrs prior to admission. Pt denies
symptoms of orthopnea, chest pain, shortness of breath, syncope
and no amaurosis fugax. She was prehydrated with bicarb and
given periprocedural n-acetylcysteine for renal protection. She
had uncomplicated placement of [**Doctor First Name 3098**] stent with residual 10%
normal flow. She was continued on aspirin and plavix post
procedure. She was notably hypertensive pre and post procedure
requiring nitroprusside gtt with goal SBP 100-150 for adequate
cerebral perfussion. Her antihypertensive regimen was increased
to hydralazine 100mg po q8, imdur 90mg po qd, lisinopril 20mg po
qd, and metoprolol 100mg po bid.
.
2) HCT drop: Following the procedure her hct decreased from
32.1-->25.8-->now 26.2. She had reported a headache/neck pain
immeadiately following the procedure but those resolved and the
decrease hct was thought to be dilutional. She had no
hypotension or tachycardia.
.
3) DM: She was maintained with ISS and had fingersticks QID.
.
4) CKD- Creatinine remained stable. Likely due to diabetic
nephropathy. She received hydration with bicarb and mucomyst for
renal protection.
.
5) Prophylaxis: PPI, sc heparin, bowel regimen
.
6) Code Status: Full
Medications on Admission:
Allergies: Ativan
.
Home Medications (Per Life-Care Center of [**Location 15289**] (meds
given [**2-7**]):
Hydralazine 50mg PO tid
Plavix 75mg PO qD
Lisinopril 10mg PO qD
Protonix 40mg PO qD
Folic acid 1mg PO qD
Imdur 60mg PO qD
Lasix 60mg PO qD
Plaquenil 200mg PO bid
Metoprolol 100mg PO bid
Glyburide 5mg PO bid
Colace 100mg PO bid
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
7. Plaquenil 200 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
Disp:*30 Tablet(s)* Refills:*2*
9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
11. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO qam.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Primary diagnosis:
- Carotid stenosis
Secondary diagnosis:
- Coronary artery disease
- Hypertension
- Chronic renal insufficiency
- Diabetes mellitus
- Psoriasis
- Chronic obstructive pulmonary disease
- Chongestive heart failure
Discharge Condition:
Good, respiratory status stable
Discharge Instructions:
Please take all your medications as prescribed.
.
If you develop dizziness, visual changes, leg or arm or facial
weakness or numbness, chest pain, or shortness of breath, seek
medical attention immediately.
Followup Instructions:
Follow-up appointment with Dr. [**Last Name (STitle) 17025**] on [**2-18**] at
11am. Phone number [**Telephone/Fax (1) 3183**]. Office address [**Street Address(2) 42096**]; [**Location 15289**], MA
.
Follow up with Dr. [**First Name (STitle) **], phone ([**Telephone/Fax (1) 7236**]
|
[
"696.1",
"403.91",
"585.6",
"250.40",
"428.0",
"414.01",
"583.81",
"433.10",
"496",
"682.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.61",
"38.91",
"00.40",
"00.63",
"88.41",
"00.45"
] |
icd9pcs
|
[
[
[]
]
] |
8051, 8118
|
4984, 6575
|
365, 519
|
8392, 8426
|
3409, 3409
|
8682, 8971
|
2675, 2685
|
6960, 8028
|
8139, 8139
|
6601, 6937
|
8450, 8658
|
3202, 3390
|
2700, 3097
|
227, 327
|
547, 1745
|
8198, 8371
|
3425, 4961
|
8158, 8177
|
3112, 3185
|
1767, 2546
|
2562, 2659
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,110
| 169,711
|
36482
|
Discharge summary
|
report
|
Admission Date: [**2124-6-9**] Discharge Date: [**2124-6-19**]
Date of Birth: [**2063-8-24**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Wellbutrin
Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
GU abscess.
Major Surgical or Invasive Procedure:
CT-guided drainage of perinephric and prostatic fluid
collections.
Operative drainage of prostatic abscess
Foley placement
History of Present Illness:
Mr. [**Known lastname 82640**] is a 60 yo man with history of renal stones, ESRD on
HD, anxiety, and hypertension admitted from the ED with
abdominal pain.
The pt reports an intermittent history of renal stones,
stretching back as long as twenty years ago. Two months ago he
underwent external lithotripsy for a left kidney stone. He
reports tolerating this procedure well, but his stone-related
symptomes persisted. Two weeks ago he underwent left
ureteroscopy with laser lithotripsy and uretal stent placement.
On [**2124-6-6**], the pt was scheduled to undergo stent removal in the
office his urologist (Dr. [**Last Name (STitle) 3694**] at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital.
The stent could not be successfully retrieved, thus the pt was
scheduled to go to the OR at a later date. Over the last two
days, the pt began to notice increasing fatigue and malaise. On
the day of admission, he had N/V, chills, suprapubic pain,
dysuria and urinary frequency. He presented to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Hospital for evaluation, where his initial temperature was
100.6. There, a CT scan was suspicious for pylonephritis,
prostatitis, left renal absess and possible prostate abscess.
He was treated there with vancomycin, gentamycine and
levofloxacin, then transferred to the [**Hospital1 18**] for further urologic
care. In our ED, repeat CT scan preliminarily confirms the
presence of left renal abscess and possible prostate abscess, as
well as bilateral renal calculi and left ureteral calculus.
Urology recommended speaking with IR, who has agreed to attempt
drainage of the renal abscess.
Initial vitals in the ED were HR 103 / 108/63 / RR 18 / 98% on
RA. The pt was given Dilaudid for pain control and admitted to
the [**Hospital Unit Name 153**] for further care. Upon arrival to the unit, the pt
endorses some ongoing GU discomfort but otherwise feels mildly
improved.
ROS: As above. No difficultly swallowing but decreased appetite.
No chest, jaw or arm pain. No palpitations. No cough, SOB or
wheeze. Mild constipation. No focal weakness.
Past Medical History:
ESRD on HD MWF (follows with Dr. [**Last Name (STitle) 49187**] in [**Location (un) 5028**])
HTN
Renal stones
Past EtOH abuse
S/p appendectomy
Jaw surgery
Left wrist surgery
Social History:
Home: lives with wife and two children
Occupation: former machinist, currently disabled
EtOH: none current, formerly heavy use
Drugs: endorses marijuana use
Tobacco: quite in [**2-18**], previously 1 ppd x 45 years
Family History:
Mother had multiple CVAs and died at 69. Father died of lung Ca
at 65. One brother with esophageal Ca at 62. Another brother
with mental illness.
Physical Exam:
Gen: Well appearing adult male, moderate discomfort.
HEENT: PERRL, EOMI. MMM. Conjunctiva well pigmented.
Neck: Supple, without adenopathy or JVD. No tenderness with
palpation.
Chest: CTAB anterior and posterior. Right subclavian HD catheter
in place without focal evidence of infection.
Cor: Normal S1, S2. RRR. No murmurs appreciated.
Abdomen: Positive voluntary guarding with rebound tenderness.
Non-distended. +BS, no HSM.
GU: Positive CVA tenderness, mostly on left. Per urology exam,
"exquisitely tender and boggy" prostate.
Extremity: Warm, without edema. 2+ DP pulses bilat.
Neuro: Alert and oriented. CN 2-12 intact. Motor strength intact
in all extremities. Sensation intact grossly.
Pertinent Results:
Labs at Admission:
[**2124-6-9**] 03:25AM BLOOD WBC-25.8* RBC-4.03* Hgb-12.4* Hct-36.1*
MCV-90 MCH-30.8 MCHC-34.4 RDW-15.9* Plt Ct-160
[**2124-6-9**] 03:25AM BLOOD Neuts-57 Bands-28* Lymphs-2* Monos-5
Eos-0 Baso-0 Atyps-0 Metas-6* Myelos-2*
[**2124-6-9**] 03:25AM BLOOD PT-16.5* PTT-29.4 INR(PT)-1.5*
[**2124-6-9**] 03:25AM BLOOD Glucose-105 UreaN-43* Creat-7.0* Na-135
K-4.8 Cl-94* HCO3-25 AnGap-21*
[**2124-6-9**] 03:25AM BLOOD Albumin-3.9 Calcium-8.8 Phos-5.7* Mg-1.5*
[**2124-6-9**] 03:25AM BLOOD ALT-11 AST-12 AlkPhos-67 TotBili-0.3
[**2124-6-9**] 03:28AM BLOOD Lactate-3.3*
.
Imaging Studies:
CT abdomen and pelvis ([**6-9**]):
1. Left perinephric fat stranding, striated nephrogram and a
focal fluid collection in the perinephric space concerning for
abscess and pyelonephritis as described above.
2. Prostatic hypodensities also concerning for abscesses as
described above. Extensive perivesicular, periprostatic, and
perirectal fat stranding.
3. Bilateral renal calculi and left ureteral calculus. Left
ureteral stent in place. No evidence of hydronephrosis.
4. Vascular calcifications.
5. Gallbladder adenomyomatosis.
.
CT interventional procedure ([**6-9**]):
1. 4 cc of hemorrhagic fluid aspirated from left perinephric
collection.
2. 5 cc of turbid reddish pus aspirated from prostate.
3. No immediate complications.
.
CXR ([**6-10**]):
1) Probable subsegmental atelectasis or scarring at the left
base. Consider followup imaging to exclude progression to
infiltrate, if clinically indicated.
2) No CHF.
3) Right IJ line tip, as described. No ptx.
.
MICROBIOLOGY:
Blood culture [**2124-6-9**]:
[**2124-6-9**] 3:30 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 4 S
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 8 I
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ =>16 R
Aerobic Bottle Gram Stain (Final [**2124-6-10**]):
GRAM NEGATIVE ROD(S).
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 5/2/09/ 1115AM #[**Numeric Identifier 11727**].
.
[**2124-6-9**] 3:30 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 4 S
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 8 I
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ =>16 R
Aerobic Bottle Gram Stain (Final [**2124-6-10**]):
GRAM NEGATIVE ROD(S).
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 5/2/09/ 1115AM #[**Numeric Identifier 11727**].
Brief Hospital Course:
The patient is a 60 year old man with history of ESRD on HD,
nephrolithiasis, hypertension who initally presented on [**6-9**] with
left peri-nephric abscess, prostatic abscess and pseudomonas
bacteremia.
.
# Pseudomonas bactremia/Pylonephritis/Prostatitis/perinephric
and prostatic abscesses: Patient was in his usual state of
health until approximately 2 months ago when he underwent
lithotripsy for left kidney stone. However, he had continued
symptoms following this procedure, so ultimately underwent
ureteroscopy with stent placement approximately 2 weeks prior to
admission. 2 days prior to admission, he developed left sided
flank pain, malaise, fatiuge, fevers.
He presented to [**Hospital3 26615**] hospital with these symptoms on
[**3-28**], where CT scan was performed and was suspicious for
pylonephritis, prostatitis, left renal absess and possible
prostate abscess. He was therefore transferred to [**Hospital1 18**] for
urologic evaluation.
He was initially admitted to the ICU for peri-sepsis. His work
up and evaluation demonstrated definite left peri-nephric
abscess, pseudomonas bacteremia, and possible prostatic abscess.
He was started on appropriate antibiotics, and urology and ID
were consulted. He also underwent IR drainage of the left
peri-nephric abscess with removal of pus (on [**6-9**] - pus grew
pseudomonas). The possible prostatic abscess was attempted to
be drained at IR as well, but only clear-ish fluid was removed
(?urine from bladder). There was thought that perhaps there was
no abscess and more edema/prostatitis.
He subsequently stabilized in [**Hospital Unit Name 153**] and was called out to the
regular medical floor where he was maintained on antibiotics,
with urology and ID following. On floor, he continued to have
severe rectal pain. Ultrasound was attempted to evaluate for
?persistent prostatic abscess but was not tolerated due to pain
- therefore patient underwent MRI that demonstrated clear
prostatic abscess. He was therefore taken to the OR on [**2124-6-16**]
by urology with unroofing of the abscess with removal of pus.
The procedure was tolerated well, and he was re-admitted to the
[**Hospital Unit Name 153**] prophylactically following the procedure.
He was then called out to the regular medical floor where he
remained stable and was then discharged home.
He was discharged to complete a 6 week course of ceftazadime to
be dosed at dialysis. He has a foley catheter in placed, and
was discharged on Tamsulosin and Finasteride with follow up
scheduled with both urology and infectious disease. His LFTs
and CBC will need to be monitered on a weekly basis.
.
# End-stage renal disease on hemodialysis: He is on a MWF
schedule. Renal was following during this admission. He has a
right tunneled HD line which initially renal wanted to
remove/change given pseudomonas bacteremia, but ID felt the line
could stay in. Of note, the pt had an AV fistula, but this
fistula has been damaged by use of a blood pressure cuff over it
while maturing, so his only access is his catheter at this time.
He was discharged to continue outpatient dialysis.
.
# Hypertension: We held his antihypertensives at admission due
to tenuous clinical status. When blood pressure allowed, his
lisinopril, clonidine, and amlodipine were restarted.
.
# Anemia: There was no baseline for comparison. Likely this is
multifactorial from acute marrow suppression and end-stage renal
disease. An active type and screen was maintained but there was
no need for transfusion. Iron studies showed Fe 15. Reticulocyte
count low at 1.5. Patient is receiving EPO with HD.
.
# Urinary retention: As above, foley catheter was placed and he
was started on tamsulosin and finasteride, with urology follow
up on discharge.
Medications on Admission:
Lisinopril 20mg daily
Amlodipine 10mg daily
Clonidine 0.1mg twice daily
Nephrocaps once daily
Renagel 2400mg three times daily
Folate 1mg daily
Bactrim DS twice daily - started [**2124-6-8**], planned for 14 day
course
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime): This medication
may may you dizzy. It is best to take this medicine at night and
stand-up slowly so as to prevent falls.
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Sevelamer HCl 400 mg Tablet Sig: Six (6) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain: This is tylenol.
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Ceftazidime 2 gram Recon Soln Sig: Two (2) gram Injection QHD
(each hemodialysis) for 38 days.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): This is an over the counter stool softener.
10. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as
needed for constipation: This is an over the counter stool
softener.
11. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
Disp:*100 ML(s)* Refills:*0*
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation: This can be purchased over the counter for
constipation. Can use oral or suppository.
13. Finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Outpatient Lab Work
PLEASE BRING THIS SLIP TO DIALYSIS
Please check weekly liver function tests (AST, ALT, total bili,
LDH) and weekly CBC and fax to Dr. [**Last Name (STitle) 976**] at [**Telephone/Fax (1) 432**]
16. Ceftazidime 2 gram Recon Soln Sig: Two (2) grams Injection
QHD (each hemodialysis): through [**7-22**].
Discharge Disposition:
Home
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnoses:
Prostatitis and prostatic abscess
Pseudomonas bacteremia
Pyelonephritis
Kidney stones
Urinary retention
Secondary Diagnoses
End-stage renal disease on hemodialysis
Hypertension
Discharge Condition:
Vital signs stable. Pain adequately-controlled.
Discharge Instructions:
You were admitted to the hospital for evaluation of fluid
collections around the kidney and prostate gland. Under
CT-guidance, these fluid collections were drained and they were
found to grow out bacteria. The same bacteria were also isolated
from samples of the urine and blood. We have treated the
infection with antibiotics. Urology and infectious disease has
recommended for continuation of the antibiotics for 6 weeks.
.
You will need to follow up with Dr. [**First Name (STitle) **] of urology in 2 weeks
to have your stent removed and your foley removed. You also will
need to follow up with Dr. [**Last Name (STitle) 976**] of infectious disease as
scheduled. Please see below for details.
.
Please note the following changes to your medicines:
-tamsulosin and finasteride were started to help with prostate
enlargement
-senna, colace, and bisacodyl as needed to treat constipation
(these are over the counter)
-lactulose as needed for constipation (you were given a
prescription for this)
.
Please call your doctor or return to the emergency room if you
have:
-fever
-worsening abdominal or pelvic pain
-any other symptoms that are concerning to you
Followup Instructions:
1. Urology: Please follow up with Dr. [**First Name (STitle) **] on [**6-27**] at 8:45
AM, [**Hospital Ward Name 23**] Building [**Location (un) 470**], Surgical Specialties, [**Hospital Ward Name 5074**] [**Hospital1 18**]. They will take your foley and ureteral stent out
at this appointment.
.
2. Infectious Disease: Dr. [**Last Name (STitle) 976**] on [**2124-7-4**] at 11:00 AM
Phone:[**Telephone/Fax (1) 457**]; [**Last Name (NamePattern1) 439**], [**Hospital Unit Name **], Ground
floor, [**Hospital Ward Name 517**], [**Hospital1 69**]
3. Please follow up with your nephrologist Dr. [**Last Name (STitle) 49187**] at
dialysis. You will need to have weekly labs done at dialysis,
and a prescription is written for these labs - please bring this
prescription with you to dialysis.
.
4. Please follow up with Dr. [**Last Name (STitle) 82641**] in the next 1 week.
|
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82,950
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48521
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Discharge summary
|
report
|
Admission Date: [**2123-9-8**] Discharge Date: [**2123-9-22**]
Date of Birth: [**2083-3-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14689**]
Chief Complaint:
Hypotension, purulent feeding tube drainage
Major Surgical or Invasive Procedure:
RIJ Central Line
History of Present Illness:
Mr. [**Known lastname **] is a 40 year-old male with hx of metastatic gastric
cancer s/p multiple abdominal surgeries s/p intrabdominal
chemo/XRT who presented to the ED yesterday after his G-tube
fell out and was admitted to the [**Hospital Unit Name 153**] due to sepsis.
.
Per her wife, he was fine until yesterday when she noticed pus
around the G-tube. She cleaned it and the button came out
(however the tube was in). He was eating soup and liquids and
food was coming out around the tube. He took a nap, then woke up
and the it was out on the floor with pus coming from the site.
Per OMR records the patient had a fever to 101.4 the day prior
to admission.
.
He had a recent admission from [**Date range (1) 45889**]/10 for ARF,
hyperkalemia, and small bowel versus gastric outlet obstruction.
During this admission a PEG tube was placed for decompression of
his stomach and a Port-A-Cath was placed for initiation of TPN.
He was also started on epirubicin, cisplatin, and fluorouracil
on [**2123-8-10**]. He was discharged on [**2123-8-16**] on continuous
fluorouracil. He then returned to the hospital from [**Date range (1) 102117**]/10
due to abdominal pain and nausea during which his chemo was
stopped. During this admission, he was made DNR/DNI and was
discharged home with hospice care.
.
His wife brought him to the [**Name (NI) **] where initial VS: T 100, BP
114/74, HR 140, RR18, 97%. He subsequently dropped his blood
pressure to 70/64 with MAPs in the 40's. Labs were notable for a
WBC of 24 and a mild transaminitis. On exam he was reported to
have a tender abdomen and pus was noted to come from the G-tube
site. A right IJ was placed and he received 8 L of NS and was
started on levophed. He also was given 2 gm cefepime IV, 1 gm
vanc IV, and 1 mg ativan IV. He denied pain on presentation and
was on his home dilaudid PCA pump. Code status was addressed and
reportedly he was made full code again.
.
Currently he only groans to most questions and requests to be
left alone so he can sleep. He denied pain.
.
Review of systems: Unable to obtain.
Past Medical History:
Past Oncologic History:
Gastric cancer, metastatic
Other Past Medical History:
H/o CRE BSI
Chronic pain
Past Surgical History:
s/p Subtotal gastrectomy/Billroth II anastomosis
s/p Omentectomy
s/p Radical LN dissection L gastric region [**9-/2120**]
s/p percutaneous cholecystostomy tube [**11/2122**]
s/p CCY
s/p Roux-en-Y hepaticojejunostomy to right posterior hepatic
duct and
confluence of right anterior and left hepatic ducts over two
5-French feeding tubes ([**2123-2-26**])
s/p Ex-lap/repair colon enterotomy/peritoneal bx on [**5-/2123**] for
Roux limb obstruction
Social History:
Lives in [**Location 669**] with his wife. [**Name (NI) **] a son from a prior marriage.
Unemployed chef. Tobacco: denies. EtOH: denies. Illicits:
denies
Family History:
Maternal grandmother with "stomach cancer"
Father with diabetes
Physical Exam:
Vitals: T: 98.6 BP: 115/58 P: 141 R: 21 O2: 92 % on 2 L NC.
General: Middle-aged male lying in bed. Will mostly groan to
questions or examination and will not answer specific questions
other then his son's name. Does not consistently follow commands
and asks to be left alone to sleep.
HEENT: Would not open his eyes or mouth.
Neck: right IJ present
Lungs: Breathing comfortably, clear anteriorly.
CV: regular and tachycardic. No MRG.
Abdomen: G-tube in place in the LUQ with slight white discharge
around it. Two drains present in his RUQ draining dark brown
material. Abdomen is firm and appears tender to palpation. No
rebound detected when the bed is shaken.
Ext: warm, no clubbing, cyanosis or edema
Pertinent Results:
Admission Labs:
[**2123-9-7**] 10:30PM PT-15.6* PTT-32.9 INR(PT)-1.4*
[**2123-9-7**] 10:30PM PLT COUNT-662*
[**2123-9-7**] 10:30PM NEUTS-84.5* LYMPHS-9.5* MONOS-5.0 EOS-0.5
BASOS-0.5
[**2123-9-7**] 10:30PM WBC-24.0*# RBC-2.89* HGB-7.6* HCT-24.5*
MCV-85 MCH-26.4* MCHC-31.2 RDW-17.6*
[**2123-9-7**] 10:30PM ALBUMIN-2.8* CALCIUM-8.8 PHOSPHATE-3.7
MAGNESIUM-1.9
[**2123-9-7**] 10:30PM LIPASE-7
[**2123-9-7**] 10:30PM ALT(SGPT)-46* AST(SGOT)-54* ALK PHOS-367*
AMYLASE-10 TOT BILI-2.5*
[**2123-9-7**] 10:30PM estGFR-Using this
[**2123-9-7**] 10:30PM GLUCOSE-88 UREA N-17 CREAT-0.5 SODIUM-140
POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-30 ANION GAP-12
[**2123-9-7**] 10:35PM LACTATE-0.8
[**2123-9-7**] 10:35PM COMMENTS-GREEN
[**2123-9-8**] 12:35AM URINE GRANULAR-0-2
[**2123-9-8**] 12:35AM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-0-2
.
Other Labs:
[**2123-9-7**] 10:30PM BLOOD ALT-46* AST-54* AlkPhos-367* Amylase-10
TotBili-2.5*
[**2123-9-8**] 07:23AM BLOOD ALT-38 AST-42* LD(LDH)-179 AlkPhos-314*
TotBili-2.4*
[**2123-9-9**] 03:31AM BLOOD ALT-32 AST-36 AlkPhos-277* TotBili-2.0*
[**2123-9-15**] 06:00AM BLOOD Albumin-2.3*
[**2123-9-14**] 06:00AM BLOOD Triglyc-76
.
Discharge Labs:
[**2123-9-21**] 06:01AM BLOOD WBC-13.9* RBC-2.58* Hgb-7.4* Hct-23.2*
MCV-90 MCH-28.6 MCHC-31.8 RDW-19.7* Plt Ct-407
[**2123-9-21**] 06:01AM BLOOD Neuts-84* Bands-0 Lymphs-3* Monos-11
Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2123-9-21**] 06:01AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-OCCASIONAL
Macrocy-OCCASIONAL Microcy-1+ Polychr-1+ Target-2+ Stipple-1+
Pappenh-OCCASIONAL Envelop-1+
[**2123-9-21**] 06:01AM BLOOD PT-16.6* PTT-33.5 INR(PT)-1.5*
[**2123-9-21**] 06:01AM BLOOD Glucose-112* UreaN-15 Creat-0.5 Na-133
K-4.1 Cl-100 HCO3-28 AnGap-9
[**2123-9-21**] 06:01AM BLOOD Calcium-8.2* Phos-3.9 Mg-1.9
.
Microbiology
[**2123-9-7**] Blood cultures: negative
[**2123-9-8**] Biliary drain site swab: Mixed bacterial types (>=3),
abbreviated workup is performed; P.aeruginosa, S.aureus and beta
strep.
[**2123-9-8**] Bile culture: 1+ polys, 4+ GPCs in pairs and chains, 4+
GNRs, 4+ GPRs on gram stain, mixed bacterial flora in culture
[**2123-9-8**] Bile culture: 4+ GNRs on gram stain, mixed bacterial
flora in culture
[**2123-9-9**] Urine Culture: negative
[**2123-9-9**] Blood culture: Lactobacillus
[**2123-9-13**] Blood cultures: negative
[**2123-9-14**] Blood cultures: negative
[**2123-9-19**] Blood cultures: pending, no growth to date at time of
discharge
[**2123-9-19**] Urine Culture: negative
.
Imaging:
[**2123-9-7**] CXR: 1. Left basilar atelectasis and effusion.
Infection cannot be excluded. 2. Stable positioning to
Port-A-Cath catheter. Biliary drains in place.
.
[**2123-9-8**]: CT ABDOMEN/PELVIS:
1. New rim enhancing intra-abdominopelvic fluid collection,
likely infected.
2. Enhancing dilated biliary ducts around anterior
internal-external biliary drain, concerning for cholangitis.
3. Segment VIII lesion, which may be an abscess or metastasis.
4. Fluid-filled distended duodenum, which may be partially
obstructed.
Edematous loops of bowel in the mid abdomen. Complex
post-surgical anatomy,
full evaluation limited by lack of oral contrast.
5. Foley in the stomach which is markedly thickened suggesting
possible
gastric cancer growth.
6. Bilateral effusions and atelectasis much greater on the left.
Infection
of the lung bases cannot be excluded.
.
[**2123-9-20**] CXR: There is a right IJ line with tip in the SVC.
Right hemidiaphragm is mildly elevated. Drainage catheter is
seen overlying the right abdomen. There is a small left pleural
effusion that is increased compared to prior.
Brief Hospital Course:
40 year-old male with hx of metastatic gastric cancer, s/p
multiple abdominal surgeries, and s/p intra-abdominal chemo/XRT
who presented to the ED after his G-tube fell out and was
admitted with sepsis, likely from intra-abdominal source.
.
# Hypotension/Sepsis: The patient presented to the ED with frank
pus extravastating from his G-tube site and hypotension. CT
abd/pelvis revealed an intra-abdominal rim-enhancing fluid
collection. Based upon abdominal imaging and clinical picture,
he was diagnosed with sepsis. Early goal therapy was initiated.
He was covered with broad spectrum antibiotics (vanc, cefepime,
flagyl) in addition to anti-fungal therapy with micafungin since
he had been receiving TPN. He required pressure support with
leveophed, which was eventually weaned. CT body and IR were
consulted for potential drain(s) replacement, and a new G-tube.
He would have required multiple procedures and general
anesthesia. After a goals of care discussion with his wife, he
was made DNR/DNI with treatment goals for symptom and sepsis
management. He was transferred to the floor in stable condition.
Blood culture from [**2123-9-9**] was positive for lactobacillus.
Surveillance blood cultures drawn after that time were negative.
The patient was closely followed by the Infectious Disease
consult team, and antibiotic/antifungal coverage was gradually
narrowed. He remained hemodynamically stable, but did have
several spikes in temperature to as high as 101.5 while on the
floor. The most likely source for his fever was felt to be
persistent intra-abdominal infection, with limited antibiotic
penetrance into abdominal fluid collection. The patient again
declined any surgical or IR-guided drainage of the fluid
collection, as his goal was to be discharged home with hospice
care. He was discharged home on ceftriaxone, and per ID he will
need to be on this antibiotic indefinitely. He was afebrile at
the time of discharge, hemodynamically stable, and feeling well.
He was instructed to take acetaminophen as needed for
pain/fever, but advised not to take more than 4g of
acetaminophen per day.
.
#. Metastatic gastric cancer: The patient had been on hospice
previously, however per oncology and surgery providers who know
him, consistency in goals of care has been difficult. At time of
discharge, the patient was again to receive hospice care at
home. He is not currently receiving chemotherapy. He will
continue to use a dilaudid PCA for pain control, and will
receive IVFs through his portacath. He will no longer receive
TPN at home, but is able to tolerate a clear liquid diet. He
will continue to take prochlorperazine as needed for nausea.
.
# Anemia: Patient's baseline HCT prior to admission was in mid
20's. There was no evidence of acute bleeding during his
hospital course. He was transfused one unit PRBCs while in the
ICU. His HCT remained stable, around 22-23, while he was on the
medical oncology floor. He had some episodes of tachycardia,
but otherwise remained hemodynamically stable.
Medications on Admission:
Home medications: (per OMR)
-Dilaudid PCA through intravenous route.
-TPN: 2000ml/day, Amino Acid: 100g/day, Dextrose 350g/day, fat
40g/day NaCl: 110, NaAc: 0, NaPO4: 45, KCl: 75, KAc: 0, KPO4: 0,
MgSO4: 17, CaGluc: 10
-Ursodiol 300 mg po bid
-Docusate Sodium 100 mg po bid
-Senna 8.6 mg 2 tabs po daily prn constipation
-Ferrous Sulfate 300 mg po daily
-Zofran 4 mg 1-2 Tablets PO q8hrs prn nausea
-Prochlorperazine Maleate 10 mg PO q6hrs prn nausea
-Imodium A-D 2 mg PO q4hrs prn diarrhea
-Ativan 0.5 mg 1-2 tabs PO q4hrs prn nausea/anxiety
-Morphine Concentrate 5 mg PO q4hrs prn pain/SOB
Discharge Medications:
1. Hydromorphone 10 mg/mL Solution Sig: Four (4) mg/hr Injection
ASDIR (AS DIRECTED): HYDROmorphone (Dilaudid) 2 mg IVPCA ASDIR
Lockout Interval: 10 minutes Basal Rate: 4 mg(s)/hour 1-hr Max
Limit: 16 mg(s)
This can be uptitrated as needed by hospice nurse.
[**Last Name (Titles) **]:*4 cassettes* Refills:*2*
2. Ceftriaxone 1 gram Recon Soln Sig: One (1) gram Intravenous
once a day.
[**Last Name (Titles) **]:*30 doses* Refills:*2*
3. Prochlorperazine Edisylate 5 mg/mL Solution Sig: Ten (10) mg
Injection Q6H (every 6 hours) as needed for nausea.
[**Last Name (Titles) **]:*30 doses* Refills:*0*
4. IVFs
d5 1/2 NS at 75 cc/hour, to be adjusted by hospice nurses based
in symptoms and I/Os
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 3005**] Hospice and Palliative Care
Discharge Diagnosis:
Metastatic Gastric Cancer
Sepsis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with an infection in your
blood, which was caused by an infected fluid collection in your
abdomen. You were treated in with IV fluids, medications to help
your blood pressure, and antibiotics. You were initially treated
in the ICU, then transferred to the general oncology floor when
your blood pressures were stable. You were see by the Infectious
Disease team, who made recommendations about what antibiotics
you should continue taking. After you leave the hospital, you
will only need to continue taking ceftriaxone. If you continue
to have fevers, you may take Tylenol for your symptoms. It is
important that you do not take more than 4 grams of tylenol per
day.
.
You received nutrition through your portacath line while you
were here. At home you will continue to receive IV fluids though
your port to keep you hydrated. You may continue to eat/drink
clear liquids and foods such as broth and jello.
.
Your pain was well-controlled with a dilaudid PCA (the machine
that delivers the pain medication). You will be able to use this
machine to continue managing your pain at home. The hospice
nurses will be able to adjust your dosing if you develop more
pain.
.
You will be discharged to your home, with hospice services in
place. You will continue to receive one antibiotic
(ceftriaxone), IV fluids, and pain medication.
Followup Instructions:
You will have hospice care at home. You may follow-up with your
primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The clinic number is
[**Telephone/Fax (1) 14918**].
You should also follow-up with your oncologist, Dr. [**First Name (STitle) **]. The
clinic number is [**Telephone/Fax (1) 34802**].
[**Name6 (MD) **] [**Name8 (MD) 10341**] MD [**MD Number(2) 14690**]
|
[
"285.22",
"199.1",
"E878.3",
"151.9",
"536.49",
"197.6",
"197.7",
"785.52",
"518.0",
"996.69",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12203, 12281
|
7708, 10743
|
359, 377
|
12358, 12358
|
4069, 4069
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|
3262, 3328
|
11386, 12180
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12302, 12337
|
10769, 10769
|
12509, 13870
|
5274, 7685
|
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|
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|
276, 321
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405, 2438
|
4085, 4927
|
12373, 12485
|
2578, 2603
|
3089, 3246
|
4939, 5258
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,267
| 122,518
|
48381
|
Discharge summary
|
report
|
Admission Date: [**2192-11-2**] Discharge Date: [**2192-11-21**]
Date of Birth: [**2138-3-6**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 3283**]
Chief Complaint:
Fevers and SOB
Major Surgical or Invasive Procedure:
HD tunneled line removal
HD tunneled line placement
hemodialysis
TEE
Corpectomy anterior C4-C5
History of Present Illness:
Ms. [**Known lastname 37559**] is a 54F with multiple medical problems, most s/f
ESRD on HD, and severe PVD c/b multiple stump infections with
highly resistant organisms who presented to the ED with fevers
to 101 for the past two days at her nursing home. Today she was
noted to be hypoxic to 85% on room air. ROS is notable for
generalized weakness, shortness of breath, nausea, and diarrhea.
She denies headache, sinus congestion, sore throat, or cough.
.
Past Medical History:
- Peripheral Vascular Disease s/p L SFA-DP bypass for L
gangrenous heel in [**2187**]; s/p R proximal SF-proximal AT bypass in
[**4-4**]; s/p multiple debridements of b/l LE for
infected/non-healing wounds; s/p L BKA [**12-6**], L AKA for
non-healing BKA ulcer (prior MRSA, VRE and MDR Klebsiella) [**1-6**]
- Likely left AKA stump osteomyelitis requiring admission in
[**3-/2192**], on IV antibiotics, VAC dressing in place
- ESRD on HD. Last HD yesterday. Usually MWF schedule.
- HTN
- Diabetes Mellitus
- Renal Cell Carcinoma s/p right nephrectomy
- Obesity
- Depression
- s/p CCY
- Gastric Ulcer
- Obstructive Sleep Apnea. The patient reports that she used to
use a CPAP however her machine broke and she no longer uses it.
- Gastroparesis
- COPD on 3-4L NC baseline
- h/o ischemic colitis
- left adrenal adenoma
Social History:
Admitted from rehab. Has two sisters, one daughter. [**Name (NI) **] is
a former smoker with a 30 pack year history, quit 20 years ago.
Family History:
Mother died of stomach cancer in her 40s. Father had an unknown
cancer in his 70s. Stated that diabetes, high cholesterol, and
high blood pressure run in her family.
Physical Exam:
per admitting team:
VITAL SIGNS:
T=100.7... BP=111/51... HR=82... RR=22... O2=94% on 4L
GENERAL: Obese african american female in NAD, having trouble
finishing sentences from shortness of breath.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: Obese, soft, NABS
EXTREMITIES: Left AKA c/d/i, no skin breakdown. RLE cool, with
good pulses. No edema or calf pain at that site.
SKIN: Stage II pressure ulcer on posterior aspect of left thigh,
appears new.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Admitting labs:
Trop-T: 0.14
CK: 97 MB: Notdone
.
133 93 31
--------------< 203
4.6 34 4.2
ALT: 25 AP: 154 Tbili: 0.5 Alb:
AST: 28 LDH: 263 Dbili: TProt:
[**Doctor First Name **]: 57 Lip: 57
.
WBC: 5.8
HCT: 32
PLT: 97
N:81.1 L:10.3 M:7.6 E:0.5 Bas:0.5
.
Trends:
HCT stale 28-32
ALT and AST normal
.
Micro:
High Grade MRSA Bacteremia - last positive blood cx: [**11-13**]
Tissue from c-spine [**Doctor First Name **] grew MRSA
.
CT NECK:
IMPRESSION:
1. No focal signs of infection or abscess in the neck.
2. Probable small right pleural effusion.
CT Abdomen/Pelvis:
IMPRESSION:
1. No evidence of ischemia and no etiology for diffuse abdominal
pain.
2. Stable extensive vasculopathy.
3. Small right pleural effusion, perihepatic fluid, and
generalized anasarca without evidence of abscess.
TTE:
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality as the patient was difficult to
position. Suboptimal image quality - patient unable to
cooperate.
Conclusions
The left atrium is normal in size. 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. The right ventricular cavity is moderately dilated.
Free wall motion could not be assessed. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
[**11-9**] MRI C spine:
1. Confirming the suspicion of infectious phlegmon in the left
more than right ventral epidural space, extending over roughly 4
cm (CC), from the C3 through C6 level. Though there is no
specific evidence of liquefactive necrosis to suggest frank
abscess formation, such findings are unusual, in general, in the
cervical spine, and this study has poor contrast resolution.
2. Process is centered on the C3 through C5 vertebrae, which
demonstrate
abnormal signal and patchy heterogeneous enhancement after
contrast
administration, suggestive of vertebral osteomyelitis, with
probable component of discitis at the C4-5 level, at least.
There is also a prevertebral component to the phlegmon, as
demonstrated on the earlier study.
3. No cervical spinal cord signal abnormality at this time.
4 No other finding suspicious for osteomyelitis or epidural
abscess in the remainder of the cervical or thoracolumbar spine
(though the imaging is quite limited).
.
[**11-16**] C Spine CT:
Status post C4 and C5 vertebrectomy and anterior fusion with
normal alignment.
Brief Hospital Course:
54 year-old woman initially admitted w fever and found to have
persistent MRSA bacteremia. Hospital course by problem:
.
1. Cervical osteomyelitis, MRSA bacteremia: She underwent spine
imaging and TEE. Noted to have osteo of c-spine. Her HD line
was pulled and she underwent a line holiday. She was treated
with c4/5 corpectomy and c3-6 anterior fusion on [**11-15**] by spine
surgery. The tissue grew MRSA. Last positive blood cx was from
[**11-13**]. Patient will need the following:
- continue [**Location (un) **] J per spine team. She may remove for shower
only
- continue IV vanco dosing w dialysis. Continue rifampin [**Hospital1 **].
She will need 6 weeks of total therapy from [**11-15**] - [**12-27**]. She
will followup with the [**Hospital **] clinic. She will need surveillance
labs sent WEEKLY to the [**Hospital **] clinic attng Dr. [**First Name (STitle) **] via f
[**Telephone/Fax (1) **]
- f/u with neurosurgery, Dr. [**Last Name (STitle) 548**], within the next 4-6 weeks.
- Please remove staples on [**11-23**] per neurosurgery team.
- continue surveillance blood cultures intermittently during HD
- oxycodone, tylenol, tramadol prn, lidocaine patch for pain
control
.
2. End-stage renal disease on HD: Continue HD T,Th,Sat as
scheduled. She underwent line holiday with new HD line placed
in left IJ on [**11-19**]. She tolerated HD well with her new line
prior to discharge. F/u with renal team. Continue phos
binders.
.
3. Diabetes mellitus: continue outpt regimen of DM control
- metoclopramide for gastroparesis prn
.
4. Insomnia, depression
- continue bupropion, trazadone, mirtazapine,
.
5. Right eye pain - seen by ophthmo and dx w episcleritis during
hosp stay. Received motrin 800mg q8h scheduled. Had no eye
pain by discharge. We recommend using motrin prn then
discontinuing it as tolerated. She is at risk of GIB given her
renal disease so this should not be longterm med.
- she should f/u with Dr. [**First Name (STitle) **] in ophthmo in [**Last Name (un) **].
.
6. CAD, hypertension, hyperlipidemia
- continue metoprolol, statin; held ASA post-operatively
- restarted ASA 81mg on [**11-21**]. Ok per d/w neurosurgery
.
FEN. renal diet; sevelamer with meals when eating
Access. PIVx2, L subclavian CVL
- L subclavian CVL was removed on [**11-21**] prior to discharge to
rehab
Prophylaxis. HepSQ; bowel regimen
Code. Full
Medications on Admission:
-1500mL fluid restriction
-CINACALCET 60mg daily
-HEPARIN 5000 units TID
-ISS
-METOCLOPRAMIDE 5mg with meals
-METOPROLOL tartrate 12.5mg [**Hospital1 **]
-MIRTAZAPINE 15mg QHS
-NEPHROCAPS daily
-SEVELAMER HCL 800MG three tabs TID
-SIMVASTATIN 10mg daily
-TRAMADOL 50mg [**Hospital1 **]
-ASPIRIN 81 mg daily
-Trazodone 25mg qhs prn
-Folic acid 1mg daily
-buproprion 75mg dialy
-bowel regimen
Discharge Medications:
1. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
3. Insulin Lispro 100 unit/mL Solution Sig: variable units
Subcutaneous four times a day: routine insulin sliding scale.
4. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO four times
a day: w meals.
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. Sevelamer Carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
9. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID PRN () as
needed for pain.
11. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
12. Bupropion 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours): scheduled.
16. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for Episcleritis: continue prn x1 week then wean off.
17. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12h on,
12h off.
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. Rifampin 150 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours): continue until [**12-28**].
20. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for neck pain: wean off as tolerated.
21. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous HD PROTOCOL (HD Protochol): give with HD per
protocol. continue until [**12-28**].
22. home O2
continue home O2 as per previous
23. 1500ml fluid restriction
24. Outpatient Lab Work
Please obtain weekly LFTs, CBC, electrolytes and fax to [**Hospital **]
clinic attng Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 432**]
25. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] nursing facility
Discharge Diagnosis:
Primary:
Cervical Discitis and osteomyelitis
MRSA bacteremia
ESRD on HD
Secondary:
Anemia chronic inflammation
PVD s/p L AKA
obesity hypoventilation syndrome
PUD
Discharge Condition:
Stable, on 3L O2
Discharge Instructions:
You came in with fevers and were found to have a MRSA
bacteremia. The source was osteomyelitis of the cervical spine.
You underwent spine surgery to remove the infection and your
blood cultures cleared. You tolerated this procedure well.
It is very important that you stay on your antibiotics at least
until [**12-28**] or until told otherwise by your infectious
disease doctor. You will be treated with vancomycin (with
dialysis) and rifampin (orally).
Please keep all followup appointments. Please keep the neck
collar onn at ALL TIMES unless taking a shower. Please return
if you experience fevers, chills, weakness, inability to eat,
chest pain, or trouble breathing.
?????? Do not smoke.
?????? Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery. When washing
be gentle. Do not scrub, and pat dry.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting. Avoid vigorous pulling or tugging on your arms.
?????? Limit your use of stairs to 2-3 times per day.
?????? You are required to wear your cervical collar at all times,
except when showering
Your sutures should be removed from your neck on [**11-23**]. This
can be done by the rehab staff.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine.
?????? Any weakness, numbness, tingling in your extremities.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
?????? Fever greater than or equal to 101?????? F.
?????? Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
Please followup with Dr. [**Last Name (STitle) 548**] in 6weeks. Please call for an
appointment [**Telephone/Fax (1) 2992**]
Please followup with Dr. [**First Name (STitle) **] in the [**Hospital **] clinic. Call ([**Telephone/Fax (1) 10**] for an appointment.
Please have weekly LFTs, CBC, and electrolytes faxed to [**Hospital **]
clinic (attng Dr. [**First Name (STitle) **] via f: [**Telephone/Fax (1) **]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8145**], M.D. Date/Time:[**2193-1-3**] 10:10
|
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"041.12",
"250.00",
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icd9cm
|
[
[
[]
]
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[
"88.72",
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] |
icd9pcs
|
[
[
[]
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] |
11001, 11065
|
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|
286, 383
|
11271, 11290
|
2815, 5775
|
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11314, 13004
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2067, 2796
|
232, 248
|
5918, 8176
|
411, 871
|
893, 1714
|
1730, 1869
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,843
| 125,814
|
2814
|
Discharge summary
|
report
|
Admission Date: [**2156-12-27**] Discharge Date: [**2156-12-31**]
Service: MEDICINE
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 2234**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
upper endoscopy
colonoscopy
History of Present Illness:
[**Age over 90 **]yo gentleman with PMH of chronic LBP on celebrex, complete
heart block s/p [**Age over 90 4448**] [**2-3**], and DVT/PE [**12-4**] s/p IVC filter
and on coumadin presents with 2 days of dark, smelly bowel
movements. His wife reports that she noticed he was having
smelly bowel movements Saturday night. She reports that they
were black and very sticky. She cannot quantify how many per
day because she gave him Depends. He has never had a similar
incident in the past. +Fatigue. No BRBPR. He denies chest
pain, dyspnea, dizziness/lightheadedness, or abdominal pain. He
also denies fevers, chills, nausea, or vomiting.
Of note, Mr. [**Known lastname 1352**] had a small bowel enteroscopy in [**7-/2156**] for
duodenal thickening found on CT abdomen. The proximal jejunum
was reached, there was no luminal narrowing or lesion, biopsies
were negative. Colonoscopy in [**2151**] demonstrated diverticuli.
ED course: VS were 95.3 118/64 67 20 98% RA. Exam
positive for melenic stools; NG lavage was negative. He was
given 2 large bore IVs and received IV protonix. INR was noted
to be 1.8, and he was given 5mg po Vitamin K. SBP dropped from
the 130s to the 90s. Although no IV fluids were documented in
the ED notes, he may have received 1L of NS in the ED. GI
recommended monitoring in the ICU.
Past Medical History:
PCP [**First Name8 (NamePattern2) **] [**Name9 (PRE) **]
- GERD/hiatal hernia
- h/o pancreatitis (etiology unknown) and SBO in [**8-7**]
- Osteoarthritis
- Chronic LBP - likely sciatica
- Varicose veins s/p stripping in RLE
- Type IIb heart block, now s/p Dual chamber PM implantation
[**2155-1-29**]
- PE in [**12-4**] with placement of IVC filter.
- Parkinson disease diagnosed [**2156-7-29**]
All: Vancomycin--? reaction
Social History:
Married. Lives with wife. [**Name (NI) **] etoh. Quit smoking 40 years ago,
no illicit drug use. Pt is a retired jazz pianist.
Family History:
Non Contributory
Physical Exam:
VS 98.0 119/67 57 16 98% RA
GENERAL: Pleasant elderly gentleman in NAD.
HEENT: MMM, OP clear
NECK: Supple.
CARDIOVASCULAR: S1, S2, RRR. No MRG.
LUNGS: CTAB no RRW.
ABDOMEN: soft, non-tender, mildly distended with gas
EXTREMITIES: WWP. 1+ edema at ankles. Support hose in place on
LLE.
NEURO: Grossly intact, alert and oriented x 3.
Stool: Malodorous and sticky, tarry black with dark red tinge.
Pertinent Results:
[**2156-12-27**] 03:15PM BLOOD WBC-10.3 RBC-4.25* Hgb-12.8*# Hct-37.1*
MCV-87 MCH-30.2 MCHC-34.6# RDW-14.3 Plt Ct-183
[**2156-12-27**] 07:00PM BLOOD Hct-33.6*
[**2156-12-27**] 11:19PM BLOOD Hct-30.5*
[**2156-12-28**] 02:55AM BLOOD WBC-10.0 RBC-3.45* Hgb-10.2* Hct-30.5*
MCV-88 MCH-29.5 MCHC-33.4 RDW-14.1 Plt Ct-146*
[**2156-12-28**] 09:03AM BLOOD Hct-26.4*
[**2156-12-28**] 03:59PM BLOOD Hct-25.2*
[**2156-12-28**] 10:33PM BLOOD Hct-32.8*#
[**2156-12-29**] 04:55AM BLOOD WBC-8.7 RBC-3.53* Hgb-10.4* Hct-31.4*
MCV-89 MCH-29.4 MCHC-32.9 RDW-13.9 Plt Ct-140*
[**2156-12-29**] 11:20AM BLOOD Hct-33.6*
[**2156-12-27**] 03:15PM BLOOD PT-19.4* PTT-26.7 INR(PT)-1.8*
[**2156-12-29**] 04:55AM BLOOD PT-16.7* PTT-26.0 INR(PT)-1.5*
[**2156-12-27**] 03:15PM BLOOD Glucose-102 UreaN-45* Creat-1.5* Na-141
K-5.0 Cl-107 HCO3-24 AnGap-15
[**2156-12-28**] 02:55AM BLOOD Glucose-84 UreaN-42* Creat-1.2 Na-142
K-4.2 Cl-113* HCO3-21* AnGap-12
EKG:
V paced with left axis deviation, rate of 65. LBBB, which is
changed from RBBB pattern in [**7-7**]. EKG repeated on presentation
to the ICU, at which point he was A-paced with rate in 50s and
RBBB pattern. No ST/T changes.
EGD [**7-/2156**]:
Medium hiatal hernia
Erythema and congestion in the antrum compatible with mild
gastritis.
Normal mucosa in the first part of the duodenum, second part of
the duodenum, third part of the duodenum and fourth part of the
duodenum.
No luminal narrowing was noted upto proximal jejunum.
Otherwise normal EGD to second part of the duodenum.
Colonoscopy [**6-/2152**]:
Diverticulosis of the sigmoid colon
Otherwise normal Colonoscopy to cecum
Brief Hospital Course:
[**Age over 90 **] year old man with history of Parkinson's and Pulmonary
embolism admitted with melena and INR 1.8 on coumadin.
# MICU course: Hct decreased dropped to a nadir of 25 with
frequent episodes of melena. Given 2 units packed RBCs when Hct
< 30; incremented appropriately. He was placed on IV PPI drip
as well as vitamin K 5mg PO and 3 bags of FFP. His INR improved
to 1.5. Upper endoscopy showed gastritis but no obvious source
of bleed; tagged RBC scan was negative. His hematocrit
stabilized, and he was transferred to the floor while awaiting
colonoscopy. Creatinine improved in the setting of receiving
blood and IV fluids; Foley was kept in place to monitor I/O
closely.
Course on floor:
Colonoscopy with diverticulosis, no discrete bleeding source.
Crit stable.
Decision made to discontinue anti-coagulation indefinitely to be
re started at discretion of PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **]. Mental
status, creatinine at baseline on discharge.
Discharged to home with services.
.
# Comm: [**Name (NI) **] [**Name (NI) 1352**] [**Telephone/Fax (1) 13765**] (c); [**Telephone/Fax (1) 13766**] (w);
[**Telephone/Fax (1) 13767**] (h). Sister-in-law (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6930**])
[**Telephone/Fax (1) 13768**]. Son [**Doctor Last Name **] [**Telephone/Fax (1) 13769**].
Medications on Admission:
Warfarin 6 mg PO HS
HCTZ 25 mg
calcium 600 mg
nexium prn (none in past 2 weeks)
MVI
sinemet 25/250 QDay
ASA 81 mg QDay
celebrex--one tablet daily, taking during last couple of weeks
Advair 100/50 QAM
Spiriva QPM
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) inhalation Inhalation QAM (once a day (in the morning)).
3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation HS (at bedtime).
4. Carbidopa-Levodopa 25-250 mg Tablet Sig: One (1) Tablet PO
QAM (once a day (in the morning)).
5. Carbidopa-Levodopa 25-250 mg Tablet Sig: One (1) Tablet PO
NOON (At Noon).
6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
7. Calcium 500 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
1.Acute blood loss anemia
2. Gastrointestinal bleeding
3. Pulmonary embolism
Secondary:
1. Parkinson's disease
2. COPD
3. GERD
Discharge Condition:
Stable, at baseline, no further evidence of bleeding
Discharge Instructions:
FOllow up as below.
Contact your doctor or go to the emergency room if you noticed
blood in your stool, recurrence of black, tarry stools,
light-headedness, shortness of breath, chest pain, fevers,
abdominal pain or any other new concerning symptoms.
All medications as prescribed. The only medications I have
changed is discontinuing the coumadin and aspirin. Discuss with
Dr. [**Last Name (STitle) **] if and when to restart these medications. You should
take the nexium every day.
Followup Instructions:
Follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] within the next one to two weeks.
Please call [**Telephone/Fax (1) 13770**] to make an appointment.
You also have the following upcoming appointments:
Provider: [**Name10 (NameIs) 13771**] CHANT, AU.D. Phone:[**Telephone/Fax (1) 41**]
Date/Time:[**2157-1-4**] 1:15
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2157-1-14**]
1:00
Provider: [**Name10 (NameIs) **],TEACHING [**Hospital **] CLINIC-CC2 (SB)
Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2157-2-14**] 9:30
|
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"338.29",
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,163
| 105,250
|
37023
|
Discharge summary
|
report
|
Admission Date: [**2175-11-2**] Discharge Date: [**2175-11-6**]
Date of Birth: [**2131-4-16**] Sex: F
Service: MEDICINE
Allergies:
Calcitonin
Attending:[**First Name3 (LF) 4421**]
Chief Complaint:
Left femur fracture
Major Surgical or Invasive Procedure:
Fixation with intramedullary nail, Bone biopsy.
History of Present Illness:
44 F with history of squamous cell cancer of the thigh, and
metastatic to bone and lung, s/p local resection and
chemotherapy presents with spontaneous left femur fracture. The
patient was a direct transfer from [**Hospital3 22439**] to the
orthopedic service by Dr. [**Last Name (STitle) 1005**].
.
On arrival to [**Hospital1 18**] the patient was found to be clinically
unstable with a HR in the 115 range, RR of about 8, and
somnolence. She was having difficulty completing sentences
during interview. However, she did state that on [**2175-11-1**] she
experienced an atraumatic fracture of her femur, which was
corroborated by accompanying records.
.
Of significance, she is a Jehovah's Witness and refuses to
accept any human blood products. Her most recent hematocrit from
the OSH is 20.2. She has also had profoundly abnormal
electrolytes.
Past Medical History:
PAST ONCOLOGIC HISTORY:
======================
The patient's attending physician is [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], and much of
the following information has been obtained from his notes. She
has had a subepidermal cyst on the inner thigh for nearly 15
years. 9 years ago, it ruptured through the surface of the skin
and drained non-smelly material. In recent months, 2
mushroom-like masses eroded through the surface of the skin at
separate sites overlying the large subepidermal cyst. A 3rd site
began to drain foul-smelling material.
.
In addition to this large inner left thigh mass, a similar
smaller mass developed several years ago on the lateral aspect
of her left knee. While this mass has never eroded or drained
throught the skin, she feels that an aspect of this mass has
begun to thin the overlying skin, in a similar manner to how her
left inner thigh mass behaved before it spontaneously drained
through the skin.
.
On [**2175-6-5**], CT scan of the pelvis and thigh obtained at [**Hospital1 83480**] showed a cavitated thick-walled soft tissue
mass in the superficial soft tissues of the mid left thigh with
air fluid level and a superior focus that appeared to be
draining to the skin. The wall of the cystic mass varied in
thickness from 5 to 12 mm; its superior portion was 3.5 cm in
diameter while its inferior portion was 6.5 cm in diameter; the
longitudinal dimension of the lesion was 9.1 cm. Surrounding
subcutaneous fat was edematous and skin appeared thickened.
Underlying muscle and bone appeared normal. Pelvic images were
said to be normal, with enlarged "hyperemic" lymph nodes in the
left groin. The largest node measured 24 and 18 mm. In addition
to this left inner thigh mass was a subcutaneous bilobed 4 x 2.2
cm nodule in the lateral soft tissues just above the knee,
lateral to the lateral femoral condyle.
.
On [**2175-6-6**], the cyst was drained by fine needle aspiration, and
material was sent for cell block preparation. This showed
"poorly differentiated non-keratinizing SCC with necrosis and
acute inflammation." Additionally, an incisional biopsy of 1 of
the mushroom-like masses was obtained. The biopsy specimen
measured 1.0 x 0.5 x 0.3 cm; the surface was "focally
hemorrhagic and slightly friable." This showed "ulcerated
basosquamous cell carcinoma."
.
Metastatic workup revealed adenopathy involing the iliac vessles
and superficial inguinal region. She underwent excision of the
mass on [**2175-7-18**] at [**Hospital1 18**]. The surgeon recovered eight inguinal
and femoral lymph nodes, two of which showed metastatic tumor
without clear-cut extracapsular extension. He also excised 12
lymph nodes from the true pelvis, one of which again showed
tumor, but no clear-cut extension. Finally, 12 proximal left
common iliac lymph nodes were all normal. Her primary tumor was
a deeply invasive squamous cell carcinoma, which was at least 17
cm in size with negative margins. Within the left pelvis,
although only one lymph node was positive, there was a second
lymph node, which showed tumor within the afferent lymphatics
but not within the true lymph node sinuses or parenchyma. She
was evaluated for XRT, but decided against it as she felt the
chance of recurrence was low and the risks were high.
.
Iron deficiency anemia - During workup for her SCC she underwent
an endoscopy and colonoscopy which showed no cause for her
anemia. She was treated with IV iron dextran and epo which
brought her Hct to the low 30's.
Social History:
She is a Jehovah's Witness. She lives in [**Hospital1 6687**] with her
husband. She is a bookkeeper. Denies tobacco, alcohol, or drug
use.
Family History:
Her father and sister have had sebaceous cysts. There are a
number of non-immediate family members with history of cancer;
details are lacking
Physical Exam:
General: Very drowsy, frequently sleeping
HEENT: Sclera anicteric, dry MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs
Abdomen: Linear scar, NT, ND, No rebound or guarding, No HSM
GU: foley in place
Ext: Left mid medial thigh with area where tissue removed and
Right thigh with area of discoloration from skin graft
placement. Right LE cool to touch but with 2+ DP pulse. Left hip
and thigh no sign of hematoma, nontender to touch.
Neuro: Pupils constricted. Tongue midline; patient too tired to
assess strength exam.
Pertinent Results:
ADMISSION LABS:
[**2175-11-2**] 05:06PM PT-32.5* PTT-33.1 INR(PT)-3.3*
[**2175-11-2**] 05:06PM HCT-15.8*
[**2175-11-2**] 05:06PM CALCIUM-9.8 PHOSPHATE-1.8* MAGNESIUM-1.5*
[**2175-11-2**] 05:06PM estGFR-Using this
[**2175-11-2**] 05:06PM GLUCOSE-139* UREA N-14 CREAT-0.6 SODIUM-128*
POTASSIUM-3.3 CHLORIDE-92* TOTAL CO2-26 ANION GAP-13
[**2175-11-2**] 07:41PM HGB-8.3* calcHCT-25
[**2175-11-2**] 07:41PM PO2-50* PCO2-38 PH-7.44 TOTAL CO2-27 BASE
XS-1
[**2175-11-2**] 07:51PM FIBRINOGE-300
[**2175-11-2**] 07:51PM PT-24.4* PTT-24.4 INR(PT)-2.3*
[**2175-11-2**] 08:05PM HCT-19.5*
[**2175-11-2**] 08:06PM HGB-6.6* calcHCT-20
[**2175-11-2**] 08:38PM freeCa-1.25
[**2175-11-2**] 08:38PM HGB-7.1* calcHCT-21
[**2175-11-2**] 08:38PM GLUCOSE-120* LACTATE-2.2* NA+-127* K+-3.1*
CL--93*
[**2175-11-2**] 08:38PM TYPE-ART PO2-124* PCO2-35 PH-7.46* TOTAL
CO2-26 BASE XS-2 INTUBATED-NOT INTUBA
[**2175-11-2**] 10:47PM CALCIUM-9.2 PHOSPHATE-2.1* MAGNESIUM-1.4*
[**2175-11-2**] 10:47PM GLUCOSE-129* UREA N-13 CREAT-0.6 SODIUM-130*
POTASSIUM-3.1* CHLORIDE-95* TOTAL CO2-24 ANION GAP-14
.
.
PERTINENT LABS/STUDIES:
.
WBC: 18.7 -> 22.1 -> 26.5
Hct: 15.8 -> 19.5 -> 20.5 -> 21.6 -> 20.6
INR: 3.3 -> 2.3 -> 1.2
Na: 128 -> 129
Cr: 0.6
ALT: 77 -> 91
AST: 125 -> 148
LDH: 3965 -> 4115
Alk Phos: 412 -> 523
Ca: 9.8 -> 11.0
Phos: 1.8 -> 1.6
.
Femur XRay ([**11-3**]): There is an oblique fracture at roughly the
mid diaphyseal level with nearly one shaft width lateral
displacement of the distal fragment. No additional fracture is
seen. IMPRESSION: There is an oblique/transverse fracture of
the mid femoral shaft.
.
CXR ([**11-4**]): As compared to the previous radiograph, a
double-lumen Port-A-Cath has been placed in right pectoral
position. The tip of the catheter projects over the inflow tract
of the right atrium. The pre-existing massive bilateral hilar
and mediastinal masses have slightly increased in size, there is
no obvious narrowing of both the right and the left main
bronchus. The pre-existing retrocardiac atelectasis is less
severe than on the previous examination. There still is the
suggestion of a small left-sided pleural effusion. New focal
parenchymal opacities that would suggest infectious lung disease
are not present. No evidence of bone destruction.
.
.
DISCHARGE LABS:
.
[**2175-11-6**] 12:00AM BLOOD WBC-26.5* RBC-2.42* Hgb-6.8* Hct-20.6*
MCV-85 MCH-28.2 MCHC-33.1 RDW-24.7* Plt Ct-135*
[**2175-11-6**] 12:00AM BLOOD Plt Ct-135*
[**2175-11-6**] 12:00AM BLOOD Glucose-145* UreaN-14 Creat-0.6 Na-129*
K-4.2 Cl-92* HCO3-27 AnGap-14
[**2175-11-6**] 12:00AM BLOOD Calcium-11.0* Phos-1.6* Mg-2.2
Brief Hospital Course:
44 yo female with metaststic squamous cell carcinoma of the left
mid medial thigh s/p excision in [**7-6**] admitted with fracture of
femur
.
# Fracture of Femur: On admission, the patient was found to have
a pathologic fracture of her femur. She had a Hct 15.8 and INR
3.3. She was taken emergently to the OR, where she underwent
fixation with intramedullary nail, and bone biopsy (results
pending) with minimal blood loss. She received 10mg IV vit K
preop and 10mg SC post-op. She was extubated and was
transferred to the ICU, where she had tachycardia. She was
oriented and awake with SBP 115s; she recieved IVFs; morphine
PCA. Post op, she was found to have a leukocytosis of 18, Na
127, hct 20.5, and received Ancef. On [**11-3**], the patient was
transferred to the oncology service, where her pain was
initially controlled with a Morphine PCA. She was subsequently
transitioned to long acting po pain regimen with morphine iv for
breakthrough pain. She was maintained with lovenox for dvt ppx.
Ortho recs for further follow up are:
(1) Femur fracture:
- Weight bearing activity as tolerated, under the direction of
physical therapy
- Continue lovenox for 4 weeks
(2) Shoulder nondisplaced fracture of the acromion:
- Range of motion as tolerated
- Sling for comfort
- Follow up with outpatient surgeon
.
# Hyponatremia: The patient's Na on admission was 128. Urine
lytes were consistent with SIADH, which was thought to be
secondary to post-op pain. Patient received continous IVFs in
the SICU, and iv electrolyte repletions. She remained
asymptomatic. Na on discharge was 129.
.
# Chronic iron-deficiency anemia: Patient was continued on
ferrous sulfate supplements. As she is Jehova's witness she
refused any blood transfusions. Procrit was started [**11-5**]. She
was started on Epoetin Alfa 10,000 UNIT SC on Monday, Wednesday,
and Friday. Her Hct on discharge was stable at 20.6.
.
# Metastastic squamous cell carcinoma: The patient has a
history of invasive squamous cell carcinoma, for which she is
treated by her primary oncologist on [**Hospital1 6687**], Dr. [**First Name (STitle) 7049**], and
for which she is also followed at [**Hospital1 18**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. She
should follow up with Dr. [**First Name (STitle) 7049**] regarding further chemotherapy.
Per orthopeadic surgery, it is okay to resume chemotherapy
within 1 week.
.
# Electrolytes: Patient had persistent hypokalemia to 2's and
hypophosph to 1's. She was repleted aggressively. Calcium
levels remained stable at 9.2-10.4. Potassium, Phosph, and Ca
on discharge were: 11.0, 1.6, and 2.2.
.
# Sinus Tachycardia: Patient was persistently tachycardic with
HR in 130s-150s. This was thought to be secondary to her
anemia, pain, and anxiety. She was treated w/ procrit, pain
medications, and ativan. An evaluation for etiologies such as
PE or infection was planned, and the importance of this was
explained. However, the patient was anxious to return to
[**Hospital3 22439**], and her primary attending (Dr. [**Last Name (STitle) **] is
comfortable with pursuing further evaluation at that
institution. Patient refused blood cultures as an inpatient.
Please check blood cultures and a CT-PA upon arrival to
[**Hospital3 **].
.
# Leukocytosis: The patient's WBC has increased from 18.7 to
26.5. Urine cultures were negative and the patient refused
blood cultures. CXR not significant for focal parenchymal
opacities. The patient has remained afebrile since admission,
and the patient has not had any focal signs of infection.
Please check blood cultures upon arrival to [**Hospital1 6687**].
.
# Blood pressure: In SICU, patient's antihypertensive
medications were held. While on the floors, patient remained
normotensive. Her home dose of Labetalol was restarted on
[**2175-11-6**], but we continued to hold Amlodipine. Please restart
this medication if the patient again becomes hypertensive.
.
# Left Lower Extremity Edema: The patient has had progressive
left lower extremity edema on this admission up to her hip. Per
the husband's report, the patient often develops edema in this
leg, as this is the site of her prior surgery. However, on
[**2175-11-6**], the edema was more than the husband had noticed in the
recent past. A LE U/S was planned, although the patient wished
to pursue further evaluation at [**Hospital3 22439**]. Please
check at LLE U/S upon arrival to [**Hospital3 22439**].
Medications on Admission:
1. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
2. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety/nausea.
4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours):
6. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One
(1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily)
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
10. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
11. Oral Wound Care Products Gel in Packet Sig: Fifteen (15)
ML Mucous membrane TID (3 times a day) as needed for mucositis.
12. Normal Saline Please administer 4L of NS at 250cc per hour
daily.
13. Potassium & Sodium Phosphates 280-160-250 mg Powder in
Packet Sig: One (1) Powder in Packet PO QID (4 times a day).
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
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 BID (2
times a day) as needed for prefers pill, not liquid.
5. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
6. Morphine 15 mg Tablet Sustained Release Sig: Three (3) Tablet
Sustained Release PO Q12H (every 12 hours).
7. Potassium & Sodium Phosphates 280-160-250 mg Powder in Packet
Sig: One (1) PO four times a day.
8. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
9. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
10. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
11. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
12. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
13. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, instill Heparin as above per lumen.
14. Labetalol 200 mg Tablet Sig: One (1) Tablet PO twice a day.
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day as needed for
constipation.
16. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for anxiety or nausea.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
Left femur fracture
Right shoulder fracture
Anemia
Metastatic Squamous Cell Carcinoma
Discharge Condition:
Stable: T 96.1; 124/68; HR 136; 95/RA
Discharge Instructions:
You were transferred to [**Hospital1 18**] because of your Left femur
fracture. You went through surgery to repair this fracture.
You tolerated the surgery well. Your hematocrit prior and after
the surgery was low. You refused blood transfusion and so we
treated you with a medication called erythropoietin so that you
can make more red blood cells. Your electrolytes were low and
so we repleted many of your electrolytes.
The following changes have been made to your medications:
(1) We increased the dose of your MS Contin from 30mg twice a
day to 45 mg twice a day
(2) We have changed your Morphine pain medication from PO to IV,
when you are able to tolerate PO medication you can switch back
(3) We have changed your PO Zofran IV
(4) We have started you on tylenol for pain and multivitamin
(5) We have started you on lovenox for prophylaxis of deep vein
thrombosis; this should be continued for four weeks
(6) We have started you on erythropoietin 10,000U Mon, Wed, Fri.
You will receive your first dose at [**Hospital3 22439**]
(5) We have restarted your labetalol, but have held your
amlodipine. The doctors [**First Name8 (NamePattern2) **] [**Last Name (Titles) 6687**] [**Name5 (PTitle) **] decide when to
restart this.
This is a very sedating medication take only as prescribed.
Please do not take morphine while driving or operating a motor
vehicle.
If you should experience worsening pain, lightheadedness, fevers
> 101, chills or any concerning symptom please call your primary
care physician or return to the emergency room.
Followup Instructions:
You are being transferred to [**Hospital3 **] for further
medical care.
They should continue your Lovenox and start your erythropoietin.
They should also continue to evaluate the cause of the
asymmetrical swelling of your lower extremities, as well as the
cause of your fast heart rate.
They will need to follow up with your shoulder fracture. They
will also need to check your electrolytes as these were depleted
during your hospitalization. Your serum sodium should also be
followed as these levels were low. They will decide if you
should restart your amlodipine.
Your oncologist will decide when to restart your chemotherapy
cycle, in conjunction with Dr. [**Last Name (STitle) **], who is aware of these
arrangements.
Completed by:[**2175-11-6**]
|
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232, 253
|
368, 1217
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5771, 8051
|
1239, 4779
|
4795, 4935
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58,810
| 192,291
|
46783
|
Discharge summary
|
report
|
Admission Date: [**2197-8-13**] Discharge Date: [**2197-8-24**]
Date of Birth: [**2129-4-5**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
Hypoxia, cough
Major Surgical or Invasive Procedure:
G-tube clogging, replacement with 22F foley
History of Present Illness:
68 year old male with stage II-III esophageal cancer receiving
treatment with chemoradiation and recently admitted from [**2197-8-3**]
to [**2197-8-8**] for cycle #4 cisplatin/5FU who presents from [**Hospital 7137**] with hypoxia and tachycardia. During his prior admission,
he tolerated his chemo well although was noted to refuse exams
and vital signs frequently. He was discharged home with plans
to start G-CSF on day #7.
In the ED, initial vitals were: T 97.4, BP 111/63, HR 137, RR
22, and SpO2 88% on 15L NRB. Physical exam showed tachypnea
with increased respiratory effort and diffuse rhonchi
throughout. Labs showed leukocytosis to 26.6 with 92%
neutrophils, sodium 131, bicarb 20, BUN 30, lactate 4.1, and
Troponin < 0.01. CXR showed bilateral patchy infiltrates. He
was given 2.5L NS, Duonebs x2, Vancomycin 1 gm IV, Metronidazole
500 mg IV, Levofloxacin 750 mg IV, and Tylenol 650 mg x1. On
transfer, vitals were T 98.3, BP 111/76, HR 113, RR 27, and SpO2
100% on BIPAP.
Initially in the ICU, the patient refused to answer any
questions and asked the ICU team to leave the room. He did
allow a brief lung exam after some discussion.
Subsequent to his course in the ICU, the patient was
transitioned to the medical inpatient floor, for continued
management of his pneumonia, hyponatremia, and [**Hospital 29218**] infections.
Past Medical History:
(per review of OMR records, key points confirmed with the
patient)
Past Oncologic History:
[**2197-3-21**] CT chest: Upper mediastinal mass, partly displayed on
the examination, with a diameter of approximately 2.2 x 4 mm.
The mass includes the esophagus andobliterates its lumen.
[**2197-3-23**] Head MRI: no evidence of metastatic disease.
[**2197-3-23**] PET: left mediastinal mass with avid FDG uptake, no
definitive metastatic disease.
[**2197-3-27**]: Upper esophageal mucosal biopsy: gastric type mucosa
consistent with heterotrophic gastric tissue. Cell block showed
poorly differentiated carcinoma.
[**Date range (2) 99290**]: Admitted. Tumor felt to be unresectable. Drs.
[**Last Name (STitle) **] and [**Name5 (PTitle) 3877**] assumed primary oncology care. Desicion made
to treat with 5-FU/cisplatin and XRT.
[**2197-4-5**]: Placement of 2 tracheal stents by IP.
[**2197-4-13**]: left portacath, open G-tube, tracheal stent replacement
by thoracic surgery.
[**2197-4-17**]: Cycle #1 cisplatin/5FU, radiation initiated.
[**2197-5-17**]: Cycle #2 cisplatin/5FU.
[**2197-5-30**]: XRT finished.
[**2197-6-4**] Pt admitted for aspiration pneumonia with hypoxia.
[**2197-7-6**]: Cycle #3 cisplatin/5FU.
[**2197-8-3**]: Cycle #4 cisplatin/5FU.
.
Other Past Medical History:
- ADHD.
- [**Doctor Last Name 9376**] syndrome.
- Tracheostomy at 3 years of age for PNA.
- Appendectomy [**2162**].
- ORIF Right ankle [**2168**].
Social History:
He denies exposure to hazardous materials, nor has had any
employment putting him at carcinogenic risk. He was a small
business owner with many friends. [**Name (NI) **] still walks including
stairs.
- Tobacco: Smoked 1 PPD for about 25-30 years, quit in [**2180**].
- etOH: He consumed about [**1-8**] drnks per day, but has stopped
since he had had difficulty swallowing.
- Illicits: None.
Family History:
Mother- Died 97, [**Name2 (NI) **], breast CA.
Father- Died 76, PNA.
Sister - breast CA.
Niece - thyroid CA.
Physical Exam:
Admission Physical Exam:
(on arrival to the ICU, patient deferred a complete evaluation)
Vitals: T 98.1, BP 88/60, HR 102, RR 20, SpO2 100% on 4L NC
General: Pale and chronically ill appearing. Alert, oriented, no
acute distress.
HEENT: Sclera anicteric.
Lungs: Coarse breath sounds and rhonchi throughout. Decreased
breath sounds and egophony at left base.
Pertinent Results:
[**2197-8-23**] 06:28AM BLOOD WBC-8.6 RBC-3.23* Hgb-9.8* Hct-28.6*
MCV-89 MCH-30.2 MCHC-34.2 RDW-16.4* Plt Ct-236
[**2197-8-22**] 06:08AM BLOOD WBC-8.0 RBC-3.12* Hgb-9.5* Hct-27.8*
MCV-89 MCH-30.4 MCHC-34.1 RDW-16.5* Plt Ct-209
[**2197-8-21**] 11:13AM BLOOD WBC-8.1 RBC-3.13* Hgb-9.3* Hct-27.5*
MCV-88 MCH-29.8 MCHC-34.0 RDW-16.4* Plt Ct-196
[**2197-8-20**] 05:05AM BLOOD WBC-5.7 RBC-2.90* Hgb-8.7* Hct-25.4*
MCV-88 MCH-29.9 MCHC-34.1 RDW-16.1* Plt Ct-186
[**2197-8-19**] 05:45AM BLOOD WBC-5.0 RBC-2.86* Hgb-8.5* Hct-25.2*
MCV-88 MCH-29.8 MCHC-33.8 RDW-15.9* Plt Ct-164
[**2197-8-18**] 05:26AM BLOOD WBC-5.3 RBC-2.91* Hgb-8.8* Hct-25.2*
MCV-87 MCH-30.3 MCHC-34.9 RDW-15.5 Plt Ct-151
[**2197-8-17**] 06:00AM BLOOD WBC-5.8 RBC-3.16* Hgb-9.5* Hct-27.9*
MCV-88 MCH-29.9 MCHC-34.0 RDW-15.4 Plt Ct-178
[**2197-8-16**] 06:00AM BLOOD WBC-4.6 RBC-3.01* Hgb-9.2* Hct-26.4*
MCV-88 MCH-30.5 MCHC-34.7 RDW-15.2 Plt Ct-126*
[**2197-8-15**] 03:10AM BLOOD WBC-5.0 RBC-2.92* Hgb-9.0* Hct-25.6*
MCV-88 MCH-30.7 MCHC-34.9 RDW-15.3 Plt Ct-110*
[**2197-8-14**] 05:09AM BLOOD WBC-6.9 RBC-3.09* Hgb-9.5* Hct-27.4*
MCV-89 MCH-30.7 MCHC-34.7 RDW-15.1 Plt Ct-125*
[**2197-8-13**] 04:45PM BLOOD WBC-8.7# RBC-2.88*# Hgb-9.0*# Hct-25.6*#
MCV-89 MCH-31.3 MCHC-35.2* RDW-15.5 Plt Ct-109*#
[**2197-8-17**] 06:00AM BLOOD Neuts-85.5* Lymphs-11.0* Monos-2.8
Eos-0.2 Baso-0.4
[**2197-8-15**] 03:10AM BLOOD Ret Aut-4.2*
[**2197-8-23**] 06:28AM BLOOD Glucose-112* UreaN-16 Creat-0.5 Na-131*
K-3.6 Cl-95* HCO3-32 AnGap-8
[**2197-8-22**] 06:08AM BLOOD Glucose-122* UreaN-15 Creat-0.5 Na-131*
K-3.7 Cl-96 HCO3-31 AnGap-8
[**2197-8-21**] 11:13AM BLOOD Glucose-119* UreaN-16 Creat-0.5 Na-133
K-3.5 Cl-95* HCO3-32 AnGap-10
[**2197-8-20**] 05:05AM BLOOD Glucose-128* UreaN-15 Creat-0.4* Na-130*
K-3.3 Cl-95* HCO3-29 AnGap-9
[**2197-8-19**] 05:45AM BLOOD Glucose-124* UreaN-19 Creat-0.5 Na-131*
K-3.5 Cl-95* HCO3-28 AnGap-12
[**2197-8-17**] 06:00AM BLOOD Glucose-137* UreaN-23* Creat-0.5 Na-131*
K-3.7 Cl-94* HCO3-29 AnGap-12
[**2197-8-16**] 06:00AM BLOOD Glucose-141* UreaN-22* Creat-0.6 Na-132*
K-3.8 Cl-96 HCO3-29 AnGap-11
[**2197-8-14**] 05:09AM BLOOD Glucose-141* UreaN-22* Creat-0.6 Na-134
K-4.2 Cl-102 HCO3-24 AnGap-12
[**2197-8-13**] 11:00PM BLOOD Glucose-123* UreaN-22* Creat-0.5 Na-133
K-4.4 Cl-103 HCO3-24 AnGap-10
[**2197-8-13**] 04:45PM BLOOD Glucose-122* UreaN-21* Creat-0.4* Na-138
K-3.7 Cl-113* HCO3-20* AnGap-9
[**2197-8-13**] 09:20AM BLOOD Glucose-219* UreaN-30* Creat-0.7 Na-131*
K-5.2* Cl-97 HCO3-21* AnGap-18
[**2197-8-14**] 05:09AM BLOOD ALT-41* AST-21 LD(LDH)-129 AlkPhos-223*
TotBili-0.7
[**2197-8-13**] 04:45PM BLOOD ALT-35 AST-21 LD(LDH)-93* AlkPhos-203*
TotBili-0.4
[**2197-8-15**] 03:10AM BLOOD LD(LDH)-110
[**2197-8-13**] 09:20AM BLOOD cTropnT-<0.01
[**2197-8-15**] 03:10AM BLOOD Hapto-264*
[**2197-8-19**] 05:45AM BLOOD Vanco-15.9
[**2197-8-13**] 04:52PM BLOOD Lactate-1.7
[**2197-8-13**] 09:36AM BLOOD Lactate-4.1.*
.
MICROBIOLOGY:
[**2197-8-15**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2197-8-14**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2197-8-13**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2197-8-13**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
[**2197-8-13**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
.
EKG [**8-13**]-Sinus tachycardia. Non-specific lateral T wave changes.
Compared to the previous tracing of [**2197-6-4**] the heart rate is
increased. Atrial premature beats are not seen on the current
tracing.
.
CXR [**8-13**]-IMPRESSION: Left mid to lower lung consolidation,
worrisome for pneumonia. Recommend follow-up to resolution.
.
CXR [**8-14**]- IMPRESSION: Progressive infrahilar left greater than
right opacification could relate to either aspiration and/or
infection, with superimposed component of atelectasis.
.
[**8-15**] CXR-FINDINGS: As compared to the previous radiograph, the
extent of the right and left basal and perihilar parenchymal
opacities, likely to reflect pneumonia, are unchanged. A mild
left pleural effusion might have newly occurred. Otherwise, the
radiograph is constant in appearance, including the left
pectoral Port-A-Cath and the tracheal stent.
.
Head CT [**8-19**]-IMPRESSION: No evidence of intracranial lesions.
.
CT chest/neck-IMPRESSION:
1. Increased ground-glass and consolidative appearance of both
lower lobes
and the dependent aspect of the upper lobes, likely represent
infectious
etiology such as pneumonia/aspiration, and are less typical of
metastatic
lesions.
2. Increased endoluminal soft tissue attenuation at the trachea
at the distal end of the stent is nonspecific and may be
secondary to secretions, although tumor infiltration cannot be
excluded. Either repeat imaging or correlation with bronchoscopy
may yield further assessment.
3. Asymmetry in the region of the right false cords is better
seen on the CT of the neck performed concurrently, and would be
better assessed by direct visualization as indicated.
.
KUB [**8-20**]-FINDINGS: Contrast was injected over the newly placed
J-tube. The balloon projects over the stomach, expected contrast
markings of the stomach and the duodenum.
Brief Hospital Course:
68 year old male who presents with hypoxia and tachycardia and
was found to have presumed aspiration pneumonia and hyponatremia
in the setting of stage II-III esophageal cancer receiving
treatment with chemoradiation and recently admitted from [**2197-8-3**]
to [**2197-8-8**] for cycle #4 cisplatin/5FU.
# Hypoxia: In the emergency department, the patient had O2
saturation in the low 80s and required supplemental oxygen with
a face mask. He was rapidly weaned to 4L NC over the first day
of his stay in the ICU. The first night in the ICU he again
desaturated to the low 80s and required face mask for several
hours. This was thought to be due to significant mucus
production and decreased cough. The second day in the ICU his
cough and oxygenation improved, and he was maintained on nasal
cannula between 2-4L. Treatment included antibiotics for
presumed pneumonia (as below), hydration, and pulmonary hygiene
to assist mucus clearance. As his oxygenation improved, he was
moved to the floor for further treatment. He has been on room
air for days. Sat on day of discharge 95% on RA.
The patient was subsequently transitioned to the medical floor
for ongoing management of his pneumonia. He was continued on
broad spectrum antibiotics. We suspect that his pneumonia was at
least in part related to his secretions related to his
esophageal mass and oral secretions. During the admission, a CT
confirmed multilobar involvement of a likely infectious process.
His hypoxia resolved while on treatment for the pneumonia.
Discussed with patient and his family that given his mass and
NPO status, pt is at continued risk of aspiration and recurrent
pneumonia.He has been on room air for days. Sat on day of
discharge 95% on RA.
# Pneumonia (health care acquired) Likely cause of fever,
hypoxia given new consolidation on CXR. Given his significant
secretions, and his deferral of mouth care at times in his
course, it is likely that he aspirates intermittently.
Additional sources considered included a TE fistula (secondary
to disease and tracheal stenting), reflux from tube feeds, or
HCAP. Blood and sputum cultures were sent, although
unfortunately sputum samples were not sufficient for testing.
Blood cultures did not reveal evidence of acute bacterial
infection. Antibiotics were started to cover possible sources of
infection (vancomycin and cefepime). Flagyl was then added for
anaerobic coverage. Plan is for a 14-day course ending on
[**2197-8-26**].
# Hypotension: On arrival to the ICU, the patient was
hypotensive with BP 88/60. Per report, he appeared dehydrated.
His blood pressure responded well to hydration, and on transfer
to the floor he had SBPs in the 110-120s. He did not have
recurrence of hypotension, but did require IV fluids for
hyponatremia related to presumed dehydration at a later point in
his hospital stay. This did not reoccur on the medical floor.
# Leukocytosis: The patient's WBC count was elevated to 26.6 on
admission, most likely due to HCAP as above. Other possible
etiologies include [**Name (NI) **] (pt was on vanco PO in outpt setting
prior to admit), G-tube (although site looks clean) and UTI (but
has clean UA). Repeat stool and urine studies were sent. His
white count rapidly dropped to normal while on IV antibiotics
for the pneumonia, and continued therapy for his [**Name (NI) 29218**]
persistent infection. Pt did have increase in diarrhea while on
antibiotic therapy. For this, vancomycin was increased to 500mg
q6 while on IV abx therapy. Plan is to decrease to 125mg QID
for 2 weeks after IV therapy ends.
# Urinary retention: This was an issue during the patient's last
hospitalization and he was empirically started on [**Name (NI) 32316**].
As this is not available for NG administration, it was held
during the admission. A Foley catheter was in place throughout
his stay.
# Mucositis: Chronic issue. Caphosol continued, although the
patient found it painful to use and often refused it during his
initial course. Viscous lidocaine was helpful at times of
significant pain, although was not required as improved mouth
care was achieved.
# C.diff colitis: The patient was started on PO vancomycin for C
difficile colitis on his prior admission. Therapy was continued
as an outpatient. This was continued during his stay, with a
targeted 14 day course of therapy from the last day of
antibiotic treatment. His dose was increased to 500mg qid during
his admission, when his diarrhea was noted to increase in
frequency and there was concern for the need for ongoing IV
antibiotics which could be worsening his [**Name (NI) 29218**]. Plans include
decreasing his oral [**Name (NI) 29218**] treatment to 125mg qid of PO vanco
once he completes his IV antibiotics. (This can start on [**8-27**]
for 2 weeks). I/O's should be closely monitored in the
outpatient setting so that ins match outs especially in the
setting of diarrhea. Pt should be given IV fluids (normal
saline) to meet goals prn.
# Hyponatremia: On presentation, the patient was mildly
hyponatremic to 131. This was considered to be likely
hypovolemic, and his sodium level rapidly corrected with
hydration. Urine electrolyte testing revealed a possible
component of SIADH, probably secondary to his pulmonary disease.
The amount of water in his tube feed flushes was monitored, as
were his electrolytes. There was likely some degree of total
body salt deficit, which improved with IV normal saline, but
remained below his usual baseline sodium level. Sodium levels
should be monitored in the outpatient setting. Decreased free
water flushes on [**8-23**] to 150cc Q6hrs. Ulytes more c/w SIADH. If
sodium remains stable and pt needs increased free water, can
increase to 200cc Q6hrs. Sodium 131 on day of discharge.
.
# Depression/Insomnia/Anhedonia: On admission, the patient
initially refused most medical care including vital signs,
turning, and medications. He has had many hospitalizations
during the last few months, and has been frustrated by the
perceived lack of progress. His home regimen of citalopram,
Ritalin, and trazodone was continued throughout his stay.
# Headache: Per his friends, he has been having progressively
worsening headaches over the last few weeks. He had a CT head
on [**2197-5-13**] with no acute findings and PET imaging on [**2197-6-27**]
without apparent intracranial findings, although this did not
extend above the sinuses. Although this could have a benign
source, it was concerning for possible metastatic disease. A
head CT was discussed with the treating oncologist. A head CT
with contrast was pursued while inpatient given his ongoing
headaches, to preclude metastasis, which did not show evidence
of metastasis. Pt was given oxycodone and tylenol for pain
control.
.
#Esophageal Cancer: Unresectable, poorly differentiated tumor.
Pt is s/p cycle 4 of cisplatin/5FU, which is last intended
cycle. This was discussed with outpatient oncologist [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 5280**] [**8-19**], who agreed with CT scans to assess for
metastasis. CT scan showed redemonstration of a cervical
esophageal mass posterior to the thyroid and endoluminal soft
tissue attenuation in the proximal trachea at distal end of
tracheal stent concerning for tumor and secretions. Findings
were discussed with patient's oncologist Dr. [**Last Name (STitle) 45322**] who has
arranged for a PET scan to determine if these findings are
related to scar vs. continued mass. Pt will have a PET scan and
then follow up in clinic to go over the findings.
#Anemia, likely hypoproliferative due to chemo: Anemia likely
due to marrow suppression. HCT was trended daily. HCT remained
stable and was >??? on day of discharge.
# Pain: The patient's outpatient regimen of fentanyl patch and
oxycodone liquid was continued.
# Nutrition: The patient's outpatient tube feeds were continued.
Tubefeeding: Start After 12:01AM; Nutren 2.0 Full strength;
Starting rate: 30 ml/hr; Advance rate by 10 ml q4h Goal rate: 50
ml/hr
Residual Check: q4h Hold feeding for residual >= : 200 ml
Flush w/ 150 ml water q6h
.++can consider speech and swallow exam at rehab, if indicated++
# FEN: IVF boluses as needed, replete electrolytes, Tube feeds
# Prophylaxis: Subcutaneous heparin, pneumoboots
# Access: peripherals/port-a-cath
# Communication: Patient
# Code: DNR/DNI
# Disposition: to rehab today.
.
TRANSITIONAL: CONTINUING OF ANTIBIOTICS THROUGH [**8-26**]. CHANGING
PO VANCO TO 125MG QID ON [**8-27**]. DAILY MONITORING OF I/O'S WITH
DIARRHEA TO ENSURE EVEN. GIVE IVF TO MEET GOALS PRN. PORTOCATH
CARE PER PROTCOL.
Medications on Admission:
Vancomycin 125 mg PO TID per G tube
Neupogen 300 mcg IJ daily for 7 days (begin [**2197-8-9**] pm)
DuoNeb (0.5 mg-3 mg) IH Q6H PRN SOB or wheezing
[**Month/Day/Year 32316**] 0.4 mg PO QHS per G tube
Omeprazole 20 mg PO BID per G tube
Zofran (4 mg/5 mL) [**5-16**] ml PO TID PRN nausea per G tube
Prochlorperazine 5-10 mg PO Q6H PRN nausea per G tube
Bismuth subsalicylate (262 mg/15 ml) 15-30 mL PO QID PRN per G
tube
Calcium carbonate (500 mg/5 mL) 5 ml PO TID PRN per G tube
Lactobacillus acidophilus 1 cap PO BID per G tube
Scopolamine 1.5 mg Patch 2 patches Q72H
Citalopram 20 mg PO daily per G tube
Methylphenidate 20 mg PO BID per G tube
Trazodone 25 mg PO QHS per G tube
Fentanyl 75 mcg/hr Patch one patch Q72H
Oxycodone (5 mg/5 mL) 5 ml PO Q4H PRN pain
Caphosol 30 mL ORAL TID Swish and spit
Multivitamin (Liquid) PO daily
Discharge Medications:
1. cefepime 2 gram Recon Soln [**Month/Year (2) **]: Two (2) grams Intravenous
three times a day for 3 days: Last day of therapy is [**8-26**].
2. vancomycin 1,000 mg Recon Soln [**Month/Year (2) **]: One (1) gram Intravenous
twice a day for 3 days: last day [**8-26**].
3. vancomycin 125 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO Q6H (every
6 hours) for 14 days: continue for 14 days after finishing other
antibiotics. To start on [**8-27**].
4. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization [**Month/Year (2) **]: [**1-8**] nebs Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
5. [**Month/Day (2) **] 0.4 mg Capsule, Ext Release 24 hr [**Month/Day (2) **]: One (1)
Capsule, Ext Release 24 hr PO at bedtime.
6. metronidazole 500 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q8H (every
8 hours) for 3 days: last day is [**8-26**].
7. bismuth subsalicylate 262 mg/15 mL Suspension [**Month/Year (2) **]: 15-30 mL
PO four times a day as needed for indigestion.
8. calcium carbonate 500 mg/5 mL (1,250 mg/5 mL) Suspension [**Month/Year (2) **]:
Five (5) ml PO three times a day as needed for heartburn.
9. lactobacillus acidophilus 700 million cell Capsule [**Month/Year (2) **]: One
(1) Capsule PO twice a day.
10. scopolamine base 1.5 mg Patch 72 hr [**Month/Year (2) **]: One (1) Patch 72 hr
Transdermal EVERY 3 DAYS (Every 3 Days).
11. citalopram 10 mg/5 mL Solution [**Month/Year (2) **]: Twenty (20) ml PO DAILY
(Daily).
12. methylphenidate 10 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO BID (2
times a day).
13. trazodone 50 mg Tablet [**Month/Year (2) **]: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
14. fentanyl 75 mcg/hr Patch 72 hr [**Month/Year (2) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
15. oxycodone 5 mg/5 mL Solution [**Month/Year (2) **]: Five (5) ml PO Q4H (every
4 hours) as needed for pain.
16. saliva substitution combo no.2 Solution [**Month/Year (2) **]: Thirty (30)
ML Mucous membrane TID (3 times a day).
17. lidocaine HCl 2 % Solution [**Month/Year (2) **]: Twenty (20) ML Mucous
membrane TID (3 times a day) as needed for mouth pain.
18. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
19. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) ml PO BID (2
times a day).
20. senna 8.8 mg/5 mL Syrup [**Last Name (STitle) **]: [**5-16**] mL PO BID (2 times a day)
as needed for Constipation.
21. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
22. vancomycin 250 mg Capsule [**Month/Year (2) **]: Two (2) Capsule PO every six
(6) hours: from [**Date range (1) **].
23. acetaminophen 650 mg/20.3 mL Solution [**Date range (1) **]: 325-650 mg PO Q8H
(every 8 hours) as needed for pain.
24. Zofran 4 mg/5 mL Solution [**Date range (1) **]: One (1) PO three times a
day.
25. Outpatient Lab Work
BNP (sodium) every 4-7 days to ensure stable.
26. Port flush
Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
Acute bacterial aspiration pneumonia, health care associated
Clostridium difficile diarrhea infection
-hyponatremia
Secondary Diagnoses
Esophageal Cancer
ADHD
[**Doctor Last Name 9376**] Syndrome
G-tube dislodgement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with difficulty breathing and found to have a
pneumonia. You were treated with antibiotics and you symptoms
improved. In addition, you were treated for a C.diff (diarrhea)
infection. For this, you were given an additional antibiotic.
You will need to take this antbiotic for 2 weeks after your IV
antibiotics stop.
.
Your G tube was replaced twice. Your original tube was clogged
and moved, and the first replacement tube had a balloon that
broke. You have a 22 french tube in place currently. If a
problem were to develop, you can consider having this changed to
a G-tube.
Your medications have been changed. ******You have been started
on cefepime, vancomycin, and metronidazole to to treat your
pneumonia.***** You have been started on oral vancomycin for
diarrhea. Your medicine for heartburn and to prevent ulcers
called omeprazole (PRILOSEC) has been switched to lansoprazole
(PREVACID). You have also been started on viscous lidocaine for
mouth pain and a bowel regimen to prevent constipation while you
are on the pain regimen with oxycodone and fentanyl.
Please continue to take all other medications as previously
prescribed.
Followup Instructions:
Department: RADIOLOGY / PET SCAN
When: MONDAY [**2197-8-28**] at 2:00 PM
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Must be NPO 4 hours prior including tube feeds, no need for PET
diet or contrast
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2197-8-31**] at 11:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) 831**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2197-8-31**] at 11:30 AM
With: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"314.01",
"E933.1",
"253.6",
"276.2",
"482.9",
"E878.3",
"933.1",
"285.3",
"V15.82",
"277.4",
"536.42",
"150.0",
"V49.86",
"E915",
"528.00",
"008.45",
"788.29",
"285.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
22083, 22153
|
9273, 17885
|
285, 331
|
22433, 22433
|
4093, 9250
|
23793, 24695
|
3588, 3698
|
18767, 22060
|
22174, 22174
|
17911, 18744
|
22609, 23770
|
3738, 4074
|
231, 247
|
359, 1711
|
22193, 22412
|
22448, 22585
|
3012, 3161
|
3177, 3572
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,749
| 164,075
|
47155
|
Discharge summary
|
report
|
Admission Date: [**2111-1-18**] Discharge Date: [**2111-1-24**]
Service: MEDICINE
Allergies:
Sulfonamides / Pentothal
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
chest pain, melena
Major Surgical or Invasive Procedure:
EGD
chest tube placement
intubation
History of Present Illness:
83 female w/ cad w/ cath [**7-6**] showing T.O. of RCA, severe AS
(valve 0.5-9 w/ cath gradient close to 50), mr, ?copd, cri
baseline 2.2 and recent GI bleed admission at [**Hospital1 112**] now w/
intermittent chest pressure, dynamic ecg changes in setting of
crit to 23 from presumed gi source. Hemodymically stable,
enzymes negative and chest pain free post 1 dose of morphine. NG
lavage negative, getting 2 units blood. Cards, Gi on boards. TO
MICU. IF rules out, scope by GI in am.
Past Medical History:
1. Status post recent GI bleed. s/p excision colonic polyp.
2. Chronic renal insufficiency, baseline 2.2.
3. CAD. cath [**7-6**] 1 vessel dz, RCA, mild MR, severe AS, area 0.5
4. H/o critical aortic stenosis. valve 0.5. not felt to be an
operative candidate.
5. H/O CHF with diastolic dysfunction.
6. Bronchiectasis/emphysema.
7. H/O peptic ulcer disease.
8. Hypertension
9. Hypercholesterolemia. on Pravachol.
10. Hypothyroidism.
11. Peripheral vascular disease (aortic and iliac).
12. CVA [**2095**] c/b mild L handed weakness
13. Renal Artery Stenosis s/p stenting R renal artery.
14. Hemarrhoid
Social History:
Pt lives with her sister, [**Name (NI) **], at their home in [**Name (NI) **].
Family History:
NC
Physical Exam:
pt expired
Pertinent Results:
[**2111-1-24**] 05:30AM BLOOD WBC-6.5 RBC-3.28* Hgb-10.4* Hct-30.5*
MCV-93 MCH-31.6 MCHC-34.1 RDW-15.3 Plt Ct-208
[**2111-1-24**] 05:30AM BLOOD Glucose-69* UreaN-49* Creat-1.6* Na-144
K-4.3 Cl-111* HCO3-26 AnGap-11
[**2111-1-24**] 05:30AM BLOOD Calcium-8.9 Phos-3.1 Mg-2.0
Brief Hospital Course:
In the ED, her hematocrit was 23 and her EKG demonstrated new ST
depressions in V3-V6. She was admitted to the MICU and evaluated
by Cardiology and GI. GI didn't want to scope her until her
cardiac status was stable. Cardiology felt that this was demand
ischemia, and did not feel intervention was necessary (she had a
cath [**7-6**] which revealed RCA disease only).
MICU course [**Date range (1) 23499**]: She was transfused for a Hct >30, which
was complicated by flash pulmonary edema. This resolved with
Lasix. She was hypertensive and tachycardic requiring an Esmolol
gtt, which was weaned off as her Metoprolol dose was increased.
Her troponin continued to rise to an initial peak of 0.41. Her
EKG changes resolved. Her hematocrit remained stable without
transfusion requirement. She was transferred out to the floor on
[**2111-1-20**].
On the floor, she became tachycardic, hypertensive, and hypoxic
(her O2 sat dropped to 80% on 10L). She did not respond to
lasix. She was transferred back to the MICU and emergently
intubated.
MICU course [**Date range (1) 34518**]: Initial CXR demonstrated CHF, and it was
felt she had flash pulmonary edema [**2-4**] tachycardia. She was
rate-controlled with Lopressor. Her troponin peaked again at
0.84, and is now trending down. (also in setting of renal
insufficiency). She went into afib on [**1-21**] and was placed on a
diltiazem gtt. After 8 hours she converted back into sinus
rhythm. She was not anticoagulated [**2-4**] GI bleed. She had an EGD
done which revealed gastritis, and was kept on Protonix [**Hospital1 **]. She
required only one more unit PRBCs for a hematocrit of 28 on
[**1-21**]. Her hematocrit has since remained stable. She has remained
hypertensive (150s-160s), with pulse in the 70s-80s. Her
captopril and metoprolol are being titrated up for better
bp/rate control. She was transferred back out to the floor on
[**1-23**].
The AM of [**1-24**], she was noted to brady down to the 20s on
telemetry. She was unresponsive and a code was called. She
went into a PEA arrest, and despite attempts at resuscitation
including epi, intubation, and bilateral chest tube placement,
she could not be resuscitated and she died that morning.
Medications on Admission:
Levoxyl 75 mcg alternating with 50 mcg q.o.d.
Lasix 20 mg half a tablet q.o.d.
hydroxyzine 25 mg two t.i.d. and one q.h.s.
ASA 325 mg q.d.
Flovent 110 mcg two puffs b.i.d.
metoprolol 50 mg two tablets b.i.d.
Norvasc 10 mg q.d.
Plavix 75 mg q.d.
Pravachol 80 mg which she splits in half and takes b.i.d.
Protonix 40 mg q.d.
Tylenol No. 3 half a tablet q.h.s. p.r.n. cough
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
aortic stenosis
gastritis
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
|
[
"398.91",
"593.9",
"535.01",
"285.1",
"518.81",
"410.71",
"041.86",
"427.5",
"584.9",
"276.5",
"401.9",
"396.2",
"414.01",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"99.04",
"34.04",
"96.04",
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
4545, 4554
|
1887, 4094
|
250, 288
|
4624, 4633
|
1590, 1864
|
4686, 4694
|
1540, 1544
|
4516, 4522
|
4575, 4603
|
4120, 4493
|
4657, 4663
|
1559, 1571
|
192, 212
|
316, 804
|
826, 1428
|
1444, 1524
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,930
| 104,696
|
20135
|
Discharge summary
|
report
|
Admission Date: [**2190-7-27**] Discharge Date: [**2190-8-2**]
Date of Birth: [**2129-9-8**] Sex: F
Service: ORTHOPAEDICS
Allergies:
doxycycline
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back and leg pain
Major Surgical or Invasive Procedure:
Anterior/posterior lumbar fusion with instrumentation L4-S1
History of Present Illness:
Ms. [**Known lastname **] has a long history of back and leg pain. She has
undergone a previoius scoliosis fusion and now requires an
extension.
Past Medical History:
PMH/PSH:
-Lumbar spondylosis and stenosis.
-Hypertension
-History of childhood polio
-History of scoliosis s/p rod placements.
-History of right ICA possible source of embolism, right
retinal artery occlusion noted on incidental finding for an eye
exam, question fibromuscular disease, now s/p angiography
revealing no selective carotid artery disease
Social History:
Denies
Family History:
N/C
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:
[**2190-8-1**] 05:20AM BLOOD WBC-7.2 RBC-3.58*# Hgb-11.1*# Hct-32.3*#
MCV-90 MCH-31.2 MCHC-34.5 RDW-15.4 Plt Ct-210
[**2190-7-31**] 05:30AM BLOOD WBC-6.8 RBC-2.59* Hgb-8.3* Hct-23.4*
MCV-90 MCH-32.1* MCHC-35.6* RDW-14.9 Plt Ct-163
[**2190-7-30**] 05:43AM BLOOD Hct-27.7*
[**2190-7-30**] 02:52AM BLOOD WBC-10.5 RBC-3.15* Hgb-9.7* Hct-26.7*
MCV-85 MCH-30.7 MCHC-36.2* RDW-15.1 Plt Ct-121*#
[**2190-7-31**] 05:30AM BLOOD Glucose-123* UreaN-3* Creat-0.3* Na-140
K-3.8 Cl-104 HCO3-32 AnGap-8
[**2190-7-30**] 02:52AM BLOOD Glucose-163* UreaN-7 Creat-0.4 Na-134
K-3.3 Cl-99 HCO3-30 AnGap-8
[**2190-7-29**] 03:22PM BLOOD Glucose-138* UreaN-8 Creat-0.4 Na-132*
K-3.7 Cl-101 HCO3-27 AnGap-8
[**2190-7-28**] 09:26PM BLOOD Glucose-174* UreaN-8 Creat-0.5 Na-138
K-3.9 Cl-109* HCO3-24 AnGap-9
[**2190-7-31**] 05:30AM BLOOD Calcium-7.5* Phos-2.2* Mg-2.1
[**2190-7-30**] 02:52AM BLOOD Calcium-7.5* Phos-2.2* Mg-2.0
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2190-8-2**] and taken to the Operating Room for L4-S1 interbody
fusion through an anterior approach. Please refer to the
dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
given per standard protocol. Initial postop pain was controlled
with a PCA. On HD#2 she returned to the operating room for a
scheduled L4-S1 decompression with PSIF as part of a staged
2-part procedure. Please refer to the dictated operative note
for further details. The second surgery incurred substantial
bleeding and she was transfered to the SICU for hemodynamic
monitoring. Postoperative HCT was low and she was transfused
with good effect. She 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#3 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:
synthroid 125', ASA, Lisinopril 40', multivitamins, metop 50'
Discharge Medications:
1. 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*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
5. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas pain.
6. 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*
7. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q8H (every 8 hours).
Disp:*90 Tablet Extended Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA
Discharge Diagnosis:
Lumbar disc degeneration and scoliosis
Acute post-op blood loss anemia
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:
Activity: Activity: Out of bed w/ assist
Thoracic lumbar spine: when OOB
Treatments Frequency:
Please continue to change the dressings daily
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days
Completed by:[**2190-8-2**]
|
[
"311",
"138",
"530.81",
"285.1",
"401.9",
"E870.0",
"458.29",
"244.9",
"272.4",
"721.3",
"349.31",
"737.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.62",
"81.07",
"84.52",
"03.59",
"80.51",
"81.06",
"78.69"
] |
icd9pcs
|
[
[
[]
]
] |
4817, 4868
|
2409, 3833
|
292, 354
|
4983, 4990
|
1486, 2386
|
7147, 7226
|
946, 951
|
3945, 4794
|
4889, 4962
|
3859, 3922
|
5014, 5113
|
966, 1467
|
6975, 7055
|
7077, 7124
|
5149, 5342
|
235, 254
|
5378, 5845
|
5857, 6957
|
382, 529
|
551, 906
|
922, 930
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,209
| 144,958
|
40075
|
Discharge summary
|
report
|
Admission Date: [**2146-10-11**] Discharge Date: [**2146-10-24**]
Date of Birth: [**2076-3-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Cardiac arrest
Major Surgical or Invasive Procedure:
Aortic balloon pump
Cardiac catheterization
Central line
Arterial line
Arctic cooling protocol
Endotracheal intubation
Orogastric tube
History of Present Illness:
Mr [**Known lastname **] is a 70 y.o. M h/o CAD, cardiomyopathy (EF 20% in [**2137**]
that has improved with medical management up to 45-50% in [**2143**]
echo), PVD, HLD, HTN who is admitted for cardiac arrest and
STEMI. Per outside records, Mr. [**Known lastname **] is an active man who
performs heavy manual labor on a daily basis. During his visit
with cardiology in [**11/2145**], pt denied any chest pain history or
exertional angina.
Mr [**Known lastname **] was working as a landscaper today and collapsed. He
was seen by a bystander 10 seconds prior to event. Bystander
started CPR until EMS came. Fire Dept came and shocked pt twice
per automatic external defibrillator. Paramedics arrived, pt was
found to be in PEA arrest and given epi and atropine, he was
then found to be in V fib and shocked again. He was then in
asystole and given epi again. Pt subsequently regained
spontaneous circulation. He was hypotensive and started on
dopamine. He arrived to [**Hospital1 18**] with a pulse and intubated. ED
vitals: HR 54, BP 90/palp, Sat 100. He was found to be in
complete heart block so cooling procedure was initially
deferred. Initial labs found pt to be acidotic with pH 7.22,
Anion Gap 19, lactate of 6.9, trop 0.01. He was emergently sent
to cath lab where 2 bare metal stents were placed in his RCA.
During procedure, pt was in V. Tach and he was shocked twice. He
was given lidocaine. Also found to be in rapid A. Fib and was
started on amiodarone drip. Aortic balloon pump was placed.
Pt had laceration on head with head CT negative of intracranial
bleed, although did reveal zygomatic fracture.
.
ROS unable to obtain since pt is sedated and intubated.
Past Medical History:
1. CARDIAC RISK FACTORS: Hyperlipidemia, HTN, CAD
2. CARDIAC HISTORY:
Cardiomyopathy: echo in [**2137**] revealed EF 20% but [**2143**] echo
revealed echo 45-50% with inferoposterior hypokinesis.
CAD
3. OTHER PAST MEDICAL HISTORY:
-Tuberculous Bronchiectasis
-Chronic sinusitis
-Anemia
-Hematuria
Social History:
Unable to obtain
Family History:
Unable to obtain
Physical Exam:
VS: T=35.7 ' C BP= 107/50 with balloon pump, HR=90, RR=100%O2 on
vent: CMV mode, PEEP 1, Tidal Volume 690, sat 100%.
GENERAL: sedated, bleeding in mouth, has hematoma on left eye,
bleeding on face from fall. Pt with neck collar.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
CARDIAC: S1 and S2, systolic murmur at left sternal border.
LUNGS: Intubated on vent. No crackles, no rhonchi, no wheezes.
No chest wall deformities, scoliosis or kyphosis. Bilateral
breath sounds appreciated.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits. Has a line in both
groin sites. Ext warm (warm calf) but feet and hands cool. Has
ostial line in left tibia.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Does
have wound on face and hematoma on left eye, bleeding from
wound.
PULSES:
Right: Carotid 2+ Femoral 2+
Left: Carotid 2+ Femoral 2+
Neuro: pupils reactive
Pertinent Results:
CT head no contrast:
IMPRESSION:
1. No acute intracranial process.
2. Fractures of the left anterior and posterior maxillary sinus
walls, left
lateral orbital wall, and left zygomatic arch.
3. Free air in the right infratemporal region highly suspicious
for an occult
right maxillary sinus fracture. Dedicated maxillofacial CT
should be obtained
when the patient is stable.
[**10-14**] CT head:
1. Multiple facial fractures as detailed above consistent with a
LeFort type
1, 2 and 3 and tripod fractures on the left, with possible
involvement of the
left infraorbital canal and small extraconal hematoma.
2. Right mandibular ramus and fracture of the right lateral wall
of the
maxillary sinus on the right.
3. Fractures of the nasal septum, and left hard palate extending
into the
alveolus.
4. Probable old fractures of the left zygomatic arch and greater
[**Doctor First Name 362**] of the
sphenoid on the left.
Cardiac Cath:
COMMENTS:
1. Selective coronary angiography in this right dominant system
demonstrated two vessel coronary artery disease. The LMCA had
no
angiographically apparent disease. The LAD had a calcified
lesion in
the mid-vessel that was diffuse with 60-70% stenosis. The LCx
had mild,
diffuse disease throughout. The RCA had an ostial 99% stenosis
and a
70% stenois in the mid-vessel.
2. Resting hemodynamics revealed elevated [**Hospital1 **]-ventricular filling
pressures with RVEDP 17 mmHg and mean PCWP 17 mmHg. The
pulmonary
arterial pressure was high normal with PASP 28 mmHg. The
cardiac index
was depressed at 1.8 L/min/m2. There was systemic hypotension
with SBP
85 mmHg on dopamine gtt at 5 mcg/kg/min, and with IABP giving
1:1
assistance.
3. Left ventriculography was deferred.
4. An intraortic balloon pump was placed sheathed via the left
femoral
artery with appropriate systolic unloading and diastolic
augmentation on
1:1 counterpulsation.
5. A temporary venous pacing wire was placed with fluoroscopic
guidance
into the RV apex.
6.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Cardiogenic shock.
3. Complete heart block.
4. Elevated biventricular filling pressures.
5. Successful placement of an intra-aortic balloon pump.
6. Successful placement of a temporary venous pacing wire.
Echo:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. There
is mild to moderate regional left ventricular systolic
dysfunction with near akinesis of the basal half of the inferior
wall and mild dyskinesis of the inferolateral wall. There is
mild hypokinesis of the remaining segments (LVEF = 30-35 %). The
right ventricular cavity is moderately dilated with severe
global free wall hypokinesis. 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 quantified.
There is no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with regional
systolic dysfunction c/w CAD. Right ventricular cavity dilation
with free wall hypokinesis. Mild aortic regurgitation.
This constellation of findings is suggestive of a proximal RCA
distribution infarct pattern.
CLINICAL IMPLICATIONS:
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from a beta blocker and an ACE
inhibitor or [**Last Name (un) **].
Based on [**2142**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
Admission labs:
[**2146-10-11**] 04:03PM WBC-22.8*# RBC-4.02* HGB-10.7* HCT-32.7*
MCV-82 MCH-26.7* MCHC-32.8 RDW-16.5*
[**2146-10-11**] 04:03PM NEUTS-85* BANDS-6* LYMPHS-4* MONOS-4 EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2146-10-11**] 04:03PM CALCIUM-7.3* PHOSPHATE-4.9*# MAGNESIUM-2.1
[**2146-10-11**] 04:03PM GLUCOSE-216* UREA N-32* CREAT-1.4* SODIUM-137
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-22 ANION GAP-14
[**2146-10-11**] 04:10PM TYPE-ART PO2-204* PCO2-44 PH-7.31* TOTAL
CO2-23 BASE XS--4
[**2146-10-11**] 04:03PM CALCIUM-7.3* PHOSPHATE-4.9*# MAGNESIUM-2.1
[**2146-10-11**] 10:23PM GLUCOSE-167* UREA N-35* CREAT-1.3* SODIUM-140
POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-21* ANION GAP-15
Brief Hospital Course:
70 y.o. M here for cardiac arrest and STEMI s/p 2 bare metal
stents in RCA. Pt currently intubated with balloon pump.
.
# CORONARIES: Had STEMI of RCA which resulted in cardiac arrest.
Pt shocked and intubated in the field then brought emergently to
[**Hospital1 18**]. Had cardiac cath, s/p 2 bare metal stents in RCA, aortic
balloon pump to improve perfusion of coronaries. Arctic cooling
protocol was performed. Pt given ASA 325mg, Prasugrel initially
and then plavix, atorvastatin 80mg daily, metoprolol 25mg [**Hospital1 **].
.
# PUMP: Cardiogenic Shock- ikely from both being in and out of
VF as well as complicated with complete heart block. Initially
had aortic balloon pump to both improve forward flow by
decreasing afterload as well as to perfuse coronaries. Balloon
pump was weaned and removed early in hosp course. Pt placed on
dopamine drip that was weaned off quickly.
.
# SEIZURES: During arctic cooling protocol, it was noted on EEG
that patient had status epilepticus on EEG without outward
symptoms. Neurology team closely followed patient. He was given
Keppra, Vimpat, and valproic acid in escating doses to attempt
to control seizures. After those medications had been maximized,
he was also given Phenobarbital. Seizures were never brought
fully under control, but patient was kept on four antiepileptics
to reduce seizures/epileptiform discharges.
.
# RHYTHM: Pt was initially in and out of both V fib and Vtach
since initial event. Pt also initially presented with complete
heart block that resolved, likely vagally induced. Received
lidocaine in cath lab, switched to amiodarone drip. No further
episodes of arrythmias hospital day 1.
.
#RESPIRATORY: The patient was on a ventilator for airway
protection for most of his hospitalization. Multiple discussions
with patient's next of [**Doctor First Name **] revealed that she did not think he
would want tracheostomy or PEG tube. She also made him
DNR/do-not-reintubate. On [**10-24**], the team decided to
extubate the patient. Four hours later, he began to experience
respiratory distress. Shortly thereafter, the patient went into
asystole. As he was DNR/DNI, no agrressive measures were pursued
and the patient expired.
.
# Zygomatic Fracture: Has zygomatic fx from fall after cardiac
arrest. Both Plastic surgery and Ophtalmo were consulted.
Recommended ice packs and clindamycin. Plastics does not feel
extensive plating was appropriate in this patient.
.
# HTN: Held home lasix, lisinopril, metoprolol, amlodipine for
now in setting of cardiac arrest episode. Patient's lisinopril
and metoprolol were eventually restored.
.
# HLD: Atorvastatin 80mg daily.
Medications on Admission:
Furosemide 20mg daily
Metoprolol succinate 25mg SA tab
Guaifenesin 100mg- 1 teaspoon TID for cough
Lisinopril 40mg [**Hospital1 **]
Loratidine 10mg daily
Amlodipine 5mg daily
Simvastatin 80mg tablet daily
ASA- dose unknown, per report from VA record
Discharge Medications:
None. Patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory failure secondary to brain injury secondary to
myocardial infarction.
Discharge Condition:
Patient is expired.
Discharge Instructions:
Expired.
Followup Instructions:
Patient is expired.
|
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"410.31",
"802.4",
"427.5",
"414.01",
"873.42",
"801.05",
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"276.2",
"426.0",
"427.1",
"345.3",
"V49.86",
"873.44",
"443.9",
"V70.7",
"401.9",
"785.51",
"427.41",
"425.4",
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] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"96.6",
"37.23",
"88.56",
"96.04",
"00.46",
"37.61",
"96.72",
"86.59",
"36.06",
"00.66",
"08.81",
"00.40",
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] |
icd9pcs
|
[
[
[]
]
] |
11015, 11024
|
8026, 10667
|
332, 469
|
11150, 11172
|
3579, 3966
|
11229, 11252
|
2550, 2568
|
10968, 10992
|
11045, 11129
|
10693, 10945
|
5578, 6876
|
11196, 11206
|
2583, 3560
|
2271, 2401
|
6899, 7297
|
278, 294
|
497, 2179
|
3975, 5561
|
7313, 8003
|
2432, 2500
|
2201, 2251
|
2516, 2534
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,108
| 121,902
|
43293
|
Discharge summary
|
report
|
Admission Date: [**2148-5-17**] Discharge Date: [**2148-6-5**]
Date of Birth: [**2085-7-5**] Sex: F
Service: SURGERY
Allergies:
Iodine; Iodine Containing / Trileptal / Dilantin
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Polycystic kidneys requiring removal due to size and pain
Major Surgical or Invasive Procedure:
[**2148-5-17**]: Bilateral nephrectomy for polycystic kidney disease
with repair of umbilical hernia.
History of Present Illness:
62 y/o female with end-stage kidney disease secondary to
polycystic kidney
disease. She has recently started hemodialysis. Her chief
complaint is that the kidneys are painful, causing discomfort
and they interfere with her breathing and make it difficult to
get around. She has been advised to have the kidneys removed.
Past Medical History:
PMHx:
- [**Month/Day/Year 93249**] (autosomal dominant w renal/liver involvement, c/b [**Doctor Last Name **]
aneurysmal bleed and ESRD)
- multiple liver cysts
- ESRD [**1-1**] [**Month/Day (2) 18048**]
- subarachnoid hemorrhage 2/2 L MCA [**Doctor Last Name **] aneurysm s/p surgical
clipping c/b peri-operative hemorrhagic stroke resulting in
right hemiparesis([**2136**])
- HTN
- secondary hyperparathyroidism
- anemia
- acidosis
- nephrolithiasis
- stress fracture of the right ankle.
- seizure disorder
.
PSHx:
- s/p appy,
- s/p hysterectomy,
- s/p rectal prolapse repair,
- urethral elevation,
- tonsillectomy as a child,
- eye surgeries,
- aneurysmal repair
Social History:
Lives w husband in [**Name (NI) 86**]. Ambulates w cane. Worked as a city
planner.
Smoking: denies
EtOH: 1 glass of wine/day
Drugs: denies
Family History:
Father and son with [**Name (NI) 18048**].
F - died in his 80s, [**Name (NI) 18048**] and prostate cancer
M - died at [**Age over 90 **] yrs of old age
Sister w [**Name (NI) 11398**].
Physical Exam:
POst Op;
VS: 97.3, 85, 110/60, 15, 100% (intubated)
General: Intubated and sedated
Card: RRR
Lungs: on CMV
Abd: significant hapatomegaly, soft, no peritoneal signs,
appropriately tender
Extr: No edema
Pertinent Results:
On Admission: [**2148-5-17**]
WBC-6.0 RBC-2.73* Hgb-8.5*# Hct-25.8*# MCV-94# MCH-31.3
MCHC-33.1 RDW-17.6* Plt Ct-205
PT-18.1* PTT-36.1* INR(PT)-1.6*
Glucose-147* UreaN-25* Creat-3.1* Na-140 K-3.6 Cl-112* HCO3-18*
AnGap-14
ALT-207* AST-254* AlkPhos-38* TotBili-0.8
Albumin-3.0* Calcium-8.6 Phos-4.0 Mg-1.7
Brief Hospital Course:
62 y/o female with known polycystic kidney disease who presented
for bilateral nephrectomy. On [**2148-5-17**] she underwent bilateral
nephrectomy with repair of umbilical hernia. Surgeon was Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Per Dr.[**Name (NI) 1381**] operative note, the kidneys were quite
large and difficult to remove. Ascites was noted and there was a
significant amount of oozing as her INR was 1.8. She received
FFP and DDAVP during the case. 2 Drains were placed. She also
has a small umbilical hernia that was primarily repaired.
She was not extubated prior to transfer to the PACU. She did
remain on Levophed and received albumin for volume resusciation.
Additional FFP and cryo were administered. She was able to be
extubated about 4 hours later and received an additional 2 units
pRBCs post op.
She was transferred for overnight stay in the SICU. Renal was
consulted and she received hemodialysis via her AVG. On [**5-18**],
she was transferred out of the SICU to the med-surgical unit
where her diet was advanced and tolerated. Hemodialysis was
continued, but was frought with hypotension secondary to volume
loss from high JP drain outputs. Therefore, extravolume was
unable to be removed.
JP drain outputs were high (4000-1000cc/day of ascitic fluid).
She received IV fluid replacements for this. On [**5-20**], she was
noted to be orthostatic during PT evaluation. Nifedipine was
stopped given orthostasis and nephrology adjusted hemodialysis
to prevent excess fluid removal. Lopressor was also stopped.
On [**2148-5-29**], she became hypotensive in dialysis necessitating IV
fluid boluses (3800cc)to maintain sbp in high 70s. She was
transferred to the SICU after having an ABD CT for management.
CT demonstrated fluid collections in both postoperative beds
containing locules of air. There were no findings to suggest
definite abscess at the sites. Innumerable cystic structures
resulting in near complete obliteration of
normal liver parenchyma and architectural distortion from known
polycystic kidney disease. The main portal, left and right
portal veins were patent. There was hyperenhancement of the
gallbladder mucosa, gastric mucosa, and small bowel mucosa.
Hyperenhancement of bilateral adrenal glands may reflect
hypovolemic state. There was hypoenhancement of the
normal-appearing liver parenchyma at the inferior left tip of
the liver. On [**5-30**] fluid was sent from the JP for culture. This
grew vancomycin sensitive enterococcus (also sensitive to
ampicillin and PCN). Cell count revealed wbc count of 110 with
70 polys. Levaquin was started. She completed a seven day course
finishing on [**6-5**].
While in the SICU, she was started on IV albumin 25grams of 5%
every 8 hours, midodrine 5mg [**Hospital1 **], fluid replacements and sodium
chloride tablets (1gram [**Hospital1 **]). Blood pressure stabilized. She
transferred out of the SICU back to the med-[**Doctor First Name **] unit where BP
remained relatively stable. The JP was removed on [**6-2**] -2 weeks
after bilateral nephrectomies. A small amount of ascitic
drainage was noted initially, but this became scant. Albumin was
stopped on [**6-3**] with BP remaining stable. She was ambulating
without complaints of dizziness.
PT was consulted given h/o CVA/brain aneurysm in past and
followed throughout this hospitalization. Initial
recommendations were for rehab due to orthostasis, but this
improved after the SICU stay. She was ambulating independently
and denied dizziness.
Of note, thyroid function tests were checked revealing TSH of
19, T4 6.7 and T3 of 59. Levoxyl was increased to 100mcg from
88mcg. Endocrine was consulted and agreed with plan. Repeat TFTs
were reccommended in one month.
She was discharged home in stable condition. Tolerating a renal
diet and ambulating independently. Hemodialysis was to continue
on the Tues-Thurs-Sat schedule.
Medications on Admission:
renagel 800"', levothyroxine 88', nifedipine 30', metoprolol
50', nephrocaps
Discharge Medications:
1. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO three
times a day: With meals.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Sodium Chloride 1 gram Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily) as needed for
reflux.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily): New dose. Have thyroid function tested in one month.
Disp:*30 Tablet(s)* Refills:*2*
8. Midodrine 5 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) 86**] VNA
Discharge Diagnosis:
polycystic liver and kidney disease s/p bilateral nephrectomy
ESRD
umbilical hernia s/p repair
cirrhosis
Hypothyroid
hypotension secondary to large JP drain output (ascites)
Discharge Condition:
stable
Discharge Instructions:
Please call Dr.[**Name (NI) 1381**] office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, dizziness
No heavy lifting
[**Month (only) 116**] shower
Resume usual dialysis schedule
Have throid function tests checked in one month. Dose of thyroid
replacement was increased while in hospital
Followup Instructions:
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2148-6-13**] 8:00
[**Month/Day/Year **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2148-9-18**] 9:00
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2148-9-19**]
10:00
Completed by:[**2148-6-6**]
|
[
"571.5",
"276.50",
"753.13",
"285.21",
"458.29",
"553.1",
"E879.1",
"585.6",
"403.91",
"789.59",
"751.62",
"588.81",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"53.49",
"55.54"
] |
icd9pcs
|
[
[
[]
]
] |
7386, 7443
|
2431, 6341
|
364, 469
|
7661, 7670
|
2102, 2102
|
8022, 8423
|
1680, 1866
|
6468, 7363
|
7464, 7640
|
6367, 6445
|
7694, 7999
|
1881, 2083
|
267, 326
|
497, 818
|
2116, 2408
|
840, 1507
|
1523, 1664
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,128
| 139,179
|
52398
|
Discharge summary
|
report
|
Admission Date: [**2158-11-18**] Discharge Date: [**2159-1-27**]
Date of Birth: [**2111-11-22**] Sex: M
Service: SURGERY
Allergies:
Bactrim / Flexeril
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
liver transplant [**2159-1-9**]
ERCP with stent placement [**2159-1-18**]
History of Present Illness:
Mr. [**Name13 (STitle) **] is a 46 yo man with HIV (CD4 535; VL <50), HCV
cirrhosis s/p recent hospitalization at [**Hospital1 2025**] for confusion which
was thought to be secondary to prerenal azotemia secondary to
several large volume taps. At home his confusion continued and
he returned to medical care, this time at [**Hospital1 18**] ER, for this
continued complaint. He has reportedly been having [**5-3**] BMS/day
on lactulose and had been continuing to take his rifaximin for
hepatic encephalopathy as well as norfloxacin for SBP ppx.
In the ED, he was found to be trace guaiac positive and to have
a mildly decreased Hct. His ammonia was 128 but according to his
wife this was down from 220 at [**Hospital1 2025**]. His Cr was 2.7 (up form 1.7)
but according to his wife he had been 2.8 at [**Hospital1 2025**].
Past Medical History:
- HCV x 13y- last VL 637,000 genotype I, s/p pegasys treatment;
h/o diuretic resistent ascites and hepatic encephalopathy x 2
episodes
- HIV x 16y: CD4 535 on [**2158-10-16**]; VL <50 on [**2158-10-16**]
- CRI with baseline Cr 1.7
- s/p CCY
- s/p herniorrhaphy
- s/p repair of nasal septum deviation
Social History:
Lives with common law wife of 13 years, [**Doctor First Name **]. has been clean
and sober x 17 years, past use of alcohol, cocaine, heroin and
"everything." Smokes 1/2ppd tobacco. In past was in prison for
1.5 years for illicit drug sales
Family History:
mother - pancreatic cancer, father - bladder cancer, stroke and
diabetes. brother - prostate cancer
Physical Exam:
96.8, 117/67, 82, 95% RA, wt 105kg
Gen; somnolent and minimally arousable, does not follow commands
HEENT: NCAT, psoriasis ofver scalp, scleral icterus, PERRL
Neck: no LAD; cannot assess JVP
Cor: [**3-6**] holosystolic murmur at LUSB, nonradiating, RRR, nl S1
S2
Pulm: diffuse wheezes B
Abd: tense ascites, no BS, NT, cannot assess organomegally
Ext: 3+ pitteing edema B
Neuro: somnolent
Skin: many tatoos; psoriatic plaques, stage 1-2 decub over
buttocks
.
on discharge
Gen: alert and oriented, carries on appropriate conversations
Lungs: clear
Abdomen; soft, NT, minimally distended, no fluid wave, JP
securely in place with serosanguinous fluid, large midepigastric
incision scar c/d/i and healing with staples in place, +BS
Ext: edema improved
Pertinent Results:
LABS: see below: ammonia 128 (per pt's wife was 220 at [**Hospital1 2025**] few
days ago); LFTs below baseline; BUN 84/Cr 2.7; INR 1.7;
platelets 89; Hct 27.5.
.
STUDIES:
RUQ U/s: preliminary report- A large amount of ascites is seen.
A spot for paracentesis was marked in the right mid abdomen.
.
CXR: clear
.
[**11-24**] Abd MRI pending read
.
[**11-22**] UCx + enterococcus, pan [**Last Name (un) 36**] (macrobid, amp)
[**11-24**] UA + few bacteria, [**4-2**] wbc, otherwise clear
.
[**9-18**] Peritoneal fluid: no growth, <30% PMNs, alb<1, gram stain
negative
.
Admit Cr 2.7, Nadir Cr 1.7 (baseline 1.5), discharge Cr
Admit tbili 3.4, peak tbili 6.1, discharge bili
INR
.
Echo:
1. The left atrium is mildly dilated.
2. Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Regional left ventricular wall
motion is normal.
3. The aortic valve leaflets (3) are mildly thickened.
4. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
.
Colonoscopy: normal to cecum
EGD: No varices were noticed. Granularity, friability,
erythema, congestion and abnormal vascularity in the whole
stomach compatible with portal gastropatrhy. Otherwise normal
EGD to second part of the duodenum
[**2159-1-18**] 05:15AM BLOOD WBC-5.2 RBC-3.80* Hgb-11.7* Hct-34.9*
MCV-92 MCH-30.8 MCHC-33.5 RDW-18.1* Plt Ct-74*
[**2159-1-17**] 05:44AM BLOOD WBC-4.8 RBC-3.56* Hgb-11.3* Hct-32.5*
MCV-91 MCH-31.7 MCHC-34.8 RDW-17.9* Plt Ct-61*
[**2159-1-18**] 05:15AM BLOOD Plt Ct-74*
[**2159-1-12**] 11:54AM BLOOD Fibrino-215
[**2159-1-18**] 05:15AM BLOOD Glucose-171* UreaN-46* Creat-1.8* Na-140
K-3.9 Cl-115* HCO3-17* AnGap-12
[**2159-1-18**] 05:15AM BLOOD ALT-109* AST-44* AlkPhos-166*
TotBili-2.4*
[**2159-1-17**] 05:44AM BLOOD ALT-111* AST-50* AlkPhos-200*
TotBili-5.5*
[**1-15**] U/S: Hepatic arterial flow is now more normal in
appearance compared to the prior study but the portal velocities
have increased across the anastomosis from 60-160 cm/sec.
Clinical consideration should be given to the possibility of
significant portal stenosis and correlation with the clinical
and biopsy findings is recommended.
[**1-17**] CTA: no evidence of stenosis, large amount of ascites, 10
x 4 cm infrahepatic hematoma.
[**1-18**] ERCP: Evidence of extravasation of contrast from the
cystic stump, consistent with biliary leak. Status post plastic
CBD stent placement. Filling defects within the biliary system
could be consistent with air, but other causes cannot be
entirely excluded.
Brief Hospital Course:
46 yo man with HIV (CD4 535; VL <50), HCV cirrhosis was being
evaluated for liver transplant and diuretic resistent ascites
who presented with confusion.
He was obtunded/encephalopathic, most likely hepatic
encephalopaty + effect of ambien in patient with poor hepatic
fx. He was admitted and had a basic infectious workup including
diagnostic paracentesis, blood, and urine Cx which were all
negative for infection. Ambien/other sedating meds were held and
he was begun on for goal BM [**6-3**]/day + rifaxamib. His MELD score
on admission was 32 and he was listed for liver transplant.
The patient received a liver transplant on [**2159-1-9**].
Postoperatively he was taken to the SICU, where on POD 1 his
drain output increased and he began to drop his hematocrit. He
was taken to the operating room for washout and control of
bleeding. Postoperatively he was taken back to the SICU in
stable condition. On POD [**3-1**], liver u/s showed patent right,
left, and main hepatic arteries, however without diastolic flow,
and a subhepatic hematoma measuring 8 x 4 x 8 cm. He was
extubated on the morning of POD [**3-30**] and transfered to the
regular floor in the PM in stable condition.
On POD [**8-3**], there was an elevation in his Tbili and alk phos and
a transjugular liver biopsy was obtained, and was indeterminate
for acute cellular rejection. An ultrasound showed good
arterial flow but a questionable portal stenosis. A CTA was
obtained, showing patent hepatic and portal flow, with a large
amount of ascites and a 10 x 4 cm infrahepatic hematoma. JP
drain Tbili checked the following day was 21.9. He underwent
ERCP on POD [**10-6**], and a biliary stent was placed after contrast
was noted to drain from the cystic duct stump. His JP drainage
cleared, and on POD [**12-8**], his drain bilirubin was measured at
0.8.
His drain output decreased. On POD 17/16, his drain was taken
off of bulb suction, and on POD 18/17, his drain was removed and
the site sutured with 3-0 nylon suture. He was discharged to
home on POD19/18 with follow-up with Dr. [**Last Name (STitle) 816**].
Medications on Admission:
Furosemide 120 mg per day,
Aldactone 300 mg per day,
Epivir 300 mg per day,
lactulose 45 cc per day,
rifaximin 400 mg three times a day,
tenofovir 300 mg per day,
quinine sulfate 260 mg as needed,
Sustiva 600 mg per day,
Ambien CR 6.25 mg po once daily,
Prilosec 40 mg per day,
albuterol inhaler 1-2 puffs q4-6h,
Dovonex cream,
and (----------?dosevan) as needed.
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. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. Efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
6. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Prednisone 5 mg Tablet Sig: 3.5 Tablets PO once a day for 6
days: Continue until [**2-3**], then drop to 3 tablets (15 mg)
Continue taper as directed by transplant clinic.
10. Lamivudine 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO 2X/WEEK (MO,TH).
12. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
13. Insulin Syringe Syringe Sig: One (1) syringe
Miscellaneous for insulin.
Disp:*1 Box* Refills:*3*
14. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
Disp:*180 Capsule(s)* Refills:*2*
15. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO twice a
day: Take three 1mg capsules and one 0.5 mg capsule together
(for a total dose of 3.5 mg) twice a day.
Disp:*60 Capsule(s)* Refills:*2*
16. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
17. Insulin Glargine 100 unit/mL Solution Sig: Nine (9) Units
Subcutaneous at bedtime.
Disp:*1 bottle* Refills:*2*
18. Insulin Lispro (Human) 100 unit/mL Solution Sig: Per sliding
scale Subcutaneous Per sliding scale.
Disp:*1 Bottle* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary Diagnosis: ESLD awaiting transplantation.
- HCV x 13y- last VL 637,000 genotype I, s/p pegasys treatment;
currently being evaluated for possible liver transplant
candidacy; h/o diuretic resistent ascites and hepatic
encephalopathy x 2 episodes
- HIV x 16y: CD4 535 on [**2158-10-16**]; VL <50 on [**2158-10-16**]
- s/p liver transplant
Discharge Condition:
good
Discharge Instructions:
Call Transplant office if fevers, chills, nausea, vomiting,
inability to take medications, abdominal pain, jaundice,
increased drainage from drain, bleeding/redness/pus at drain
site or from incision, lightheadedness.
Labs every Monday & Thursday for cbc, chem 10, ast, alt, alk
phos, tbili, albumin and trough prograf level.
Please do not drive while taking narcotic pain medications.
Please take all medications as prescribed.
Please follow up as directed.
Follow Up HIV Viral load at clinic visit
Take 3.5 mg of Prograf twice a day, unless instructed otherwise
Followup Instructions:
Please follow-up as directed.
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2159-2-1**]
8:10
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2159-2-1**]
10:00
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2159-2-8**]
8:20
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
|
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75,737
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36747
|
Discharge summary
|
report
|
Admission Date: [**2190-10-30**] Discharge Date: [**2190-11-5**]
Date of Birth: [**2113-1-8**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
PICC removal
History of Present Illness:
Ms. [**Known lastname 76883**] is a 77 year old woman with a history of chronic
pulmonary fibrosis on chronic prednisone therapy who has had a
significant functional decline since [**2190-5-17**] when she
underwent an abdominal surgery to correct a colovescicular
fistula that presented to the ED with unresponsiveness. From
[**Date range (1) 83080**] she was admitted to the [**Hospital1 18**] with back pain and was
diagnosed with [**Female First Name (un) 564**] Albicans Vertebral Osteomylelitis,
health-care associated pneumonia and an enterococcal UTI.
Patient reportedly had several episodes of unresponsiveness
during her prior [**Hospital1 18**] admission and underwent neurologic
evaluation. Infection was felt to be the most likely etiology
of her episodes of unresponsiveness and she was not started on
any anti-seizure medications. She was treated with vancomycin,
cefepime and fluconazole and discharged on [**2190-10-26**] to [**Hospital 21585**]
Rehab. On the day of admission she was noted at rehab to be
unresponsive and febrile. She was transferred to the [**Hospital1 18**] for
further evaluation.
In the ED patient was found to be hypotensive and hypoxic
(initial vitals were: T 98 P 80 BP 85/20 RR10 88% O2 sat on
NRB). Patient was given metronidazole, vancomycin, and cefepime
and 2L normal saline and admitted to the [**Hospital Ward Name 332**] ICU.
Past Medical History:
Interstitial Pulmonary Fibrosis, not oxygen dependent
[**Female First Name (un) 564**] albicans vertebral osteomyelitis
L1-L2 compression fracture
Spinal stenosis
Rheumatoid arthritis
Hypothyroidism
Anemia
Stage IV Decubitus ulcer
Recent diverticulitis s/p sigmoid colectomy
Colovesciular fistula s/p laparotomy and take-down with
coloproctostomy
s/p tonsillectomy
Anxiety
Depression
Social History:
Lived with husband at home until [**5-25**]. Up until that time she
was independent with ADLs and kept physically active (raking
leaves, able to go up and down stairs at home). Following her
surgery her mobility and ability to perform ADLs was impaired by
her back and leg pain. Her husband is terminally ill with
metastatic lung cancer. Both she and her husband moved into a
[**Name (NI) 1501**] following her surgery in [**Month (only) **]. Denies tobacco, alcohol,
illicit drugs.
Family History:
Mother died of MI
Two brothers died of MI in 60s-70s
Physical Exam:
On Admission to [**Hospital Unit Name 153**]:
T=96.9 BP=122/52 HR=96 RR=21 O2= 93% on 4L
PHYSICAL EXAM
General: NAD
Neck: Supple, no JVD, no LAD
Cardiac: RRR, systolic murmur in RUSB.
Resp: Rhonchi and mild wheezing throughout, mild crackles at
bases
GI: Soft, NT/ND, +BS, no organomegaly, guiac trace +
Extremities: 2+ DP pulses and 2+ radial pulses.
Neurologic: A&O x3. DTR 3+ in R patella, 2+ in L patella. UE
reflexes +2 bilaterally. Sensation grossly intact. Pupils
sluggishly reactive. Good finger to nose with left hand and
difficulty on right secondary to
Motor: LE strength 3+/5 in quads and dorsiflexion. 4+/5
planterflexion
Delt Tri [**Hospital1 **] Grip
R 4 4- 4- 5
L 4 5- 5- 4+
On Transfer to Floor:
Vitals: T: 98.4 BP: 100/55 P: 93 R: 16 O2: 97% RA
General: Alert, oriented, complaining of back pain
HEENT: Left pupil sluggish 4mm to 3mm; Right pupil non-reactive
Sclera anicteric, cataract in right eye, dry MM, oropharynx
clear
Neck: supple, JVP not elevated, no LAD
Lungs: Expiratory crackles and rhonchi in bases bilaterally left
greater than right
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, large
well-healed scar down center of badomen approx. 20cm in length
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Back: Large grade IV decubitus ulcer in midback that is packed;
5cmx1cm grade I decubitus ulcer over sacrum
Skin: paper-thin skin; skin scrape on left lower leg and left
arm both approx. 2x3cm in size
Neuro: CNII-XII intact; decreased strength throughout right (3)
worse than left (4) in both upper and lower extremitis;
sensation grossly intact; DTRs 2+; [**Name2 (NI) **] 2+
Pertinent Results:
*****************
CBC
*****************
[**2190-10-30**] 11:40PM [**Month/Day/Year 3143**] WBC-25.4* RBC-3.12* Hgb-8.3* Hct-26.1*
MCV-84 MCH-26.6* MCHC-31.8 RDW-17.8* Plt Ct-528*
[**2190-10-31**] 09:26AM [**Month/Day/Year 3143**] WBC-25.0* RBC-2.94* Hgb-7.7* Hct-25.2*
MCV-86 MCH-26.1* MCHC-30.5* RDW-17.4* Plt Ct-489*
[**2190-11-1**] 04:07AM [**Month/Day/Year 3143**] WBC-16.8* RBC-2.92* Hgb-7.8* Hct-25.1*
MCV-86 MCH-26.6* MCHC-30.9* RDW-16.9* Plt Ct-524*
[**2190-11-2**] 03:48AM [**Month/Day/Year 3143**] WBC-13.2* RBC-3.33* Hgb-8.7* Hct-27.3*
MCV-82 MCH-26.2* MCHC-31.9 RDW-16.9* Plt Ct-544*
[**2190-11-3**] 06:41AM [**Month/Day/Year 3143**] WBC-10.2 RBC-2.90* Hgb-7.8* Hct-24.4*
MCV-84 MCH-26.8* MCHC-31.9 RDW-17.6* Plt Ct-506*
[**2190-11-3**] 01:42PM [**Month/Day/Year 3143**] WBC-13.7* RBC-3.17* Hgb-8.3* Hct-27.3*
MCV-86 MCH-26.4* MCHC-30.5* RDW-17.0* Plt Ct-566*
[**2190-11-3**] 07:39PM [**Month/Day/Year 3143**] Hct-25.8*
[**2190-11-4**] 06:05AM [**Month/Day/Year 3143**] WBC-11.3* RBC-2.99* Hgb-7.7* Hct-25.4*
MCV-85 MCH-25.8* MCHC-30.4* RDW-17.1* Plt Ct-523*
*****************
DIFF
*****************
[**2190-10-30**] 11:40PM [**Month/Day/Year 3143**] Neuts-91.1* Lymphs-7.0* Monos-1.8* Eos-0
Baso-0.1
[**2190-11-3**] 01:42PM [**Month/Day/Year 3143**] Neuts-84.6* Lymphs-10.0* Monos-4.3
Eos-1.0 Baso-0.1
*****************
ELECTROLYTES
*****************
[**2190-10-30**] 11:40PM [**Month/Day/Year 3143**] Glucose-88 UreaN-29* Creat-0.7 Na-142
K-4.5 Cl-106 HCO3-29 AnGap-12
[**2190-10-31**] 09:26AM [**Month/Day/Year 3143**] Glucose-97 UreaN-25* Creat-0.5 Na-142
K-4.2 Cl-109* HCO3-26 AnGap-11
[**2190-11-1**] 04:07AM [**Month/Day/Year 3143**] Glucose-162* UreaN-17 Creat-0.5 Na-135
K-4.4 Cl-102 HCO3-30 AnGap-7*
[**2190-11-2**] 03:48AM [**Month/Day/Year 3143**] Glucose-95 UreaN-9 Creat-0.5 Na-135 K-3.6
Cl-97 HCO3-31 AnGap-11
[**2190-11-3**] 06:41AM [**Month/Day/Year 3143**] Glucose-175* UreaN-11 Creat-0.5 Na-129*
K-4.5 Cl-95* HCO3-29 AnGap-10
[**2190-11-3**] 01:42PM [**Month/Day/Year 3143**] Glucose-205* UreaN-10 Creat-0.5 Na-130*
K-4.6 Cl-97 HCO3-28 AnGap-10
[**2190-11-3**] 07:39PM [**Month/Day/Year 3143**] UreaN-10 Creat-0.4 K-4.5
[**2190-11-4**] 06:05AM [**Month/Day/Year 3143**] Glucose-96 UreaN-9 Creat-0.4 Na-135 K-4.6
Cl-103 HCO3-27 AnGap-10
******************
OTHER LABs
******************
[**2190-11-4**] 06:05AM [**Month/Day/Year 3143**] Hapto-389*
[**2190-11-1**] 12:53PM [**Month/Day/Year 3143**] TSH-5.0*
[**2190-11-2**] 03:48AM [**Month/Day/Year 3143**] T3-68* Free T4-1.1
[**2190-10-30**] 11:56PM [**Month/Day/Year 3143**] Lactate-2.4*
********************
IMAGING AND STUDIES
********************
ECG: [**2190-10-30**]:
Sinus rhythm. Atrial ectopy. Compared to the previous tracing
the rate is
slower and atrial ectopy is new.
CXR [**2190-10-30**]:
1. Multifocal opacities concerning for multifocal pneumonia.
2. Diffuse hazy interstitial markings, compatible with
superimposed pulmonary edema.
3. Small Bilateral Pleural Effusions
EEG [**2190-11-2**]: Resultings Pending
Femur Xray (left) [**2190-11-3**]:
No fracture or focal bone lesion detected involving the left
femur.
MRI Head w and w/o contrast [**2190-11-3**]:
A few scattered areas of high signal intensity identified at the
subcortical and periventricular white matter, likely consistent
with chronic microvascular ischemic changes. There is no
evidence of acute hemorrhage, mass, or territorial infarction.
No diffusion abnormalities are detected. After the
administration of gadolinium contrast, there is no evidence of
abnormal enhancement.
MICROBIOLOGY
[**2190-10-30**] - [**Year (4 digits) **] Cultures NGTD
[**2190-10-30**] - Urine Cultures NGTD
[**2190-10-31**] - MRSA negative
[**2190-10-31**] - Influenza A/B - negative
Brief Hospital Course:
Ms. [**Known lastname 76883**] is a 77 year old woman with a history of chronic
pulmonary fibrosis on chronic prednisone therapy who has had a
significant functional decline since [**2190-5-17**] when she
underwent an abdominal surgery to correct a colocovescicular
fistula that presented four day ago to the ED with
unresponsiveness.
* Altered mental status:
On admission, the patient was initially alert and unoriented.
Neurology was consulted and recommended Keppra for seizure
prophylaxis although there was never any evidence that the
patient was having seizures. On the second day of admission, the
patient was found to be unresponsive. Vital signs were within
normal limits. [**Year (4 digits) **] glucose was 102. ABG was 7.42/52/65. The
patient was given Narcan 0.1 mg with immediate response. The
patient was made NPO, and all sedating medications were
discontinued. The patient's mental status waxed and waned
throughout the day, requiring a second a third bolus of
naltrexone with the third bolus followed by a Narcan drip. The
neurology service felt that he patient's intermittent
unresponsiveness improved with naltrexone was clearly
medication-related, with no need for repeat head CT and no
concern for seizure activity, with no need to continue Keppra.
The neurology service felt that gabapentin could be discontinued
as well. On the morning of [**2190-11-2**] (the third day of
admission), the naltrexone drip was discontinued, and the
patient remained alert and oriented throughout the day. Low dose
gabapentin and hydromorphone were added for pain control in
accordance with the recommendations of the chronic pain team.
After further discussion with the patient's family, it was noted
that the patient's mental status changes were first noted the
day after she started fluconazole. It was hypothesized that a
pharmacokinetic interaction between methadone and fluconazole,
with fluconazole increasing methadone levels, might be
responsible for the patient's episodes of unresponsiveness. Her
methadone ws discontinued. She was transferred to the floor
with no further episodes of unresponsiveness. A repeat MRI was
unremarkable. An EEG was done consistent with diffuse slowing
without epileptiform activity.
* Pneumonia:
CXR showed multifocal pneumonia. The patient was swabbed for
influenza and treated with oseltamivir until the swab came back
negative. The patient was continued on the antibiotics she came
in on, cefepime and vancomycin, and ciprofloxacin was added for
double pseudomonas coverage given radiograph was concerning for
worsened pneumonia. She completed a full 14 day course of
antibiotics on [**2190-11-4**]. She remained afebrile >24 hours after
cessation of antibiotic therapy. She should have a follow up
chest radiograph in [**3-22**] weeks to document resolution of her
pneumonia.
* [**Female First Name (un) 564**] Albicans Vertebral Osteomyelitis:
The patient was placed on log roll precautions, and she used her
TLSO brace at all times if >30 degrees. Fluconazole 400mg was
continued until day 4 of admission when she was changed to 200mg
fluconazole per ID. The patient was seen by neurosurgery who did
not recommend any intervention but wanted to have outpatient
neurosurgery follow-up. Patient will also have outpatient ID
follow-up
* Pain
Patient was on methadone and gabapentin for pain control on
admission. Her unresponsiveness was believed to be due to
methadone stacking in the context of taking fluconazole when she
responded to narcan. Her methadone and gapapentin were
initially stopped in the ICU. After her mental status improved
she was started on IV dilauded and restarted on gabapentin per
the pain service's recommendations. On the floor she was
transitioned to po hydromorphone with improvement in symptoms
and no further episodes of unresponsiveness.
* Leg Pain
Patient complained of severe [**9-25**] left upper leg pain upon
leaving the ICU and arriving on the floor. A radiograph was
done that showed no evidence of a fracture. Exam was
unremarkable. Pain was belived to be sciatic in nature. She
was started on standing tylenol and lidocaine patches.
* Chronic Normocytic Anemia:
The patient's hematocrit remained stable while in the hospital
ranging from 24.4 to 27.3. She was guiac negative. Patient was
not transfused.
* Compression fracture/osteoporosis:
The patient continued calcium, ergocalciferol, and calcitonin.
Alendronate was not ordered given the patient's altered mental
status and recumbant position. Patient has outpatient
neurosurgery follow-up and wears a TLSO brace.
* Idiopathic pulmonary fibrosis:
Continued home Prednisone 5 mg daily
* Hypothyroid:
Continued on Levothyroxine 75 mcg PO daily. Checked TSH, which
was 5.0, with free T4 1.1 and T3 68.
* Depression/Anxiety:
Continued home citalopram. Mirtazapine was also started started
to help with patient's depression/anxiety and to stimulate her
appetite.
* Skin Ulcers:
The wound care service was consulted and made recommendations
for local care. On discharge, the extended care facility where
the patient is going has been provided with instructions on
wound care.
* Nutrition:
Speech and swallow evaluated the patient for dysphagia and
recommended a diet of thin liquids and pureed then soft solids
with pills taken whole with purees.
The patient received SC heparin for DVT prophylaxis. During a
previous admission she had been DNR/DNI but after discussion
with her and her daughter in law she elected to be full code
during this admission.
Medications on Admission:
-Citalopram 20 mg PO daily
-Vancomyicin 750 mg IV BID
-Cefepime 2 mg IV daily
-Fluconazole 400 mg PO daily
-Gabapentin 300 mg PO TID
-Methadone 15 mg PO QAM and 10 mg PO QPM?
-Amlodipine 10 mg PO daily
-Senna 1 tab PO BID
-Docusate 100 mg PO BID
-MVI
-Calcitonin 200 unit spray daily
-Vitamin C 500 [**Hospital1 **]
-Calcium +D
-Alendronate 70 mg PO QSat
-Zinc 220 mg PO daily
-Levothyroxine 75 mg PO daily
-Prednisone 5 mg PO daily
-APAP 650 mg PO Q6hr:PRN
Discharge Medications:
1. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) Nasal DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation: hold if patient develops
diarrhea.
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q24 HRS (): 12 hours
on; 12 hours off.
12. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
14. Outpatient Lab Work
Please check weekly ALT, AST, TBili, Alkaline Phophatase, and
LDH and fax results to infectious disease clinic at [**Telephone/Fax (1) 1419**]
15. Gabapentin 250 mg/5 mL Solution Sig: One [**Age over 90 **]y Five
(125) mg PO three times a day.
16. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
On Saturday.
17. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week.
18. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation: hold for loose stools.
19. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
20. Hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily)
as needed for with dressing changes.
21. Hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO q3h:prn as
needed for pain.
22. Calcium 500 With D 500 mg(1,250mg) -400 unit Tablet Sig: One
(1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis
Altered Mental Status
[**Hospital 83081**] [**Hospital 9687**]
Hospital Acquired Pneumonia
[**Female First Name (un) 564**] Albicans Osteomyelitis
Vertebral Compression Fractures
Discharge Condition:
Stable.
Discharge Instructions:
You came into the hospital after several episodes of
unresponsiveness. Several tests were done and no cardiac or
neurological etiology of your episodes was found. We believe
that these episodes were a result of methadone stacking in the
context of the fluconazole that you were taking for the
infection in your spine. Fluconazole can inhibit the excretion
of methadone. We therefore recommend that you do not take
methadone while on the fluconazole.
For the infection in your spine we would like you to continue to
take the fluconazole. We have a follow-up appointment set up
for you with an Infectious disease doctor [**First Name (Titles) **] [**Last Name (Titles) 1096**] who will
help you to determine the appropriate management of this
infection and duration of treatmment.
For the compression fracture in your back, we encourage you to
continue to wear the TLSO brace when sitting up at > 30 degrees.
You also came into the hospital on antibiotics for an pneumonia
that you acquired during a previous hospitalization. We
completed this course of antibiotics for a full 14 day course.
You do not need to take any further antibiotics once you leave
the hospital.
While in the hospital you complained of leg pain. A radiograph
was done that showed no evidence of a fracture. Your symptoms
are most consistent with sciatica.
To manage your pain we recommend the following treatment:
- Tylenol 1000mg three times a day
- Lidocaine patches 5% 12 hours on; 12 hours off
- Hydromorphone 0.5mg po every three hours for breakthrough pain
or when you are having your wound dressings changed
Please continue your prednisone for your rheumatoid arthritis
and lung disease. Please continue your levothyroxine for your
hypothyroidism.
For your depression and anxiety we recommend that you continue
your citalopram and we started you on mirtazapine, which should
both help your mood and also your appetite.
We recommend that you attempt to advance your diet as you are
able to, to a regular diet. When eating, wear your brace and
sit up to avoid aspirating.
You should seek immediate medical attention should you develop
any chest pain, SOB, tingling or numbness in your lower
extremities, or incontinence or any other concerning symptoms.
Followup Instructions:
XRAY
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) 551**]
Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2190-11-16**] 1:25
ORTHOPEDICS
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) **]
Dr. [**First Name (STitle) **] [**Name (STitle) 2719**] MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2190-11-16**] 1:45
NEUROSURGERY
[**Hospital Unit Name **], Basement, [**Last Name (NamePattern1) 439**]
Dr. [**Last Name (STitle) 739**] Phone:[**Telephone/Fax (1) 1669**] Date/Time:[**2190-11-24**] 10:00
INFECTIOUS DISEASE
[**Hospital Unit Name **], Basement, [**Last Name (NamePattern1) 439**]
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: ([**Telephone/Fax (1) 4170**] Date/Time: [**2190-11-29**] 9:00
|
[
"276.1",
"244.9",
"V54.89",
"733.13",
"276.50",
"338.29",
"041.04",
"285.29",
"780.09",
"V45.89",
"714.0",
"707.24",
"507.0",
"112.89",
"733.00",
"707.03",
"300.4",
"V58.65",
"730.28",
"V44.3",
"599.0",
"E928.9",
"E935.1",
"515"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
16471, 16541
|
8347, 8693
|
337, 352
|
16783, 16793
|
4583, 8324
|
19089, 19857
|
2688, 2742
|
14382, 16448
|
16562, 16762
|
13899, 14359
|
16817, 19066
|
2757, 4564
|
276, 299
|
380, 1763
|
8708, 13873
|
1785, 2171
|
2187, 2672
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,483
| 187,941
|
33761
|
Discharge summary
|
report
|
Admission Date: [**2124-5-6**] Discharge Date: [**2124-5-8**]
Date of Birth: [**2048-2-29**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
76M well known to Dr. [**Last Name (STitle) 468**] who became hypotensive in rehab
and
is now being transferred from [**Hospital3 10310**] Hospital for
further management.
Patient was admitted in [**1-21**] for gallstone pancreatitis
complicated by pancreatic necrosis and pseudocyst formation. He
had a prolonged ICU stay, underwent tracheostomy, open GJ-tube
and percutaneous cholecystostomy tube in addition to pigtail
drainage of the pseudocyst during his two-month long admission.
In rehab his perc chole tube fell out and he was subsequently
taken to the OR for open subtotal cholecystectomy with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
drain placed in the gallbladder fossa. Unfortunately, he
developed a wound infection requiring opening of the involved
portion of his incision. Suspicion for a bile leak was confirmed
with percutaneous cholangiography and an internal/external PTC
drain was placed [**4-7**]. Pull-back cholangiogram also demonstrated
a distal CBD stricture. He was ultimately discharged to rehab on
[**5-1**] with the PTC capped and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] in the biloma.
On day 2 in rehab the staff noted his SBP to be in the 80's, but
was reportedly asymptomatic during the event. He had no fevers,
chills, nausea, abdominal pain, cough or dysuria. He was sent to
[**Hospital3 10310**] Hospital where he was found to be afebrile with
HR 67 and BP 94/58; he still had no complaint and was mentating
well. WBC there was 17.7 with 13% bands and normal LFTs. Chest
CTA was (-)PE but notable for LLL PNA. He was initiated on
vancomycin & levofloxacin prior to his transfer to [**Hospital1 18**].
Past Medical History:
Severe Acute pancreatitis [**1-21**]
CAD s/p MI [**30**] years ago, HTN, hyperlipidemia, obesity, OA,
BPH, duodenal ulcer, diabetes
Atrial fibrillation
[**2124-1-21**] ECHO EF 70%
PSH: Open Tracheostomy [**2124-2-4**]; Open G/J tube placement [**2124-2-11**];
Percutaneous Cholecystostomy tube placed on [**2124-2-17**].
B TKR (most recent R TKR [**2124-1-5**])
Social History:
Retired contractor, living with 2nd wife. [**Name (NI) **] a daughter and 4
sons. Quit smoking 15 yrs. ago. No history of alcohol and
IVDU.
Family History:
Parents - hypertension
Mom - CVA
Physical Exam:
PE: 96.8 51 103/47 23 98%/RA
Gen: NAD, A&Ox3, MM dry (-)scleral icterus
Pul: slightly diminished B bases
Cor: RRR
Abd: soft/ND (-)tenderness (-)guarding (-)rebound (-)tympani;
[**Doctor Last Name **](scant pus) and PTC in place with minimal erythema
Pertinent Results:
[**2124-5-6**] 05:49PM GLUCOSE-108* UREA N-10 CREAT-0.7 SODIUM-136
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-24 ANION GAP-11
[**2124-5-6**] 05:49PM estGFR-Using this
[**2124-5-6**] 05:49PM ALT(SGPT)-15 AST(SGOT)-15 ALK PHOS-102
AMYLASE-39 TOT BILI-0.3
[**2124-5-6**] 05:49PM LIPASE-28
[**2124-5-6**] 05:49PM ALBUMIN-2.1* CALCIUM-8.0* PHOSPHATE-2.9
MAGNESIUM-1.7
[**2124-5-6**] 05:49PM WBC-10.0 RBC-3.17* HGB-9.1* HCT-28.7* MCV-90
MCH-28.8 MCHC-31.9 RDW-15.3
[**2124-5-6**] 05:49PM NEUTS-72* BANDS-11* LYMPHS-6* MONOS-10 EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2124-5-6**] 05:49PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL SPHEROCYT-OCCASIONAL
[**2124-5-6**] 05:49PM PLT COUNT-276
[**2124-5-6**] 05:49PM PT-14.1* PTT-28.2 INR(PT)-1.2*
[**5-7**] CT
Innumerable intra-abdominal and pelvic fluid collections many of
which are contiguous with each other. Some of these collections
have slightly increased in size and the rest are not
significantly changed. Multiple gas pockets are now evident
within some of the collections, now contain pockets of gas
within them, new since the prior study. The significance of this
finding is not clear in the setting of multiple intra-abdominal
drains. However, superinfection of these pancreatic pseudocysts
cannot be excluded.
[**5-7**] CXR
A new left lower lobe opacity obscuring the hemidiaphragm and
part of the left heart border with leftward mediastinal shift is
demonstrated, findings consistent with left lower lobe
atelectasis and is new since a prior study. There is also small
left pleural effusion present most likely unchanged compared to
the prior film. The left upper lung is unremarkable. The
evaluation of right lung demonstrates faint opacity in the right
upper lobe slightly obscuring the upper portion of the right
hilus which might represent atelectasis or developing pneumonia.
A small right pleural effusion is also present.
Multiple catheters projecting over the right upper quadrant are
demonstrated, new since the prior study and their precise
definition is difficult in the absence of clinical history.
Brief Hospital Course:
The patient was admitted to Gold Surgery for management of his
hypotension and possible pneumonia. The patient was admitted to
the ICU and started on vanc/levo. The patient had an uneventful
ICU course and was transferred to the floor on HD 2. We held
the patient's lisinopril and atenolol for hypotension, and the
patient was normotensive throughout the hospital course. On
[**5-7**], the PTC drain was capped without complications or acute
events. Upon discharge, the patient is afebrile with all vitals
stable, tolerating po feeds, ambulating, and with pain
controlled. The patient will be discharged off of his atenolol
and lisinopril with instruction to follow up with PCP to
cautiously restart his BP meds.
Medications on Admission:
Amiodarone 200'', Ursadiol 300'', Atenolol 25', Lisinopril ',
Pantoprazole 40', Simvastatin 20', Terazosin 10', Finasteride
5', Viokase ''''
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Month/Year (2) **]: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
2. Amiodarone 200 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times
a day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Amylase-Lipase-Protease 30,000-8,000- 30,000 unit Tablet [**Month/Year (2) **]:
One (1) Tablet PO QID (4 times a day).
5. Simvastatin 10 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY
(Daily).
6. Finasteride 5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
7. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
8. Ursodiol 300 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO BID (2 times
a day).
9. Levofloxacin 500 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
10. Terazosin 5 mg Capsule [**Month/Year (2) **]: Two (2) Capsule PO HS (at
bedtime).
11. Senna 8.6 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day) as needed.
12. Paroxetine HCl 20 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a
day.
13. Colace 100 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO twice a day.
14. Viokase 16 935 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO four times a
day.
Discharge Disposition:
Extended Care
Facility:
[**Month (only) 53281**] Rehabilitation & Nursing Center - [**Location (un) 28318**]
Discharge Diagnosis:
Hypotension
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please note the changes made in your medications. We are
holding your atenolol and lisinopril because of your low blood
pressure.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* No heavy lifting (>[**9-27**] lbs) for 6 weeks.
* Monitor your incision for signs of infection
* You may shower and wash. No tub baths or swimming. Keep your
incision clean and dry.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 476**] Date/Time:[**2124-5-22**]
11:30
|
[
"V43.65",
"401.9",
"412",
"427.31",
"250.00",
"577.2",
"458.9",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7426, 7537
|
5082, 5802
|
323, 330
|
7592, 7601
|
2936, 5059
|
9245, 9388
|
2606, 2640
|
5994, 7403
|
7558, 7571
|
5828, 5971
|
7625, 9222
|
2655, 2917
|
272, 285
|
358, 2043
|
2065, 2430
|
2446, 2590
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,229
| 159,913
|
16153
|
Discharge summary
|
report
|
Admission Date: [**2184-12-30**] Discharge Date: [**2185-1-12**]
Date of Birth: [**2112-6-18**] Sex: F
Service: MEDICINE
Allergies:
Morphine
Attending:[**Doctor First Name 3290**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
EGD x 2
History of Present Illness:
72F on warfarin and aspirin for AF, CHF EF 35%, CAD/PVD s/p
multiple stents and interventions, admit 7 months ago for UGIB
from ulcer requiring massive transfusion p/w 2 days of abd
cramps, dry heaves, and today with black tarry guiac + stools.
She states she was feeling fine prior to two days ago, noted
feeling increasingly fatigued yesterday. Had a BM that may have
been melena, but didn't see it. This AM she had a dark stool and
felt extremely weak, called her son to take her to the [**Name (NI) **].
.
Of note in [**2184-4-13**] patient had severe UGIB requiring massive
transfusion. EGD at that time showed large necrotic duodenal
lesion of unclear nature near a dudenal diverticulum. Colonic
diverticulosis was seen on CT abdomen/pelvis. At the time, she
declined surgical intervention so prophylactic embolization of
the gastroduodenal artery was performed by IR. Warfarin + low
dose aspirin were restarted at discharge due to her high risk of
stroke in the setting of Afib + CAD with s/p stents.
.
.
On presentation to the ED patient was hypotensive to the 80s, HR
100. Hct was 24.7 from baseline 30. Creatinine 2.2 from baseline
1.6-2.1. INR 2.7. She received 1200cc NS, 1 unit pRBCs, 1 unit
frozen plasma and 5mg IV Vit K. NG lavage with small amount of
coffee grounds that cleared after 500cc. Advanced IJ (3 lumen
and sheath) and PIV placed. Started on protonix drip with bolus
and admitted to the ICU for close monitoring and EGD. Vital
signs on transfer were 105/48, 98 20 96%RA.
.
.
On the floor, pt is complaining of lower abdominal tenderness,
feeling unwell, mostly disturbed by the NG tube. GI came to
evaluate the patient, EGD showed several gastric and duodenal
lesions. Prior to further assessment, pt had an aspiration event
and procedure was emergently discontinued. O2 sats dropped
briefly then improved.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
1. Diabetes
2. Hypertension
3. Coronary artery disease
- MI [**2168**]
- PCI [**2173-6-29**]
- Cath [**7-21**]
4. Atrial fibrillation
5. CHF, EF 35% ([**Hospital1 112**] TTE on [**11/2182**]), LVH, mod TR/pulm HTN
6. PVD s/p multiple lower ext bypasses
7. CKD (baseline Cr 1.2)
8. Colonic adenoma (on [**2180-4-13**])
9. Anxiety
10. Gout
Social History:
Lives with daughter, spends most of the day alone, but has a
"lifeline" for emergencies. Able to get up and down her stairs
with some difficulty.
Occupation: homekeeper
Tobacco: quit in [**2178**], 10pack years,
EtOH: denies
Family History:
Lung cancer - son
CAD/PVD - mother, maternal grandmother
Physical Exam:
ADMISSION 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,
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
Pertinent Results:
ADMISSION LABS:
[**2184-12-30**] 12:10PM BLOOD WBC-8.4 RBC-3.04* Hgb-8.0* Hct-24.7*
MCV-81* MCH-26.3*# MCHC-32.3 RDW-16.6* Plt Ct-244#
[**2184-12-30**] 12:10PM BLOOD Neuts-80.3* Lymphs-15.6* Monos-3.0
Eos-0.9 Baso-0.4
[**2184-12-30**] 10:20AM BLOOD PT-28.0* PTT-26.0 INR(PT)-2.7*
[**2184-12-30**] 10:20AM BLOOD Glucose-157* UreaN-129* Creat-2.2*#
Na-139 K-4.7 Cl-103 HCO3-22 AnGap-19
[**2184-12-30**] 10:20AM BLOOD ALT-18 AST-23 AlkPhos-54 TotBili-0.2
[**2184-12-30**] 10:20AM BLOOD Lipase-36
[**2184-12-30**] 10:20AM BLOOD cTropnT-<0.01
[**2184-12-30**] 10:20AM BLOOD Calcium-9.2 Phos-3.0 Mg-2.2
[**2185-1-3**] 04:20AM BLOOD Triglyc-195*
[**2184-12-31**] 09:57PM BLOOD Type-MIX pO2-63* pCO2-51* pH-7.24*
calTCO2-23 Base XS--5 Intubat-INTUBATED
[**2184-12-31**] 09:57PM BLOOD Glucose-160* Lactate-1.7 Na-142 K-5.7*
Cl-117*
[**2184-12-31**] 09:57PM BLOOD Hgb-9.0* calcHCT-27
[**2184-12-31**] 09:57PM BLOOD freeCa-1.00*
[**2185-1-12**] 07:20AM BLOOD WBC-10.9 RBC-5.10 Hgb-15.1 Hct-43.8
MCV-86 MCH-29.6 MCHC-34.4 RDW-14.9 Plt Ct-583*
[**2185-1-12**] 07:20AM BLOOD Glucose-134* UreaN-67* Creat-1.8* Na-139
K-4.3 Cl-102 HCO3-20* AnGap-21*
Brief Hospital Course:
72F on Coumadin and baby ASA for AF, CHF EF 35%, CAD/PVD s/p
multiple stents and previous admission in [**4-/2184**] for UGIB from a
peridiverticular duodenal lesion admitted for GIB.
ACTIVE ISSUES
# Gastrointestinal bleed: Initially suspected to be UGIB. Pt
had coffee grounds on NG lavage and had documented h/o
persistent gastritis despite PPI therapy. Pt was on
anticoagulation and antiplatelet therapy. Was hemodynamically
stable on admission and underwent EGD which showed two small
ulcers in the stomach body with overlying clots as well as non
invasive gastritis, but EGD terminated prematurely when patient
went into V-tach and was shocked twice before stabilizing. This
occurred shortly after intubation. Pt remained intubated and
admitted to [**Hospital Unit Name 153**], where she was monitored with q6h Hct checks
and transfused numerous times to maintain a Hct > 30. She was
placed on pressors. She was also given vitamin K and aspirin,
anti-hypertensives and coumadin were held. She self-extubated
the morning after admission and was breathing well on her own,
but was re-intubated on HD3 for repeat EGD. Second EGD showed a
few small ulcers in the stomach body with old blood as well as
angioectasias of the stomach body which were clipped and
injected with epinephrine. She also had duodenal ulcers and a
duodenal diverticulum, at which fresh blood was seen. She was
then sent to IR for embolization, where she got 300cc of
contrast during procedure. Bleed was not identified after 4h
search. During procedure got PRBC and IV fluids and was
subsequently weaned off pressors. She continued to require [**2-15**]
PRBC transfusions per day. IR declined further attempts at
embolization due to risk of bowel ischemia. Surgery was
consulted and considered Whipple to resect duodenal ulcers, but
pt was a poor surgical candidate and pt's family also agreed
surgery was not in the patient's best interest. Pt's Hct
stabilized on HD5 and remained stable throughout the the
remainder of her hospitalization.
Her aspirin was held throughout her hospitalization, but, given
that she is on high dose PPI, and is off coumadin, it can be
restarted, with close attention paid to any signs of recurrent
GI bleeding. HPylori ordered and is pending at the time of
discharge.
# Acute on chronic renal failure - Creatinine slightly elevated
from baseline 1.8 (was 2.2 on admission). Pt appeared dry on
admission exam, and in setting of acute bleed, prerenal etiology
seemed most likely. Medications were renally dosed and she was
rescuscitated with fluids and PRBCs. Creatinine returned to
baseline, and was 1.8 on day of discharge.
# Pneumonia: It was difficult to wean the patient off the vent
after second intubation. Increased secretions and fevers
developed so she was suspected to have VAP. CXR difficult to
interpret, so started empirically on vanc/zosyn. Cipro was
later added for double coverage of pseudomonas. She was found
to have H. flu on sputum on [**1-5**]. Her vancomycin was
discontinued and she completed an 8 day course of zosyn.
# Afib: The patient was continued on beta blockers, but she
developed atrial fibrillation with RVR. She was put on
metoprolol 50 mg po qid and started on diltiazem 15 mg po q6
hours. Her heart rate is overall controlled, but she still
occasionally has brief episodes of heart rate to 120. She needs
continued monitoring with telemetry and possible uptitration of
diltiazem.
#Anticoagulation: Patient continued on aspirin, but coumadin
held for now. I have emailed her PCP and gastroenterologist to
consider whether it should be restarted at all given her
recurrent large volume GI bleeding. Risks of GI bleeding need
to be weighed against prevention of stroke secondary to Atrial
fibrillation. Patient has GI appointment with Dr [**First Name (STitle) 26390**] at the
end of [**Month (only) 1096**]. I discussed the risks of recurrent GI bleeding
on asa/coumadin and the benefit of stroke prevention. Family
understandably concerned about preventing stroke, but they also
understand that she has had two large GI bleeds. They will
continue to consider this, and I have advised them to discuss
further with rehab doctors if they feel strongly that they want
to have another trial of restarting coumadin.
CHRONIC ISSUES
# Congestive heart failure: Pt had no evidence of fluid overload
on admission. She was given PRBC and fluids for her GI bleeding
and when her Hct stabilized, she was diuresed to improve her
respiratory status. Her po intake has been somewhat poor during
this hospitalization, so her lasix has been held. She denies
complaints of shortness of breath, and has no e/o volume
overload on exam. When she is eating regularly, she can be
restarted on her home dose of lasix, which is 60-80 mg by mouth
daily.
# Diabetes mellitus: Patient receiving lantus 10 units daily,
and blood sugars are well controlled. Patient with diabetic
neuropathy. Was on gabapentin at home, but held in the
hospital.
# Full code
Medications on Admission:
Furosemide 40mg [**Hospital1 **] MWF, 40mg qAM and 20mg qPM all other days
Docusate Sodium 100 mg daily prn
Gabapentin 300 mg tid
Warfarin as directed
Trazodone 100 mg qhs
Simvastatin 40 mg qhs
Losartan 50 mg daily
Pantoprazole 40 mg daily
Aspirin 81 mg daily
Fluticasone 220 mcg/Actuation Inhalation Aerosol 2 puffs [**Hospital1 **]
Albuterol Sulfate (PROAIR HFA) 90 mcg/Actuation Inhalation HFA
1-2 puffs q4-6h prn
Lantus 50units daily
NOVOLOG FLEXPEN 100 UNIT/ML SUB-Q (INSULIN ASPART) tid prn
Senna 8.6 MG TAB 2 tabs at bedime daily
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO Q12H (every 12 hours).
2. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
3. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lantus 100 unit/mL Solution Sig: 10 units Subcutaneous once
a day.
6. diltiazem HCl 30 mg Tablet Sig: 0.5 Tablet PO QID (4 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Gastrointestinal Bleeding
Atrial Fibrillation
Coronary Artery Disease (heart disease)
Congestive Heart Failure
Peripheral Vascular Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Requiring a walker, assist with movement
Discharge Instructions:
You were hospitalized for bleeding in your stomach and duodenum
(part of your intestine). You suffered significant blood loss
and required many transfusions of blood. You had two
endoscopies, which showed that your bleeding was due to ulcers
in the stomach and duodenum as well as a diverticulum, or
outpouching, in the duodenum.
We have held your coumadin for now. You have atrial
fibrillation (irregular heart rate). There is a small risk of
stroke if you do not take the coumadin. This has to be weighed
against the risk of another bleed if you are on coumadin. Since
you have had two major bleeds this year, you should talk to your
primary care doctor, Dr [**Last Name (STitle) **], about whether to continue the
coumadin in the future.
You have had a rapid heart rate during this hospitalization, and
we have adjusted some of your medicines to keep your heart rate
better controlled.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Specialty: INTERNAL MEDICINE
Location: [**Hospital1 641**]
Address: [**University/College 2899**], [**Location (un) **],[**Numeric Identifier 46146**]
Phone: [**Telephone/Fax (1) 2115**]
**Please discuss with the staff at the facility the need for a
follow up appointment with your PCP when you are ready for
discharge**
Name: [**Last Name (LF) **], [**Name8 (MD) **] MD
Specialty: GASTROENTEROLOGY
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2296**]
Appointment: THURSDAY [**2-3**] AT 1PM
|
[
"584.9",
"997.1",
"V58.61",
"250.00",
"562.02",
"V45.82",
"531.40",
"414.01",
"428.22",
"518.81",
"285.1",
"427.1",
"585.9",
"416.0",
"428.0",
"403.90",
"276.0",
"274.9",
"V58.67",
"427.31",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"96.04",
"88.47",
"44.43",
"96.07",
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
11225, 11296
|
4976, 9988
|
275, 284
|
11479, 11479
|
3817, 3817
|
12567, 13208
|
3243, 3301
|
10576, 11202
|
11317, 11458
|
10014, 10553
|
11645, 12544
|
3316, 3798
|
2167, 2615
|
232, 237
|
312, 2148
|
3833, 4953
|
11494, 11621
|
2637, 2985
|
3001, 3227
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,414
| 194,637
|
36511
|
Discharge summary
|
report
|
Admission Date: [**2199-3-5**] Discharge Date: [**2199-3-12**]
Date of Birth: [**2123-3-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Near syncope
Major Surgical or Invasive Procedure:
[**2199-3-6**] Three Vessel Coronary Artery Bypass Grafting(left
internal mammary artery to left anterior descending with
saphenous vein grafts to obtuse marginal and PDA)
[**3-7**] ICD
History of Present Illness:
Mr. [**Known lastname **] is a 76 year old male who presented to OSH with
near syncopal episode associated with lightheadedness and
nausea. He ruled out for myocardial infarction. While in the
Emergency Dept, experienced Torsades on telemetry which was
treated with Magnesium and Potassium. He underwent cardiac
catheterization which demonstrated severe three vessel coronary
artery disease. He was subsequently transferred to the [**Hospital1 18**] for
surgical revascularization.
Past Medical History:
Coronary Artery Disease, Ejection Fraction 45-55%
History of Myocardial Infarction 25 years ago
Hypertension
Dyslipidemia
Parkinsons Disease
Gastroesophogeal Reflux Disease
Appendectomy
Obstructive Sleep Apnea, CPAP at home
Social History:
Former smoker. Social ETOH. Retired government worker.
Family History:
No premature coronary disease
Physical Exam:
Vitals: 96.0, 158/72, 62, 18, 98% RA
General: elderly male in no acute distress
HEENT: oropharynx benign
Neck: supple, no JVD
Lungs: clear bilaterally
Heart: regular rate and rhythm, normal s1s2, no murmur or rub
Abd: soft, nontender, nondistended, normoactive bowel sounds
Ext: warm, no edema
Neuro: right upper extremity tremor noted otherwise non-focal
Pulses: 2+ distally, no carotid or femoral bruits
Pertinent Results:
[**2199-3-5**] WBC-6.6 RBC-4.84 Hgb-14.3 Hct-39.8* MCV-82 RDW-12.9 Plt
Ct-197
[**2199-3-5**] PT-13.1 PTT-32.7 INR(PT)-1.1
[**2199-3-5**] Glucose-109* UreaN-19 Creat-1.3* Na-144 K-3.9 Cl-107
HCO3-26 AnGap-15
[**2199-3-5**] ALT-23 AST-18 LD(LDH)-188 AlkPhos-81 TotBili-2.6*
[**2199-3-5**] Albumin-4.4 Mg-2.1 %HbA1c-5.9
[**2199-3-6**] Intraop TEE:
PREBYPASS - No atrial septal defect is seen by 2D or color
Doppler. There is mild symmetric left ventricular hypertrophy
with normal cavity size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is low normal
(LVEF45-50%). There is a small apical aneurysm. The apex and
distal inferior walls are akinetic.The remaining left
ventricular segments contract normally. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. POST-BYPASS - Bivenrticular
systolic function remains unchanged from prebypass. No changes
in other exam findings.
[**2199-3-11**] 03:44PM BLOOD WBC-6.6 RBC-3.55* Hgb-10.3* Hct-30.0*
MCV-85 MCH-29.0 MCHC-34.4 RDW-13.0 Plt Ct-214
[**2199-3-12**] 06:20AM BLOOD Glucose-110* UreaN-29* Creat-1.6* Na-143
K-4.4 Cl-106 HCO3-28 AnGap-13
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the cardiac surgical service and
underwent routine preoperative evaluation. Workup was
unremarkable and he was cleared for surgery. The following day,
Dr. [**Last Name (STitle) **] performed coronary artery bypass grafting surgery.
Operative course was notable for another episode of Torsade
which again responded to Magnesium. For additonal surgical
detail, please see dictated operative note. Given inpatient stay
prior to surgery was greater than 24 hours, he was given
Vancomycin for perioperative antibiotic coverage. Following the
operation, he was brought to the CVICU for invasive monitoring.
Within 24 hours, he awoke neurologically intact and was
extubated without incident. Given ventricular arrhythmias, the
electrophysiology service was consulted and it was recommended
that an AICD be placed. On [**3-7**] the AICD was placed. It was
interogated on the following day without complication. He was
transferred to the surgical step down floor. His chest tubes and
epicardial wires were removed. His beta blockade was increased
as tolerated and he was gently diuresed. He was seen in
consultation by the physcial therapy service. By post-operative
day six he was ready for discahrge to home.
Medications on Admission:
Aspirin 81 qd, Lipitor 40 qd, Protonix 40 qd, Heparin 5000 SQ
[**Hospital1 **], Avapro 300 qd, Coreg ER 80 qd, Xalantan eye gtts, Alphagan
eye gtts, Travatan eye gtts, Requip, HCTZ 50 qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. 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*
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
take 400mg daily for one week, then decrease to 200mg daily.
Disp:*60 Tablet(s)* Refills:*2*
6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
Disp:*10 Tablet(s)* Refills:*0*
7. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. AZILECT 1 mg Tablet Sig: One (1) Tablet PO daily ().
Disp:*30 Tablet(s)* Refills:*2*
10. Travoprost 0.004 % Drops Sig: Two (2) Ophthalmic QHS (once
a day (at bedtime)).
Disp:*qs * Refills:*2*
11. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
Disp:*qs * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary Artery Disease - s/p CABG
Pre and Postoperative Torades/Ventricular Fibrillation
History of Myocardial Infarction 25 years ago
Hypertension
Dyslipidemia
Parkinsons Disease
Gastroesophogeal Reflux Disease
Obstructive Sleep Apnea, CPAP at home
Discharge Condition:
Good
Discharge Instructions:
No driving for one month.
No lifting greater than 10 pounds for 10 weeks.
No lotions, creams or powders on any incision.
Shower daily and pat incisions dry.
Call for fever greater than 100.5, redness, drainage, weight
gain of 2 pounds in 2 days or 5 pounds in 1 week.
Followup Instructions:
Dr. [**Last Name (STitle) **] (cardiac surgery) 2-3 weeks at [**Hospital1 **] heart
center - please call for appointment at [**Numeric Identifier 26917**]
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] (cardiology) on [**3-15**] at 8:30am for device check
(ICD) ([**Telephone/Fax (1) 6256**])
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (PCP)in 1 week [**Telephone/Fax (1) 5835**]
Completed by:[**2199-3-12**]
|
[
"429.9",
"327.23",
"412",
"272.4",
"414.01",
"427.41",
"530.81",
"413.9",
"332.0",
"401.9",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"36.15",
"37.94",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6103, 6162
|
3232, 4484
|
332, 520
|
6457, 6464
|
1838, 3209
|
6780, 7245
|
1366, 1397
|
4721, 6080
|
6183, 6436
|
4510, 4698
|
6488, 6757
|
1412, 1819
|
280, 294
|
548, 1031
|
1053, 1278
|
1294, 1350
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,250
| 163,048
|
46847
|
Discharge summary
|
report
|
Admission Date: [**2205-6-19**] Discharge Date: [**2205-7-3**]
Date of Birth: [**2132-5-30**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Nausea
Major Surgical or Invasive Procedure:
-Cystoscopy, right retrograde pyelogram, and right ureteral
stent placement on [**6-19**]
-Intubated and sedated from [**6-19**] to [**6-27**]
History of Present Illness:
73 yo F h/o CNS lymphoma, h/o CVA, afib, CHF, OSA presented with
nausea, vomitting, dyspnea and abdominal pain to the ER. Patient
was in discomfort, but apparently could not localize where pain
was originating. She was felt to be somewhat disoriented at this
time, but this is not documented in the ED notes.
.
In the ED, she was febrile to 101.2 and treated with vancomycin
1 g and Pip/Tazo 4.5 g. She was also given 650 mg po tylenol.
Workup included CT abdomen/pelvis which revealed a 7 mm
obstructing stone in the right ureter, with a UA significant
only for many bacteria. Urology was consulted re: the
obstructing stone, and they advised consulting IR for
percutaneous nephrostomy tubes. IR was consulted and decided
patient was not a candidate for perc tubes because of her body
habitus. CXR revealed a RML opacity and she was given combivent
nebs and solumedrol 125 mg IV x1. Patient subsequently developed
hypoxic respiratory failure while in CT, with desaturation to
the 70s. She improved to the 80s on a NRB. At this time, her
mental status apparently improved but she was intubated for her
respiratory distress. She placed on Bipap during the interim,
and eventually intubated. Post intubation ABG was 7.21/37/75/16.
Saturations remained in the high 80s despite FiO2 100%, so
patient was given 20 mg IV lasix and PEEP was increased from 10
to 15. Saturations transiently improved to the 90s, but them
went back to 80s so she was given vecuronium 10 mg prior to
transfer. On transfer VS were 114, 144/69, sat 88%.
.
In the ICU, patient is intubated and sedated.
Past Medical History:
1. Primary CNS lymphoma in cerebellum, frontal lobes, left
temporal lobe, and right occipital lobe
- dx in [**7-16**]
- S/p 6 cycles of high dose MTX, changed to Rituxan and Temodar
in [**9-16**], last cycle [**10-17**]. Per pt, is now cancer free and being
monitored with serial outpt MRIs. Followed by Dr. [**Last Name (STitle) 4253**].
- L chest portacath
2. Stroke (x3, all in [**1-15**], posterior circulation; Subarachnoid
hemorrhage on [**2200-10-1**] related to Coumadin therapy)
3. Hypertension
4. Hyperlipidemia
5. Subarachnoid hemorrhage (while on coumadin for stroke)
6. Diastolic dysfunction, last ejection fraction =55%
7. Hypothyroidism/multinodular goiter -seen by endo, has MNG and
chronically low TSH
for unclear reasons
8. CAD s/p MI in the 80s
9. GERD
10. s/p cholecystectomy for gallstones ([**2195**])
11. Atrial fibrillation
- not on coumadin due to subarachnoid hemorrhage
12. Chronic bronchitis/COPD
13. Neovascular glaucoma complicated by right eye blindness-not
compliant with drops
14. Hyperparathyroidism, primary. mild. followed by Endocrine.
Only intermittent mild Hyper Ca
[**10**]. Mild Vit D def
16. Anxiety/depression
17. OSA
Social History:
Home: lives in [**Hospital1 **] senior living; ambulates with a cane,
but also uses a wheelchair as needed
Occupation: retired [**Hospital1 18**] nurse, previously worked on 7 [**Hospital Ward Name 1826**]
as a gynecology nurse
EtOH: Denies
Drugs: Denies
Tobacco: 90 pack-year smoking history (3 PPD x 30 years), quit
smoking in [**2178**].
Family History:
Father - Esophageal problems, unsure of the specifics
Mother - Bradycardia, AAA
Physical Exam:
Admission PE:
General: Intubated, Sedated, minimal grimace to sternal rub
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP difficult to assess [**2-12**] body habitus
Lungs: crackles at bases bilaterally
CV: irregular, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: foley with clear urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Discharge PE:
Vitals: T:96.9 BP:106/42 P:69 R:18
General: Alert, oriented, NAD.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple.
Lungs: Normal respiratory effort. CTAB.
CV: Irregular, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: foley with clear urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A+Ox3. Right pupil dilated and non-reactive. Left pupils
round and reactive. EOMI. Face symmetric. Palate elevated
symmetrically. Tongue protrudes in midline. Strength 4+ in
bilateral deltoids, otherwise [**5-15**] throughout. Finger-to-nose
grossly impaired bilaterally, with marked ataxia on right.
Pertinent Results:
[**6-19**] EKG: Atrial fibrillation with rapid ventricular response.
Diffuse repolarization changes that are non-specific. Compared
to the previous tracing of [**2205-2-26**] there is no significant
diagnostic change.
.
[**6-19**] CT head without contrast:
IMPRESSION:
1. No acute intracranial process.
2. No CT evidence of recurrence of tumor.
.
[**6-19**] CXR: FINDINGS: Lung volumes are diminished. Mild hazy
opacity is noted over the left hemidiaphragm, consistent with
atelectasis. There is an indwelling left subclavian Port-A-Cath,
with the catheter tip projecting over the area of the superior
cavoatrial junction. There is mild aortic tortuosity. The
cardiac silhouette size is difficult to truly assess, but is
likely at least borderline enlarged. No definite effusion or
pneumothorax is noted. Degenerative changes are noted
throughout the thoracic spine.
IMPRESSION: No definite acute pulmonary process.
.
[**6-19**] CT abdomen/pelvis:
IMPRESSION:
1. 7-mm obstructive renal stone within the right proximal ureter
with
associated moderate hydronephrosis, periureteric and
perinephritic stranding. Perinephric fluid is concerning for
forniceal rupture.
2. Unchanged left medial limb adrenal hyperplasia.
3. Unchanged pneumobilia.
4. Stable hypodensity in the upper pole of the right kidney.
.
[**6-20**] ECHO: The left atrium is markedly dilated. The right atrium
is moderately dilated. There is moderate symmetric left
ventricular hypertrophy. Regional left ventricular wall motion
is normal. Left ventricular systolic function is hyperdynamic
(EF>75%). There is abnormal septal motion/position consistent
with right ventricular pressure/volume overload. The aortic
valve leaflets are mildly thickened (?#). There is no aortic
valve stenosis. The mitral valve leaflets are mildly thickened.
Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Moderate LVH with hyperdynamic LV systolic function.
Dilated and hypokinetic RV. Mild mitral and moderate tricuspid
regurgitation.
Brief Hospital Course:
This is a 73 year old female with PMH of CNS lymphoma, history
of CVA, atrial fibrillation/flutter, diastolic CHF, and OSA who
presented with nausea, vomiting, dyspnea, and abdominal pain and
found to have obstructive nephrolithiasis and Klebsiella
bacteremia/sepsis.
.
#. Klebsiella Sepsis/Obstructive nephrolithiasis. The patient
was found to have an obstructing 7mm right ureteral stone and a
right middle lobe lung opacity. In the ED, the patient rapidly
developed respiratory failure requiring intubation and MICU
admission. For the obstructing stone, the patient underwent
placement of a ureteral stent by urology and will have the stent
removed in a month at an outpatient urology appointment. She
was growing Klebsiella in her blood and urine culture on
admission. She cleared her subsequent blood cultures with
appropriate antibiotic treatment. The patient was initially
treated with meropenem, vancomycin, and ciprofloxacin, narrowed
to just ciprofloxacin on [**2205-6-22**] when the patient's urine grew
pan-sensitive Klebsiella. Ciprofloxacin was changed to
ceftriaxone on [**2205-6-26**] due to concerns that cipro might be
contributing to agitation. Vancomycin and meropenem were
briefly added back due to hypothermia and hypotension, but they
were again stopped on [**2205-6-24**]. The patient was briefly treated
with micafungin from [**2205-6-22**] to [**2205-6-25**]. B-glucan and
galactomannan were negative. She was continued on ceftriaxone
alone after the changes listed above to complete a 14 day course
ending [**2205-7-3**].
.
#. Hypoxic respiratory failure: On the ventillator, the patient
had difficulty with oxygenation which required paralysis and
increased PEEP. There were also difficulties with weaning.
Precedex was tried, but the patient had a long sinus pause with
associated hypotension. After extensive diuresis with IV Lasix,
the patient was weaned off of the ventilator on [**2205-6-27**]. She
should be maintained on CPAP at night.
.
# Left Eye pain. Chronic in nature and of unclear etiology. She
is blind in the eye and was continued on her home eye drop
regimen including atropine, latanoprost, combigan, and artficial
tears eye drops.
.
# Afib/flut: On admission she had poor rate control likely in
the setting of sepsis, which has since improved after
appropriate anitbiotics treatment. She is not on rate
controlling agents at baseline and not anticoagulated due to
prior hemorrhagic CVAs despite her CHADS score of 4. She was
continued on aspirin 325 mg daily and no long term rate control
[**Doctor Last Name 360**] was initiated.
.
# Chronic diastolic CHF: Her last ECHO was [**2205-6-20**] and showed an
EF>75%. She was continued on her home lisinopril and statin.
Furosemide 60mg PO BID was initiated and should continue to be
titrated to achieve her estimated dry weight of 245 pounds.
.
# Hypertension: The patient was on acetazolamide, amlodipine,
and lisinopril. Given her hypotension, her home acetazolamide
and amlodipine were discontinued and not restarted upon
discharge. She was maintatined on her home dose of lisinopril
and furosemide 60mg twice daily was started given her diastolic
heart failure.
.
# Dyslipidemia: Continued home statin.
.
#. Anxiety/Depression: The patient was continued on her home
Lamictal and Seroquel as needed. Trazodone was also added as
needed for sleep.
.
#. Hypercalcemia: The patient's MICU course was complicated by
hypercalcemia with a peak of 11.1, which was attributed to
hyperparathyroidism. Her home calcium supplementation was
discontinued. Endocrine was consulted and the patient was
treated with cinacalcet 30mg [**Hospital1 **]. Her corrected calcium
(calcium with albumin correction) should continue to be trended
on this regimen.
.
#. Access: Portacath in place
.
#. Communication: [**Name (NI) **] [**Last Name (NamePattern1) **] (niece, [**Name (NI) 382**], [**Telephone/Fax (1) 99411**]
.
#. Code: Confirmed DNR/DNI with the patient. In the MICU, there
was some disagreement about the patient's code status. The
patient's primary care doctor indicated that the patient had
expressed a desire to be DNR/DNI, but the [**Hospital 228**] health care
proxy favored aggressive treatment. After extensive discussion
with the [**Hospital 228**] healthcare proxy, the decision was made to
make the patient's code status DNR/okay to reintubate. However,
when the patient was extubated, she stated that she wished to be
DNR/DNI.
Medications on Admission:
-LAMOTRIGINE [LAMICTAL] 100 mg qam and 150 mg qpm
-QUETIAPINE [SEROQUEL] 50 mg po qhs
-ACETAZOLAMIDE 500 mg [**Hospital1 **]
-AMLODIPINE [NORVASC] 10 mg daily
-AMMONIUM LACTATE - 12 % Lotion - Apply as directed once a day
-ATROPINE - 1 % Drops - 1 drop in the right eye twice a day
-BRIMONIDINE-TIMOLOL [COMBIGAN] - 0.2 %-0.5 % Drops - 1 drop in
the right eye twice a day
-CODEINE-GUAIFENESIN - 100 mg-10 mg/5 mL Liquid prn cough
-ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit weekly
-FEXOFENADINE - 60 mg daily
-FLUTICASONE 50 mcg spray inh [**Hospital1 **]
-IBUPROFEN 400 mg [**Hospital1 **]
-LATANOPROST [XALATAN] - 0.005 % Drops - 1 drop in the right eye
at bedtime
-LIDODERM PATCH
-LISINOPRIL 5 mg daily
-MVI
-OMEPRAZOLE [PRILOSEC]20 mg daily
-SIMVASTATIN 40 mg daily
-TRAMADOL - 50 mg [**Hospital1 **] prn
-ACETAMINOPHEN [**Telephone/Fax (1) 24628**] mg prn
-ASPIRIN dosage uncertain
-BISACODYL 5 mg [**Hospital1 **] prn
-CALCIUM CARBONATE 500 mg TID
-DOCUSATE SODIUM [COLACE] 100 mg [**Hospital1 **] prn
-POLYVINYL ALCOHOL [AKWA TEARS] - 1.4 % Drops - 1 drop in the
right eye three times a day
-SENNA PRN
-SIMETHICONE PRN
Discharge Medications:
1. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
2. Lamotrigine 150 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
3. Seroquel 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for agitation, insomnia.
4. Ammonium Lactate 12 % Lotion Sig: One (1) application Topical
once a day as needed for dry skin.
5. Atropine 1 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times
a day): into right eye.
6. Combigan 0.2-0.5 % Drops Sig: One (1) drop Ophthalmic twice a
day: into right eye.
7. Dextromethorphan Poly Complex 30 mg/5 mL Suspension,
Sust.Release 12 hr Sig: Ten (10) mLs PO Q12H (every 12 hours) as
needed for cough.
8. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
9. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO once a day.
10. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
spray Nasal twice a day.
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
12. Xalatan 0.005 % Drops Sig: One (1) drop Ophthalmic at
bedtime: in right eye.
13. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) patch Topical once a day as needed for localized pain:
12 hours on, 12 hours off.
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Multivitamins Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
16. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
17. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
19. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
20. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
22. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-12**]
Drops Ophthalmic PRN (as needed) as needed for dry eye.
23. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for bloating/gas.
24. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
4-6 Puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
25. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: Four (4) Puff Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
26. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
27. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
28. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Primary Diagnoses:
-Klebsiella urosepsis
-Obstructive nephrolithiasis
-Respiratory failure requiring intubation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
further evaluation of fevers, nausea, vomiting, shortness of
breath, and abdominal pain. You were found to have a kidney
stone that was blocking the flow of your urine from the kidney
to the bladder. You were also found to have a severe urinary
tract infection that also spilled over into your blood to make
you extremely sick to the point where you needed care in the ICU
and required placement on a breathing machine. The urologists
were able to perform a procedure to open up the tube that was
blocked by the kidney stone by inserting a stent. You will need
to have this stent removed as an outpatient when you follow-up
with the urologist. You improved after an extended course of IV
antibiotics.
.
The following changes have been made to your home medication
regimen:
-You should stop your home acetazolamide, amlodipine, tramadol,
and calcium
-You should start taking trazodone as needed for sleep,
albuterol and ipratropium inhalers as needed for shortness of
breath or wheezing, cinacalcet for your high calcium levels, and
furosemide
Followup Instructions:
Please follow-up with all of your outpatient medical
appointments listed below:
.
1. Department: [**Hospital3 249**]
When: TUESDAY [**2205-7-9**] at 1:10 PM
With: [**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
.
2. Department: SURGICAL SPECIALTIES
When: MONDAY [**2205-7-29**] at 2:30 PM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
3. Department: MEDICAL SPECIALTIES
When: MONDAY [**2205-7-29**] at 4:20 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 16624**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"995.92",
"427.32",
"486",
"401.9",
"242.20",
"491.20",
"428.32",
"780.65",
"300.4",
"428.0",
"412",
"592.1",
"V12.54",
"V85.4",
"327.23",
"252.01",
"202.80",
"591",
"427.31",
"599.0",
"272.4",
"584.9",
"276.2",
"530.81",
"278.01",
"038.49",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"59.8",
"87.74",
"96.04",
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
15495, 15585
|
7159, 11611
|
321, 466
|
15741, 15741
|
5008, 7136
|
17035, 18048
|
3633, 3714
|
12786, 15472
|
15606, 15720
|
11637, 12763
|
15919, 17012
|
3729, 4225
|
4239, 4989
|
275, 283
|
494, 2069
|
15756, 15895
|
2091, 3258
|
3274, 3617
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,797
| 154,271
|
51219
|
Discharge summary
|
report
|
Admission Date: [**2165-12-19**] Discharge Date: [**2165-12-27**]
Date of Birth: [**2103-3-15**] Sex: M
Service: CCU
CHIEF COMPLAINT: Right lower extremity pain, presumed
secondary peripheral vascular disease.
HISTORY OF PRESENT ILLNESS: The patient is a 62 year-old
male with a history significant for coronary artery disease
status post coronary artery bypass graft in [**2154**], abdominal
aortic aneurysm status post endovascular stent graft in [**2165-2-2**] now being evaluated for total occlusion of right iliac
limb graft. On [**9-7**] the patient developed increased right
lower extremity pain with exertion (walking about the length
of a football field), which started in his right buttock with
radiation to his right foot. This pain was relieved with
rest. On the day prior to admission the patient presented
for CT angiogram, which revealed total occlusion of his right
limb of his graft with collateral flow from contralateral
iliac artery branches. The patient underwent angiography on
the day of admission showing a patent aortic graft with
normal left iliac graft limb. However, right limb was flesh
occluded with no filling of entire limb extending proximally
to the Voda wire. The patient subsequently had a guidewire
passed through occluded right limb graft and then underwent
intra-arterial thrombolysis with tissue plasminogen
activator. The patient was transferred to the Coronary Care
Unit for further evaluation with a planned relook
catheterization on the following day. At the time of initial
evaluation the patient was comfortable without any pain.
Denies fevers or chills, nausea or vomiting. No abdominal
pain. No melena or bright red blood per rectum. No
shortness of breath. No chest pain, edema, palpitations.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post three vessel coronary
artery bypass graft in [**2154**]. Left internal mammary coronary
artery to left anterior descending coronary artery, saphenous
vein graft to D1 and obtuse marginal one with subsequent
cardiac catheterization [**2165-1-5**] demonstrating an
occluded saphenous vein graft D1 graft with patent jump graft
to obtuse marginal one.
2. Ejection fraction 28% presumed ischemic cardiomyopathy.
3. Abdominal aortic aneurysm status post endovascular stent
graft [**2165-2-2**].
4. Hypertension.
5. Hyperlipidemia.
6. Presumed gout.
7. Cataracts.
8. Status post tonsillectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Lipitor 10 q day.
2. Aspirin 81 q day.
3. Lopressor 25 b.i.d.
4. Zestril 40 q day.
5. Allopurinol 150 q day.
6. Vitamin E q day.
SOCIAL HISTORY: The patient lives with wife and [**Name (NI) **]
Retriever named [**Name (NI) 106271**], occasional alcohol. Quit tobacco 15
years ago. Retired engineer. He is quite active.
PHYSICAL EXAMINATION: Afebrile at 97.1. Blood pressure
122/61. Pulse 74. Respiratory rate 16. 98% on room air.
General, he is a well developed, well nourished man
comfortably lying flat on back without shortness of breath.
HEENT no JVD appreciated. Cardiovascular he has a 1 out of 6
systolic ejection murmur, regular rate and rhythm. Lungs
clear. Abdomen is benign. Extremities have bilateral
femoral lines with sheaths and transducers and bilateral
Dopplerable pulses. Right foot cool. Left foot is warm.
LABORATORIES ON ADMISSION: White blood cell count of 5.9,
hematocrit 44.1, platelets 267. Chemistries are
unremarkable. His coags are unremarkable.
HOSPITAL COURSE: 1. Peripheral vascular disease: The
patient was evaluated for presume occluded right limb graft
of previous endovascular stent repair from [**2165-2-2**].
Initial angiography showed occluded right limb graft and the
patient underwent passage of guidewire through thrombosis and
intra-arterial tissue plasminogen activator beginning in the
catheterization laboratory. Transfer to the Coronary Care
Unit overnight where tissue plasminogen activator infusion
continued as well as heparin. Subsequent relook angiography
on [**12-20**] showed successful thrombolysis of the
previously occluded right limb aortic stent graft with
persistent and widely patent aortic stent graft. However,
there was narrowed distal thrombus present in the proximal
right posterior tibial artery at the level of the foot and
dorsalis pedis. This was felt secondary to embolization of
previous right limb thrombus. The patient was subsequently
placed on systemic heparin therapy times four days. On
[**12-24**] he returned to the catheterization laboratory
where angiography showed thromboembolic occlusion of his
right posterior tibial artery. The patient subsequently
underwent successful PTA and thrombectomy of his right
posterior tibial artery. Post intervention the patient was
placed on anticoagulation and intravenous heparin later to
Coumadin with goal INR change 2.3 to 3. He was placed on
aspirin and will be on life long Plavix. At the time of
discharge the patient's INR had not yet reached 2. He was
subsequently bridged with Lovenox 80 mg q 12. He was sent
home on 5 mg of Coumadin q.h.s. He will need frequent
laboratory checks to ensure that his INR becomes therapeutic.
He will follow up with Dr. [**First Name (STitle) **] in several weeks time who
will determine the duration of his Coumadin therapy likely
four to six weeks.
2. Cardiovascular: The patient was maintained on his
preexisting cardiac regimen throughout his hospital course.
He has a history of coronary artery disease, but did not have
any chest pain. During his hospital course he was continued
on aspirin, beta blocker and statin and ace inhibitor. As
mentioned above he will be on life long Plavix for his
peripheral vascular disease. He did have an episode post
second angiography where he was bradycardia and hypotensive
into the 70s. The patient was given intravenous fluids,
atropine and responded appropriately. He remained
hemodynamically stable during the remainder of his hospital
course. The event being to possible vasovagal episode.
3. Hematology: The patient was treated with tissue
plasminogen activator for occluded right limb graft as
mentioned above. He was transfused 2 units of packed red
blood cells earlier during his hospital course for a decrease
in hematocrit in the setting or recent tissue plasminogen
activator. His hematocrit responded appropriately to that
and his hematocrit remained stable during the rest of his
hospital course, although showed a slight decrease near the
end. He will be sent home on life long Plavix. He was
anticoagulated with intravenous heparin and later to
Coumadin. He will be using Lovenox as bridging therapy for
his Coumadin with goal INR of 2 to 2.5. He did have small
bilateral hematomas at the site of his groin sticks that
remained stable during his hospital course. He did undergo
bilateral groin ultrasounds, which were negative for
pseudoaneurysms or fistulas.
4. Renal: The patient's electrolytes and renal function
remained stable during his entire hospital course.
5. Musculoskeletal: The patient came in with a history of
reported gout on Allopurinol. During his hospital course he
developed increased diffuse bilateral joint pain and
swelling, which was initially attributed to his gout.
However, his uric acid was within normal limits. He was
treated empirically with anti-inflammatories Indocin, which
has worked for him in the past. He reported improved
symptoms. His Allopurinol dose was increased from 150 to 300
mg q day. This has been a problem that has plagued him for
quite some time and he was advised to follow up with
Rheumatology for further evaluation of his pain as the team
was not completely convinced that this is true gout pain.
DISCHARGE DIAGNOSES:
1. Peripheral vascular disease status post occluded right
limb graft, status post successful localized tissue
plasminogen activator thrombolysis complicated by right
posterior tibial thrombus, status post successful
thrombectomy and PTA.
2. Coronary artery disease, stable.
3. Congestive heart failure, stable.
4. Presumed gout.
DISCHARGE CONDITION: Good.
DISCHARGE MEDICATIONS:
1. Metoprolol 25 mg b.i.d.
2. Lisinopril 40 mg q day.
3. MVI one tablet q day.
4. Lipitor 10 q day.
5. Coumadin 5 mg q.h.s.
6. Plavix 75 mg q day.
7. Indocin 25 mg t.i.d.
8. Aspirin 81 q day.
9. Vitamin E 400 q day.
10. Lovenox 80 mg subcutaneous q 12.
11. Allopurinol 300 mg q day.
12. Senokot b.i.d.
13. Colace 100 mg b.i.d.
The patient was to have his INR checked on [**12-30**] and on
[**1-2**] and have results faxed to Dr.[**Name (NI) 3101**] office. He
is advised to follow up with Dr. [**First Name (STitle) **] for an appointment in
three to four weeks time.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**]
Dictated By:[**Last Name (NamePattern1) 5539**]
MEDQUIST36
D: [**2166-2-5**] 02:42
T: [**2166-2-7**] 10:32
JOB#: [**Job Number 106272**]
|
[
"997.2",
"998.12",
"443.9",
"425.4",
"996.74",
"444.22",
"274.9",
"E934.4",
"287.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.50",
"88.47",
"88.48",
"99.04",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
8109, 8116
|
7753, 8087
|
8139, 9002
|
3507, 7732
|
2842, 3351
|
152, 229
|
258, 1775
|
3366, 3489
|
1797, 2624
|
2641, 2819
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,497
| 146,241
|
984
|
Discharge summary
|
report
|
Admission Date: [**2151-1-7**] Discharge Date: [**2151-1-12**]
Date of Birth: [**2071-11-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
CC:[**CC Contact Info 6518**]
Major Surgical or Invasive Procedure:
Colonoscopy [**2151-1-11**]
History of Present Illness:
79 yr-old gentleman with a past medical history significant
for iron deficiency anemia presents with 1 week of BRBPR and
anorexia with worsening weakenss and fatigue. He notes the
bleeding began 1 week ago with each bowel movement. He had
multiple stools daily with increasing frequency over this past
week up to 1 per hour yesterday and today. No cramping, pain or
straining. The stools were maroon and grossly bloody mixed with
brown, occasionally filling the bowl with red blood. No
immediate LH or cp. Had had increased DOE and fatigue with
walking [**Age over 90 **] yards. No f/c/n/v, taking po well but never has an
appetite. Wt loss of 50 lbs over past 2 years. Has been taking
ASA 81 for years, recent advil use [**2-1**] daily "for sleep" and
arthritis pain. Dr. [**Last Name (STitle) **] did colonoscopy in [**Month (only) **] of
[**2148**], grade 1 hemorrhoids; EGD [**2-3**] with no pathology but tight
esophagus. Recent CT abd/pelvis [**2150-11-27**] for wt loss with no
definative pathology.
.
In the ED [**Company 6519**] 97.8 BP 130/64 down to 105/54, HR 111, O2
sat 100% on NRB, had NG lavage with clear result. Recieved 2 U
PRBCs after 2 large bores placed, sent to MICU. In MIC, BP
continued to be low 100s and 2 more units given. Surgery
consulted. Tagged scan ordered.
.
PMH: zenkers diverticulum s/p surgical repair by [**Last Name (un) 6520**]
[**4-3**], h/o splenomegaly and thrombocytosis, anemia iron
deficiency--baseline 31-32%, bilateral inguinal hernia repair 35
years ago as well as repair of a right inguinal hernia in [**2146**],
decreased hearing, was diagnosed with an esophageal stenosis
several years ago at the [**Hospital6 1708**], but chose
not to undergo surgical procedure. He does state that while he
has not had frank hemoptysis, he coughed up what appeared to be
chocolate, coffee ground-colored material in the past, history
of pulmonary asbestosis diagnosed by CT scan in [**2142**], history of
a jejunal microperforation diagnosed by barium swallow in [**2144**],
left rotator cuff partial tear, manic depression/anxiety.
Past Medical History:
PMH:
-Zenkers diverticulum s/p surgical repair by [**Last Name (un) 6520**] [**4-3**],
-h/o splenomegaly and thrombocytosis,
-Anemia iron deficiency--baseline 31-32%,
-Bilateral inguinal hernia repair 35 years ago as well as repair
of a right inguinal hernia in [**2146**],
-Decreased hearing,
-Esophageal stenosis diagnosed several years ago at the [**Hospital1 **], but chose not to undergo surgical
procedure.
-History of pulmonary asbestosis diagnosed by CT scan in [**2142**],
-History of a jejunal microperforation diagnosed by barium
swallow in [**2144**],
-Left rotator cuff partial tear
-Manic depression/anxiety.
Social History:
-Iron
-ASA
-Zoloft
-Advil. He takes not more than 2 qd for arthritis
Family History:
Family
Has one brother [**Initials (NamePattern4) **] [**Name (NI) 6521**] and other c [**Name (NI) 2481**] Disease
Doesn't remember parents illness
Physical Exam:
VITALS: 98.0 100/48 104 18 100% 2 L
GENL: cachectic, pale, pleasant appearing frail man in NAD
HEENT: anicteric, mmm, pale conjunctiva, JVP not elevtated
CV: tachy, [**4-5**] late-peaking systolic m, radiated to carotids, no
RG, warm extremities, radial pulses 1+ b/l
RESP: CTAB without crackles or wheeze
ABD: scaphoid, s/nt/nd, hyperactive bs, no bruit, +splenomegaly,
no CVA tenderness
EXTREM: cap refill <3 sec, trace pedal edema
Rectal:Guaiac (+) stools
Pertinent Results:
Hc 30 -------19 .Went back to 30
[**2151-1-7**] 10:04PM HGB-6.4* calcHCT-19
[**2151-1-12**] 05:56AM BLOOD WBC-7.2 RBC-3.67* Hgb-10.1* Hct-30.5*
MCV-83 MCH-27.4 MCHC-32.9 RDW-16.8* Plt Ct-571*
[**2151-1-7**] 09:55PM BLOOD Glucose-129* UreaN-33* Creat-0.8 Na-141
K-3.8 Cl-107 HCO3-22 AnGap-16
-GI bleeding study [**1-8**]:no evidence of GI bleeding during this
study.
-Colojnoscopy [**1-11**]:
#Diverticulosis of the sigmoid colon and descending colon
#Polyp in the hepatic flexure
#Otherwise normal colonoscopy to cecum
Brief Hospital Course:
79 yo man c hx of iron deficiency anemia, Zenker Diverticulum
and esophageal stenosis presented c new worsening anemia(Hc
dropped from 30 to 19) ,admitted to MICU d/2 borderline Blood
Pressure and requiring > 6 U PRBCs.
1)GI:Pt states he had been having melena for at least 2 weeks.
Pt is poor historian , it is likely he's been chronically
bleeding Pt had a (-) tagged RBC scan the day after admission.
Also had a negative colonoscopy [**2149**]. Nl EGD [**2148**].New
Colonoscopy [**2151-1-11**] showed a sesile polyp in the hepatic
flexure of the colon. GI attributed the bleeding to this lesion.
Biopsies are pending . There was no need to do upper GI scope
considering this new finding.
Pt had no new active bleeding ,remained hemodynamically stable
24 hours after the procedure, Hc remained around 30-32.
-Pt will f/u c Dr [**Last Name (STitle) **] after biospy results.
-Surgery recommends repeat colonoscopy in 3 months
-Will start iron .
-Continue PPIs
-Avoid NSAIDs for pain (he was on Advil).
2)CV: Pt has mod Aortic stenosis , not candidate for surgery.Pt
asymtptomatic.
3)Renal: Creatinine stable , no evuidence of worsening GFR.
4)Hem:pt has splenomegaly on CT from [**2149**] no clear etiology.
LFTs seem c low albumin
Pt will be f/u by PCP.
Medications on Admission:
Iron
ASA
Zoloft
Advil. He takes not more than 2 qd for arthritis
Discharge Medications:
1. 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:*2*
2. Ferrous Sulfate 200 mg Tablet Sig: One (1) Tablet PO three
times a day.
Disp:*90 Tablet(s)* Refills:*2*
3. Outpatient Lab Work
Please draw CBC in 1 week.
4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Lower GI bleeding - Ascending colon polyp.
Aortic Stenosis Moderate.
Iron deficiency Anemia
splenomegaly
Ostearthritis
Discharge Condition:
Good, no dark black stools , hemodynamically stable , tolerating
oral feeds.
Discharge Instructions:
-Please come back to ED if you notice blood coming from you
rectum or continue haveing black stools, or if you feel dizzy ,
lightheaded , short of breath or any [**Last Name **] problem that you
consider significant.
-Avoid Advil , Naproxen, Ibuprophen or any non steroidal pain
medication since they can cause new bleeding form you
intestines.
Followup Instructions:
[**Hospital **] Clinic on [**2150-2-2**] c Dr. [**Last Name (STitle) **]
(2:30 PM).Loc: [**Last Name (NamePattern1) **] [**Location (un) **]. He will check the
results of your biopsy and your blood tests.
Completed by:[**2151-1-13**]
|
[
"287.31",
"501",
"280.0",
"261",
"578.9",
"153.0",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.42"
] |
icd9pcs
|
[
[
[]
]
] |
6263, 6269
|
4417, 5684
|
342, 372
|
6432, 6511
|
3869, 4394
|
6906, 7142
|
3223, 3374
|
5800, 6240
|
6290, 6411
|
5710, 5777
|
6535, 6883
|
3389, 3850
|
274, 304
|
400, 2473
|
2495, 3120
|
3136, 3207
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,851
| 198,978
|
44323
|
Discharge summary
|
report
|
Admission Date: [**2127-1-21**] Discharge Date: [**2127-1-24**]
Date of Birth: [**2061-2-21**] Sex: M
Service: MEDICINE
Allergies:
Motrin / Codeine / Nortriptyline
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hypotension, lethargy
Major Surgical or Invasive Procedure:
mechanical ventilation
History of Present Illness:
65 year old gentleman with HIV on HARRT (CD4 392 and neg VR in
[**2126-6-9**]), hep C, CHF (EF50%) DM and ESRD on HD brought in from
[**Hospital3 105**] with actinobacter growing in his blood. He has
a history of line infections from his left groin HD line and was
recently discharged on [**2127-1-8**] after a course of vanc. At
[**Hospital3 105**], it is unclear why the blood culture was drawn
in the first place and there is no paperwork accompanying the
patient. The call-in to the ED reports that the actinobacter was
sensitive to bactrim and unasyn. One dose of Unasyn was given
and he was then transferred to the ED.
.
In the ED, initial vitals were: 97.1, 67, 114/60, 17, 100%RA. He
remained afebrile and he blood pressure and heart rate remained
about the same durin ghis ED course. Unasyn was given. Initial
lactate was 3.4 and it came down to 1.4 with 1L NS. His abd was
noted to be distended and he admitted to some intermittent
abdominal pain. CT abd was done that showed dilated small bowels
suggestive of SBO. Surgery was called and felt like there is no
need for surgery this point. NGT was offered but the patient
adamantly refused. Pt reportedly was passing gas. He was then
admitted to medicine for further care.
.
On arrival to the floor, he denied fevers, chills, chest pain,
shortness of breath, abd pain, n/v/d. He reported that he has
been passing gas. He refused an NGT. On routine vitals, he was
noted to be unresponsive to sternal rub. No blood pressure was
able to be obtained so a code blue was called. He was given an
amp of epi for PEA and CPR was started but he pushed people off
of him. He was started on levophed and a L arterial line was
placed. He was transferred to the ICU for further management.
.
On arrival to the ICU he was still somnolent and not following
commands and not able to answer questions. He was intubated for
airway protection. His R tunnelled HD cath was accessed as he
only had a L PICC. He was listed as DNR/DNI on prior d/c summary
but his HCP wishes him to be full code at this point.
Past Medical History:
1) HIV: diagnosed in [**2106**], on HAART. followed by Dr. [**Last Name (STitle) 1057**] at
[**Hospital1 18**].
2) Diabetes Mellitus, type 2, since ~[**2106**] with neuropathy,
charcot foot, nephropathy, and ? mild retinopathy.
2) Chronic renal failure on Hemodialysis and graft infections,
thrombus: dx approx. [**2115**]. Started HD in 2/[**2118**]. On HD on tues,
thurs, sat at [**Doctor Last Name **] hospital. Dialysis unit - ([**Telephone/Fax (1) 17592**] /
Nephrologist - Dr. [**Last Name (STitle) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] -([**Telephone/Fax (1) 94989**]
3) [**Female First Name (un) 564**] esophagitis
4) Hepatitis C: genotype IB
5) Congestive heart failure: echocardiogram [**10-15**] w/ EF 50%.
6) Necrotizing Fasciitis: [**2112-10-17**]- [**2113**]: multiple surgeries and
circumcision during hospitalization.
7) Hypertension
8) Hypercholesterolemia
9) LE Diabetic ulcers
10) Herpes zoster of the left mandibular distribution of the
trigeminal nerve. [**2115**]
11) R suprapatellar abscess: [**2115**].
12) IVDU (heroin and cocaine) [**2079**]-[**2102**], none since [**2102**]
13) Obesity
15) GI Bleed: [**2117**]. OB positive stool.
16) Anemia
18) Colonic Polyps
19) Gastritis with large hiatal hernia.
20) Lipodystrophy
21) Charcot foot: dx in [**9-13**].
22) Colonic AVM: seen on [**3-9**] colonoscopy on the ileocecal
valve. Treated with thermal therapy.
23) Positive AFB in sputum: [**2119-11-17**]. MYCOBACTERIUM GORDONAE. No
abnormalities on CT chest in [**2121**].
24) VISA/MRSA- grew out from culture from R anterior chest wound
25) L3 compression deformity
Social History:
Lives in extended care facility. Quit smoking 20 years ago.
History of IVDU and alcohol abuse. Quit both over 20 years ago.
Has a fiance who says she is the HCP.
Family History:
Patient not close to family and is thus unaware of family
history.
Physical Exam:
65 year old man with HIV on HARRT (CD4 392 and neg VR in [**Month (only) **]
[**2126**]), hep C, CHF (EF50%) DM and ESRD on HD brought in from
[**Hospital3 105**] with positive blood cultures of actinobacter
.
# Septic Shock: The patient was initially admitted to the
floor, however became acutely hypotensive overnight the night of
admission. He was then transferred to the MICU. He was started
on pressors, ultimately requiring triple pressor therapy to
maintain adequate MAPs. The etiology of the hypotension, was
likely septic shock from Actinobacter bacteremia for which he
was sent from [**Hospital1 **]. The patient did not have subsequent
positive blood cultures. The patient was started on unasyn and
tobramycin to cover acinetobacter and added vancomycin to cover
recent MRSA as recent staph sensitive to vancomycin (previous
cultures were VISA).
- based on sensitivities, will change antibiotics to unasyn and
tobramycin to cover acinetobacter and add Vanc to cover MRSA
(recent staph cx sensitive to Vanc)
-- surveillance blood cultures
-- Contact IR to replace fem dialysis line and to place an
additional triple lumen cath (difficult access)
- will check MVO2 as no JVP assessment to guide recussitation
.
# Respiratory failure: His O2 sats were difficult to obtain on
the floor. He had very altered mental status so was intubated
for airway protection. No obvious infiltrates on CXR.
-- hold pscyhotropic drugs: gabapentin and narcotics. Continued
celexa to avoid rebound.
.
# Cdiff: During last hospitalization, he was found to have +
cdiff stool culture on [**1-6**] and was discharged on Flagyl. Given
clinical picture of infection with high leukocytosis, will
continue Flagyl for now even though he has no stool.
-- continue Flagyl given broad-spectrum antibiotics
-- surveillance Cdiff cultures
.
# ?SBO: Surgery following. He was passing flatus prior to the
code.
-- surgery following
-- OGT/NPO
-- monitor for flatus and BM
.
# History of graft thrombosis: Multiple clots in grafts and IVC
in past. INR 3.1. Goal INR [**2-11**]. [**Month (only) 116**] need FFP for line change.
- T&S
- heparin ggt if INR < 2
.
# HIV: Last VL was undetectable in [**6-16**]. Continue outpatient
HAART regimen.
- Stavudine 20 mg PO Q24H, RiTONAvir 100 mg PO BID, Indinavir
Sulfate 800 mg PO BID, LaMIVudine 150 mg PO Q TUES AND THURS
.
# HCV: no recent VL but last VL in 07 was 4,290 IU/mL. Unclear
synthetic fx of liver although recent albumin in [**Month (only) **] was 2.5.
INR 3.1 which is presumably from anticoagulation. MRI of abdomen
showed hemosiderosis of liver.
.
# Chronic systolic heart failure: EF 35-40% which is global and
likely from either etoh or cocaine. Currently hypotensive but
this is likely from septic shock but not CHF. PO2 low even on
1.0 FIO2 so will not give additional fluids.
.
# Anemia: Macrocytic so possibly from liver disease vs HAART.
Appeared to iron-deficient in [**Month (only) 1096**]. Also ESRD on HD so
likley this is a contributor. HCT higher than on discharge on
[**1-8**].
- trend for now
- check b12/folate
- guaic stools
.
# DM: sliding scale insulin
.
# HTN: nifedipine and metoprolol
.
# ESRD: on HD
-- appreciate renal following, will need a new HD line for CVVH
.
# L3 compression deformity: chronic
.
# FEN: NPO
# PPX: PPI and anticoagulated
# CODE: confirmed full w/ HCP fiance-[**Name (NI) **] [**Telephone/Fax (1) 95042**] but his
brothers-[**Telephone/Fax (1) 95043**] and fiance will talk today about overall
goals of care given that he had recently requested DNR/DNI
status at last admission.
# DISPO: ICU for now
Pertinent Results:
CT Abd/Pelvis: IMPRESSION:
1. Markedly dilated loops of small bowel, with the greatest
degree of
distention seen proximally, and within the stomach. Patient
would likely
benefit from nasogastric tube decompression. However, overall
appearance is very unusual for small bowel obstruction, as there
is no obvious transition point, no interloop fluid, and no small
bowel fecalization. However, the decompressed colon is somewhat
concerning. Findings could represent a complete small bowel
ileus, or a partial obstruction. Small bowel follow- through may
be helpful to evaluate transit.
2. Unchanged incidental findings including large hiatal hernia,
atrophic
kidneys, with multiple small cystic lesions and L3 compression
fracture.
.
Lab Results:
[**2127-1-21**] 12:30PM BLOOD WBC-19.6*# RBC-3.26*# Hgb-11.3*#
Hct-34.9*# MCV-107*# MCH-34.8*# MCHC-32.5 RDW-23.7* Plt Ct-271
[**2127-1-22**] 07:44AM BLOOD WBC-19.0* RBC-3.19* Hgb-11.2* Hct-35.0*
MCV-110* MCH-35.2* MCHC-32.1 RDW-24.1* Plt Ct-251
[**2127-1-22**] 08:17AM BLOOD WBC-20.0* RBC-3.48* Hgb-11.8* Hct-37.7*
MCV-108* MCH-33.9* MCHC-31.4 RDW-23.8* Plt Ct-291
[**2127-1-23**] 03:17AM BLOOD WBC-31.2*# RBC-3.46* Hgb-12.0* Hct-37.9*
MCV-110* MCH-34.8* MCHC-31.7 RDW-23.2* Plt Ct-262
[**2127-1-23**] 03:18PM BLOOD WBC-30.4* RBC-3.26* Hgb-11.5* Hct-35.6*
MCV-109* MCH-35.3* MCHC-32.3 RDW-23.1* Plt Ct-181
[**2127-1-24**] 03:00AM BLOOD WBC-28.8* RBC-3.04* Hgb-10.6* Hct-33.1*
MCV-109* MCH-34.7* MCHC-31.9 RDW-23.4* Plt Ct-225#
[**2127-1-21**] 12:30PM BLOOD Neuts-87* Bands-3 Lymphs-7* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-1*
[**2127-1-22**] 08:17AM BLOOD Neuts-72* Bands-21* Lymphs-4* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-2*
.
[**2127-1-22**] 07:44AM BLOOD PT-30.6* PTT-68.1* INR(PT)-3.1*
[**2127-1-22**] 08:17AM BLOOD PT-29.9* PTT-60.5* INR(PT)-3.0*
[**2127-1-23**] 03:17AM BLOOD PT-43.3* PTT-150* INR(PT)-4.8*
[**2127-1-23**] 05:21AM BLOOD PT-42.0* PTT-113.0* INR(PT)-4.6*
[**2127-1-23**] 03:18PM BLOOD PT-42.6* PTT-82.4* INR(PT)-4.7*
[**2127-1-24**] 03:00AM BLOOD PT-38.2* PTT-91.5* INR(PT)-4.1*
.
[**2127-1-21**] 12:30PM BLOOD Glucose-136* UreaN-17 Creat-4.3* Na-138
K-3.8 Cl-95* HCO3-26 AnGap-21*
[**2127-1-22**] 07:44AM BLOOD Glucose-128* UreaN-22* Creat-4.6* Na-138
K-3.8 Cl-100 HCO3-23 AnGap-19
[**2127-1-22**] 08:17AM BLOOD Glucose-142* UreaN-22* Creat-4.6* Na-137
K-4.0 Cl-100 HCO3-22 AnGap-19
[**2127-1-22**] 08:03PM BLOOD Glucose-216* UreaN-24* Creat-4.6* Na-135
K-4.2 Cl-101 HCO3-18* AnGap-20
[**2127-1-23**] 03:17AM BLOOD Glucose-186* UreaN-25* Creat-4.6* Na-132*
K-4.6 Cl-100 HCO3-17* AnGap-20
[**2127-1-23**] 03:18PM BLOOD Glucose-135* UreaN-30* Creat-4.8* Na-132*
K-5.5* Cl-100 HCO3-17* AnGap-21*
[**2127-1-24**] 03:00AM BLOOD Glucose-128* UreaN-33* Creat-4.9* Na-132*
K-5.7* Cl-102 HCO3-16* AnGap-20
.
[**2127-1-22**] 07:44AM BLOOD ALT-7 AST-16 AlkPhos-237* TotBili-1.1
[**2127-1-22**] 08:17AM BLOOD ALT-7 AST-21 CK(CPK)-68 AlkPhos-243*
TotBili-1.1
.
[**2127-1-21**] 12:30PM BLOOD Calcium-9.0 Phos-3.9 Mg-1.4*
[**2127-1-22**] 07:44AM BLOOD Calcium-8.6 Phos-4.9* Mg-1.9
[**2127-1-22**] 08:17AM BLOOD Calcium-8.9 Phos-4.9* Mg-1.9
[**2127-1-22**] 08:03PM BLOOD Calcium-8.6 Phos-4.9* Mg-1.8
[**2127-1-23**] 03:17AM BLOOD Calcium-8.2* Phos-4.6* Mg-1.7
[**2127-1-23**] 03:18PM BLOOD Calcium-8.5 Phos-5.5* Mg-1.7
[**2127-1-24**] 03:00AM BLOOD Calcium-8.2* Phos-5.9* Mg-1.7
.
[**2127-1-22**] 09:00AM BLOOD Ammonia-95*
[**2127-1-23**] 03:17AM BLOOD Ammonia-97*
.
[**2127-1-22**] 07:24AM BLOOD Type-ART pO2-98 pCO2-47* pH-7.30*
calTCO2-24 Base XS--3
[**2127-1-22**] 08:20AM BLOOD Type-ART Rates-/26 FiO2-100 pO2-68*
pCO2-44 pH-7.32* calTCO2-24 Base XS--3 AADO2-614 REQ O2-98
Intubat-NOT INTUBA
[**2127-1-22**] 10:16AM BLOOD Type-ART Rates-14/ Tidal V-550 PEEP-5
FiO2-100 pO2-160* pCO2-47* pH-7.28* calTCO2-23 Base XS--4
AADO2-519 REQ O2-85 -ASSIST/CON Intubat-INTUBATED
[**2127-1-22**] 12:09PM BLOOD Type-ART Rates-16/0 Tidal V-550 PEEP-5
FiO2-80 pO2-106* pCO2-41 pH-7.33* calTCO2-23 Base XS--4
AADO2-434 REQ O2-74 -ASSIST/CON Intubat-INTUBATED
[**2127-1-22**] 06:07PM BLOOD Type-ART Temp-36.6 Rates-22/ Tidal V-410
PEEP-10 FiO2-70 pO2-111* pCO2-54* pH-7.17* calTCO2-21 Base XS--9
-ASSIST/CON Intubat-INTUBATED
[**2127-1-22**] 08:24PM BLOOD Type-ART Temp-37.7 Rates-26/ Tidal V-410
PEEP-10 FiO2-60 pO2-103 pCO2-43 pH-7.23* calTCO2-19* Base XS--9
Intubat-INTUBATED Vent-CONTROLLED
[**2127-1-23**] 03:27AM BLOOD Type-ART pO2-129* pCO2-38 pH-7.26*
calTCO2-18* Base XS--9
[**2127-1-23**] 06:53AM BLOOD Type-ART Temp-37.6 Rates-28/ Tidal V-410
PEEP-10 FiO2-50 pO2-109* pCO2-38 pH-7.28* calTCO2-19* Base XS--7
Intubat-INTUBATED Vent-CONTROLLED
[**2127-1-23**] 04:07PM BLOOD Type-ART Temp-37.4 Rates-28/2 PEEP-10
pO2-119* pCO2-38 pH-7.28* calTCO2-19* Base XS--7 -ASSIST/CON
Intubat-INTUBATED
[**2127-1-24**] 03:16AM BLOOD Type-ART Temp-37.9 Rates-28/2 Tidal V-410
PEEP-10 FiO2-50 pO2-153* pCO2-33* pH-7.31* calTCO2-17* Base
XS--8 Intubat-INTUBATED Vent-CONTROLLED
Brief Hospital Course:
65 year old gentleman with HIV on HARRT (CD4 392 and neg VR in
[**2126-6-9**]), hep C, CHF (EF50%) DM and ESRD on HD brought in from
[**Hospital3 105**] with positive blood cultures with actinobacter.
.
# Septic Shock: The patient was initially admitted to the
floor, however became acutely hypotensive overnight. He was
then transferred to the MICU. He then required blood pressure
support, ultimately requiring triple pressor therapy. The cause
of his hypotension was likely secondary to septic shock from
acinetobacter bacteremia diagnosed at [**Hospital1 **]. No subsequent
blood cultures were positive. The patient was started on unasyn
and tobramycin to cover acinetobacter and vancomycin was added
to cover MRSA (recent staph cx sensitive to Vanc with a history
of VISA). Surveillance blood cultures were sent. The patient
continued to increase the amount of pressors required to
maintain adequate MAPs. Ultimately, the [**Hospital 228**] health care
proxy decided to withdraw pressor support and make the patient
[**Hospital 3225**].
.
# Respiratory failure: Initially his O2 sats were difficult to
obtain on the floor. He had very altered mental status in
addition thus was intubated for airway protection. He did not
develop obvious infiltrates on subsequent CXRs. His
psychotropic drugs, gabapentin and narcotics, were held. He was
continued on celexa. When the HCP decided to make the patient
[**Name (NI) 3225**], ventilatory support was withdrawn. Within 30 min the
patient underwent respiratory arrest with subsequent cardiac
arrest.
.
# Cdiff: During last hospitalization, he was found to have +
cdiff stool culture on [**1-6**] and was discharged on Flagyl.
Continued flagyl given broad-spectrum antibiotic therapy. Sent
surveillance Cdiff cultures
.
# SBO: Surgery was consulted. Thought to have had possible
ileus or abscess. OG tube was placed and drained feculent
material. The patient was kept NPO.
.
# History of graft thrombosis: Multiple clots in grafts and IVC
in past. Goal INR [**2-11**].
.
# HIV: Last VL was undetectable in [**6-16**]. Continued outpatient
HAART regimen of Stavudine 20 mg PO Q24H, Ritonavir 100 mg PO
BID, Indinavir Sulfate 800 mg PO BID, LaMIVudine 150 mg PO Q
TUES AND THURS.
.
# HCV: no recent VL but last VL in 07 was 4,290 IU/mL. Unclear
synthetic fx of liver although recent albumin in [**Month (only) **] was 2.5.
INR 3.1 which was presumably from anticoagulation. MRI of
abdomen showed hemosiderosis of liver.
.
# Chronic systolic heart failure: EF 35-40% which was global and
likely from either etoh or cocaine.
.
# Anemia: Macrocytic so possibly from liver disease vs HAART.
Appeared to iron-deficient in [**Month (only) 1096**]. Also ESRD on HD so
likley this was a contributor. HCT higher than on discharge on
[**1-8**].
.
# DM: continued sliding scale insulin
.
# HTN: continued nifedipine and metoprolol
.
# ESRD: on HD. Decided not to start CVVH.
.
# L3 compression deformity: chronic
.
# FEN: maintained NPO
# PPX: PPI and anticoagulated
# CODE: made the patient DNR and [**Month/Day (4) 3225**] confirmed w/ HCP
fiance-[**Name (NI) **] [**Telephone/Fax (1) 95042**] and his brothers-[**Telephone/Fax (1) 95043**]
Medications on Admission:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
6. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
7. Lamivudine 150 mg Tablet Sig: One (1) Tablet PO 2X/WEEK
(TU,TH).
8. Insulin Lispro 100 unit/mL Solution Sig: As indicated by
scale Subcutaneous ASDIR (AS DIRECTED).
9. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
10. Indinavir 400 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
11. Stavudine 20 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
12. Nifedipine 10 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
13. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for heartburn.
14. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
16. Carbamide Peroxide 6.5 % Drops Sig: 5-10 Drops Otic [**Hospital1 **] (2
times a day) for 4 days.
17. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed.
18. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain.
19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Discharge Disposition:
Expired
Discharge Diagnosis:
septic shock
Discharge Condition:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2127-1-24**]
|
[
"250.40",
"403.91",
"707.09",
"250.60",
"272.0",
"V45.11",
"428.0",
"585.6",
"250.50",
"428.22",
"V08",
"785.52",
"276.2",
"518.81",
"560.9",
"583.81",
"357.2",
"070.54",
"038.3",
"281.9",
"362.01",
"995.92",
"707.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
17767, 17776
|
12914, 16118
|
322, 347
|
17832, 18006
|
7956, 12891
|
4267, 4335
|
17797, 17811
|
16144, 17744
|
4350, 7937
|
261, 284
|
375, 2423
|
2445, 4071
|
4087, 4251
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
371
| 113,500
|
28118
|
Discharge summary
|
report
|
Admission Date: [**2147-12-8**] Discharge Date: [**2148-1-2**]
Date of Birth: [**2114-10-13**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
s/p MVC with injuries
Major Surgical or Invasive Procedure:
[**2147-12-9**]: Traction pin to LLE
[**2147-12-9**]: 1.IM nail right femur, 2.Closed reduction right pilon
fracture, 3.Application multiplanar external fixator,
4.Operative treatment of left subtrochanteric femur fracture
with intramedullary nail, 5.Washout and debridement, left open
femur fracture wound, 6.Treatment of left femoral shaft fracture
with IM implant.
[**2147-12-12**]: IVC filter placement, I&D Left open femur fx
[**2147-12-22**]: ORIF Right pilon fx
History of Present Illness:
Mr. [**Name13 (STitle) 27294**] is a 33 year old man who was invoved in a high speed
rollover motor vehicle crash on [**2147-12-8**]. He was trapped under
his car for 30 minutes with a GCS of 3 He was taken by
[**Location (un) **] to [**Hospital1 18**] for further care and treatment.
Past Medical History:
denies
Social History:
Works as a forklift operator
Lives with wife
Family History:
n/a
Physical Exam:
Upon admission
Intubated
Cardiac: Regular rate rhythm
Chest: No crepitus, equal but decreased breath sounds
Abdomen: Soft nontender nondistended
Extremities: In cervical collar
Left arm, large laeration over dorsum of left hand
Bilateral LE: Thighs grossly swollen, L lateral thigh with open
laceration around 2 cm in lenght, Right lower extremity
externall rotated to 90 degrees, Right ankle grossly unstable,
RLE pappable DP, Doppler PT weak, LLE no DP doppler PT
Pertinent Results:
[**2147-12-25**] 10:35AM [**Month/Day/Year 3143**] WBC-8.3 RBC-3.25* Hgb-9.6* Hct-28.3*
MCV-87 MCH-29.6 MCHC-33.9 RDW-14.2 Plt Ct-666*
[**2147-12-23**] 10:31AM [**Month/Day/Year 3143**] WBC-12.1* RBC-3.37* Hgb-10.1* Hct-29.4*
MCV-87 MCH-30.0 MCHC-34.4 RDW-14.5 Plt Ct-677*
[**2147-12-19**] 06:07AM [**Month/Day/Year 3143**] WBC-12.4*# RBC-3.14* Hgb-9.8* Hct-27.4*
MCV-87 MCH-31.2 MCHC-35.7* RDW-15.0 Plt Ct-610*#
[**2147-12-13**] 06:37AM [**Month/Day/Year 3143**] WBC-7.6 RBC-3.03*# Hgb-9.0*# Hct-26.7*#
MCV-88 MCH-29.8 MCHC-33.8 RDW-14.4 Plt Ct-206
[**2147-12-12**] 06:50AM [**Month/Day/Year 3143**] WBC-7.9 RBC-2.26* Hgb-7.1* Hct-19.5*
MCV-86 MCH-31.4 MCHC-36.4* RDW-14.2 Plt Ct-149*
[**2147-12-11**] 05:45PM [**Month/Day/Year 3143**] Hct-21.2*
[**2147-12-11**] 01:30PM [**Month/Day/Year 3143**] Hct-20.8*
[**2147-12-11**] 07:57AM [**Month/Day/Year 3143**] WBC-8.9 RBC-2.63* Hgb-8.0* Hct-22.6*
MCV-86 MCH-30.5 MCHC-35.6* RDW-13.9 Plt Ct-134*
[**2147-12-11**] 05:00AM [**Month/Day/Year 3143**] WBC-9.3 RBC-2.32* Hgb-7.2* Hct-20.0*
MCV-86 MCH-30.9 MCHC-36.0* RDW-14.2 Plt Ct-135*
[**2147-12-10**] 01:15PM [**Month/Day/Year 3143**] WBC-9.0 RBC-2.35* Hgb-7.5* Hct-20.5*
MCV-87 MCH-31.9 MCHC-36.7* RDW-13.4 Plt Ct-143*
[**2147-12-10**] 03:13AM [**Month/Day/Year 3143**] WBC-8.4 RBC-2.61* Hgb-8.1* Hct-22.9*
MCV-88 MCH-31.2 MCHC-35.5* RDW-13.5 Plt Ct-154
[**2147-12-9**] 02:28PM [**Month/Day/Year 3143**] WBC-9.1 RBC-3.38* Hgb-10.5* Hct-29.4*
MCV-87 MCH-31.0 MCHC-35.6* RDW-13.5 Plt Ct-213
[**2147-12-9**] 04:54AM [**Month/Day/Year 3143**] WBC-8.0 RBC-3.96* Hgb-12.0* Hct-34.8*
MCV-88 MCH-30.4 MCHC-34.6 RDW-13.5 Plt Ct-214
[**2147-12-9**] 01:11AM [**Month/Day/Year 3143**] WBC-11.6* RBC-3.93* Hgb-12.1* Hct-34.3*
MCV-87 MCH-30.9 MCHC-35.4* RDW-13.5 Plt Ct-216
[**2147-12-11**] 07:57AM [**Month/Day/Year 3143**] Neuts-75.7* Lymphs-13.4* Monos-5.9
Eos-4.9* Baso-0.2
[**2147-12-23**] 10:31AM [**Month/Day/Year 3143**] Glucose-133* UreaN-7 Creat-0.7 Na-130*
K-4.2 Cl-94* HCO3-25 AnGap-15
[**2147-12-19**] 06:07AM [**Month/Day/Year 3143**] Glucose-102 UreaN-12 Creat-0.7 Na-133
K-4.4 Cl-97 HCO3-26 AnGap-14
[**2147-12-12**] 06:50AM [**Month/Day/Year 3143**] Glucose-104 UreaN-8 Creat-0.7 Na-138
K-3.5 Cl-103 HCO3-28 AnGap-11
[**2147-12-11**] 05:00AM [**Month/Day/Year 3143**] Glucose-109* UreaN-8 Creat-0.8 Na-136
K-3.7 Cl-102 HCO3-29 AnGap-9
[**2147-12-10**] 01:15PM [**Month/Day/Year 3143**] Glucose-138* UreaN-12 Creat-0.9 Na-129*
K-4.2 Cl-99 HCO3-26 AnGap-8
[**2147-12-10**] 03:13AM [**Month/Day/Year 3143**] Glucose-148* UreaN-13 Creat-0.8 Na-134
K-4.2 Cl-103 HCO3-26 AnGap-9
[**2147-12-9**] 02:28PM [**Month/Day/Year 3143**] Glucose-150* UreaN-9 Creat-0.7 Na-139
K-4.3 Cl-108 HCO3-23 AnGap-12
[**2147-12-9**] 04:54AM [**Month/Day/Year 3143**] Glucose-113* UreaN-10 Creat-0.8 Na-143
K-3.5 Cl-108 HCO3-21* AnGap-18
Brief Hospital Course:
Mr. [**Name13 (STitle) 27294**] presented to [**Hospital1 18**] via [**Location (un) **] on [**2147-12-8**] after a
motor vehicle crash in which he was ejected and pinned under the
car. He was intubated at the scene. He was seen by the trauma
surgery service and was consulted on by orthopaedics and plastic
surgery.
Injuries:1. Left open femur fx, 2. Right femur fx, 3. Avulsion
of left hand with extension tendon exposure. 4. Right pilon fx.
He was admitted to the trauma intensive care unit for further
monitoring. On [**2147-12-9**] a traction pin was placed on his LLE
which resulted in return of DP/PT doppler pulses. Later that
day he was consented and prepped for surgery, he was taken to
the operating room for a IM nail right femur, Closed reduction
right pilon fracture, Application multiplanar external fixator,
Operative treatment of left subtrochanteric femur, fracture with
intramedullary nail, Washout and debridement, left open femur
fracture wound, Treatment of left femoral shaft fracture with IM
implant. He tolerated the procedure well and was taken back to
the trauma intensive care unit for recovery. He was later
extubated without difficulty. He remained hemodynamically
stable and was able to be transferred out of the trauma
intensive care unit to the floor on [**2147-12-10**]. He returned to the
operating room on [**2147-12-12**] for a washout and debridement of the
Left open femur fracture. During that procedure an IVC filter
was placed by Dr. [**Last Name (STitle) **] of trauma surgery. He tolerated the
procedure well without difficulty. He was also transfused with
2 units of packed red [**Last Name (STitle) **] cells for post-operative anemia. On
[**2147-12-15**] Mr. [**First Name (Titles) 27294**] [**Last Name (Titles) **] pressure was noted consistently high,
with his pain controlled and was started on 12.5mg daily of
lopressor, with noted effect. On [**2147-12-22**] he was taken to the
operating room for removal of the right leg ex-fix with ORIF of
ther fibula and tibia. He remained hemodynamically stable and
tolerated the procedure well. He continued to work with
physical therapy to improve his strenght and mobility.
Throughout his stay his pain was controled and his vital signs
remained within normal limits. He was discharged in stable
condition with instructions for follow up care.
Medications on Admission:
denies
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for sleep.
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily): Hold for SBP less than 120.
7. Oxycodone 5 mg Tablet Sig: 1-4 Tablets PO Q4-6H (every 4 to 6
hours) as needed for pain.
8. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) 30mg syringe
Subcutaneous Q12H (every 12 hours) for 4 weeks.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Multi-trauma
Post operative anemia
Discharge Condition:
Stable
Discharge Instructions:
If you develop any swelling, redness, or drainage from your
incision, or if you have a temperature greater than 101.5 or if
you become short of breath please call the office or come to the
emergency department.
Continue to be nonweight bearing on your right leg and weight
bearings as tolerated on your left leg.
Continue your lovenox injestions as directed
Physical Therapy:
Activity: Activity as tolerated
Right lower extremity: Non weight bearing
Treatment Frequency:
You may apply a dry sterile dressing to draining right ex-fix
areas.
Your staples on your right pilon fx can be removed in 4 days (14
days after surgery)
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in clinic in 2 weeks, please
call [**Telephone/Fax (1) 1228**] to schedule that appointment.
Completed by:[**2148-1-2**]
|
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icd9cm
|
[
[
[]
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icd9pcs
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844, 1132
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8557, 8713
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1178, 1224
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,821
| 191,606
|
28283
|
Discharge summary
|
report
|
Admission Date: [**2172-10-27**] Discharge Date: [**2172-11-20**]
Date of Birth: [**2118-7-26**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
Liver laceration [**1-18**] MVC
Major Surgical or Invasive Procedure:
Dobhoff tube placement
paracentesis
central line
Angiogram for possible arterial bleeding (no intervention)
History of Present Illness:
54 yo M, Pt has long h/o EtOH cirrhossis s/p TIPS c/b clot and
on coumadin. Presented as t/f from OSH [**1-18**] MVC ran into parked
car, unclear the situation around the accident, mod-severe car
damage, no airbag in car, unclear if LOC at scene but GCS 14-15
on arrival here. OSH scans sig for T3 dens and T8 wedge
compression (unkown if old/new), rib fx, knee laceration. No
intrathoracic/intra-abdominal injury. Had ? hematemesis in out
ED, but NG lavage clear. BP has slowly trended down throughout
day and uop decreased.
Past Medical History:
Alcoholic cirrhosis, s/p TIPS [**2170**]
Portal gastropathy
Ascites with spontaneous bacterial peritonitis
Grade II hemorrhoids
Grade I varices
Hepatic encephalopathy
Non insulin dependent diabetes
Hypothyroidism
Anemia
S/p ventral hernia repair
S/P splenectomy
Social History:
Patient disabled and lived alone in [**Hospital1 **]. No drugs or
tobacco. Alcoholic for 25 years, now quit since [**2168**].
Family History:
No hx of liver or GI dz. Mother with cancer of HTN. Father with
h/o cancer, unknown type.
Physical Exam:
VS: T 96.1 BP 127/79 P 89 R 20 Sat 92% on RA
Gen: Middle-aged male in a hard cervical collar laying in bed in
NAD
HEENT: Pupils were equal b/l, EOMI, some of his front teeth were
missing, his MM were dry
Neck: hard cervical collar in place
Lungs: Patient breathing comfortably on RA. CTAB anteriorly and
from the sides.
Heart: RRR, 3/6 systolic murmur heard best at the LLSB
Abd: + BS, distended, but soft, nontender. + fluid wave. Two
supernumerary nipples present half way down his abdomen.
Extrem: slight edema in his legs b/l, 2+ DP b/l, [**Doctor First Name 15569**] nail
changes present
Neuro: CN II-XII grossly intact, lower extrem strength 5/5 b/l
and normal hand grip strength b/l; sensation to light touch
intact throughout; asterixis by handgrip present
Psych: alert and oreinted x3
Skin: Spider angioma presnt on his chest
Pertinent Results:
On Admission:
[**2172-10-27**] 09:51PM GLUCOSE-233* UREA N-26* CREAT-2.0* SODIUM-140
POTASSIUM-4.8 CHLORIDE-111* TOTAL CO2-11* ANION GAP-23*
[**2172-10-27**] 09:51PM ALT(SGPT)-27 LD(LDH)-287* ALK PHOS-77 TOT
BILI-1.3
[**2172-10-27**] 09:51PM ALBUMIN-2.3* CALCIUM-7.7* PHOSPHATE-5.2*#
MAGNESIUM-2.0
[**2172-10-27**] 09:51PM WBC-7.7 RBC-2.52* HGB-8.2* HCT-24.7* MCV-98
MCH-32.7* MCHC-33.3 RDW-15.9*
[**2172-10-27**] 09:51PM PT-27.1* PTT-60.4* INR(PT)-2.7*
[**2172-10-27**] 07:10PM FIBRINOGE-160
[**2172-10-27**] 06:01PM HCT-24.3*
[**2172-10-27**] 12:26PM GLUCOSE-147* LACTATE-3.3* NA+-140 K+-4.2
CL--114* TCO2-15*
[**2172-10-27**] 12:18PM UREA N-18 CREAT-1.2
[**2172-10-27**] 12:18PM ALT(SGPT)-19 AST(SGOT)-36 ALK PHOS-121*
AMYLASE-50 TOT BILI-1.1 DIR BILI-0.5* INDIR BIL-0.6
[**2172-10-27**] 12:18PM LIPASE-62*
[**2172-10-27**] 12:18PM ALBUMIN-2.9*
[**2172-10-27**] 12:18PM AMMONIA-77*
[**2172-10-27**] 12:18PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2172-10-27**] 12:18PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2172-10-27**] 12:18PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-1 PH-6.5 LEUK-NEG
[**2172-10-27**] 12:18PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2 TRANS EPI-0-2
[**2172-10-27**] 11:46PM URINE EOS-NEGATIVE
.
On Discharge:
[**2172-11-20**] 05:26AM BLOOD WBC-7.5 RBC-3.07* Hgb-9.8* Hct-30.4*
MCV-99* MCH-31.9 MCHC-32.3 RDW-18.2* Plt Ct-317
[**2172-11-16**] 06:00AM BLOOD Neuts-72.1* Lymphs-11.9* Monos-8.3
Eos-6.8* Baso-0.9
[**2172-11-20**] 05:26AM BLOOD PT-19.7* INR(PT)-1.8*
[**2172-11-20**] 05:26AM BLOOD Plt Ct-317
[**2172-11-20**] 05:26AM BLOOD Glucose-167* UreaN-70* Creat-1.5* Na-145
K-4.2 Cl-113* HCO3-22 AnGap-14
[**2172-11-20**] 05:26AM BLOOD ALT-9 AST-23 AlkPhos-125* TotBili-2.3*
[**2172-11-20**] 05:26AM BLOOD Calcium-10.1 Phos-2.7 Mg-3.3*
.
Imaging:
CTA Neck Admission: 1. Minimally displaced type 3 dens fracture.
No evidence for osseous encroachment upon the spinal canal. If
there is clinical concern for ligamentous injury, further
evaluation with MRI could be performed. 2. No evidence for
vertebral artery or carotid stenosis, dissection or aneurysmal
dilatation. 3. Paranasal sinus disease as detailed above.
.
CTA Abdomen: IMPRESSION: 1. Liver laceration causing massive
hemoperitoneum and vascular depletion. 2. Suspected recent or
current active extravasation, although IV contrast was witheld
to avoid further decline in renal function. 3. Multiple
right-sided rib fractures. 4. Signs of renal failure, including
delayed contrast excretion from previous study, and vicarious
excretion through gallbladder. 5. Cholelithiasis without
cholecystitis.
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Study Date of
[**2172-10-28**] 1. Patent TIPS with relatively stable velocities. 2.
Massive hemoperitoneum.
.
Right hip x-ray: prelim: mild right osteoarthritis (no
fracture).
Brief Hospital Course:
MICU Course:
[**10-27**]: patient was transferred from an OSH, seen by
trauma/neurosurgery, admitted to ICU for liver and spine
injuries. C collar placed, to be kept on at all times
[**10-28**]: Angiogram for decreasing hematocrit, it did not reveal
any arterial source of bleeding and no intervention could be
performed for the venous bleeding. U/S liver showed TIPS patent,
transfused 3 units PRBC's, 1 unit platelets, 1 cryo, 2 FFP,
given Factor VII, intubated for increasing respiratory distress
[**10-29**]: Central line placed, continued intubated, sedated
[**10-30**]: paracentesis removed 1.6L fluid, lasix gtt started
[**10-31**]: Tube feeds started
[**11-2**]: vancomycin started for VAP
[**11-3**]: extubated successfully, lasix drip stopped, started on
prn lasix IV
[**11-5**]: PICC line placed, central line removed
[**11-6**]: transferred to [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] with hepatic encephalopathy
on 4 L NC
[**11-8**]: On [**11-8**], day of transfer to MICU, noted to be
increasingly tachypneic to 30s, O2 req increase f/3LNC to 5LNC.
Concern for PE (had been on hep sq since [**10-31**]), but given hx of
bleed and RF, CTA not performed. Abx coverage broadened to
linezolid/meropenem for [**Hospital 68679**] transferred to MICU.
[**11-8**] - [**11-13**] In the MICU his hypoxia was worked up and it was
felt to be secondary to his ascites. He underwent two large
volume paracentesis during which 14 L of fluid were removed with
improvement in his respiratory status, currently on room air. He
had a few days of low grade fevers, however infectious workup
has been negative. On [**11-12**] he underwent a diagnostic para due
to fever which was bloody, however had no evidence of SBP. The
meropenem and linezolid were stopped and he was placed back on
vancomycin for a 10 day course (which will end on [**11-18**]). His Hct
has remained stable and he has no required transfusions while in
the MICU. He is currently NPO and getting tube feeds.
[**11-14**] - [**11-15**] [**Doctor Last Name 3271**] [**Doctor Last Name 679**] - The patient was transferred back
to [**Doctor Last Name 3271**] [**Doctor Last Name 679**] on RA, and was alert and oriented x 2, although
with some delirium. He began requiring 1 L of oxygen the next
day and had decreased mental status, likely hepatic
encephalopathy. His lactulose was increased and he underwent a
diagnostic para which showed no evidence of SBP and a CXR showed
no infiltrate.
.
Course on Floor:
.
A/P: 54 yo male with PMH of ETOH cirrhosis, DM, and
hypothyroidism was tranferred from an OSH on [**10-27**] after a MVA
complicated by a a dens fracture, a non-weight bearing T8 wedge
fracture, and hemoperitoneum (now stable with medical
management) with continued hepatic encephalopathy since
extubation.
.
# Altered mental status: The patient was alert and oriented when
he presented to the hospital, but after he was extubated in the
TICU he was persistently encephalopathic. A head CT showed no
bleed or acute intracranial process. Infectious workups were
presistently negative, blood and urine cultures were no growth
and repeated paracenteses showed no evidence of SBP. The only
sign of infection was MRSA in his sputum as described below. He
was given increased doses of lactulose and rifaximin and
eventually his mental status began to clear. Most likely
delirium versus continued hepatic encephalopathy.
.
# ARF: The patient's Cr increased from 1.2 to 2.0 the night of
admission likely secondary to acute blood loss causing volume
depletion and possible ATN, although no documented hypotension.
There was a question of compartement syndrome during his
hospitalization. A renal US on [**11-7**] showed no hydronephrosis
and normal dopplers. Patient was started on octreotide and
midodrine for possible HRS, however was later discontinued as it
is felt ARF secondary to pre-renal. His creatintine peaked at
2.9 and is 1.5 on discharge.
- Aldactone 100 mg [**Hospital1 **] was on hold due to acute renal failure,
will need to re-started.
.
# Respiratory status: The patient was on RA when he was
transferred out of the TICU initially, however he began to have
increasing oxygen requirement and tachypnea. There was concern
for PE, but no DVTs seen on b/l lower extremity US. This
episode of hypoxia attributed to his massive ascites. His
hypoxia resolved after he had 14 L of asictic removed during two
therapeutic paracenteses.
# Hospital aquired pneumonia: The patient was started on
vancomycin on [**11-2**] when MRSA grew out of his sputum culture; he
was intubated and on the ventilator at the time. He completed a
14 day course of vancomycin (on [**11-18**]).
.
# Cirrhosis - The patient has EtOH cirrhosis and is not on the
transplant list due to social issues; He has a hx of portal
gastropathy, h/o acites requiring large volume paracenteses in
the past, SBP, grade 1 esophageal varices, grade 2 internal
hemorrhoids, and hepatic encephalopathy. TIPS procedure was
performed in [**2171-8-17**], with balloon angioplasty in [**Month (only) 547**]
[**2171**] for thrombosis. His last abdominal US on [**10-29**] showed his
TIPS to be patent. The patient was treated with lactulose and
rifaximin as above for encephalopathy. He was placed on IV
ciprofloxacin for SBP ppx given his hemoperitoneum. Diuretics
held given his ARF. He was continued on ursodiol for puritis.
On Bactrim for SBP ppx.
- Aldactone 100 mg [**Hospital1 **] was on hold due to acute renal failure,
will need to re-started.
.
# Liver laceration: The patient developed a liver laceration
after a MVA and was medically managed with 16U PRBCs, 8U FFP, 2U
platelets, 2 units of cryp, and a factor 7 infusion (his last
transfusion was on [**10-28**]). His Hct has been stable since [**10-29**]
and he has not required transfusion since then. Would recommend
guaiac stools.
# Hypernatremia: The patient had issues with hypernatremia
during his hospitalization given his NPO status and inability to
regulate his water intake (on nectar thickened liquids).
- Continue Flush w/ 500 water q4h and encourage thickened water
intake
# Dens fracture: Patient was found to have a dens fracture and
was evaluated by neurosurgery who recommended conservative
treatment. He will need to wear a hard cervical collar for 3
months and will follow up with neurosurgery as an outpatient.
Please call ([**Telephone/Fax (1) 88**] to schedule an appointment.
# Non-weight bearing T8 fracture: Patient with a T8 wedge
fracture. Per the trauma fellow, currently supposed to be
non-weight bearing with the HOB at 45 degrees. This was deemed
an ould fracture by neurosurgery and requires no activity
limitation.
# DM: continue nph and sliding scale.
.
# Hypothyroidism: Continued outpatient Levothyroxine 50 mcg qd
.
# R hip pain: prelim x-ray demonstrated mild osteoarthritis. No
fracture.
.
# History of tips thrombosis: Coumadin was stopped due to acute
bleed. Patient has scheduled ultrasound to re-evaluate TIPS
ULTRASOUND Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2172-12-25**] 10:15.
.
# FEN: Patient had dobhoff placed as not adequate po caloric
intake. He was given free water flushes for hypernatremia. He
was placed on folic acid and thiamine. Speech and swallow
evaluated and recommended: Regular Renal Protein: 60 gm;
Potassium: 2 gm; Sodium: 2 gm; Phosphorus: 1 gm and Nectar
prethickened liquids. Can be re-evaluated for thin liquids. TPN:
Pulmonary Full strength; Starting rate:40 ml/hr; Advance rate by
10 ml q4h Goal rate:50 ml/hr Residual Check:q4h Hold feeding for
residual >= :150 ml Flush w/ 500 water q4h (hyponatremia).
Medications on Admission:
Levothyroxine 50 mcg qd
Coumadin 4mg qd @ 4pm
Cyclobenzaprine 5 mg tid prn pain
Bactrim 160-800 mg qd ([**Doctor First Name **],MO,WE,TH,SA)
Lactulose 30 mL (20 mg of 10 g/15ml) TID
Ursodiol 300mg [**Hospital1 **]
Aldactone 100mg TID
thiamine 50 mg qd, folate 1mg qd, B12 100 mcg qd, FeS 325mg tid
docusate 100mg [**Hospital1 **] prn constipation
Omeprazole 40 mg Capsule DR [**Last Name (STitle) **]
Discharge Medications:
1. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
2. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
3. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) puff Inhalation Q2H (every 2 hours) as
needed for shortness of breath.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) puff
puff Inhalation Q6H (every 6 hours) as needed.
6. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO [**Doctor First Name **], Mo,
We, Th, Sa.
7. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Lactulose 10 gram/15 mL Syrup Sig: Forty Five (45) ML PO TID
(3 times a day).
9. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO once a
day.
10. Thiamine HCl 50 mg Tablet Sig: One (1) Tablet PO once a day.
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
12. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO once
a day as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] east region
Discharge Diagnosis:
MVA
Dens fracture
Hemoperitoneum
Liver laceration
Alcohol cirrhosis
Hypernatremia
Acute renal failure
Discharge Condition:
Fair.
Discharge Instructions:
You were admitted for injuries related to a motor vehicle
accident. You suffered a spinal cord fracutre (Dens) and must
wear you collar for 3 months. You also had some bleeding in your
abdominal cavity from a liver laceration. You need to take your
lactulose to prevent encephalopathy.
.
Attend all your follow up appointments. Your Aldactone 100 mg
[**Hospital1 **] was on hold due to acute renal failure, will need to
re-started.
.
Take all your medications as directed.
.
Return to the ER if you experience fever, chills, nausea,
vomiting, shortness of breath, worsening abdominal pain or any
other concerning symptoms.
Followup Instructions:
[**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 13146**] Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2172-12-3**] 3:00
ULTRASOUND Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2172-12-25**] 10:15
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2172-12-25**] 2:00
Please schedule an appointment with neurosurgery clinic [**Hospital1 18**]
([**Telephone/Fax (1) 88**] regarding his Dens fracture.
Completed by:[**2172-11-20**]
|
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icd9cm
|
[
[
[]
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[
"38.93",
"99.05",
"99.07",
"96.72",
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"99.04",
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icd9pcs
|
[
[
[]
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] |
14627, 14681
|
5380, 8201
|
307, 417
|
14827, 14835
|
2380, 2380
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15506, 16063
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1416, 1509
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13459, 14604
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14702, 14806
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13032, 13436
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14859, 15483
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1524, 2361
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3784, 5357
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236, 269
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445, 972
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2394, 3770
|
8216, 13006
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994, 1257
|
1273, 1400
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,343
| 182,844
|
47054
|
Discharge summary
|
report
|
Admission Date: [**2145-3-15**] Discharge Date: [**2145-3-18**]
Date of Birth: [**2075-1-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Norvasc / Zestril / Heparin Agents
Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
70 year old woman with hx of multipe comorbidities,
HTN/TIA/COPD, s/p right upper lobectomy for lung cancer, and a
remote hx of sb and large bowel resection (18 cm) for unknown
parastic infection, was transferred from OSH where she had
presented with 2-3 d hx of nausea/vomiting and one day hx of
abdominal pain and developed an episode of hematemesis at the
OSH. Pt reports that 3 days of intermittent nausea/vomiting with
increasing abdominal pain over middle quadrants since 1:00AM
last night. She reports she has had 3 years of intermittent
nausea and vomiting and had a recent viral gastroenteritis with
diarrhea 1 week ago. At the OSH an abdominal CT scan was done
that was suspicious for partial SBO given mild dilation of the
duodenum and then subsequent decompression after the second
portion and was transferred to [**Hospital1 **].
.
In ED, initial VS were 97.5, 120, 135/60, 20, 92%RA. An NG
lavage was performed that revealed black material that was not
clearing despite 1 liter of lavage. The patient did not have
another episode of frank hematemesis. Her serum alcohol level
was found to be high (127) in the ED.
.
On the floor, initial vitals were T: 98.6 BP: 160/83 P: 117 R:
27 O2: 94% 3L NC. The Pt was uncomfortable but in no acute
distress, and her exam was notable for epigastric abdominal
tenderness with minimal guarding and no rebound tenderness. GI
was consulted and planned to perform EGD on the Pt shortly after
arrival to the MICU.
Past Medical History:
-bronchoalveolar carcinoma s/p right upper lobectomy [**2138**]
by Dr. [**Last Name (STitle) 175**] in [**5-/2139**]
-Hypertension
-TIA
-Angioedema
-Rheumatoid arthritis
-Diverticulosis (colonscopy [**2134**])
-Vertigo
-COPD
-Appendectomy (age 14)
-Small and large bowel (~18cm) resection ~30 years ago
(for a parasite infection)
-? Left breast mass
- Tachycardia attributed to effect of theophylline and albuterol
Social History:
Originally from [**Country 19828**], married, lives with husband.
-Previous smoker 1 pack per day for over 40 years; stopped 8
years ago.
-Daily 2 shots of scotch
-Denies IVDA
Family History:
+breast cancer. No GI cancer. +hypertension
Physical Exam:
Vitals: T: 98.6 BP: 160/83 P: 117 R: 27 O2: 94% 3L NC
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: Tachycardic, regular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mid epigastric tenderness with minimal guarding,
non-distended, bowel sounds present, no rebound tenderness, no
organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
On admission:
[**2145-3-15**] 08:50AM BLOOD WBC-9.2 RBC-3.89* Hgb-12.9* Hct-37.8*
MCV-97 MCH-33.2* MCHC-34.1 RDW-14.4 Plt Ct-173
[**2145-3-15**] 08:50AM BLOOD Neuts-82.5* Lymphs-13.9* Monos-3.1
Eos-0.4 Baso-0.2
[**2145-3-15**] 08:50AM BLOOD Glucose-86 UreaN-23* Creat-0.9 Na-142
K-3.3 Cl-99 HCO3-28 AnGap-18
[**2145-3-15**] 08:50AM BLOOD Albumin-3.8
[**2145-3-15**] 08:50AM BLOOD ASA-NEG Ethanol-127* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
[**3-15**]: GI bx
Esophagus, mucosal biopsy: Ulcerated squamous mucosa with
fibrino-purulent exudate. Stains for bacteria and fungi are
negative.
.
[**3-15**] CT abd/pelvis
IMPRESSION:
1. Circumferential mural edema involving the distal esophagus as
well as the gastric pylorus more than antrum, suggesting
esophagitis and gastritis, which may be inflammatory in
etiology. Further evaluation by upper endoscopy is recommended.
2. No evidence of abdominal aortic aneurysm. Diffuse
atherosclerotic disease with calcification involving much of the
abdominal aorta and the origin of the SMA and celiac arteries
with mild narrowing.
3. Fatty liver. Small hypodensities within bilateral kidneys,
too small to characterize.
4. A sebaceous cyst within the right back appears unchanged.
5. Diffuse hepatosteatosis without focal lesion. No evidence of
small-bowel obstruction.
6. Small right pleural effusion.
.
[**3-18**] ECHO
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 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. The right ventricular free wall is hypertrophied. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Normal biventricular systolic function.
Brief Hospital Course:
This is a 70 year old woman with COPD, history of lung CA s/p
RUL lobectomy, possible ETOH abuse, presenting with hematemesis
and abdominal pain, found to have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear.
.
#. Hematemesis. An EGD was performed which showed exudative
esophagitis, gastritis, and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear. The
[**Doctor First Name **]-[**Doctor Last Name **] tear was likely from vomiting as a result of
concomitant NSAID and EtOH use with a blood alchohol level of
around 300 at OSH prior to transfer. Biopsies showed ulcerated
squamous mucosa with fibrino-purulent exudate and stains were
negative for bacteria/fungus. An active type and screen as well
as access with 2 large bore IVs was maintained. She was
initiated on Protonix 40mg IV BID which was transitioned to
Protonix 40mg PO BID prior to discharge. Her hematocrit was
trended frequently but remained stable and she did not require a
blood transfusion. Her home aspirin was also held and a
decision to restart it was deferred to the outpatient setting.
.
#. Hypoxemia. She had a significant 5-6L O2 requirement, but
was weaned to 88-92% on RA [**3-17**]. She was satting in the low 90s
on RA both at rest and on exertion prior to discharge which is
felt to be her baseline. She does have a baseline RUL lobectomy
plus COPD but does not have a home O2 requirement. Her CXR had
effusions and possible edema likely from volume overload after
resusciation with possible diastolic dysfunction. Her JVD was
not elevated and she did not appearing grossly volume
overloaded, but her sats improved dramatically after several
doses of Lasix 10mg IV. She was started on Lasix 20 mg PO daily
on discharge. She was transitioned to albuterol/ipratropium
nebs in addition to her home Flovent for COPD management. The
nebs were changed back to her home regimen of albuterol inhaler
and tiotropium prior to discharge. Her home theophylline was
also initially discontinued due to tachycardia but was restarted
on [**3-17**] as her blood levels were WNLs.
.
# Tachycardia: The patient was tachycardic to the 120s on
arrival to the MICU. She has a history of tachycardia based on
PCP clinical notes which is thought to be secondary to her
theophylline and bronchodilators. She had no other signs of
alcohol withdrawal. She was bolused 1L NS on arrival given
hematemesis and her heart rate came down to low 100s. TSH was
ordered and within normal limits at 2.7. There was some concern
for pulmonary embolism and an ECHO was obtained prior to
discharge which did not show signs of right heart strain. She
was monitored on telemetry without significant cardiac events.
.
#. ETOH abuse: She admits to drinking 2 shots of scotch nightly
and was noted to have an ETOH level in the 300s at the OSH and
was measured at 127 on admission here. She has evidence of
fatty liver disease, and hx of elevated urine metanephrines
which could also be consistent with ETOH abuse. Her LFTs also
revealed a classic 2:1 AST/ALT ratio. CIWA was started, but the
patient did not require any Valium dosing. She was started on a
MVI, folate, and thiamine. Her magnesium and potassium were
also noted to be low and she was discharged on daily potassium
repletion. Social work was consulted.
.
#. Hypertension. Her home antihypertensives were all initially
held. Her home nifedipine, HCTZ, and doxazosin were all
restarted prior to discharge.
.
#. Gout. She was continued on her home regimen of allopurinol.
.
#. Code: The patient's code status was confirmed as full code
this admission.
Medications on Admission:
ALBUTEROL SULFATE [VENTOLIN HFA] - 90 mcg HFA Aerosol Inhaler -
2
inhalations po four times a day as needed for PRN
ALLOPURINOL - 300 mg Tablet - 1 Tablet(s) by mouth once a day
ASPIRIN - 81 MG TABLET - ONE EVERY DAY
BETAXOLOL [BETOPTIC S] - 0.25 % Drops, Suspension - 1 drop left
eye twice a day
DOXAZOSIN - 4 mg Tablet - 1 Tablet(s) by mouth once a day
EPINEPHRINE [EPIPEN] - 0.3 mg/0.3 mL (1:1,000) Pen Injector -
use as instructed x1
FLUTICASONE [FLOVENT HFA] - 220 mcg Aerosol - [**12-26**] inhalation [**Hospital1 **]
twice a day
HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth every
morning
IBUPROFEN - 600 mg Tablet - 1 Tablet(s) by mouth four times a
day
take with food
NIFEDIPINE - 90 mg Tablet Sustained Release - 1 Tablet(s) by
mouth once a day
POTASSIUM CHLORIDE [MICRO-K] - 10 mEq Capsule, Sustained Release
- 2 Capsule(s) by mouth once a day
THEOPHYLLINE - 200 mg Tablet Sustained Release 12 hr - 1
Tablet(s) by mouth twice a day
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - inhale contents of one capsule once a day
DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a
day
MULTIVITAMINS-MINERALS-LUTEIN [CENTRUM SILVER] - (Prescribed by
Other Provider; OTC) - Tablet - 1 Tablet(s) by mouth daily
POLYCARBOPHIL CALCIUM [FIBERCON] - (Prescribed by Other
Provider; OTC) - 625 mg Tablet - 1 Tablet(s) by mouth daily
VITAMIN E - (Prescribed by Other Provider; OTC) - 400 unit
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB.
2. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Betaxolol 0.25 % Drops, Suspension Sig: One (1) Ophthalmic
twice a day: left eye.
4. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO once a day.
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
8. Theophylline 200 mg Tablet Sustained Release 12 hr Sig: One
(1) Tablet Sustained Release 12 hr PO BID (2 times a day).
9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Multivitamins-Minerals-Lutein Tablet Sig: One (1) Tablet
PO once a day.
12. FiberCon 625 mg Tablet Sig: One (1) Tablet PO once a day.
13. Vitamin E 400 unit Tablet Sig: One (1) Tablet PO once a day.
14. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Esophagitis
[**Doctor First Name **]-[**Doctor Last Name **] Tear
Pulmonary Edema
Secondary:
Bronchoalveolar carcinoma s/p right upper lobectomy
COPD
Hypertension
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 while you were in the
hospital. You were admitted because of bleeding in your
stomach. You underwent an endoscopy that showed inflammation of
your esophagus and a small tear. You did not have any further
bleeding and remained stable.
You also had fluid in your lungs and were given medications to
help remove the fluid. Your breathing improved and were able to
walk around with oxygen levels greater then 92%. You may have
also aspirated when you were vomiting. Your follow-up chest
x-ray did show improvement.
The following changes were made to you medications:
- You should hold your aspirin until you follow-up with GI and
your PCP on [**Name9 (PRE) 766**] [**3-22**]
- You were started on lasix 20mg daily. When you follow-up with
your PCP on [**Name9 (PRE) 766**] he should check your electrolytes and volume
status.
- Please continue your potassium supplements as before
- You should stop taking your hydrochlorothiazide 25mg.
Please follow-up with the appointments below.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) 349**], for GI follow-up
after your bleed on [**3-22**] at 1:30pm
([**Telephone/Fax (1) 2233**]
You have an appointment with [**Company 191**] [**Hospital **] [**Hospital **] Clinic
on [**3-22**] at 2:50pm.
([**Telephone/Fax (1) 1300**]
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2145-4-26**] 9:30
Provider: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. Date/Time:[**2145-5-5**] 10:00
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
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2272, 2450
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,956
| 175,993
|
54895
|
Discharge summary
|
report
|
Admission Date: [**2187-6-14**] Discharge Date: [**2187-6-16**]
Service: MEDICINE
Allergies:
lisinopril
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **] year old female with a history of hip fracture s/p mechanical
fall 1 week ago, s/p ORIF, course complicated by DVT and
subsequent IVC filter placement, just discharged on [**6-12**] to
rehab on coumadin, lovenox, and aspirin 325. She initially
presented to OSH with a Hct of 15 from 30 on discharge two days
ago. Her INR was 8.5. She recieved 10 mg IV Vitamin K. She is
Jehovah Witness and the son was refusing blood product or [**Name (NI) 9087**].
CT scan at OSH showed large right [**Name (NI) **] hematoma. Patient was
transferred to [**Hospital1 18**] for further management. In the ED, her
initial BPs were in the 70s/50s. Hct confirmed to be 15, INR had
decreased to 4.2. She received 5 L NS total, with pressures
improving to high 90s systolic. A compression bag was placed on
the patient's [**Hospital1 **] per surgery recommendations. Her urinalysis
was also positive so she was given a dose of ceftriaxone. Per
discussion with family in the ED, patient made DNR/DNI. On
transfer, vitals were 97/56 78 100%2LNC.
Past Medical History:
CAD s/p STEMI [**9-/2186**] per [**1-11**] [**Hospital3 **] d/c summary
-cath with distal LAD disease, EF 40-45%
-repeat cath [**10/2186**] at LGH
CKD
Aortic aneurysm at 4.3cm dilation noted in [**10-11**]
HTN
Peripheral Neuropathy
nephrolithiasis
OA
h/o cellulitis
actinic keratosis
eczema
allergic rhinitis
recurrent lateral right foot edema
h/o abnormal Pap (ASCUS)
healthcare maintenance: colonoscopy summer [**2180**], [**Last Name (un) 3907**] [**7-/2183**],
pneumovax [**6-/2178**], TDaP [**11/2186**]
Hip fracture
DVT s/p IVC filter placement
Social History:
Came from rehab, denies smoking, EtOH.
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
ADMISSION LABS:
[**2187-6-14**] 05:55PM BLOOD WBC-20.0*# RBC-1.69*# Hgb-4.8*#
Hct-16.4*# MCV-97 MCH-28.4 MCHC-29.3* RDW-19.3* Plt Ct-487*
[**2187-6-14**] 05:55PM BLOOD Neuts-84.0* Lymphs-11.8* Monos-4.0
Eos-0.1 Baso-0.1
[**2187-6-14**] 05:55PM BLOOD PT-42.9* PTT-42.2* INR(PT)-4.2*
[**2187-6-14**] 05:55PM BLOOD Glucose-148* UreaN-29* Creat-2.0* Na-135
K-5.0 Cl-104 HCO3-22 AnGap-14
[**2187-6-14**] 05:55PM BLOOD ALT-23 AST-49* AlkPhos-90 TotBili-0.3
[**2187-6-14**] 05:55PM BLOOD Albumin-2.6* Calcium-8.9 Phos-4.9*#
Mg-2.4
[**2187-6-14**] 05:55PM BLOOD Lipase-15
[**2187-6-14**] 05:55PM BLOOD cTropnT-<0.01
[**2187-6-14**] 06:06PM BLOOD Lactate-2.6*
[**2187-6-15**] 09:49AM BLOOD Lactate-2.8*
[**2187-6-15**] 10:05AM BLOOD Lactate-3.1*
.
PERTINENT LABS:
[**2187-6-14**] 05:55PM BLOOD Hct-16.4
[**2187-6-14**] 09:33PM BLOOD Hct-15.4
[**2187-6-15**] 03:57AM BLOOD Hct-13.6
[**2187-6-15**] 09:38AM BLOOD Hct-11.8
.
MICROBIOLOGY:
[**2187-6-14**] Blood culture: no growth to date
[**2187-6-15**] Urine culture: GNRs ~4000/ml
.
IMAGING:
[**2187-6-15**] CTA abdomen/pelvis:
1. Bilateral pulmonary emboli with small bilateral pleural
effusions.
2. No evidence for active extravasation.
3. Right [**Month/Day/Year **] hematoma, unchanged from comparison CT of
approximately one day prior.
4. Appropriately positioned inferior vena cava filter containing
trapped emboli.
Brief Hospital Course:
[**Age over 90 **] year old woman s/p ORIF for hip fracture one week ago, c/b
DVT with subsequent IVC filter placement, who presented with
hypotension, found to have a large right [**Age over 90 **] hematoma and new
PEs.
.
# Hypotension: Secondary to hypovolemic shock in the setting of
a HCT drop to 16.4 from 30 two days prior to admission. Patient
was discharged on lovenox and coumadin and had a
supratherapeutic INR (8.5 at OSH) on the day of admission. CTA
revealed a large right [**Age over 90 **] hematoma though no active
extravasation. She was administered vitamin K, amicar, DDAVP,
and over 10 liters of fluid resuscitation. A pressure dressing
was placed over her right [**Age over 90 **] to prevent further bleeding. She
is a Jehovah's Witness, so declined blood products. Hematology
and the blood bank were consulted regarding administration of
recombinant factor VII. This had a risk of arterial thrombi,
therefore after discussion with the patient's family, including
her daughter (HCP), the decision was made to not administer
recombinant factor VII. IR and surgery were consulted, however
it was felt that there was no surgical or interventional
procedure indicated. The family was made aware of the patient's
very poor prognosis and she was made DNR/DNI. Her HCT further
dropped to 11.8 and she had progressively worsening hypotension.
She passed away at 07:05 on [**2187-6-16**]. The medical examiner was
notified and is considering an autopsy.
.
# Urinalysis: UA with questionable UTI so the patient was given
a dose of ceftriaxone at the OSH. Given her hypotension and
shock, she was broadly covered with vanc and zosyn.
.
# PEs: Seen on abdominal/pelvic CTA. Given her bleeding, no
treatment was initiated.
Medications on Admission:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
6. valsartan 160 mg Tablet Sig: One (1) Tablet PO once a day.
7. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily): hold for loose
stools.
11. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
12. magnesium citrate Solution Sig: Three Hundred (300) ML
PO once a day as needed for constipation.
13. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours): Continue until INR is therapeutic.
14. warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once): New
medication, adjust dose as needed with frequent INR testing.
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Right [**Date Range **] hematoma
Hypovomic shock
PE
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2187-6-16**]
|
[
"V49.86",
"356.9",
"415.19",
"785.59",
"V62.6",
"427.31",
"584.9",
"V12.51",
"412",
"453.41",
"414.01",
"285.1",
"599.0",
"998.09",
"403.90",
"E878.1",
"996.74",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7102, 7111
|
4047, 5778
|
237, 243
|
7206, 7215
|
2661, 2661
|
7268, 7303
|
1970, 1988
|
7073, 7079
|
7132, 7185
|
5804, 7050
|
7239, 7245
|
2003, 2642
|
186, 199
|
271, 1323
|
2677, 3400
|
3416, 4024
|
1345, 1897
|
1913, 1954
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,208
| 127,240
|
9032
|
Discharge summary
|
report
|
Admission Date: [**2170-10-19**] Discharge Date: [**2170-10-25**]
Date of Birth: [**2125-3-12**] Sex: F
Service: SURGERY
Allergies:
Codeine / Percocet / Oxycodone
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Drainage from incision
Major Surgical or Invasive Procedure:
none
History of Present Illness:
45F s/p laparoscopic cholecystectomy on [**2170-9-15**] by Dr. [**First Name (STitle) **] for
biliary dyskinesia complicated by wound infection. Patient was
seen recently in clinic by Dr. [**First Name (STitle) **] on [**2170-10-10**] where the
umbilical port site was opened and packing with sterile
dressing. Patient reports since that time she was also started
on Augmentin and then Bactrim and has continued to have drainage
from the
site. The drainage was initially green, however has changed to
yellow in color. Patient denies fevers, chills, nausea, vomiting
or changed in bowels.
Past Medical History:
-Chronic abdominal pain for 3-5 years
-hydrocephalus as an infant and apparently has seventeen clips
in her brain.
-two major car accidents that have left her with some cognitive
deficiency and pain.
-appendectomy,
-breast biopsy
-right inguinal hernia repair,
-hysterectomy for endometriosis
-carpal tunnel repair.
-Type 1 DM on insulin for 25 years
-Hyperlipidemia
-hypothyroidism
-GERD
-Anxiety
-Proteinuria
-chronic UTIs
Social History:
Current smoker, since age 16, smoking 2 packs/week. Occ. EtOH.
Denies illicits. Currently on disability
Family History:
father who had CAD and died of a MI. Her mother had [**Name2 (NI) 500**] cancer.
She has an aunt who had [**Name (NI) 4522**] disease.
Physical Exam:
VS: T 98.4 P 96 BP 129/64 RR 15 O2 100%RA
PE: Gen - alert and oriented times 3
CV - RRR
Pulm - CTAB
Abd - Soft, nondistended, umbilical site with packing in
place, upon removal foul smelling, purulent discharge
noted, erthema tracking infraumbilically, very tender to
palpation around incision
Ext - no edema
Pertinent Results:
[**2170-10-23**] 02:59AM BLOOD WBC-7.0 RBC-2.97* Hgb-9.3* Hct-27.4*
MCV-92 MCH-31.4 MCHC-34.0 RDW-13.8 Plt Ct-460*
Brief Hospital Course:
The patient was admitted to the surgical floor for evaluation
and treatment. CT scan showed no acute intra-abdominal process.
IV antibiotics were utilized. Dressing changes were initiated
with iodoform. Pain control was also maintained. On hospital day
2, the patient was noted to be unarousable on morning rounds.
Her blood glucose was 27. She was given 1 amp of D50, and she
responded well. Her glucose normalized. She was transferred to
the ICU and an insulin drip was started. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was
obtained. The lantus dose was decreased to 20 units. Blood
glucose levels were improved and the patient was transferred to
the floor. The patient was discharged to home on hospital day 5.
On hospital day 6, the patient again experienced low blood
sugars. [**Last Name (un) **] was again consulted and the sliding scale was
adjusted. Suguar subsequently improved. At the time of
discharge, she was afebrile and blood sugar were controlled,
with no evidence of hypoglycemia. At the time of discharge,
[**Last Name (un) **] recommended Lantus 22 units QHS and the use of her home
sliding scale.
Medications on Admission:
Lipitor 20', Desipramine 25', Bentyl 10 Q4, Zetia 10',
Vicodin, Lantus 18 units daily, Humalog SS, Synthyroid 100',
Reglan 10 prior to meals, Prilosec 20'', Paxil 5', Diovan 160',
Colace, Senna
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Desipramine 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
7. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Dicyclomine 10 mg Capsule Sig: One (1) Capsule PO QID (4
times a day).
9. Nitrofurantoin Macrocrystal 50 mg Capsule Sig: Two (2)
Capsule PO DAILY (Daily).
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
11. Paroxetine HCl 10 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
12. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO every 4-6 hours as needed: DO NOT DRIVE WHILE TAKING THIS
MEDICATION.
Disp:*30 Tablet(s)* Refills:*0*
13. medication
Sliding scale: please use your home sliding scale [**First Name8 (NamePattern2) **] [**Last Name (un) **].
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: While taking narcotic pain medication.
Disp:*60 Capsule(s)* Refills:*2*
15. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
16. Insulin Glargine 100 unit/mL Cartridge Sig: One (1) 22
Subcutaneous at bedtime.
Discharge Disposition:
Home With Service
Facility:
VNA of Greater [**Hospital1 189**]
Discharge Diagnosis:
cellulitis
Discharge Condition:
good
Discharge Instructions:
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Monitor your blood glucose with fingersticks and take insulin
according to the sliding scale. VNA nursing services will help
you.
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2998**] to schedule your appointment.
You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]/[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Tues [**2170-10-30**] at 11:30 AM at [**Last Name (un) **].
Please follow-up with your primary care physician.
Completed by:[**2170-11-5**]
|
[
"250.61",
"585.9",
"300.00",
"E878.6",
"998.59",
"682.2",
"272.4",
"305.1",
"V58.67",
"294.9",
"357.2",
"250.81",
"244.9",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5125, 5190
|
2183, 3334
|
316, 322
|
5244, 5250
|
2044, 2160
|
6213, 6656
|
1527, 1663
|
3580, 5102
|
5211, 5223
|
3360, 3557
|
5274, 6190
|
1678, 2025
|
253, 278
|
350, 940
|
962, 1389
|
1405, 1511
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,481
| 178,134
|
23407
|
Discharge summary
|
report
|
Admission Date: [**2137-12-12**] Discharge Date: [**2137-12-15**]
Date of Birth: [**2068-7-3**] Sex: M
Service: TRA
HISTORY OF PRESENT ILLNESS: This 69 year old male fell off a
ten foot high roof and had head trauma and loss of
consciousness. He was transferred from an outside hospital
with the diagnosis of multiple left rib fractures of ribs
three through eight and a questionable subarachnoid
hemorrhage on CT. Upon arrival to [**Hospital1 190**], the patient had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] Coma Scale of 15,
but was unable to recall the events of the fall. He did not
complain of chest pain, shortness of breath or
lightheadedness. He did have a mild headache at
presentation.
PAST MEDICAL HISTORY: Hypertension.
Anxiety.
Arrhythmia (specific type unknown).
PAST SURGICAL HISTORY: Status post hernia repair times
three.
Status post knee surgery times one.
Status post appendectomy.
Status post discectomy times four.
MEDICATIONS ON ADMISSION:
1. Paroxetine 20 mg p.o. daily.
2. Diovan 80 mg p.o. daily.
3. Hydrochlorothiazide 25 mg p.o. daily.
4. Norvasc 10 mg p.o. daily.
5. Alprazolam 0.5 mg p.o. q.h.s. p.r.n.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Past history of heavy alcohol use, currently
drinks one beer per day. Past history of tobacco use but
quit thirty years ago.
PHYSICAL EXAMINATION: Vital signs on admission revealed
temperature 98.6, blood pressure 124/82, heart rate 79,
respiratory rate 18, oxygen saturation 93 percent on two
liters. The patient was in no acute distress. The pupils
are equal, round and reactive to light and accommodation.
Extraocular movements are intact. Tympanic membranes clear.
Cervical collar in place. Lungs are clear to auscultation,
bilateral breath sounds. Tender to palpation over the left
chest with no crepitus. Cardiac regular rate and rhythm, no
murmurs, rubs or gallops. Abdomen - normal bowel sounds,
soft, nontender, nondistended. Normal rectal tone and guaiac
negative. Extremities well perfused. Tender to palpation
over the left shoulder, no focal tenderness, and had full
range of motion. Neurologically, alert and oriented times
three. Cranial nerves II through XII are intact. Moving all
extremities with 5/5 strength throughout.
LABORATORY DATA: On admission, white blood cell count 11.8,
hemoglobin 14.7, hematocrit 41.8, platelet count 217,000.
Glucose 135, blood urea nitrogen 26, creatinine 1.0, sodium
141, potassium 3.3, chloride 102, bicarbonate 28 with an
anion gap of 14. Initial CK was 1,270 which trended down
over the course of his admission. CK MB 4.0. Calcium 9.0,
phosphorus 2.8, magnesium 1.9.
Pertinent radiology studies on admission included a head CT
which showed a subarachnoid hemorrhage in the left temporal
sulci with a scalp hematoma. Cervical spine CT showed a
grade I anterolisthesis of C4 on C5. Chest x-ray showed left
rib fractures of ribs number three, four and five with no
pneumothorax. Thoracolumbosacral films were negative. Left
shoulder film was negative. Magnetic resonance imaging of
the cervical spine was negative. Subsequent head CT done on
hospital day number one showed a stable subarachnoid
hemorrhage with no increase in size.
HOSPITAL COURSE: Subsequently, the patient was followed by
the trauma surgery team and the neurosurgery team and was
monitored in an Intensive Care Unit setting on the day of
admission and on hospital day number two. He was transferred
to the surgical [**Hospital1 **] on hospital day number three,
[**2137-12-14**]. He continued to do well with no change in his
neurologic examination and was discharged on hospital day
number four, [**2137-12-15**], with follow-up arranged to have a
repeat head CT done in two weeks in the [**Hospital 4695**] Clinic
and to follow-up in the Trauma Surgery Clinic in two weeks as
well.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES: Subarachnoid hemorrhage.
Left rib fractures of ribs three, four and five.
Hypertension.
Anxiety.
History of arrhythmia.
MEDICATIONS ON DISCHARGE:
1. Alprazolam 0.5 mg p.o. q.h.s. p.r.n.
2. Percocet one to two tablets p.o. q4-6hours p.r.n. pain.
3. Paroxetine 20 mg p.o. daily.
4. Diovan 80 mg p.o. daily.
5. Hydrochlorothiazide 25 mg p.o. daily.
6. Norvasc 10 mg p.o. daily.
FOLLOW UP: The patient will follow-up in the [**Hospital 4695**]
Clinic in two weeks for a repeat head CT and the patient will
follow-up in the Trauma Surgery Clinic in two weeks.
[**First Name11 (Name Pattern1) 518**] [**Last Name (NamePattern4) **], [**MD Number(1) 17554**]
Dictated By:[**Last Name (NamePattern4) 6394**]
MEDQUIST36
D: [**2137-12-25**] 15:40:52
T: [**2137-12-25**] 18:00:14
Job#: [**Job Number 60049**]
|
[
"401.9",
"807.06",
"E882",
"300.00",
"920",
"852.02",
"427.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3943, 4068
|
4094, 4325
|
1024, 1234
|
3282, 3889
|
858, 998
|
4337, 4780
|
1401, 3264
|
166, 749
|
772, 834
|
1251, 1378
|
3914, 3921
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,544
| 104,687
|
42097
|
Discharge summary
|
report
|
Admission Date: [**2181-5-28**] Discharge Date: [**2181-6-23**]
Date of Birth: [**2121-2-4**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Cipro / vancomycin / shellfish
/ Haldol
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
Right foot bleeding.
Major Surgical or Invasive Procedure:
Right fifth open ray amputation
Esophagogastroduodenoscopy with clipping of duodenal ulcer
PICC line placement
AV fistula placement
History of Present Illness:
60F with h/o CKD on HD T/T/S, CAD s/p CABG ([**2172**]), STEMI ([**2174**]),
sCHF (EF 35%) s/p AICD placement, IDDM, PVD presents with 1 day
h/o bleeding from chronic right foot ulcer. Pt was sent in from
vascular clinic for evaluation after dressing was changed x3 for
bleeding in clinic and NP from [**Hospital3 2558**] asked to have
ulcer evaluated in ED before returning home. She does endorse
increased pain in the right foot and perhaps some green
discharge from R foot in last week, but isn't sure. Denies
malodor, fever, chills.
.
In the ED, initial vitals were 96.3 80 100/36 16 96% RA.
Podiatry and vascular surgery were consulted in the ED. Podiatry
described the wound on the 5th metatarsal as clean and stable
with sanguinous drainage, likely representing stable, chronic
osteomyelitis of the 5th metatarsal. They debrided the ulcer and
felt it was stable and not newly infected and sent samples for
gram stain and aerobic/anaerobic culture. Debridement led to
significant bleeding which was controlled with pressure and
silver cautery by vascular surgery. Plain film performed which
showed likely osteo in R 5th MTP and phalanx. Because of left
shift and renal failure, they recommended admission and to hold
antibiotics until culture results. VS at transfer: 98 80 107/58
18 94%RA.
.
Of note, the patient was admitted to the [**Hospital1 18**] in [**2181-4-24**] with
hyperkalemia and evidence of AoCRF. She had a temp line placed
for HD after her diuretic adjustment was unsuccesssful. Plan was
to follow up for fistula as outpatient. She was discharged off
all diuretics. Weight at discharge (felt to be dry) 90.6kg.
.
Currently, she is hungry and complains of chronic L stump pain
and pain in R foot.
.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
Cardiovascular Risk Factors:
+ HTN + HL + DM
# CAD: STEMI in [**2174**] with occlusion of vein graft
INTERVENTIONS:
CABG: [**2172**] with LIMA -> LAD and vein graft to [**Last Name (LF) 11641**], [**First Name3 (LF) **] 25 %
at the time
PERCUTANEOUS CORONARY INTERVENTIONS:
- [**2174**] stents in left anterior descending and [**Year (4 digits) 11641**]
# Systolic CHF - ischemic cardiomyopathy, severely reduced LV
function. ECHO in [**4-2**] with EF 25 - 30%
# PACING/ICD: Right-sided AICD in place ([**2178**]) for primary
prevention given EF
# IDDM, eye and renal manifestations, last HbA1c 9.3% ([**2180-4-23**])
# asthma
# PVD
# s/p left BKA [**2176**]
# s/p right 1st toe amputation [**2176**]
# h/o left intraductal breast cancer - s/p left mastectomy in
[**Month (only) 116**]/[**2173**], now question of right-sided breast cancer, which is
just being followed
# s/p cholecytectomy
Social History:
Hospitalized at [**Hospital1 18**] and/or rehab since [**2180-11-23**].
Otherwise lives in [**Hospital3 **]. Wheelchair-bound. Son [**Name (NI) **]
(nurse) is HCP, daughter [**Name (NI) **] also involved; a third son
[**Name (NI) **] lives in [**Name (NI) 86**].
-Tobacco history: none
-ETOH: rarely
-Illicit drugs: denies, but used marijuana in the past
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM:
VS - Temp 98.3 BP 105/56 HR 79 R 14 O2-sat 93% RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
scab in L ear canal with minimal oozing around it
NECK - supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, II/VI systolic murmur
with no radiation to carotids/axilla
LUNGS - CTAB, no r/rh/wh, moderate air movement, resp unlabored,
no accessory muscle use
ABDOMEN - NABS, firm and distended, no fluid shift, nontender,
no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, 1+ pitting edema in RLE, dopplerable pulse in
RLE, L stump well healed. Ulcer over lateral aspect of 5th
digit, with mostly sanguinous drainage striking through
dressing, no purulence or malodor
SKIN - excoriations noted over trunk, arms, legs
NEURO - awake, A&Ox3, moving all extremities, no asterixis
.
Pertinent Results:
ADMISSION LABS:
[**2181-5-28**] 06:00PM BLOOD WBC-7.9 RBC-3.17* Hgb-8.2* Hct-28.0*
MCV-88 MCH-25.9* MCHC-29.4* RDW-26.4* Plt Ct-219
[**2181-5-28**] 06:00PM BLOOD Neuts-75.4* Lymphs-16.1* Monos-5.8
Eos-1.9 Baso-0.7
[**2181-5-28**] 06:00PM BLOOD PT-16.4* PTT-33.9 INR(PT)-1.5*
[**2181-5-28**] 06:00PM BLOOD Glucose-191* UreaN-31* Creat-3.2*# Na-133
K-3.7 Cl-96 HCO3-24 AnGap-17
[**2181-5-28**] 06:00PM BLOOD Calcium-8.9 Phos-3.7# Mg-1.9
.
PERTINENT LABS:
[**2181-5-31**] 12:11AM BLOOD WBC-10.3 RBC-2.22* Hgb-5.7* Hct-20.2*
MCV-91 MCH-25.8* MCHC-28.3* RDW-28.7* Plt Ct-172
[**2181-6-1**] 07:29AM BLOOD WBC-17.5* RBC-2.74* Hgb-7.4* Hct-25.0*
MCV-91 MCH-27.1 MCHC-29.7* RDW-25.0* Plt Ct-194
[**2181-6-2**] 01:55PM BLOOD Neuts-85.2* Lymphs-8.3* Monos-4.5 Eos-1.5
Baso-0.5
[**2181-6-12**] 05:14PM BLOOD Hypochr-3+ Anisocy-3+ Poiklo-OCCASIONAL
Macrocy-3+ Microcy-1+ Polychr-1+ Ovalocy-OCCASIONAL
Target-OCCASIONAL
[**2181-6-2**] 01:55PM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-3+
Macrocy-2+ Microcy-1+ Polychr-1+ Ovalocy-3+ Stipple-1+
How-Jol-OCCASIONAL
[**2181-6-1**] 07:29AM BLOOD PT-29.3* PTT-37.3* INR(PT)-2.8*
[**2181-6-8**] 04:15AM BLOOD PT-14.2* PTT-33.7 INR(PT)-1.3*
[**2181-5-30**] 06:33AM BLOOD ESR-48*
[**2181-5-31**] 10:33AM BLOOD Glucose-75 UreaN-61* Creat-3.5* Na-139
K-5.8* Cl-96 HCO3-19* AnGap-30*
[**2181-6-4**] 02:09AM BLOOD Glucose-173* UreaN-16 Creat-1.0 Na-137
K-3.6 Cl-98 HCO3-28 AnGap-15
[**2181-5-31**] 10:00PM BLOOD Glucose-82 UreaN-40* Creat-2.3* Na-132*
K-4.9 Cl-101 HCO3-15* AnGap-21*
[**2181-5-31**] 10:33AM BLOOD ALT-9 AST-33 LD(LDH)-219 CK(CPK)-39
AlkPhos-132* TotBili-2.0*
[**2181-6-3**] 07:28AM BLOOD ALT-34 AST-153* LD(LDH)-236 AlkPhos-100
TotBili-2.6*
[**2181-5-31**] 12:11AM BLOOD CK-MB-3 cTropnT-0.30*
[**2181-5-31**] 05:02AM BLOOD CK-MB-3 cTropnT-0.32*
[**2181-5-31**] 10:33AM BLOOD CK-MB-5 cTropnT-0.37*
[**2181-5-31**] 10:33AM BLOOD Calcium-8.5 Phos-5.8* Mg-2.2
[**2181-5-29**] 05:33AM BLOOD %HbA1c-6.9* eAG-151*
[**2181-6-5**] 06:07AM BLOOD Cortsol-18.8
[**2181-6-10**] 05:55PM BLOOD Cortsol-39.9*
[**2181-5-29**] 05:33AM BLOOD CRP-58.1*
[**2181-5-31**] 10:42AM BLOOD Type-CENTRAL VE pO2-141* pCO2-43 pH-7.27*
calTCO2-21 Base XS--6 Comment-GREEN TOP
[**2181-6-1**] 07:54PM BLOOD Type-MIX Temp-36.3 O2 Flow-2 pO2-27*
pCO2-48* pH-7.40 calTCO2-31* Base XS-2 Intubat-NOT INTUBA
[**2181-6-6**] 07:55AM BLOOD Type-[**Last Name (un) **] Temp-36.7 pO2-38* pCO2-43
pH-7.37 calTCO2-26 Base XS-0 Intubat-NOT INTUBA
[**2181-5-31**] 10:42AM BLOOD Lactate-10.1*
[**2181-5-29**] 09:11PM URINE Color-DkAmb Appear-Hazy Sp [**Last Name (un) **]-1.019
[**2181-5-29**] 09:11PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-2* pH-5.0 Leuks-SM
[**2181-5-29**] 09:11PM URINE RBC-<1 WBC-4 Bacteri-MANY Yeast-NONE
Epi-14 TransE-<1
[**2181-5-29**] 09:11PM URINE CastHy-18*
[**2181-6-6**] 12:23AM URINE Color-DkAmb Appear-Clear Sp [**Last Name (un) **]-1.022
[**2181-6-6**] 12:23AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.0 Leuks-SM
[**2181-6-6**] 12:23AM URINE RBC-<1 WBC-<1 Bacteri-FEW Yeast-NONE
Epi-0
[**2181-6-10**] 05:55PM URINE Hours-RANDOM Creat-179 TotProt-740
Prot/Cr-4.1*
.
DISCHARGE LABS:
[**2181-6-16**] 05:30AM BLOOD WBC-9.7 RBC-2.77* Hgb-8.1* Hct-26.7*
MCV-96 MCH-29.4 MCHC-30.5* RDW-24.7* Plt Ct-188
[**2181-6-16**] 05:30AM BLOOD Glucose-131* UreaN-40* Creat-3.5* Na-133
K-4.5 Cl-94* HCO3-26 AnGap-18
[**2181-6-14**] 06:20AM BLOOD ALT-12 AST-19 AlkPhos-113* TotBili-1.3
[**2181-6-16**] 05:30AM BLOOD Calcium-8.6 Phos-4.4 Mg-2.2
[**2181-6-11**] 10:16PM BLOOD Lactate-2.0
.
MICROBIOLOGY:
[**2181-5-28**] 7:03 pm SWAB Source: foot.
GRAM STAIN (Final [**2181-5-28**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2181-5-30**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2181-6-3**]): NO GROWTH.
[**2181-5-30**] SWAB Site: TOE RT 5TH TOE.
GRAM STAIN (Final [**2181-5-30**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2181-6-5**]):
PSEUDOMONAS AERUGINOSA. RARE GROWTH.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
STAPH AUREUS COAG +. RARE GROWTH.
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
_______________________________________________________
PSEUDOMONAS AERUGINOSA
| STAPH AUREUS COAG +
| |
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 32 R
CIPROFLOXACIN---------<=0.25 S
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=1 S <=0.5 S
LEVOFLOXACIN---------- <=0.12 S
MEROPENEM------------- 1 S
OXACILLIN------------- <=0.25 S
PIPERACILLIN/TAZO----- I
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final [**2181-6-5**]): NO ANAEROBES ISOLATED.
Bcx (neg): [**5-28**], [**6-1**], 6/11x2, 6/16x2
Bcx (PEND): [**6-15**], [**6-15**], [**6-16**]
MRSA neg
Fecal cx: NO E.COLI 0157:H7 FOUND.
Urine cx ([**6-6**]): NEG
H.pylori Ab NEG
.
IMAGING:
Foot Xray:
IMPRESSION: Osteomyelitis involving the head of the fifth
metatarsal and base of the fifth proximal phalanx. Subluxation
at the fifth MTP joint.
Abdominal/Pelvis CT:
IMPRESSION:
1. No CT evidence of bowel ischemia without pneumatosis, mural
edema and
patent appearing vessels.
2. Prominent retroperitoneal and pelvic nodes for which
correlation with
prior imaging and medical history is recommended.
3. Fatty liver
Head CT:
IMPRESSION: No acute intracranial process including no evidence
of acute
infarction.
Echocardiogram ([**2181-6-1**]): The left atrium is moderately dilated.
The right atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is moderately
depressed (LVEF= 35 %); there is a major component of
ventricular interaction with a pressure and volume overloaded
right ventricle. The right ventricular free wall is
hypertrophied. The right ventricular cavity is dilated with
depressed free wall contractility. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate (2+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The left ventricular inflow pattern suggests a
restrictive filling abnormality, with elevated left atrial
pressure. The tricuspid valve leaflets are mildly thickened.
Severe [4+] tricuspid regurgitation is seen. There is severe
pulmonary artery systolic hypertension. There is no pericardial
effusion.
CXR portable [**2181-6-1**]:
Mediastinal and pulmonary vascular engorgement have progressed,
to the
borderline of mild edema. Moderate-to-severe cardiomegaly is
chronic.
Transvenous pacer leads are unchanged in their respective
positions projecting over the right atrium and the defibrillator
lead over the proximal right ventricle. No pneumothorax or
appreciable pleural effusion is present. Dual-channel
supraclavicular left central venous [**Month/Day/Year 2286**] ends in the SVC and
in the region of the superior cavoatrial junction.
CXR portable [**2181-6-3**]:
There is a right-sided AICD with the distal lead tips in the
right atrium and right ventricle. There is a left-sided
vascular catheter with distal lead tip at the distal SVC and
proximal right atrium. There is also a right IJ central line
with the distal lead tip at the distal SVC. Heart size is within
normal limits. There is prominence of the pulmonary vascular
markings consistent with moderate pulmonary edema. There are no
pneumothoraces identified.
CTA [**2181-6-4**]:
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic syndrome.
2. Findings of congestive heart failure including moderate
bilateral pleural effusion, pulmonary edema, cardiomegaly, and
reflux of contrast into a dilated IVC are seen.
3. Ascites is noted in the upper abdomen.
CXR (portable [**2181-6-6**]:
There is moderate cardiomegaly. Transvenous pacer lead tips at
the right
atrium and right ventricle. Right IJ catheter tip is in the
lower SVC. There is no evident pneumothorax. Mediastinal
lymphadenopathy is better seen on prior CT from [**6-4**]. There
is mild vascular congestion. Bibasilar opacities are a
combination of atelectasis and pleural effusion.
Echocardiogram [**2181-6-11**]:
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is top normal/borderline dilated.
There is moderate global left ventricular hypokinesis (LVEF = XX
%). No masses or thrombi are seen in the left ventricle. There
is no ventricular septal defect. The right ventricular cavity is
dilated with depressed free wall contractility. There is
abnormal septal motion/position. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
ECG ([**2181-5-29**]): Sinus rhythm. P-R interval prolongation.
Intraventricular conduction delay. ST-T wave abnormalities.
Since the previous tracing of [**2181-5-14**], the rate is faster.
Otherwise, unchanged.
ECG ([**2181-6-6**]): Sinus rhythm. P-R interval prolongation. Left
axis deviation. Non-specific intraventricular conduction defect.
Non-specific ST-T wave changes. Compared to the previous tracing
of [**2181-6-5**] there is no significant diagnostic change.
PATHOLOGY:
Fifth toe, right foot, amputation (A):
Bone with chronic osteomyelitis.
Skin and soft tissue with fibrosis.
Brief Hospital Course:
60 year old woman with ESRD on HD, CAD s/p CABG, systolic CHF
(EF 35%) s/p AICD, IDDM, and PVD s/p left BKA who initially
presented with a bleeding ulcer of the 5th digit of her R foot,
underwent amputation, then developed rising lactate,
hypotension, and melena requiring admission to the MICU, and was
subsequently transferred to the floor for treatment for
osteomyelitis.
# Shock/elevated lactate/melena: Given melena and dropping Hct,
shock was thought to be hypovolemic secondary to brisk upper GI
bleed, so the patient was transferred from the vascular service
to the MICU for further management. She was transfused 3 units
of blood and Hct increased from 20 to 29 and remained stable.
She was initially started on peripheral neosynephrine, which was
switched to levophed. At this point, her lactate increased to
10.1, patient became more somnolent, and abdomen became more
firm. There was concern for ischemic colitis, so a stat CT scan
was done, which showed no ischemic or infarcted bowel. Surgery
was consulted and did not feel that surgical intervention was
indicated. Her lactate eventually normalized over the next few
days. On ICU Day 3, her melena increased, Hct dropped back to
22, and her INR remained elevated at 2.8. She was transfused 4
units of PRBCs without adequate increase in Hct. An EGD showed a
nonbleeding duodenal ulcer with new clot which was clipped and
injected with epinephrine. After this, she remained
hemodynamically stable with stable HCTs. She still remained on
levophed and was + 13L. Based on NICOM measurements and CV02,
she seemed to be in cardiogenic shock. Via CVVH, 3-4 L of fluid
were removed per day for several days while on levophed.
Patient's mental status improved and she was able to be weaned
off pressors. She was empirically covered with
linezolid/cefepime for septic shock for seven days, although her
blood cultures did not grow any microbes. On the floor, her SBPs
were 90s-110s and she was mentating well. Hct remained stable
and guiaiac's were negative. She received 2 units of pRBCs on
hemodialysis ([**6-14**], [**6-21**]), per renal protocol. Her hct and blood
pressure on discharge were XXX and XXX, respectively.
# Osteomyelitis of the right 5th toe: ESR and CRP were elevated
and radiographs of the R foot were suggestive of osteomyelitis
involving the head of the fifth metatarsal and base of the fifth
proximal phalanx. Vascular surgery performed a two-step right
fifth open ray amputation. In light of her many antibiotic
allergies, the patient received empiric therapy with IV
gentamicin and cefazolin, then cefepime. Bone biopsies grew
pseudomonas and MSSA so ID recommended a six week course of
meropenem ([**6-13**]->[**7-24**]). She had a RUE PICC placed by IR for
long-term access (the LUE was avoided given plan to place AV
fistula in LUE) and R IJ was removed. Her wound vac was removed
while she was on the floor and per vascular recs, should
continue to get [**Hospital1 **] dressing changes. She will follow-up with
the vascular clinic in 2 weeks. She is set to complete her
course of meropenem on [**7-24**],
# ESRD: CVVH was initiated while the patient was in shock. This
was eventually transitioned back to HD. The patient received HD
as an inpatient on a T/Th/Sat scheduled without difficulty.
Home calcium acetate and nephrocaps were continued. We gave her
metoprolol on days that she did not get HD. She had an AV
fistula placement on her L upper extremity on [**6-22**].
# Leukocytosis:
On [**6-12**], she developed a leukocytosis of 13.0. There was
erythema, induration and yellow crust around her tunneled HD
line concerning for infection thus her lines were cultured and
there was no growth at the time of discharge. Renal also did
not feel that her HD line was infected. Her WBC trended down
and was in the normal range by [**6-16**] and remained within normal
limits for the remainder of her hospitalization. On discharge,
blood cultures ([**6-9**]) were also negative.
# CHF: Nodal blockade agents were held while in the MICU. She
was on levophed and CVVH while in shock. Repeat TTE showed EF
35%, worsening MR, small LV cavity, RV hypokinesis, and
worsening TR (Echo in [**Month (only) 547**] also w/ dilated RV and global free
wall hypokinesis). CTA was negative for PE. This was thought to
be secondary to volume overload. Fluid was removed as noted
above and her digoxin was eventually restarted. We held her
carvedilol given hypotension and gave her metoprolol on non-HD
days.
# CAD: s/p CABG LIMA->LAD and vein graft to [**Month (only) 11641**]. No chest pain
or anginal symptoms were noted during her hospitalization. Her
home aspirin and simvastatin were continued.
# PVD: s/p multiple amputations. Home plavix was continued.
# DM: Initially was on home glargine 15 units QHS + HISS. Her
BSGs remained elevated so the glargine was increased to 20 units
QHS. Home gabapentin was restarted.
# Depression/Anxiety: Patient w/ AMS while in the ICU, head CT
unremarkable, and infectious w/o stable, lytes stable. Felt to
be ICU delirium. She improved on the floor and remained A&Ox3,
appropriate. She experienced episodes of anxiety and her home
antidepressants were restarted (buproprion and venlafaxine). By
discharge, her mood had improved significantly and she reported
feeling less anxious.
# Vision changes: on [**6-20**], patient reported new onset of
difficulty with vision. She was tested at the bedside and found
to have 20/20 near vision with full visual fields. She does
have a history of myopia. She will see an ophthamologist as an
outpatient.
TRANSITIONAL ISSUES:
- Should follow-up with Vascular Surgery
- Wound care for R 5th digit osteomyelitis: dressing changes [**Hospital1 **]
- Antibiotic treatment of R 5th digit osteomyelitis: meropenem
Q24hrs until [**7-24**]
- You are scheduled to have hemodialysis 3x/week
- Please check the following labs
CBC with differential, BUN/Cr (weekly)
AST/ALT (weekly)
Alk Phos (weekly)
Total bili (weekly)
ESR/CRP (weekly)
All laboratory results should be faxed to the Infectious Disease
R.N.s at ([**Telephone/Fax (1) 4591**]. All questions regarding outpatient
parenteral antibiotics should be directed to the Infectious
Disease R.N.s at ([**Telephone/Fax (1) 21403**] or to the on-call ID fellow when
the clinic is closed.
Medications on Admission:
BUPROPION HCL [WELLBUTRIN SR] - (Prescribed by Other Provider) -
100 mg Tablet Extended Release - 1 Tablet(s) by mouth once a day
CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg
Tablet - 1 Tablet(s) by mouth once a day
DIGOXIN - (Prescribed by Other Provider) - 125 mcg Tablet - 0.5
(One half) Tablet(s) by mouth once a day non HD (MWFSun)
GABAPENTIN - (Prescribed by Other Provider) - 100 mg Capsule - 1
Capsule(s) by mouth once a day
HYDROXYZINE HCL - (Prescribed by Other Provider) - 25 mg Tablet
- 1 Tablet(s) by mouth Q8H
INSULIN ASPART [NOVOLOG] - (Prescribed by Other Provider) - 100
unit/mL Solution - sliding scale
INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) - 100
unit/mL Solution - 15 units q HS
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth
VENLAFAXINE ER - (Prescribed by Other Provider) - 37.5 mg Tablet
- 3 Tablet(s) by mouth once a day
ASCORBIC ACID - (Prescribed by Other Provider) - 500 mg Tablet -
1 Tablet(s) by mouth once a day
CALCIUM ACETATE [CALPHRON] - (Prescribed by Other Provider) -
667 mg Tablet - 2 Tablet(s) by mouth TID with meals
SENNA 2 tabs PO BID
TYLENOL 500mg PO Q4H:PRN pain
OXYCODONE 5mg PO Q4H:PRN pain
COLACE 100mg PO BID
NEPHROCAPS 1 tab PO daily
ASPIRIN 325mg PO daily
FEXOFENADINE 180mg PO daily
GUAIFENISIN 10ML PO Q6H:PRN cough
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. BuPROPion (Sustained Release) 100 mg PO QAM
3. Clopidogrel 75 mg PO DAILY
4. Digoxin 0.0625 mg PO EVERY OTHER DAY
(non-[**Telephone/Fax (1) 2286**] days: [**Last Name (LF) 12075**],[**First Name3 (LF) **])
5. Docusate Sodium 100 mg PO BID
6. Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Nephrocaps 1 CAP PO DAILY
8. Senna 1 TAB PO BID
9. Simvastatin 40 mg PO DAILY
10. Meropenem 500 mg IV Q24H Duration: 30 Days
give AFTER HD on [**First Name3 (LF) 2286**] days ([**First Name3 (LF) 12075**]). Last Day is [**7-24**]
11. Sarna Lotion 1 Appl TP QID:PRN itching
12. Ascorbic Acid 500 mg PO DAILY
13. Calcium Acetate 1334 mg PO TID W/MEALS
14. Guaifenesin [**5-3**] mL PO Q6H:PRN cough
15. Fexofenadine 180 mg PO DAILY
16. Gabapentin 100 mg PO DAILY
17. HydrOXYzine 25 mg PO Q8H:PRN itching
18. Venlafaxine XR 112.5 mg PO DAILY depression
19. Lidocaine 5% Patch 1 PTCH TD DAILY
Apply to back.
20. Metoprolol Tartrate 12.5 mg PO BID
Give on non-[**Month/Year (2) 2286**] days (TRS, [**Month/Year (2) 1017**])
21. Pantoprazole 40 mg PO Q12H
22. Outpatient Lab Work
Please check the following labs
CBC with differential, BUN/Cr (weekly)
AST/ALT (weekly)
Alk Phos (weekly)
Total bili (weekly)
ESR/CRP (weekly)
All laboratory results should be faxed to the Infectious Disease
R.N.s at ([**Telephone/Fax (1) 4591**]. All questions regarding outpatient
parenteral antibiotics should be directed to the Infectious
Disease R.N.s at ([**Telephone/Fax (1) 21403**] or to the on-call ID fellow when
the clinic is closed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Osteomyelitis
Bleeding duodenal ulcer
Heart failure
Chronic kidney disease
cardiogenic/hemorrhagic shocking requiring pressors
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 91333**],
It was a pleasure participating in your care at [**Hospital1 18**]. You came
in to the hospital for an elective right fifth toe amputation.
After the procedure your blood pressure dropped and you were
found to have a bleeding duodenal ulcer. This ulcer was clipped
and afterwards your blood counts stabilized. You remained in the
ICU because although your blood pressures were low, you had a
lot of fluid in your body, likely due to your kidney disease and
heart failure. The excess fluid was removed by [**Hospital1 2286**]. You
had an AV fistula placement in your left arm near the end of
your stay.
You were also treated for a bone infection in your right foot
with the antibiotic meropenem. You will need to continue taking
meropenem by the PICC line until [**7-24**]. You initially had a
wound vac over the amputated site but this was removed and you
had gauze dressing that was changed twice daily.
MEDICATION CHANGES:
1) Please stop taking aspirin 325mg daily and start taking a
baby aspirin daily (81 mg).
2) Your bedtime glargine was increased from 15 units to 20
units.
3) You should start taking pantoprazole 40 mg by mouth every 12
hours to prevent ulcers from forming in your stomach.
4) You should start taking metoprolol 12.5 mg twice daily on
non-[**Month/Day (4) 2286**] days to protect your heart
5) You should use sarna cream to prevent itching
6) you should use a lidocaine patch to help with your pain
7) You should continue meropenem antibiotics to treat your bone
infection
FOLLOW-UP APPOINTMENTS: please see below
Followup Instructions:
Infectious Disease --
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2181-6-25**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2181-7-17**] 9:30
Vascular Surgery --
Please follow up with Dr. [**Last Name (STitle) **] in two weeks time. The clinic
will call you to schedule this appointment.
Hemodialysis--
Time: [**2181-6-23**] 7:30 am
|
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[
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,437
| 125,924
|
20747
|
Discharge summary
|
report
|
Admission Date: [**2161-7-31**] Discharge Date: [**2161-8-12**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Aspirin
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
chest pain during stress test
Major Surgical or Invasive Procedure:
Aborted cardiac catheterization
EGD x2
Colonoscopy
PICC line placement by IR
History of Present Illness:
84F F with PVD, CAD, s/p PCI [**2158**] with OM stenting presenting
from [**Hospital **] Hosp with chest pain that started during the stress
test. Prior to ordering the ETT, pt has been having chest pian
with increasing frequency with minimal exertion and and rest,
lasting 5-30 minutes radiating to L and right arm associated
with SOB. Due to these sx, the patient's PCP ordered [**Name Initial (PRE) **] stress
test. During the stress test (unknown pharma or exercise) the
patient developed [**10-28**] CP, with ST depressions in V2-V3.
Past Medical History:
All: sulfa: nausea, ? asa. pepcid, terazosin, diltiazem, ?
levaquin
.
CAD
LV systolic heart failure
h/o prior MI
s/p BMS to OM and LCx in [**2158**]
HTN
hyperlipidemia
iron deficiency anemia
glaucoma
h/o of guaiac + stool (unknown workup)
h/o bell's palsy on L side
h/o cva (unknown conditions and workup)
pt is on prednisone 5 [**Hospital1 **] for unclear reason--need to call PCP
to clarify.
c-scope in [**2160**]: found no active, bleeding a single polyp which
was removed.
Social History:
lives by self. normally active and takes care of own adls.
drives and shops by herself. non-smoker lifetime. occasional
etoh.
Family History:
N/C
Physical Exam:
Discharge exam:
Vitals signs: Tm 96.8 BP 150-187/54-67 HR 66-75 RR 18-20 SA 02
95% 1LO2
GEN: NAD
HEENT: dry MMM, no JVD, neck supple
CVS: RRR, no MRG, nl S1/S2
RESP: CTAB with good air movement, no acessory muscle use,
minimal coughing
ABD: soft NT/ND, NABS
EXT: + edema but improving with [**Month (only) **] pitting and wrinkling of
skin; rt arm and leg with [**Month (only) **] movement and strength compared to
left side byt improved in the past several days; distal fingers
with dark spots, no splinter hemorrages, no [**Last Name (un) **] lesions.
SKIN: very thin, areas of bruising due to blood draws
NEURO: AOx3, answering questions appropriately but with some
tangential thougths due to deafness; speech dysarthric and
improved over past several days (but pt states that she has
dysarthric speak at baseline).
Pertinent Results:
Imaging: EKG (from OSH) shows: nml axis, normal intervals, ST
Depressions in V1, V2 and V3.
.
EKG while in the MICU (after 2u PRBC xfusion and stabilization):
NSR 60, normal axis, prolonged QTc; resolving ST dep V1, V2, V3.
.
CXR [**2161-8-2**]: There is dense opacity in the retrocardiac region
that is new
compared to the prior study that probably represents some volume
loss/effusion/infiltrate.
.
CXR [**2161-8-8**]:
A single AP view of the chest is obtained on [**2161-8-8**] at 04:50
hours and compared with the prior morning's radiograph. There
appears to be improvement in the appearance of the mild
pulmonary edema since the prior examination. Persistent
increased retrocardiac density on the left side likely
represents superimposed airspace disease/atelectasis. Layering
bilateral pleural effusions are a possibility. Right-sided
subclavian line is unchanged in position.
.
Echo [**2161-8-6**]: No valvular vegetations or significant regurgitant
valve disease seen. Mild regional left ventricular systolic
dysfunction, c/w CAD. Mild pulmonary hypertension. EF50%.
.
MRI [**2161-8-8**]:There is no acute stroke noted on the
diffusion-weighted imaging. There are moderate small vessel
ischemic sequela in the subcortical and periventricular white
matter. There is age-appropriate volume loss.
Xanthogranulomatous changes of the choroid plexus are seen
bilaterally. Mild scattered bilateral mastoid opacification is
noted. There is mild sphenoid sinus mucosal thickening.
Evaluation of the MRA demonstrates patency of the anterior and
posterior circulations. There is no aneurysm or stenosis within
limits of this examination.
.
CT [**2161-8-1**]:
Equivocal loss of focal differentiation in the left
frontal/parietal lobes
may signify early infarction. The findings are subtle and
therefore, this
should be correlated with the patient's clinical symptoms as no
localizing
history was provided. If there are localizing signs, MRI with
diffusion can help.No hemorrahge or mass efffect.
.
EGD/ Colonoscopy: No source of bleeding in upper GI tract.
Diverticulosis of the sigmoid colon Examination was limited to
proximal sigmoid colon due to acute angulation of her colon and
the severity of her diverticulosis.
Otherwise normal colonoscopy to sigmoid colon
Brief Hospital Course:
Patient arrived to [**Hospital1 18**], was loaded with plavix 600/given SL
NTG/given heparin and integrillin/arrived to [**Hospital1 **] pain free.
Despite the aspirin allergy (the patient does not know what the
allergy is), the patient was given asa. The patient was also
given 80mg of Lipitor, lopressor 5mg IV x 2, and SL ntg. Per
report of nuclear medicine from [**Hospital3 **]; on the
patient's stress test, a large posterolat defect was noted at
rest, with no stress imaging performed. At [**Hospital1 18**], after transfer
onto the cath table, the patient had a loose purple malodorous
bowel movemnt, indicative of GI bleeding. Patient also
apparently vomited with some coffee ground emesis.
CAtheterization was cancelled. Due to GIBleeding, the patient
was transferred to the MICU for further care. 2u PRBCs were
transfused and the patient received IVF. Patient's inital CEs
were flat, with CK 18, Mb not done.
.
#)CAD: The patient's aspirin was initially held, but restarted
after GI bleeding stopped. Plavix was stopped. The patient was
placed on Captopril 25mg TID, Metoprolol 25mg PO BID and
Atorvastatin 40mg daily for cardioprotection, afterload
reduction and HTN control. Pt's BP on discharge was 135/52.
.
#)NSVT/ PVC's: On [**8-10**], the patient had a run of 16 beats of
assymptomatic NSVT with a potassium of 3.5. Her potassium was
repleted to 3.9 and her metoprolol was increased from 12.5mg [**Hospital1 **]
to 25mg [**Hospital1 **]. She had one further 3 beat run of NSVT and
occaisonal PVC's.
.
#)GI: GI evaluated while on the floor. The patient was intubated
prior to GI procedures, given fluids and blood transfusion.
Although the procedure had to be terminated somewhat early due
to mild hypoxia and bradycardia, GI got to the 2nd part of the
duodenum, saw no active bleeding, saw what they felt was an old
clot, no intervention as far as anti-coagulation. Subsequently,
they attempted a colonoscopy, but were unable to pass the
sigmoid colon due to anatomy. She remained hemodynamically
stable, HCT stable at 34 and had no further episodes of GIB. She
was placed on Pantoprozole 40mg daily.
.
#) PNA: In the MICU, the patient was found to have a MSSA PNA
on [**8-2**] and was started on Levaquin. Initially the patient had a
leukocytosis, which trended down. The patient improved and was
afebrile, without respiratory distress on discharge.
.
#) Bacteremia: She also developed a femoral line infection with
enteroccocus, was started on Ampicillin 2g IV on [**8-5**]. A TTE
showed no evidence of endocarditis. Subsequent blood cultures
were negative. She received a PICC on [**8-10**] for a 10 day course
of Ampicillin.
.
#)Delerium: She was eventually extubated and weaned off the
ventilator; subsequently, she had altered mental status for
approx 24hrs post intubation. On the wards, the patient
alternated between lucidity and rambling, inappropriate speech,
but was always A0x3 on redirection. The patient became
increasingly appropriate over the next several days and was
presumably back to baseline on discharge.
.
#) Hypernatremia: The patient recieved a large amount of fluids
during her GI bleed. She became substantially volume overloaded
and required diuresis. The patient was diuresed with lasix with
improving lower extremity and pulmonary edema. However, she was
slightly overdiuresed in the 3 days prior to discharge, lasix
was held and PO fluids were encouraged. Her elevated sodium was
thought to be due to volume depletion and was stable at
149,149,148 and 148 over the past four days. She was given
gentle rehydration with D51/2 NS at 75ml/hr of 1L with
improvement.
.
#)CVA question: There was a concern for a new stroke while the
patient was in the MICU given her altered mental status. A CT
head was obtained with showed a questionable ishemic infarct,
but as the patient's mental status significantly improved, this
was not pursued. However, her ability to swallow remained
slightly impaired. She continued to have poor cough and visible
inabilty to swallow her own secretion. She was made NPO. She
improved over the next several days, was cleared by speech and
swallow and eventually transitioned to diet of soft solids and
thin liquids. However, once the patient was on the cardiology
service, she continued to have some dyarthria and decreased
strength of her rt arm and leg. A follow up MRI showed no acute
stroke. Her unilateral weakness was thought to be related to
decontitioning and worse edema on the right side. Physical
therapy and occupational therapy evaluated and worked with the
patient.
Medications on Admission:
spironolactone 25mg qd
lasix 40 mg qd
plavix 75 mg qd
diovan 80mg qd
prednisone 5 [**Hospital1 **]
kcl
iron
ativan PO PRN.
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. Atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Captopril 12.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Ampicillin Sodium 2 g Recon Soln Sig: One (1) Recon Soln
Injection Q6H (every 6 hours) for 3 days: total of a 10 day
course, last day [**2161-8-14**].
7. Levofloxacin in D5W 500 mg/100 mL Piggyback Sig: One (1)
Intravenous Q24H (every 24 hours) for 10 days: started on
[**2161-8-8**]; 14 day course to stop on [**2161-8-21**].
Disp:*10 * Refills:*0*
8. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1)
ML Intravenous DAILY (Daily) as needed.
Disp:*qs ML(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Coronary artery disease
GI bleed
Pneumonia (MSSA)
Bacteremia (Enteroccocus)
Discharge Condition:
stable
Discharge Instructions:
You were admitted for emergency cardiac catheterization after
chest pain during a stress test. However, you cardiac
catheterization was not performed as you had gastrointestinal
bleeding after being given multiple anticoagulant medications.
You were then admitted to the ICU, given fluids and blood
transfusion. You will need to have a colonoscopy as an
outpatient to evaluated for this bleeding. You will also need
cardiac evaluation as an outpatient.
.
If you have chest pain again, please take a nitroglycerine pill
under your tongue. You may repeat this pill 2 more times 5
minutes apart. If your chest pain does not resolve, please call
911 and go to the emergency room..
.
If you have any dark, black, sticky stools, bloody stools or
vomit or vomit with black material ("coffee grounds"), please
call 911 and go to the emergency room.
Followup Instructions:
Please see Dr. [**Last Name (STitle) 10543**] on [**2161-8-21**] at 3:15pm.
|
[
"562.10",
"293.0",
"427.89",
"790.7",
"584.9",
"578.9",
"411.1",
"427.1",
"530.20",
"428.20",
"482.49",
"V64.1",
"553.3",
"428.0",
"518.81",
"414.01",
"412",
"401.9",
"280.9",
"276.0",
"272.4",
"530.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"96.04",
"45.13",
"38.91",
"96.72",
"38.93",
"99.04",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
10445, 10517
|
4737, 9295
|
267, 346
|
10636, 10644
|
2435, 4714
|
11533, 11612
|
1574, 1579
|
9468, 10422
|
10538, 10615
|
9321, 9445
|
10668, 11510
|
1594, 1594
|
1610, 2416
|
198, 229
|
374, 914
|
936, 1415
|
1431, 1558
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,074
| 166,317
|
20645
|
Discharge summary
|
report
|
Admission Date: [**2155-5-5**] Discharge Date: [**2155-5-15**]
Service: Cardiothoracic Surgery Service
HISTORY OF PRESENT ILLNESS: This is an 83 year old white
female patient admitted to [**Hospital3 3583**] on [**2155-5-1**]
with a recent increase of shortness of breath. She was found
to be in congestive heart failure at that time and treated
with intravenous Lasix. A subsequent echocardiogram revealed
wide open mitral regurgitation by report as well as critical
aortic stenosis. She was transferred to the [**Hospital6 1760**] where she underwent cardiac
catheterization. This revealed two vessel coronary artery
disease as well as critical aortic stenosis with an aortic
valve area of 0.4 and a peak gradient of 60 and 2 to 3+
mitral regurgitation. She was referred for coronary artery
bypass graft and aortic valve replacement and mitral valve
replacement.
PAST MEDICAL HISTORY: Paroxysmal atrial fibrillation,
chronically on Coumadin, mild dementia, hypertension, Paget's
disease status post right femoral fracture with open
reduction and internal fixation many years ago, she has an
ischemic left optic nerve and she has osteoporosis.
ALLERGIES: The patient states an allergy to Ciprofloxacin
although she does not know the reaction. She is married and
lives with her husband and she has never smoked cigarettes
and denies alcohol intake.
MEDICATIONS PRIOR ADMISSION: Atenolol 50 mg p.o. q.d.,
Coumadin 5 mg p.o. q.d., Fosamax 70 mg q. week, Aricept 5 mg
q.d., Hydrochlorothiazide 25 mg q.d., Spironolactone 25 mg
q.d., Calcium and Vitamin E.
PHYSICAL EXAMINATION: Preoperative physical examination was
unremarkable with the exception of an irregular heart rhythm
and a Grade IV/VI systolic murmur.
LABORATORY DATA: Preoperative carotid studies were obtained
and revealed less than 40% occlusion, bilateral and her
preoperative laboratory values were unremarkable.
HOSPITAL COURSE: Preoperatively neurologic evaluation was
requested due to memory dysfunction and dementia. The
neurologist recommendation was to continue the Aricept and
they also commented that there was no contraindication to
surgery. This was felt to be a mild dementia with some
components of delirium.
On [**2155-5-8**], the patient was taken to the Operating
Room with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] where she underwent coronary
artery bypass graft times one with a saphenous vein to the
posterior descending artery as well as an aortic valve
replacement with a #19 mm [**Last Name (un) 3843**]-[**Doctor Last Name **] magna
pericardial valve and she had a mitral valve repair at that
time as well. Postoperatively the patient was ventricularly
paced via her epicardial wires. She was on Levophed,
Milrinone and Propofol intravenous drip and was transported
from the Operating Room to the Cardiac Surgery Recovery Unit
in stable condition. On postoperative day #1, the patient
remains on Levophed, Milrinone drips as well as Amiodarone,
was atrially paced at that time. Attempts were made to wean
from the ventilator, however, because of a decreased level of
wakefulness it was felt best to hold off at that time.
Neurology follow up recommended a repeat head imaging. The
patient did go for a computerized tomography scan which was
negative for any acute infarction. The patient was
ultimately extubated the afternoon of postoperative day #2.
Her mental status was clearing. She was much more awake at
that time and was moving all four extremities. The patient
did subsequently return to atrial fibrillation and her
temporary pacing was discontinued as a result of that. She
was begun on heparin drip on postoperative day #4 due to
continued atrial fibrillation with rate in the 90s and blood
pressure of 130/50. She had been oxygenating well on 2
liters of nasal cannula and making slow but steady progress
with her level of consciousness and physical therapy level.
On postoperative day #5, the patient was begun on oral
Lopressor, diuresis was initiated and she had been started on
Coumadin on postoperative day #4 and this was continued as
well through postoperative day #5. The patient was
transferred from the Cardiac Surgery Recovery Unit to the
Telemetry Floor on [**5-13**], postoperative day #5. She was
in good condition. She was beginning to ambulate with
physical therapy, however, it was felt in her best interest
at that time to discharge her from the hospital to a
rehabilitation facility since she is still not quite steady
on her feet requiring a fair amount of assistance with
physical therapy. She has remained hemodynamically stable in
atrial fibrillation with a rate of about 100 and a blood
pressure of 110/50. The patient remains on a heparin drip at
900/hr with a PTT of 54.3 today and her Coumadin has been 5
mg/day for the past three days, those would be [**5-12**],
[**5-13**] and [**5-14**]. Her most recent INR from today, [**5-14**], is 1.3 and she will receive 5 mg this evening as
previously stated. She should remain on her heparin drip
until her INR is above 1.8. At that point her heparin may be
discontinued and she may be maintained on Coumadin with a
target INR of 2 to 2.5. Preoperatively the patient was on 5
mg/day as her routine daily dose.
On physical examination the patient is awake and
communicating appropriately, although occasionally forgetful
as to time and place, but otherwise responds appropriately to
commands and questions. Her lungs are diminished in the
bilateral bases, otherwise clear. Her heart is irregularly
irregular with no murmurs noted. Her abdomen is soft and her
incisions are clean, dry and intact.
MEDICATIONS ON DISCHARGE:
1. Lopressor 25 mg p.o. b.i.d.
2. Lasix 20 mg p.o. q. 12 hours times ten more days.
3. Potassium chloride 20 mEq p.o. q. 12 hours, also times
ten days.
4. Colace 100 mg p.o. b.i.d.
5. Ranitidine 75 mg p.o. b.i.d.
6. Aspirin 325 mg p.o. q.d.
7. Enteric coated Aspirin 81 mg p.o. q.d.
8. Aricept 5 mg p.o. q.h.s.
9. Coumadin 5 mg p.o. q.d. to be titrated on a daily basis
dependent upon her INR over the next few days and heparin
drip at 900 units/hr and it is to be titrated according to
her PTT and discontinued when her INR is greater than 1.8.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSIS:
1. Aortic stenosis.
2. Mitral regurgitation.
3. Coronary artery disease, status post aortic valve
replacement.
4. Mitral valve repair.
5. Coronary artery bypass graft times one.
FOLLOW UP: The patient should follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 70**] approximately six weeks postoperatively. She
should also follow up with her primary care physician as well
as her cardiologist upon discharge from the rehabilitation
facility.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2155-5-14**] 14:44
T: [**2155-5-14**] 15:15
JOB#: [**Job Number 55161**]
|
[
"401.9",
"731.0",
"427.31",
"414.01",
"294.8",
"398.91",
"396.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"39.61",
"35.12",
"37.23",
"35.21",
"36.11",
"89.64",
"38.91",
"96.71",
"88.56",
"96.04",
"88.54",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
6257, 6264
|
6285, 6469
|
5679, 6235
|
1924, 5653
|
6481, 7054
|
1602, 1905
|
144, 884
|
907, 1579
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,023
| 147,727
|
39899
|
Discharge summary
|
report
|
Admission Date: [**2111-11-15**] Discharge Date: [**2111-11-26**]
Date of Birth: [**2042-9-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Worst headache of life
Major Surgical or Invasive Procedure:
right sided craniectomy for IPH evacuation and temporal
lobectomy
History of Present Illness:
(note: History obtained from medical records and nursing given
patient cannot say more than one word sentences).
Ms. [**Name13 (STitle) 87761**] is a 69yo F with PMhx of HTN, Afib on coumadin
admitted [**2111-11-15**] with "worst headache of life" and MS changes
found to have IPH with some subdural component and herniation,
now post-op day 7 from right craniotomy with IPH drainage being
transferred from neurosurgial stepdown unit to MICU team for
sepsis.
Patient was in her USOH until [**11-15**] when while talking on the
phone around 7pm she developed the worst headache of her life.
She initially went to an OSH where a head CT showed large right
parietal/temporal bleed. At that hospital her mental status
deteriorated to the point that she needed intubation. She was
given 1unit FFP and 10mg IV Vit K to reverse her anticoagulation
(coumadin for afib). She was then transferred to [**Hospital1 18**]
neurosurgical service for further care.
.
On arrival to [**Hospital1 18**] she underwent emergent head CT which showed
worsened edema of right ventricle and left shift to 15mm (was
13mm) and possible uncal herniation. She was taken emergently to
the OR for right craniotomy and decompression of SDH/IPH.
.
After the surgery she was managed in the SICU on decadron and
dilantin for seizure prophylaxis. She received cefazolin for
infection prophylaxis. She was gradually weaned off the vent,
started on tube feeds and on [**2111-11-22**] around midnight she was
transferred to the neurosurgical step down unit.
.
At about 5am the RN noted cloudy urine draining from the foley
so a UA was sent. Then at 6am the patient was noted to have
tachycardia to the 130s in atrial fibrillation. The team was
going to uptitrate her beta blocker but then she spiked a fever
to 104 rectally and dropped her BPs to 80s/50s so 500mL NS bolus
and then 100mL/hr NS was started. Cultures were sent. CXR was
done and did not reveal any changes (just retrocardiac
opacity/atelectasis). She was written initially for bactrim for
the UTI (pos nitrates and leuk esterase on UA) but with the SIRS
picture she was changed to cipro IV. She did not yet get a dose
of antibiotic, however. Over the last few hours patient's BP has
dipped in to the 80s/50s whenever she stops getting fluids. Has
gotten total of three 500cc boluses. Her temperature is now down
with a cooling blanket and tyelnol to 102. MERIT resident was
called, recommended broadening coverage to meningeal coverage
given recent craniotomy, and transfer not to medicine floor but
medical ICU team for management of SIRS/sepsis and afib with
RVR.
.
Of note the baseline neurologic exam per the neurology intern
from overnight is that she opens eyes to voice, wont track to
left, left upper and lower withdraw to noxious stimuli, right
side follows simple commands. Prior to the SDH she was
functioning independently in her ADLs.
Past Medical History:
HTN
Afib on coumadin (new since shoulder surgery pre-op assessment 2
months ago)
Fibromyalgia
HL
Social History:
Retired. Lives independently. Non-smoker quit twenty years ago.
No ETOH.
Family History:
Diabetes in Mom.
Physical Exam:
PE on Admission:
O: T: BP: 118/72 HR:70 R:18 O2Sats:100%
Gen: Intubated, Sedated
HEENT: NC, AT Pupils: R pupil 6 and NR, L 3-2.5 EOMs N/A
Extrem: Warm and well-perfused.
Neuro:
Mental status: Intubated No EO to voice or nox
Cranial Nerves:
I: Not tested
II: R pupil 6 and NR, L 3-2.5
III, IV, VI: not tested
V, VII: not tested
VIII: not tested
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: not tested
XII: not tested
Motor: Moves R upper and lower extremity purposefully. Minimal
withdrawal to L upper and lower.
DISCHARGE PHYSICAL EXAM:
VS: Tm+Tc 99.5, BP 107/79 (104-110/62-79), 127 (98-102), 98%RA
(96-98%RA)
GENERAL: female lying in bed with R side of head shaved, and
notable curved surgical incision on R scalp, NAD
HEENT: [**Doctor First Name 2994**], patient unable to track eyes to the left, but
otherwise [**Doctor First Name 3899**]. OP clear, MM dry, large healing surgical
incision over R scalp, with some very minimal erythema over the
incision.
CV: irregularly irregular heart rythm, no murmurs/rubs/gallops
PULM: Minimal crackles at lung bases bilaterally, otherwise
CTA-B.
ABD: soft, NT, ND, BS+, no guarding, no rebound
SKIN: blanchable erytematous M-P rash on R back from mid-upper
back to lower back on R side, somewhat improved from yesterday.
EXT: No peripheral edema, DP pulses 2+ bilaterally.
NEURO: MS: Pt [**Name (NI) 9830**]1, CN: Pt unable to track eyes to the left,
otherwise [**Name (NI) 3899**], pt's [**Name (NI) 2994**], pt did not blink to threat in R eye,
L facial droop, shoulder shrug [**4-22**] bilat.
Strength: [**4-22**] in RUE and RLE. Patient [**4-22**] in LUE except for
grip strength which is [**2-20**] in L hand. Patient is 4+/5 in LLE
throughout.
Sensation: Patient's sensation intact throughout. Reflexes:
toes upgoing on L, downgoing on R, no clonus at ankles
bilaterally.
Pertinent Results:
CT HEAD [**11-15**]
Large right fronto temporal parenchymal hemorrhage with
increased surrounding edema compared to prior study and with
apparent worsening effacement of right ventricle and leftward
shift of normally midline structures upto 15mm (prev 13mm) with
possible uncal herniation. IVH in right ventricle noted. right
extraxial hematoma with possible right sah.
CTA Head [**11-15**]
no definite flow limiting stenosis or aneurysm of internal
carotids or
vertebral arteries.
CT HEAD [**11-16**]
Status post right craniotomy with adjacent extra as well as
intracranial
pneumocephalus as well as intraparenchymal pneumocephalus.
Previously noted parenchymal hemorrhage is less compared to
[**2111-11-15**]. Left
parafalcine subarachnoid hemorrhage as well as a new focus of
subarachnoid
hemorrhage in the right frontal lobe are noted.
[**11-20**] MRI Head
IMPRESSION: Status post cranioplasty. A large area of signal
abnormality in the right middle cerebral artery territory and
temporal region could be due to an evolving infarct with
residual blood products. Subtle areas of signal abnormality on
the diffusion images near the convexity in the right frontal
region could be due to blood products in the sulci or less
likely due to additional subtle foci of subacute infarcts. There
is minimal midline shift to the left. Mass effect on the right
lateral ventricle is seen but decreased from the previous CT
examination of [**2111-11-15**]. No definite abnormal enhancement in
the brain except for meningeal enhancement at the site of
cranioplasty.
[**11-22**] LENI's
IMPRESSION: No DVT of the bilateral lower extremities.
[**11-22**] CTA
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Bibasilar atelectasis, with a trace left pleural effusion.
3. 3-mm right upper lobe pulmonary nodule. [**First Name8 (NamePattern2) **] [**Last Name (un) 8773**]
Society
guidelines, in the absence of risk factors for intrathoracic
malignancy, such as smoking, no further followup for this is
necessary. Otherwise, a followup chest CT in 12 months is
suggested.
4. Mediastinal and hilar adenopathy.
II. Microbiology
[**2111-11-24**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2111-11-23**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2111-11-23**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2111-11-22**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2111-11-22**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2111-11-22**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2111-11-22**] URINE URINE CULTURE-FINAL {ESCHERICHIA
COLI} INPATIENT
[**2111-11-22**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2111-11-22**] URINE URINE CULTURE-FINAL {ESCHERICHIA
COLI} INPATIENT
URINE CULTURE (Final [**2111-11-24**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2111-11-17**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2111-11-17**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2111-11-17**] URINE URINE CULTURE-FINAL INPATIENT
[**2111-11-16**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2111-11-16**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
III. Labs
A. Admission:
[**2111-11-15**] 10:10PM BLOOD WBC-13.9* RBC-4.12* Hgb-12.4 Hct-35.3*
MCV-86 MCH-30.2 MCHC-35.3* RDW-14.0 Plt Ct-205
[**2111-11-15**] 10:10PM BLOOD Neuts-88.0* Lymphs-10.0* Monos-1.6*
Eos-0.2 Baso-0.2
[**2111-11-15**] 10:10PM BLOOD PT-26.0* PTT-25.6 INR(PT)-2.5*
[**2111-11-16**] 02:58AM BLOOD CK(CPK)-130
[**2111-11-16**] 02:58AM BLOOD Calcium-11.0* Phos-1.8* Mg-1.5*
[**2111-11-15**] 10:10PM BLOOD Type-ART pO2-205* pCO2-16* pH-7.66*
calTCO2-19* Base XS-0 Comment-GREEN-TOP
[**2111-11-15**] 10:10PM BLOOD Glucose-179* Na-141 K-4.6 Cl-101
B. Discharge:
[**2111-11-26**] 05:37AM BLOOD WBC-5.3 RBC-3.64* Hgb-10.6* Hct-30.9*
MCV-85 MCH-29.2 MCHC-34.4 RDW-14.5 Plt Ct-254
[**2111-11-25**] 03:52AM BLOOD PT-13.1 PTT-21.8* INR(PT)-1.1
[**2111-11-26**] 05:37AM BLOOD Glucose-91 UreaN-14 Creat-0.5 Na-135
K-3.8 Cl-98 HCO3-29 AnGap-12
[**2111-11-26**] 05:37AM BLOOD ALT-41* AST-42* LD(LDH)-279* AlkPhos-168*
TotBili-0.4
[**2111-11-26**] 05:37AM BLOOD Phenyto-8.1* (Albumin 3.4)
Brief Hospital Course:
# INTRAPARENCHYMAL HEMORRHAGE/SUBDURAL HEMATOMA:
Pt presented to an OSH with worst headache of her life and was
found to have a IPH on the Right side. She was on Coumadin for
atrial fibrillation and her INR was 2.5. Coumadin was
discontinued. She was transferred to [**Hospital1 18**] where she underwent
right sided craniectomy and temporal lobectomy. Post operatively
she was taken to the ICU where she remained intubated. [**11-19**] she
was extubated. On [**11-20**] she had an MRI which showed a large area
of signal abnormality in the right middle cerebral artery
territory and temporal region could be due to an evolving
infarct with residual blood products. Subtle areas of signal
abnormality on the diffusion images near the convexity in the
right frontal region could be due to blood products in the sulci
or less likely due to additional subtle foci of subacute
infarcts. Pt maintained on phenytoin for sz ppx, which should be
continued until neurosurgical follow up. Mental status slowly
improved over hospital course. At time of discharge she was
alert, oriented to person only. She has near normal strength in
RUE and RLE and 4/5 strength of left upper and lower
extremities.
.
# UROSEPSIS: Pt became hypotensive, tachycardic and febrile on
[**11-22**] which was likely related to E.Coli UTI. She received IVF
hydration and broad spectrum ABX that were narrowed to
ciprofloxacin. However, she developed a maculo-papular rash on
her back (likely to keflex, see below), but the cipro was
switched to bactrim instead. She should complete a 14 day total
course of antibiotics, of which she got 4 of cipro and 1 of
bactrim while here, so she only needs 9 more days of bactrim.
We D/C'd the foley at noon on [**11-26**]. She may need to have it
replaced at her rehab facility if she does not pass her void
trial by 8pm.
.
# Atrial Fibrillation with rapid ventricular response: Pt has
known permanent Atrial fibrillation. RVR likely triggered in
setting of acute infection. Arrythmia responded to treatment of
infection and metoprolol. Her home regimen of atenolol was
changed to metoprolol succinate 75mg PO QD. However, when she
was taking her pills she would chew them even when instructed
not to, so changed to 37.5mg metoprolol tartrate [**Hospital1 **]. Warfarin
has been stopped in setting of head bleed and should not be
restarted at this time. She was started on ASA 81mg daily, which
was approved by neurosurgery (as was her TID subcutaneous
heparin DVT ppx).
.
# Subdural hematoma s/p craniotomy:
The patient remains on phenytoin for seizure prophylaxis. Her
phenytoin was changed to phenytoin infatab as this formulation
will not interact with tube feeds. Phenytoin level should be
checked weekly with goal level (corrected for albumin) >10. On
day of dispo, her phenytoin level was 8.1, so she received a
500mg IV bolus of phenytoin before leaving. In addition, her
sutures were removed [**11-24**] and there was some cellulitis noted so
keflex was started on [**11-24**] for what would have been a total 10
day course. However, pt then developed a maculo-papular drug
rash on [**11-25**], and the keflex was switched to azithromycin.
Patient will complete another 8 days of azithromycin for her
possible cellulitis. Her drug rash has dramatically improved
since stopping the keflex and cipro (see above). Pt has a wound
check with neurosurgery which has been scheduled for [**12-7**] and also has a 4 week f/u appt with her neurosurgeon with a
repeat CT head for [**12-22**].
.
# Pulmonary Nodule: Incidental 3mm right lung nodule. 12 month
follow up is recommended.
Medications on Admission:
Coumadin
Benadryl
Omeprazole
Atenolol
HCTZ
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet,
Chewable PO TID (3 times a day).
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
7. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 10 days: Patient got morning
dose of this med on [**11-26**], will need evening dose, then 9 more
days of the medication, last dose on [**12-5**].
9. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours): Pt needs 8 more days of this medication, last dose
will be [**12-4**]. .
10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or HA.
11. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day): Hold for SBP <100, HR <55.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Intraparenchymal hemorrhage
Subdural hematoma
Urosepsis
Atrial Fibrillation with Rapid Ventricular Response
SECONDARY: Hypertension, Fibromyalgia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Ms. [**Known lastname 87762**], you came to the hospital with a severe headache
and were found to have a head bleed requiring brain surgery. You
also developed a urinary tract infection. At time of discharge
your infection was improving. You are being discharged to rehab
for continued therapy to help you regain your strength.
.
PLEASE BE AWARE OF THE FOLLOWING DIRECTIONS:
?????? 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, and
Ibuprofen etc.
?????? DO NOT TAKE ANY WARFARIN
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed. Your rehab should be monitoring
this medication weekly.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
-----------
CHANGES TO YOUR MEDICATIONS:
STOP TAKING:
Warfarin
Atenolol
Hydrochlorathiazide
Omeprazole
.
START:
Metoprolol tartrate 37.5 mg twice a day
Phenytoin 150mg three times a day
Aspirin 81mg once a day
Famotidine 20 mg daily
Azithromycin
Bactrim
It was a pleasure taking care of you on this hospital admission.
Followup Instructions:
*** A 3mm nodule in your right upper lung was seen on your CT
scan. You should have a repeat CT scan in 12 months to further
evaluate this. Lung nodules are common findings and frequently
are benign. Please discuss this with your Primary Care Provider
so they can schedule this test.
.
You have a wound check appointment with neurosurgery:
Monday, [**2111-12-7**]
Wound check @ 11:00am - [**Hospital **] Medical Building, [**Hospital Unit Name 12193**]
.
Department: RADIOLOGY
When: TUESDAY [**2111-12-22**] at 2:00 PM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
.
Department: NEUROSURGERY
When: TUESDAY [**2111-12-22**] at 2:30 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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26,523
| 192,773
|
6061
|
Discharge summary
|
report
|
Admission Date: [**2192-2-28**] Discharge Date: [**2192-3-15**]
Date of Birth: [**2130-7-8**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Pepcid / Nitroglycerin / Dicloxacillin /
Methylprednisolone / Neurontin / Bactrim / Tape / Detrol
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
mental status changes
Major Surgical or Invasive Procedure:
PICC line insertion
History of Present Illness:
61F with multiple medical problems including CHF, [**Name (NI) 2320**], chronic
arachnoiditis, neurogenic bladder, recent admission for altered
mental status and recent admission for bacteremia, who now
presents to the ER with mental status changes.
.
The patient was admitted to [**Hospital1 18**] from [**Date range (1) 23798**] with
mental status changes which were attributed to her Detrol, which
was discontinued. She was discharged on her previous dose of
Morphine PCA and was admitted again [**2192-2-17**] with hypotension and
fevers. She was found to have [**2-28**] blood culture bottles with
coagulase-negative staphylococcus. The decision was made by her
PCP and ID specialist to treat through the line with vancomycin
given recent multiple line changes. She was discharged on
[**2192-2-22**] with a ten-day course of Vancomycin. She has had
multiple admissions to [**Hospital1 18**] with mental status changes and
renal failure, thought to be secondary to narcotics overdose and
decreased po intake.
.
Her husband reports that since her discharge from the hospital,
she has been "down" and not quite herself. She hasn't been
excited to talk to people who she is usually excited to speak
with and she has been less interactive and taking in fewer po's.
She had been awake and communicative, however, until this
morning when her husband tried to wake her up to give her her
Vancomycin dose. She was difficult to arouse and he called EMS.
He denies that she has had fevers, chills, night sweats, N/V,
pain, cough, aspiration events, diarrhea, foul-smelling or a
change in urine, change in her ambulation or motor ability. She
is currently on Day 13 of Levofloxacin and Vancomycin.
.
In ED, her FSG was 129, she was afebrile at 97.6 with BP 178/64.
There was a concern for narcotics overdose from her PCA and she
was given narcan 0.4mg x3. Subsequently her BP increased to
220/100 with HR in 150s and she was acutely agitated. She was
given 1mg IV haldol and 1mg of ativan to control her agitation.
She was also given metoprolol 5mg IV x 3 to control
hypertension.
Past Medical History:
1. MRSA
2. Metastatic thyroid CA s/p iodine and XRT and now on synthroid
3. Right lower extremity cellulitis
4. Nuerogenic bladder: Pt self catheterizes
5. Chronic low back pain: Pt is on continuous morphine PCA.
6. Depression
7. Type 2 DM
8. Chronic arachnoiditis
9. Esophageal dysmotility
10. DVT and PE s/p placement of IVC filter. Felt to be
hypercoagulable
11. Chronic UTIs.
12. Obstructive Sleep Apnea
13. Osteoarthritis
14. CHF: Last echo was [**2189-2-26**] with a LVEF of 60%.
15. HTN
16. Anemia of chronic disease
17. Right ankle graft
18. Seizure [**2190-8-14**]
19. s/p Klebsiella line infection [**1-1**]
20. s/p ERCP for retained stone [**1-1**]
21. Hospitalized at [**Hospital1 **] [**6-30**] with R thumb/forearm cellulitis s/p
several courses of Vancomycin
22. On home O2 at night, 3L
23. Splenic cyst
24. Osteomyelitis of the right second toe with
chronic
ulceration s/p distal phalangectomy of the right second
toe with ulcer excision
Social History:
The patient lives with her husband. She has one son. She used to
work as a research chemist, but is not currently working. No
ETOH or tobacco use. Walks with crutches/walker. She recently
explained to her PCP that her husband is using her narcotic pain
medications.
Family History:
Father has CAD, Mother with CVA
Physical Exam:
Vitals: T 97.6 BP 160/75 HR 72 RR 14 97% RA
General: somnolent, arousable, follows commands [**1-28**] of the time,
NAD
HEENT: pupils equally round and reactive, EOMI (for as much as
pt can cooperate), very dry mucous membranes
Neck: supple, no tenderness or stiffness
Lung: CTA bilaterally
Chest: right chest tunnelled line site slightly erythematous
without exudate or tenderness
Cor: RRR, nml S1S2, no m/r/g
Abd: obese, surgical scars well-healed, NABS, soft NTND
Ext: trace edema BLE up to knees bilaterally, superficial ulcer
on heel of left heel
Neuro: somnolent but arousable, moves all extremities, follows
commands [**1-28**] of the time, cranial nerves intact grossly
Pertinent Results:
UA ([**2-28**]): 6.0/1.010/negative leuks/negative nitrite
.
CULTURE DATA:
UA: neg leukocytes, neg nitrite
BCx ([**2-17**]): [**2-28**] Coag neg staph
BCx ([**2-18**]): Negative
BCx ([**2-19**]): Negative
BCx ([**2-28**]): Negative
BCx ([**2-29**]): Negative
BCx ([**3-2**]): Negative
UCx ([**3-2**]): <10,0000 organisms
BCx ([**3-5**]): Negative
UCx ([**3-5**]): 10,000-100,000 Pseudomonas resistant to Cipro, gent
and tobra
BCx ([**3-8**]): [**12-2**] Coag neg staph
UCx ([**3-8**]): Yeast
PICC tip cx ([**3-9**]): Negative
BCx ([**3-12**]): NGTD
.
STUDIES:
CXR ([**2192-2-28**]): Persistent small bilateral pleural effusions
without evidence of CHF or pneumonia.
.
Head CT ([**2192-2-28**]): Interval development of what may be a small
infarct within the region of the genu of the left internal
capsule. Clinical correlation is required to confirm this
diagnosis. A contrast enhanced MR study would obviously be more
sensitive means to assess for metastatic neoplasm.
.
EKG: NSR at 86 bpm, nml axis, nml intervals, peaked T's
Brief Hospital Course:
1. Altered Mental Status: The patient was admitted with a
change in mental status that was thought to be related to
narcotics overdose. Her mental status improved with three doses
of narcan and holding her morphine PCA. Over the next several
days of her hospitalization, her various pain medications were
gradually restarted and she was given prn morphine doses. The
pain consult service was contact[**Name (NI) **] and recommended starting
methadone and titrating according to morphine needs. Several
days later, the patient became somnolent and occasionally
apneic. She was given two doses of narcan with transient
improvement in her mental status, but she became extremely
hypertensive, necessitating transfer to the MICU for
observation. There, she was monitored without further narcan.
She made a surprisingly fast return to baseline with holding her
pain medications. This decline in mental status was almost
certainly related to her methadone and multiple pain
medications. On transfer back to the floor, she was placed again
on a morphine PCA at her outpatient basal rate of 2mg per hour
and was noted to become somnolent and less responsive once
again. Her basal rate of morphine was discontinued and she
returned to baseline. She was maintained on the morphine PCA
with demand doses only. In addition, her baclofen and tizanidine
are being held.
.
2. Fever: The patient was noted to have low-grade fevers during
the first week of her hospitalization. Blood cultures from a
prior hospitalization on [**2192-2-17**] grew staph epi in [**2-28**] BCx
bottles and the plan was to treat through the line with
Vancomycin. Given continuing fevers on Vancomycin and [**12-2**] blood
culture bottles on [**3-8**] that grew staph epi, the Hickman
catheter was discontinued. Her fevers resolved with several more
days of Vancomycin.
.
3. Urinary tract infection: In addition to her line infection,
the patient had a positive UA with a urine culture which grew
Pseudomonas. She was treated with a seven-day course of
Ceftazadime.
.
4. ARF: The patient was admitted with a creatinine of 1.7,
elevated from her baseline. Her renal function improved with
fluid hydration suggesting a prerenal etiology. Her ACEI was
initially held and restarted.
.
5. History of PE and DVT: She was continued on Coumadin with a
therapeutic INR throughout her hospitalization.
.
6. Chronic arachnoiditis: As described previously, the patient's
morphine was intermittently held throughout this admission for
altered mental status. As her pain medications were restarted
and morphine dosing increased, she would become somnolent
suggesting a very fine line between pain control and
over-narcotizing. On discharge, her pain is very well controlled
with only demand doses of morphine PCA, without a basal rate. In
addition, her baclofen and tizandine are being held.
.
7. DM: She was covered with an insulin sliding scale and
continued on [**First Name8 (NamePattern2) **] [**Doctor First Name **] diet. Her metformin was restarted prior to
discharge.
.
8. HTN: The patient was intermittently hypertensive throughout
this hospitalization, particularly in the setting of holding her
pain medications. Her HCTZ, metoprolol and clonidine were
continued. Her lisinopril dose was titrated up for improved
control. Her hydralazine was held on admission given low blood
pressures, but was restarted prior to discharge.
.
9. LE spasticity: Tizanidine and baclofen were held for altered
mental status and may be restarted as an outpatient.
.
10. Hypothyroidism: The patient was noted to have an
appropriately suppressed TSH during her hospitalization in [**1-2**]
and had a TSH 0.099 of on this admission. Her previous dose of
levothyroxine (as documented by Endocrinologist note in [**6-30**])
was continued. Dr. [**Last Name (STitle) 574**] was contact[**Name (NI) **] via email regarding
the patient's TSH goal.
Medications on Admission:
MEDS (from prior records including D/C summary):
Vancomycin 1g Q12H for 10 days
Citalopram 20mg daily
Quinine 325mg tid
Levetiracetam 500 mg [**Hospital1 **]
Hydralazine 50 mg TID
Albuterol 1-2 Puffs Inhalation Q6H
Miconazole 2% [**Hospital1 **]
Hydrochlorothiazide 25mg DAILY
Tizanidine 2mg [**Hospital1 **], 4mg QHS
Metoprolol 100 mg DAILY
Docusate 200 mg TID
Magnesium 400 mg TID
Clindamycin Phosphate 1% TID
Baclofen 10 mg Two (2) Tablet PO TID
Folic Acid 1 mg [**Hospital1 **]
Epoetin Alfa 10,000 unit/mL 2x per wk
Levothyroxine written as both 175mcg [**Hospital1 **] and TID in discharge
paperwork but Endocrine note from [**6-30**] says 175 mcg three times
per day on Sunday and Wednesday and 175 mcg twice a day on
[**Month/Year (2) 766**], Tuesday, Thursday, Friday and Saturday
Insulin SS
Amitriptyline 50 mg HS
Trazodone 100 mg HS
Lansoprazole 30 mg once a day
Lisinopril 20 mg HS
Magnesium Hydroxide 400 mg/5 mL Suspension Sig: 30ML PO Q6H
prn
Morphine PCA as directed
Levofloxacin 500 mg daily for 6 days
Warfarin 5 mg PO HS
Clonidine 0.1 mg/24 hr Patch Weekly QSUN
Polyethylene Glycol 3350 17 g Packet PO BID PRN
Lactulose 10 g/15 mL Syrup 45ML PO Q4H prn constipation
Macrodantin 100 mg at bedtime
Magnesium Oxide 400 mg PO once a day
Metformin 500mg [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO BID (2
times a day): on [**Hospital1 766**], Tuesday, Thursday, Friday and Saturday.
4. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO TID (3
times a day): on Wednesday and Sunday.
5. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSUN (every Sunday).
6. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
8. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
9. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Quinine Sulfate 325 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day) as needed for muscle spasms.
12. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
13. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO once a day.
16. Nitrofurantoin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
18. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
19. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
20. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
21. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
22. Morphine 1 mg/mL Syringe Sig: One (1) mg Injection ASDIR (AS
DIRECTED): Morphine Sulfate 1 mg IVPCA Lockout Interval: 15
minutes Basal Rate: 0 mg(s)/hour 1-hr Max Limit: 4 mg(s).
23. Lactulose 10 g/15 mL Syrup Sig: Forty Five (45) ML PO Q4H
(every 4 hours) as needed for Constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnoses:
1. Altered Mental status, secondary to morphine overdose
2. Pseudomonal UTI
3. Coagulase-negative staph line infection
.
Secondary Diagnoses:
1. Chronic arachnoiditis
2. Metastatic thyroid CA
3. Diabetes Mellitus Type II
4. History of DVT/PE
Discharge Condition:
Good
Discharge Instructions:
You are discharged to home where you should continue all
medications as prescribed. We have made several changes to your
medication list- please review the list we are providing.
Please contact your physician or present to the ER if you
experience fevers, chills, night sweats, increasing pain or
other concerns.
Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
Followup Instructions:
Please schedule a follow-up appointment with your primary care
physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within 1-2 weeks after discharge.
Provider: [**First Name11 (Name Pattern1) 312**] [**Last Name (NamePattern4) 3015**], M.D. Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2192-4-3**] 8:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6730**], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2192-4-4**]
2:45
Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2192-4-4**] 3:45
|
[
"244.9",
"965.09",
"599.0",
"E850.2",
"596.54",
"728.85",
"041.7",
"780.39",
"584.9",
"707.14",
"996.62",
"428.0",
"322.2",
"V12.51",
"401.9",
"250.00",
"V10.87"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13010, 13089
|
5607, 5618
|
390, 411
|
13394, 13401
|
4553, 5584
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13872, 14553
|
3807, 3840
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10841, 12987
|
13110, 13250
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9514, 10818
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13425, 13849
|
3855, 4534
|
13271, 13373
|
329, 352
|
439, 2515
|
5634, 9488
|
2537, 3507
|
3523, 3791
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,679
| 162,515
|
31631
|
Discharge summary
|
report
|
Admission Date: [**2161-7-29**] Discharge Date: [**2161-8-14**]
Date of Birth: [**2142-12-23**] Sex: M
Service: MEDICINE
Allergies:
Cefaclor
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Tylenol PM overdose
Major Surgical or Invasive Procedure:
intubation at OSH
OSH subclavian line removal
placement of RIJ central venous catheter
placement of L subclavian venous catheter
History of Present Illness:
Mr. [**Known lastname **] is an 18-year old gentleman with history of
schizoaffective disorder, multiple suicide attempts in the past,
who was admitted to [**Hospital 1474**] Hospital on [**2161-7-27**] after being
found down. Per report, patient had stolen his car from his
mother on [**Name (NI) 1017**] and driven from [**Doctor First Name 5256**] to [**State 350**]
to visit his girlfriend. [**Name (NI) **] had taken a large bottle of Tylenol
from his home. Poliec were contact[**Name (NI) **] by mother, and they were
searching for him both in [**Doctor First Name 5256**] and [**State 350**]. The
next afternoon, he found police waiting at his girlfriend's
house, and he ran. He left his car and called his mother at 2:19
PM, and told him that he had ingested approximately 200 Tylenol
PMs and wanted to die. He was found behind a dumpster by the
police (reportedly 2 hours after consumption) and brought to
OSH. At the OSH, he was given Narcan and intubated given
somnolence. A 4-hour Tylenol level was > 200, and he was treated
with NAC (loading dose) followed by 17.5mg/kg continous
infusion. CXR revealed infiltrate and he was started on Zosyn.
LFTs were initially in 200s and have remained in that range
through his MICU course; however, INR has trended up to 2.4 this
morning, and patient has progressively become profoundly
acidotic, with most recent ABG 7.18/45/167. On admission, his
bicarbonate was 11, and he was given a NaHCOs infusion and
aggressive IV fluids with good urine output. Creatinine was
normal on admission and has increased to 1.9 now. Lactate 4.0.
He is being transferred for considerations of transplant.
.
On arrival to the MICU, patient's VS were 98.6 Ax, HR 112, BP
111/55; RR 19; O2 97% AC TV 500, RR 18; FI02 1.0, PEEP 12.
A-line was placed for pH monitoring. NAC drip was continued,
cultures were drawn, and Zosyn was continued. Patient's sedation
was changed to Fentanyl/Versed.
Past Medical History:
1. Multiple suicide attempts in past
2. Bipolar discorder
3. Schizoaffective disorder
Social History:
Originally from [**Doctor First Name 5256**]. Attended school in MA until
[**Month (only) 956**], was then living in NC with mother because of
behavioral problems/depression.
Family History:
Father committed suicide.
Physical Exam:
VS: 98.6 Ax, HR 112, BP 111/55; RR 19; O2 97% AC TV 500, RR 18;
FI02 1.0, PEEP 12
GEN: sedated, intubated,
HEENT: Pupils round, reactive 3 -> 2mm. ET tube in place.
LUNGS: CTA B/L anteriorly
HEART: RRR No MRG.
ABD: soft, NT/ND. +BS
EXT: No CCE. Syymetric DPs
NEURO: intubated. PERRL. Downgoing toes. Sluggish patellar
reflex. No no response to verbal or painful stimuli. No clonus.
No myoclonic activity or muscle rigidity. Sluggish biceps
reflex, symmetric B/L.
Pertinent Results:
[**2161-7-29**] 10:59PM TYPE-ART TEMP-37.8 PO2-112* PCO2-48* PH-7.21*
TOTAL CO2-20* BASE XS--8 INTUBATED-INTUBATED
[**2161-7-29**] 10:59PM LACTATE-4.9*
[**2161-7-29**] 09:53PM TYPE-ART TEMP-38.1 PO2-92 PCO2-56* PH-7.15*
TOTAL CO2-21 BASE XS--9 INTUBATED-INTUBATED
[**2161-7-29**] 09:53PM LACTATE-5.2*
[**2161-7-29**] 09:53PM freeCa-1.11*
[**2161-7-29**] 09:30PM estGFR-Using this
[**2161-7-29**] 09:30PM ALT(SGPT)-213* AST(SGOT)-114* LD(LDH)-261*
CK(CPK)-751* ALK PHOS-49 AMYLASE-64 TOT BILI-1.3
[**2161-7-29**] 09:30PM LIPASE-21
[**2161-7-29**] 09:30PM WBC-13.7* RBC-4.39* HGB-13.6* HCT-40.1 MCV-91
MCH-31.1 MCHC-34.0 RDW-14.0
[**2161-7-29**] 09:30PM WBC-13.7* RBC-4.39* HGB-13.6* HCT-40.1 MCV-91
MCH-31.1 MCHC-34.0 RDW-14.0
[**2161-7-29**] 09:30PM PLT COUNT-193
[**2161-7-29**] 09:30PM PT-27.0* INR(PT)-2.8*
*
Blood culture [**8-6**]:
AEROBIC BOTTLE (Final [**2161-8-9**]):
REPORTED BY PHONE TO [**Last Name (LF) 54657**], [**First Name3 (LF) **] @0013 ON [**2161-8-7**].
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
OF THREE COLONIAL MORPHOLOGIES. ISOLATED FROM ONE SET
ONLY.
SENSITIVITIES PERFORMED ON REQUEST..
ANAEROBIC BOTTLE (Final [**2161-8-9**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
OF THREE COLONIAL MORPHOLOGIES. ISOLATED FROM ONE SET
ONLY.
SENSITIVITIES PERFORMED ON REQUEST.
*
Sputum culture:
RESPIRATORY CULTURE (Preliminary):
OROPHARYNGEAL FLORA ABSENT.
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. MODERATE
GROWTH. SENSTITIVE TO BACTRIM
*
Central venous catheter culture: No significant growth:
*
AST [**8-10**]: 21 (332 on admission)
ALT [**8-10**]: 54 (1410 on admission)
Brief Hospital Course:
[**Known firstname **] [**Known lastname **] is an 18-year-old gentleman who was transferred from
OSH after acetaminophen/benadryl overdose with worsening liver
and respiratory status. The following issues were addressed
during his MICU stay:
.
# Acetaminophen overdose with worsening hepatic function
Patient received loading dose NAC within 1st 6 hours of
ingestion and was continued on NAC drip for > 72h and
discontinued when INR was less than 2. Hepatology service was
consulted and they followed patient actively. Patient not in
fulminant hepatic failure, with peak INR 2.0, Cr 1.8. LFTs
ranged from 200-500. Transplant surgery was consulted for
considerations of liver transplant, it was felt that patient's
liver injury was not sufficient to warrant transplant at this
time.
.
# Respiratory Failure
Patient's mental status poor, likely from benadryl overdose as
part of Tylenol PM, intubated given mental status changes. CXR
at OSH showed significant RML infilatrate, patient was continued
on Zosyn for presumed aspiration PNA. Given temeprature spike
while in MICU, sputum culture was obtained which showed Gram +
cocci, and he was started on Vancomycin. It was difficult
ventilating patient, and he required high minute ventilation
with FIO2 0.1-1.0, PEEPS [**12-11**], RR in 20s. He was started on
ARDSnet ventilation. Chest CT was obtained which showed
multifocal pneumonia.
.
# AMS
Patient with depressed mental status and functioning, presumed
[**1-30**] benadryl overdose as part of Tylenol PM. Head CT negative at
OSH on presentation. Given no improvement and subsequent
development of positive Babinski bilaterally, Head CT was
repeated here, which showed no intracranial pathology. Patient
also received EEG to r/o nonconvulsive status.
.
# Lactic Acidosis
Etiology mutlifactorial, improved with increasing MV and
supportive care. Likely combination of direct effects of
acetaminophen overdose, liver injury, tissue hypoperfusion, and
hypermetabolic state.
.
Upon transfer to the medical floor, the following issues were
addressed:
.
# Pneumonia: This was thought to be an aspiration pneumonia from
his overdose complicated by a ventilator-associated process.
The patient was continued on IV vancomycin and zosyn, which he
will need to complete a ten day course of. Double strength
bactrim was added to the regimen to cover for the
ventilator-associated pathogen stenotrophomonas, which grew out
on his sputum culture.
.
# Bacteremia: This was likely a skin contaminant as the only
positive cultures were found on [**8-6**] where [**12-30**] tubes showed
coagulase negative staphylococcus of mixed morphologies. A
catheter tip culture showed no significant growth, and
surveillance cultures after [**8-6**] remained negative.
.
# Thrombocytosis: This is likely a reactive process, as the
patient has infection and multiple inflammatory conditions
including resolving transaminitis and pancreatitis. No
treatment is necessary at this time.
.
# Psychiatric problems, including bipolar disorder vs.
schizoaffective disorder: The patient will be transferred to a
psychiatric floor for further management as he is medically
stable.
.
# Transaminitis: The patient's LFT's were monitored daily, and
trended downward daily.
.
# Propofol-induced pancreatitis: the patient was monitored
clinically throughout his hospital stay. He improved and is
able to eat and drink without pain or nausea.
Medications on Admission:
HOME MEDICATIONS: Lamictal, has weaned himself off other
psychotropic medications over last 6 months
.
MEDICATIONS ON TRANSFER
1. Albuterol/Atrovent
2. Zosyn 4.5g IV q6h
3. Fentanyl
4. Midazolam
5. Propofol
6. Heparin 5000 SC TID
7. Protonix 40 IV qd
8. Chlorhexidine 5 q8h
9. Nystatin
10. Artificial Tear
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 3 days: This regimen will be
over on [**8-18**].
Disp:*3 Tablet(s)* Refills:*0*
2. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours) for 3 days: This dose will be
finished on 8/219.
Disp:*3 dose units* Refills:*0*
3. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: 4.5 grams
Intravenous Q8H (every 8 hours) for 3 days: This course will be
over on [**8-16**].
Disp:*9 dose units* Refills:*0*
4. Risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Discharge Diagnosis:
aspiration and ventilation-associated pneumonia
acute hepatic failure secondary to acetaminophen overdose
Pancreatitis secondary to propofol
Discharge Condition:
Improved
Discharge Instructions:
You were admitted after you overdosed on tylenol PM. You stayed
in the intensive care unit until you were more stable for the
general medical floor. Here, we diagnosed you with a pneumonia,
and started you on antibiotics, which you will need to take for
awhile after you leave here. You will be taking vancomycin and
zosyn through your IV until [**8-17**], and bactrim orally until
[**8-19**]. You pancreatitis and liver irritation have resolved.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"995.91",
"577.0",
"038.19",
"507.0",
"276.2",
"E950.0",
"518.81",
"295.70",
"996.62",
"965.4",
"570",
"296.80"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
9335, 9350
|
4913, 8320
|
289, 419
|
9535, 9546
|
3214, 4592
|
2688, 2715
|
8677, 9312
|
9371, 9514
|
8346, 8346
|
9570, 10145
|
2730, 3195
|
8364, 8654
|
4633, 4890
|
230, 251
|
447, 2370
|
2392, 2480
|
2496, 2672
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,284
| 166,856
|
28623
|
Discharge summary
|
report
|
Admission Date: [**2157-8-31**] Discharge Date: [**2157-9-11**]
Date of Birth: [**2112-6-6**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
CT guided pig-tail drain placed
History of Present Illness:
This is a 45 year old female transfered from [**Hospital **] Hospital
ICU after a 72 hour admission after retroperitoneal air and
perinephric stranding developed s/p ERCPon [**2157-8-29**] w/
sphincterotomy. She was admitted to the OSH on [**2157-8-27**] with mild
transaminitis/CBD and had a subsequent ERCP w/ sphincterotomy.
She was started on unasyn and gentamicin then Zosyn and
Fluconazole. She was transferred with WBC of 20K, tachycardic,
and mild hypovolemia.
Past Medical History:
Diverticulitis, Fibroids, unilateral vocal cord paralysis (after
thyroid surgery), h/o papillary thyroid cancer, GERD
PsHx: Open Chole [**2131**], Appy, Thyroidectomy+radiation [**2144**].
Social History:
45 year old married mother of 2 teenage children. Pt. works
full time as an accountant for a property management company and
is also responsible for the care of her legally blind mother.
Physical Exam:
VS: 101.9, 118, 120/59, 18, 98% RA
Gen: Appears uncomfortable
HEENT: anicteric, membranes dry, no JVD
CV: RRR, S1, S2, no murmurs
Pulm: CTA bilat.
Abd: soft, slightly distended, tender on right flank and RLQ
Ext: teds bilat.
Pertinent Results:
CT ABDOMEN W/CONTRAST [**2157-9-8**] 1:09 AM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: Please r/o acute process.
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
45 year old woman with duadenal perf s/p ercp now with fever and
RLQ pain.
REASON FOR THIS EXAMINATION:
Please r/o acute process.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Duodenal perforation following ERCP, now with fevers
and right lower quadrant pain.
TECHNIQUE: Volumetric CT imaging of the abdomen and pelvis was
performed following administration of oral and 130 cc of Optiray
IV contrast. Coronal and sagittal reformatted images were made.
COMPARISON: Abdominal CT scan from [**2157-9-3**].
CT OF THE ABDOMEN WITH IV CONTRAST: Mild bibasilar atelectasis
is present, but greatly improved since the 19th, and there is
resolution of previously small bilateral pleural effusions. The
liver, spleen, pancreas, adrenal glands, left kidney, stomach,
and small bowel are unremarkable. There is no ascites.
There is a large, multilobulated rim-enhancing fluid collection
throughout the right retroperitoneum, which extends into both
the anterior and posterior perarenal and perirenal spaces and
spans the area from the mid pole of the right kidney through the
level of the anterior inferior iliac spine. This collection
demonstrates multiple enhancing septations. The collection has
increased in size since the prior study. The enhancing rim is
new.
CT OF THE PELVIS WITH IV CONTRAST: There are innumerable
enhancing fibroids. There are scattered colonic diverticuli but
no evidence of acute diverticulitis. There is no free fluid in
the pelvis. No enlarged inguinal or pelvic nodes are identified.
No lytic or sclerotic osseous lesions are identified.
CT RECONSTRUCTIONS: Coronal and sagittal reformatted images
confirm the very large extensive right retroperitoneal
collection, which also extends into the anterior and posterior
perirenal space.
IMPRESSION: Increased size of large, multiloculated/septated
right retroperitoneal collection, which extends into the
perirenal space. The collection would be amenable to CT-guided
drainage.
Cardiology Report ECG Study Date of [**2157-9-3**] 9:40:52 AM
Sinus rhythm. Normal ECG. Compared to the previous tracing of
[**2157-9-1**] the rate
is slower.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
90 122 86 364/411.71 57 32 19
CT ABDOMEN W/CONTRAST [**2157-9-3**] 12:22 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: eval for duad perforation
Field of view: 39 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
45 year old woman with duadenal perf s/p ercp
REASON FOR THIS EXAMINATION:
eval for duad perforation
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: History of duodenal perforation status post ERCP.
Transferred from outside hospital.
COMPARISON: None.
TECHNIQUE: MDCT-acquired images of the abdomen and pelvis were
obtained after the administration of IV and oral contrast.
Multiplanar reformatted images were also obtained.
CT OF THE ABDOMEN WITH IV CONTRAST: There are bilateral pleural
effusions with a right lower lobe opacification that is
consistent with atelectasis and/or consolidation. There is
compressive left lower lobe atelectasis.
The liver enhances homogeneously with no definite focal lesions.
The gallbladder is not seen. The portal vein appears patent.
There may be minimal periportal edema. The splenic vein appears
patent. The spleen is unremarkable. The adrenal glands have a
normal contour. The kidneys enhance and excrete contrast
symmetrically.
Note is made of a 4.5 x 2.2 x 2.7 (transverse, AP,
superoinferior) air pocket in the expected region of the
duodenal bulb, located beneath the liver that on sagittal images
appears to correspond to the duodenal bulb. The pancreas appears
to enhance homogeneously. There are multiple small pockets of
free air located posteriorly to the descending duodenum (series
2, image 29 through 35). There is extensive retroperitoneal
fluid and stranding, particularly in the anterior right
pararenal space. There also appears to be fluid and stranding
surrounding the superior mesenteric vessels, presumably in the
mesenteric space. No focal, walled abscess is yet seen. Contrast
passes freely through the small bowel all the way to the rectum
with no definite small or large bowel wall thickening. There are
multiple small retroperitoneal and mesenteric lymph nodes that
do not meet CT criteria for pathologic enlargement. The left
gonadal vein appears to drain to the left renal vein, the right
gonadal vein drains to the IVC.
CT OF THE PELVIS WITH IV CONTRAST: There is a Foley catheter
within the bladder, there appears to be extensive air within the
bladder, presumably secondary to Foley catheterization. There is
an enlarged, multilobulated presumable fibroid uterus.
Bone windows reveal no suspicious lytic or sclerotic lesions.
IMPRESSION:
1. Multiple foci of retroperitoneal air and extensive fluid and
stranding within the retroperitoneum, right greater than left,
and small ascities and mesenteric stranding consistent with the
patient's reported history of perforated duodenum after ERCP.
There is no extravasation of oral contrast.
2. Bilateral pleural effusions, right greater than left, with
right lower lobe opacity that may represent collapse or
consolidation.
3. Enlarged lobulated presumed fibroid uterus.
Brief Hospital Course:
She was admitted to the SICU on [**2157-8-31**].
.
#Perforated Duodenum
She was on bowel rest - NPO, with IV fluids and she was started
on TPN. She was started on sips and her diet was slowly
advanced. Her pain was greatly improving.
HD 7 she complained of mild [**4-25**] RLQ tenderness on palpation. A
CT showed increased size of large, multiloculated/septated right
retroperitoneal collection, which extends into the perirenal
space. The next day, she went for a CT guided pigtail drain and
there was brownish fluid that was drained. Gram Stain was
negative on the fluid. She will continue with drai care at home.
.
#ID
She was running low grade temperatures and spiked to 102.2 on
[**2157-9-3**]. Several blood cultures were done and were.... C. diff
and sputum cultures were negative. Zosyn and fluconazole were
continued.
.
#CV
Tachycardic secondary to hypovolumemia. Fluid resuscitation
resolved the tachycardia.
#Pain
Dilaudid PCA initially, then changed to PO med once taking
fluids. She complained of very minimal pain.
Medications on Admission:
prilosec 20', synthroid 125mcg"
Discharge Disposition:
Home
Discharge Diagnosis:
Duodenal perforation
Fluid Collection
Discharge Condition:
Good
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F)
* Inability to eat or persistent vomiting
* Inability to pass gas or stool
* Other symptoms concerning to you
Please monitor your drain site for redness or discharge.
Please perform drain care as instructed, including emptying the
drain. See "Drain Care" instruction sheet.
Followup Instructions:
|
[
"276.52",
"E870.4",
"785.0",
"789.5",
"998.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"38.93",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
8130, 8136
|
7015, 8048
|
327, 361
|
8218, 8225
|
1537, 1700
|
8587, 8587
|
4191, 4237
|
8157, 8197
|
8074, 8107
|
8249, 8562
|
1292, 1518
|
273, 289
|
4266, 6992
|
389, 859
|
881, 1072
|
1088, 1277
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,004
| 127,794
|
29254
|
Discharge summary
|
report
|
Admission Date: [**2108-5-10**] Discharge Date: [**2108-5-25**]
Date of Birth: [**2052-5-31**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
headaches X 1 month, anterior communicating artery aneurysm
found on MRI at OSH
Major Surgical or Invasive Procedure:
ACA clipping
Cerebral angiogram
Right leg fasciotomy
History of Present Illness:
55 y/o female with a h/o polycystic kidney disease who was
sent for MRI by her nephrologist after she told him she had been
having headaches. MRI reportedly revealed an anterior
communicating artery anuerysm of 6mm X 6mm X 3mm projecting
superiorly. She complains of approximately 1 month of headaches
which last 1 day and she has [**1-28**]/week. She describes the pain as
[**5-3**] in the front of her head ans sometimes radiating down into
her neck. She does report a history of similar headaches in the
past, for many years, of which some were much worse than her
present headaches. There has been no sudden onset of her
symptoms. She has had no N/V, visual changes, and no other
associated symptoms. No fevers, CP/SOB or other complaints.
Presently she has a mild headache of [**4-3**] and claims the last
severe headache she had was last Sunday.
Past Medical History:
PCKD, HTN, MI(unknown age), hyperlipidaemia, bipolar disorder
Cholecystectomy
NKDA
Social History:
Lives with husband, no EtOH, 60 pack years tob
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM:
T: 98.7 BP: 124/67 HR: 82 R 16 O2Sats 95% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ERRLA 3-2mm EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
2 mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-28**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, bilaterally.
Reflexes: B T Pa Ac
Right 2 2 2 2
Left 2 2 2 2
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements
Pertinent Results:
Discharge labs:
Chem:
155 114 60 113 AGap=15
3.6 30 1.1
Comments: Na: Notified [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 70327**] At 0845 On [**2108-5-24**]
Ca: 10.3 Mg: 3.1 P: 3.7
Phenytoin: 11.1
CBC:
95
15.1 11.6 485
34.1
NCHCT [**5-10**]: Status post anterior communicating artery aneurysm
clipping with no evidence of an intracranial hemorrhage. Careful
followup should be obtained as the subdural and epidural gas
present overlying the left frontal lobe appear to indent the
brain in several locations, raising the possibility of tension
pneumocephalus.
Carotid/Cerebral angiogram [**5-10**]:
1. Optimal clipping of the anterior communicating arterial
aneurysm with no residual aneurysm.
2. Both A2 branches are patent.
3. Minimal vessel spasm is noted in the left A1 segment. 5 mg of
verapamil
was infused into the left common carotid artery.
CT HEAD WITHOUT IV CONTRAST [**5-12**]: Again seen are multiple areas
of low attenuation within the left parietal and frontal regions,
in the ACA and MCA distribution consistent with areas of
infarction, which were seen on the prior study. These
demonstrate low attenuation consistent with expected changes. No
new areas of intracranial hemorrhage identified. The appearance
of the ventricles are stable in comparison to the prior exam.
There is slight asymmetry and narrowing of the left frontal
[**Doctor Last Name 534**], likely reflecting mass effect from areas of infarction in
the left frontal lobe. Artifact can be seen from clips within
the suprasellar region. The basilar cisterns are stable in
appearance. There are stable post-surgical changes in the left
frontal region from a craniotomy defect, with a small amount of
pneumocephalus, which has also not significantly changed. There
is minimal mass effect in the frontal region, which is also
relatively stable in comparison to prior exam.
IMPRESSION: Stable appearance of multiple areas of infarction
within the left MCA and ACA distribution, with minimal mass
effect, no new areas of intracranial hemorrhage. No significant
interval change from the prior exam.
Rpt NCHCT [**5-21**]:
There has been interval improvement in the appearance of the
brain since the prior study. The pneumocephalus has resolved,
the mass effect on the frontal [**Doctor Last Name 534**] of the left lateral
ventricle has improved. There has been evolution of the
hypodensities involving the left anterior and middle cerebral
arteries. No new areas of hypodensity are noted. Clips are again
seen in the suprasellar region, unchanged. The metallic hardware
from prior left frontal craniotomy is again seen.
There is slightly more prominence of the extra-axial space along
the right frontal region than that was on prior studies. There
is no high-density material within this area to suggest acute
hemorrhage. No new areas of intra- or extra-axial hemorrhage are
noted. The mastoid air cells and visualized paranasal sinuses
are clear. The subcutaneous emphysema as well as the skin
staples on the left have been removed.
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Evolving hypodensities in the left ACA and MCA territories
consistent with evolving infarctions. Improved mass effect on
the frontal [**Doctor Last Name 534**] of the left lateral ventricle.
3. Slightly more prominent extra-axial space in the right
frontal region than on prior studies.
Bilat LE US5/24/07: No evidence of DVT in the bilateral lower
extremities.
[**5-23**] Video oropharyngeal swallow:
Oral and pharyngeal swallowing video fluoroscopy was performed
in collaboration with the speech and swallowing team. Thin
liquid, nectar-thick liquid, pureed consistency barium were
administered.
The oral phase demonstrates severe oral apraxia during feeding
tasks. Patient was unable to feed herself. There was
moderate-to-severe deficit regarding bolus control and
formation. Oral transit was moderately prolonged and there was
mild-to-moderate diffuse residue on the tongue and in the
anterior and lateral sulci. AP tongue movement was mild to
moderate impaired.
The pharyngeal phase demonstrates mild delay in swallow
initiation with mild vallecular residue of purees. Hyolaryngeal
excursion, laryngeal valve closure, epiglottic deflection,
pharyngeal transit time, bolus propulsion, and
pharyngoesophageal sphincter opening was adequate.
There was mild aspiration of thin liquids. There was delayed
reflexive cough.
IMPRESSION: Severe oral dysphagia with mild pharyngeal
dysphagia. There was mild aspiration of thin liquids during the
study.
Brief Hospital Course:
55 F admitted for elective ACOM aneurysm clipping. The procedure
was performed under general anaesthetic on [**2108-5-10**] and included
placement of 2 clips between L A1-A2. Post operative angiogram
demonstrated optimal positioning of clips and minimal vasospasm
treated with verapamil. The patient was transferred to the ICU
for ongoing care. The patient was extubated on [**2108-5-15**].
Transfer to step-down occurred on [**2108-5-17**].
.
CT head post angiogram demonstrated left basal ganglia, left
frontal infarct (possibly secondary to intraoperative
parenchymal retraction), and posterior left frontal infarct
thought likely secondary to embolic phenomena during angiogram.
.
Seizure prophylaxis was provided with dilantin (goal level
15-20). Please continue to monitor level (11.1 on [**5-25**] and 300mg
extra given).
.
Neurological examination during admission showed gradual
improvement in level of consciousness. The patient was speaking
in occassional words at discharge. There was evidence of partial
L CN III palsy with dilated left pupil, decreased reaction to
light and impaired left eye movements (abduction preserved).
There was persistent right sided weakness (RUE-0/5; RLE [**2-27**] at
toes/ankle). Full power in L limbs.
.
The patient was assessed and therapy provided by OT/PT.
.
Neurosurgery follow up will be with Dr [**Last Name (STitle) **] to be arranged for
4 weeks from discharge.
.
Ischaemic right foot:
Overnight following angiogram the right leg was noted to be
acutely ischaemic. Right femoral and external iliac dissection
was diagnosed on repeat angiogram. Emergent treatment was
provided consisting of thrombectomy of right iliac, common
femoral and
superficial femoral arteries with endarterectomy of the right
common femoral artery and Dacron patch angioplasty. Abdominal
and pelvic angiogram was performed with placement of right
external iliac artery stent, and four compartment right lower
extremity fasciotomies. Post stent deployment angiogram showed
resolution of obstruction and good flow through the stent.
Staples removed on [**2108-5-25**]. Steristrips placed. Allow
steristrips to come of in their own time. [**Month (only) 116**] shower.
.
Partial nephrogenic diabetes insipidus:
The patient was hypernatraemic during ICU admission with maximum
Na of 158. The endocrine team were consulted on [**5-12**]. Etiology
was felt to be most consistent with nephrogenic DI. [**Month/Year (2) **] was
closely monitored and corrected slowly with free water boluses
and desmopressin. Desmospressin was ceased on [**2108-5-18**]. Free
water boluses were continued to maintain [**Date Range **] in normal range.
While npo for PEG free water boluses were discontinued and Na
increased to 157. Free water was restarted at 250ml q4h on [**5-25**]
and endocrine advice further obtained. Dr [**Last Name (STitle) 31624**] (accepting
care at [**First Name9 (NamePattern2) 58991**] [**Hospital1 656**]) was happy to continue management of
[**Hospital1 **].
Hyperglycaemia:
The patient was treated with insulin GTT during ICU stay with
goal of normoglycaemia. This was transitioned to [**Hospital1 **] NPH and
insulin sliding scale on the floor with patient requiring
between 0-10u short acting insulin per day. Final weaning
dexamethasone dose was administered on [**2108-5-21**]. Insulin
requirements were decreasing. The patient has been on insulin
NPH 12u [**Hospital1 **], decreased to 6u [**Hospital1 **] on [**5-23**] and on that day had no
need for additional short acting insulin. During npo for PEG NPH
insulin was held and not restarted as we anticipate she will
likely have decreasing glucose levels and will continue to have
decreasing insulin requirements. Please continue to monitor
sugar levels and treat as needed with sliding scale insulin or
low dose NPH.
.
Leukocytosis: Elevated WCC to max 39 on [**5-11**] was observed post
operatively in association with slow steroid taper and UTI. WCC
decreased gradually following cessation of steroids (15 on d/c).
.
Urinary tract infection: E.coli UTI was treated with
ciprofloxacin for 10 days with final dose on [**2108-5-24**]. Repeat u/a
should be checked to ensure clearance of infection.
.
Nutrition: Nutrition was provided via NGT feeding. Video
swallow evaluation on [**5-23**] showed severe oral dysphagia with
mild pharyngeal dysphagia. There was mild aspiration of thin
liquids. PEG was placed on [**2108-5-24**] and feeds commenced on
[**2108-5-25**] with free water boluses.
Medications on Admission:
Lithium, Elevil, Buspar,
Atenolol, ASA
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Docusate [**Date Range **] 50 mg/5 mL Liquid Sig: [**12-27**] PO BID (2 times a
day).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection every eight (8) hours.
5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. Phenytoin 50 mg Tablet, Chewable Sig: Four (4) Tablet,
Chewable PO BID (2 times a day).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed: To groin intertrigo.
9. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Vaginal HS (at
bedtime) for 7 days.
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
ACA aneurysm
Right femoral and external iliac dissection
Partial nephrogenic diabetes insipidus with hypernatraemia
Hyperglycaemia associated with steroid use
UTI
Discharge Condition:
Stable neurological examination with L partial CN III palsy, and
Rsided weakness.
Discharge Instructions:
You have been treated with craniotomy and clipping of ACA
aneurysm and operation on the blood vessels approached from the
right groin.
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? You may wash your hair after sutures and/or staples have been
removed
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
Please call for neurosurgery appointment in 4 weeks with Dr
[**Last Name (STitle) **] [**Numeric Identifier 70328**]. You will need to have some imaging of the
brain before the appointment. You will be advised of
arrangements for this when you call to book follow up next week.
.
Please have your doctors watch your [**Name5 (PTitle) **] level, blood sugars
(insulin as needed) and dilantin level.
.
|
[
"518.5",
"997.02",
"443.0",
"296.80",
"998.2",
"378.51",
"E879.8",
"599.0",
"753.12",
"437.3",
"997.2",
"588.1",
"444.22",
"403.90",
"V58.65"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.45",
"43.11",
"39.50",
"38.18",
"39.90",
"83.09",
"39.51",
"88.41",
"00.43",
"96.72",
"88.47",
"88.48",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
13000, 13080
|
7495, 11986
|
400, 454
|
13287, 13371
|
2921, 2921
|
14472, 14875
|
1524, 1542
|
12075, 12977
|
13101, 13266
|
12012, 12052
|
13395, 14449
|
2937, 7472
|
1572, 1819
|
280, 362
|
482, 1336
|
2071, 2902
|
1834, 2055
|
1358, 1443
|
1459, 1508
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,765
| 163,965
|
43438
|
Discharge summary
|
report
|
Admission Date: [**2116-8-2**] Discharge Date: [**2116-8-9**]
Date of Birth: [**2057-8-27**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Hepatitis C/HCC here for liver transplant
Major Surgical or Invasive Procedure:
[**2116-8-3**]: Orthotopic Liver transplant
History of Present Illness:
58-year-old male with a history of hepatitis C genotype 1
and hepatocellular carcinoma listed for liver transplant with a
most recent exception MELD score of 29. He had a 2.8 x 0.8 cm
lesion ablated in [**2115-8-31**] and had recently a followup CT
revealing stable radiofrequency ablation site and two tiny
stable
pulmonary nodules which were likely benign.
ROS:
(+) per HPI
(-) Denies pain, fevers chills, night sweats, unexplained weight
loss, fatigue/malaise/lethargy, changes in appetite, trouble
with
sleep, pruritis, jaundice, rashes, bleeding, easy bruising,
headache, dizziness, vertigo, syncope, weakness, paresthesias,
nausea, vomiting, hematemesis, bloating, cramping, melena,
BRBPR,
dysphagia, chest pain, shortness of breath, cough, edema,
urinary
frequency, urgency
Past Medical History:
HCV genotype 1a, hypercholesterolemia,
sleep apnea, mild depression, gout, and kidney stones.
Past Surgical History: Appendectomy at 2 years old. MCCs in the
past with a plate in his left leg along with screws and pins,
and
a screw in his right wrist. He has had surgical treatment for
sleep apnea in the past.
Social History:
Married and has no children. He is retired. He
used to work as a general foreman for the Town of [**Location (un) **]. He
has had no alcohol or drug use for over 24 years. He has a
history of smoking cigars in the past. As noted, he has a
history of IV drug use and marijuana use in the past, but has
not had any use for over 20 years. He does have tattoos and
pierced ears.
Family History:
Mother died of [**Name (NI) 2481**] and his father who died of an MI.
He has two brothers, one of whom has a brain aneurysm and
hepatitis C.
Physical Exam:
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
DRE: normal tone, no gross or occult blood
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
On Admission: [**2116-8-3**]
WBC-1.2*# RBC-3.23* Hgb-11.1* Hct-32.4* MCV-100* MCH-34.4*
MCHC-34.3 RDW-15.9* Plt Ct-28*
PT-13.6* PTT-24.6* INR(PT)-1.3*
Glucose-98 UreaN-9 Creat-0.6 Na-137 K-3.8 Cl-108 HCO3-21*
AnGap-12
ALT-53* AST-92* AlkPhos-165* TotBili-1.0
Albumin-3.1* Calcium-7.9* Phos-2.7 Mg-1.9
HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE IgM HBc-NEGATIVE
HIV Ab-NEGATIVE
Brief Hospital Course:
58 y/o male with Hepatitis C on Pegasys and Ribavirin and HCC
s/p RFA admitted from home for liver transplant. The donor was a
22 year old who died of a drug overdose and was considered CDC
high-risk for this behavior. The donor's NAT serologies for HIV,
hepatitis C and hepatitis B were all negative. After counseling,
the patient accepted the liver, and he was taken to the OR with
Dr. [**First Name4 (NamePattern1) 3742**] [**Last Name (NamePattern1) **] for Deceased donor liver transplant-piggyback,
portal vein to portal vein, proper hepatic artery to right
hepatic artery, common hepatic duct to common hepatic duct.
Please see both back table preparation note and Surgical note
for operative detail.
The patient received routine induction immunosuppression to
include 500 mg solumedrol, 1 gram cellcept. In the post
operative period, Prograf was started on the evening of POD 1,
solumedrol taper per protocol was followed and cellcept 1 gram
[**Hospital1 **] was administered with good tolerance. The patient was
extubated on POD 1 and transferred to the regular surgical floor
later in the day on POD 1. Diet was advanced and tolerated. He
was moving his bowels. Pain was initially controlled with IV
dilaudid. This was changed to po dilaudid once diet was
tolerated. On POD#4 his lateral JP surgical drain was removed.
Mr. [**Known lastname **] did remarkably well during his post-operative
recovery. By POD#5 he was tolerating a regular diet and moving
his bowels regularly, had adequate pain control with PO
Dilaudid, and was restarted on his home medications as was
appropriate. He demonstrated good understanding of his
immunosuppression medication regimen, and performed well with a
self-medication program. Prior to discharge, he was seen by
physical therapy who cleared him for safe discharge to home
without need for rehabilitiation services. He was discharged
home with a plan to be seen in clinic on [**2116-8-13**].
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient and webOMR.
1. Filgrastim 300 mcg SC QTUES
2. Fluoxetine 40 mg PO DAILY
3. Omeprazole 20 mg PO BID
4. Peginterferon Alfa-2a 180 mcg SC 1X/WEEK (MO)
5. Promethazine 12.5 mg PO BID:PRN nausea
6. Ribavirin 600 mg PO BID
7. Tamsulosin 0.4 mg PO HS
8. traZODONE 50 mg PO HS:PRN insomnia
Discharge Medications:
1. Fluoxetine 40 mg PO DAILY
2. Tamsulosin 0.4 mg PO HS
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth [**Hospital1 **] PRN Disp
#*60 Capsule Refills:*2
4. Fluconazole 400 mg PO Q24H
5. Mycophenolate Mofetil 1000 mg PO BID
6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
7. ValGANCIclovir 900 mg PO Q24H
8. Pantoprazole 40 mg PO DAILY
RX *pantoprazole 40 mg 1 tablet(s) by mouth qdaily Disp #*60
Tablet Refills:*2
9. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg [**12-2**] tablet(s) by mouth q3-6
hours PRN Disp #*80 Tablet Refills:*0
10. Tacrolimus 5 mg PO Q12H
[**2116-8-8**] PM - 5 mg
[**2116-8-9**] AM - 5 mg
11. Metoprolol Tartrate 25 mg PO BID
Hold for SBP < 120 or HR < 60
Discharge Disposition:
Home
Discharge Diagnosis:
hepatocellular carcinoma and hepatitis C now status-post liver
transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever >
101, chills, nausea, vomiting diarrhea, constipation, increased
abdominal pain, pain not controlled with medication, inability
to tolerate food, fluids or medications, dizziness, weakness,
yellowing of skin or eyes or other concerning symptoms.
Please have your labs drawn every Monday and Thursday with
results to the transplant clinic at [**Telephone/Fax (1) 697**].
No lifting greater than 10 pounds
No driving if taking narcotic pain medication
You may shower, no tub baths or swimming until advised by the
surgeon you may do so. Pat the incision dry, inspect for
redness, drainage or bleeding, and leave open to the air. The
staples will be removed at about 3 weeks after transplant.
Followup Instructions:
Department: TRANSPLANT CENTER
When: THURSDAY [**2116-8-13**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14955**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: NUCLEAR MEDICINE
When: MONDAY [**2116-8-17**] at 10:15 AM
With: NUCLEAR MEDICINE WEST [**Telephone/Fax (1) 2103**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: RADIOLOGY
When: MONDAY [**2116-8-17**] at 11:45 AM
With: CAT SCAN [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
|
[
"311",
"274.9",
"070.54",
"530.81",
"327.23",
"600.00",
"155.0",
"272.4",
"V13.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.93",
"50.59"
] |
icd9pcs
|
[
[
[]
]
] |
5988, 5994
|
2846, 4786
|
342, 387
|
6112, 6112
|
2443, 2443
|
7054, 8010
|
1949, 2092
|
5215, 5965
|
6015, 6091
|
4812, 5192
|
6262, 7031
|
1340, 1536
|
2107, 2424
|
261, 304
|
415, 1200
|
2457, 2823
|
6127, 6238
|
1222, 1317
|
1552, 1933
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,672
| 116,233
|
38974
|
Discharge summary
|
report
|
Admission Date: [**2179-2-12**] Discharge Date: [**2179-2-17**]
Date of Birth: [**2101-5-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 1257**]
Chief Complaint:
Bright red blood per rectum, NSTEMI.
Major Surgical or Invasive Procedure:
Colonoscopy.
History of Present Illness:
77 yo M with h/o HTN, HL, multiple falls transferred from [**Hospital1 3325**] with NSTEMI in setting of anemia.
Pt is poor historian but reports several hours of gross blood
per rectum several days ago that resolved spontaneously. He
described this similar to prior episodes thought to be
hemorrhoidal, but lasting longer. He denied SOB, CP,
lightheadedness at that point but later, while walking to get
the mail, felt weak, dizzy, dyspneic, nauseated. He also had a
fall, which he describes as mechanical, but does not remember
any surrounding symptoms other than vomiting (bilious
nonbloody). Pt was unable to get up for many hours. Pt did have
residual left shoulder pain, and describes dislocation. He did
not get evaluated until the following day as he takes care of
his wife with [**Name (NI) 11964**] who was having a difficult day
yesterday.
In the OSH [**Name (NI) **] pt was found to have troponin of 9.8, CK 692, Hct
22. Pt was hypertensive to 190s/90s. He received ASA, Plavix,
metoprolol and was transferred to [**Hospital1 18**]. In our ED, BP 180/90,
trop 1.4, CK 600, MB 13, Hct 22 from unknown baseline and very
positive guaiac stools. BP was treated with nitro drip, pt
transfused 2U pRBCs, imaging all without abnormalities (CT
torso, CXR, shoulder x-ray). EKG here has LVH w/ ST depressions
that are 3 mm in V5-V6 and possibly some in I and aVL.
ROS: Denied chest pain. No SOB although breathing was not at
baseline. No lightheadedness, dizziness, headaches, abd pain.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
3. OTHER PAST MEDICAL HISTORY:
Unknown
Social History:
Lives with wife who has [**Name (NI) 2481**] in [**Location (un) 39908**]. Never had any
children.
-Tobacco history: Former, quit 40yrs ago
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: T=...BP=180/87 HR=78 RR=14 O2 sat= 100% RA
GENERAL: WDWN male in NAD. Oriented x3, mediocre historian.
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 without JVD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. Systolic murmur at apex and diastolic
decrescendo murmur at left USB.
LUNGS: Ecchymosis on left chest. Resp were unlabored, no
accessory muscle use. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. 1+ pulses
Pertinent Results:
Labs at Admission:
[**2179-2-12**] 08:30PM BLOOD WBC-14.2* RBC-2.43* Hgb-7.9* Hct-22.1*
MCV-94 MCH-32.6* MCHC-34.8 RDW-16.7* Plt Ct-415
[**2179-2-12**] 08:30PM BLOOD PT-13.7* PTT-24.0 INR(PT)-1.2*
[**2179-2-12**] 08:30PM BLOOD Glucose-83 UreaN-40* Creat-1.0 Na-141
K-3.8 Cl-105 HCO3-26 AnGap-14
[**2179-2-12**] 08:30PM BLOOD CK-MB-13* MB Indx-2.2
[**2179-2-12**] 08:30PM BLOOD Calcium-8.5 Phos-3.1 Mg-2.3
[**2179-2-15**] 05:11AM BLOOD calTIBC-278 Ferritn-275 TRF-214
Labs at Discharge:
[**2179-2-17**] 05:20AM BLOOD WBC-13.4* RBC-3.23* Hgb-10.2* Hct-29.4*
MCV-91 MCH-31.4 MCHC-34.6 RDW-16.8* Plt Ct-336
[**2179-2-17**] 05:20AM BLOOD Glucose-113* UreaN-19 Creat-0.8 Na-139
K-4.3 Cl-101 HCO3-33* AnGap-9
Cardiac Enzymes:
[**2179-2-12**] 08:30PM BLOOD CK-MB-13* MB Indx-2.2
[**2179-2-12**] 08:30PM BLOOD cTropnT-1.38*
[**2179-2-13**] 04:31AM BLOOD CK-MB-11* MB Indx-2.3 cTropnT-1.55*
Imaging Studies:
CT CAP ([**2179-2-12**]):
1. Several osseous fragments in left shoulder joint, which is
also distended with fluid. While no overt or displaced fracture
is seen, if there is recent trauma with resulting pain to the
left shoulder, MRI may be considered for assessment for occult
fracture. Age-indeterminate anterior/superior subluxation of the
left glenohumeral joint, likely related to chronic rotator cuff
injury.
2. Extensive atherosclerotic disease involving the entire aorta
and its major branches, and the coronary arteries.
CT Head ([**2179-2-12**]):
1. No acute intracranial process.
2. Marked left maxillary sinus mucosal thickening.
TTE ([**2179-2-15**]):
The left atrium is mildly dilated. A left-to-right flow is seen
on color Doppler across the interatrial septum c/w a small
secundum atrial septal defect. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate global left ventricular hypokinesis (LVEF = 40 %).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
is normal with mild global free wall hypokinesis. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
mild global hypokinesis suggestive of a diffuse process (toxin,
metabolic, etc. - cannot exclude multivessel CAD if clinically
suggested). Moderate pulmonary artery systolic hypertension.
Increased PCWP. Small secundum atrial septal defect.
Brief Hospital Course:
77 year old man with history of HTN, HL, multiple falls who
presented with lightheadedness, found to be anemic, hypertensive
and have had an NSTEMI.
# Type II MI (Demand Ischemia):
Known troponin leak to 9 at OSH, trending down. EKG with ST
depressions laterally unclear if related to hypertrophy or
laterally distributed ischemia. This was thought to be largely
due to his high amount of blood loss from his GI bleed. He was
started on heparin gtt for initial presumption of NSTEMI;
heparin gtt was discontinued the next morning. He was initially
started on aspirin, plavix and statin. He was transfused a total
of 4 units of PRBCs for his anemia. Plavix was stopped and
aspirin decreased to 81 mg daily. TTE showed global LV
hypokinesis. There was no cardiac intervention during this
admission. His medicines have been changed to include baby
aspirin, beta-blocker, and ace-inhibitor. He can continue on
hydrochlorothiazide for blood pressure control and statin for
cholesterol control. Amlodipine has been added to his blood
pressure regimen; this could be discontinued or weaned down if
he has better blood pressure control after discharge. He has
follow-up scheduled in cardiology clinic.
# Anemia:
The patient had an aggressive bleed (brbpr) several days prior
to admission. He was transfused 4 units, started on IV
famotidine, which was then changed to omeprazole [**Hospital1 **] and was
then colonoscoped on [**2179-2-15**]. During the prep the patient had a
large amount of maroon blood. The colonoscopy showed blood
throughout the entire length of the patient's colon, with
significant sigmoid diverticulosis. The cecum was entered and
there was no evidence of blood that would signify an upper GI
bleed. His hematocrit was 30.1 on [**2179-2-16**] and remained stable
until discharge. He has follow-up scheduled in [**Hospital **] clinic. He can
continue ranitidine as outpatient should he have any reflux-type
symptoms; the omeprazole has been discontinued at time of
discharge.
# Leukocytosis:
14, trended down. Afebrile, no localizing symptoms. UA negative,
CXR negative. Likely stress reaction.
# Hypertension:
180s/90s on presentation. He was started initially on
nitroglycerin drip in ED for blood pressure control because
medications were unknown. He was then given labetalol overnight
to help with BP control and to wean nitro drip. After calling
[**Location (un) 535**] in [**Location (un) 18825**], Mass, patient's home medications were
restarted for BP and nitro drip was turned off; started on
Imdur, Lisinopril, HCTZ. His home dose verapamil was switched to
carvedilol. He continued to be hypertensive, and was started on
amlodipine on [**2179-2-16**].
# Failure to thrive:
The patient and wife live alone together, although his wife has
advanced [**Name (NI) 2481**] and was found wandering by the neighbors.
Since then she has been admitted to the dementia unit at [**Hospital1 **]. The patient himself has reported to have had multiple
falls at home, and per the HCP the home was in a shambles after
his admission. Social work was involved in speaking with the
healthcare proxy [**Name (NI) **] [**Name (NI) **] ([**Telephone/Fax (1) 86456**] to try and either
provide home services or place both Mr. [**Known lastname 86457**] and his wife in
a long-term [**Hospital3 **] facility.
Medications on Admission:
Verapamil 240 mg [**Hospital1 **]
Isosorbide mononitrate 60 mg qday
Hydrochlorothiazide 25 mg qday
Lipitor 20 mg qday
Flomax 0.4 mg qhs
Discharge Medications:
1. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
2. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for reflux.
Disp:*30 Tablet(s)* Refills:*2*
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] Healthcare
Discharge Diagnosis:
Primary:
Elevated troponin
GI bleed
Diverticulosis
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 [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]
because you had stress on your heart. This was due to your
severe gastrointestinal bleed, which caused your heart to not
receive enough blood to function. You received several blood
transfusions to help improve your blood counts. You have been
scheduled to follow up with your cardiologist Dr. [**Last Name (STitle) **] at
the date and time below.
During your admission, you also had a colonoscopy. This showed
that you had severe diverticulosis, or outpouchings in your
colon. This is the most likely cause of your gastrointestinal
bleeding. You have been scheduled with a follow-up appointment
with the gastroenterologists.
Finally, you fell once during your admission while trying to
pick up your remote control. You had a CT scan of your head
which showed no bleeding in the brain. However, we were
concerned that you have also been falling at home and have been
having difficulty taking care of yourself and your wife while
there. You were evaluated by our physical therapists who
determined that you would benefit from going to rehab.
You have been started on several new medications while here:
-Amlodipine 10mg daily, which helps control your blood pressure.
-Lisinopril 40 mg, for blood pressure control
-Aspirin 81 mg, for prevention of heart attack and stroke
-Ranitidine 150 mg as needed, for stomach discomfort
-Carvedilol 25 mg twice daily, for blood pressure control
-Isosorbide Mononitrate 60 mg, for blood pressure control
-Verapramil was stopped during this admission
Followup Instructions:
You have a follow-up appointment with your cardiologist, Dr.
[**Last Name (STitle) **] ([**Telephone/Fax (1) 73315**] on [**3-5**] at 9:30.
Also, you have a follow up appointment with the
gastroenterologists here at [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **]:
[**2179-3-3**] 03:30p [**Name6 (MD) **] [**Name8 (MD) **], MD
RA [**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **]
([**Telephone/Fax (1) 2233**]
Completed by:[**2179-2-17**]
|
[
"783.7",
"401.9",
"E884.2",
"410.71",
"285.1",
"562.12",
"E849.7",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
9991, 10047
|
5644, 8962
|
351, 365
|
10142, 10142
|
3044, 3513
|
12011, 12577
|
2196, 2311
|
9148, 9968
|
10068, 10121
|
8988, 9125
|
10319, 11988
|
2326, 3025
|
1982, 1982
|
3768, 3931
|
275, 313
|
3533, 3750
|
393, 1888
|
10156, 10295
|
2013, 2022
|
1910, 1962
|
2038, 2180
|
3949, 5621
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,327
| 159,082
|
10640
|
Discharge summary
|
report
|
Admission Date: [**2107-8-17**] Discharge Date: [**2107-8-27**]
Date of Birth: [**2070-4-23**] Sex: F
Service: TRAUMA
HISTORY OF PRESENT ILLNESS: This is a 36-year-old female who
sustained a motor vehicle accident. The patient was a
passenger in the car. She had positive loss of consciousness
after the car struck a tree at approximately 35 miles per
hour. On arrival, the patient had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] coma scale of
15. Her vital signs were stable in the field and she was
alert and oriented times three. She is complaining of left
shoulder pain and knee pain.
PAST MEDICAL HISTORY: Asthma.
PAST SURGICAL HISTORY: Cholecystectomy.
ALLERGIES: Codeine and erythromycin.
MEDICATIONS: Asthma inhalers.
PHYSICAL EXAMINATION: The patient has a temperature of
101.8. Heart rate 87. Blood pressure 125/65. Saturation
was 99% on ten liters of oxygen. Respiratory rate 21.
General: She was alert and oriented times three. There was
no distress. Pupils were equally round and reactive to
light. Tympanic membranes were clear bilaterally. Chest was
without obvious deformity. She was tender on the left lower
chest. Lungs were clear to auscultation bilaterally. Heart
is a regular rate and rhythm without murmur. Abdomen was
tender in the right upper quadrant greater than the left
upper quadrant. She had positive guarding and left flank
abrasions without laceration. Extremities had palpable
pulses and were warm and dry. There was no tenderness on
exam. Back was normal without step-off or deformity except
for the left flank abrasions. The rectal was with normal
sphincter tone and no gross blood. She was guaiac negative.
LABORATORY STUDIES: White blood cell count of 15.5,
hematocrit 33.1, platelets 242,000. Sodium 140, potassium
3.4, chloride 105, CO2 24, BUN 12, creatinine 0.9, glucose
106. Toxicology screen was negative. Beta HCG was negative.
A C spine film showed asymmetry of the lateral masses of the
dens with unknown clinical significance. A CT of the head
was normal. CT scan of the abdomen and pelvis showed a Grade
3 splenic laceration and a posterior rib fracture found on
the 9th, 11th and 12th ribs. There was also radiopaque
foreign body seen near the fractured 12th rib. A retrograde
cystourethrogram and CT scan were also obtained which showed
extravasation of urine by a renal parenychmal injury.
HOSPITAL COURSE: Patient was, therefore, brought to the
Operating Room for exploratory laparotomy. During that
operation, a small amount of blood in the splenic bed was
seen. There was no blood in the spleen capsule itself. The
bowel was run and there were no injuries seen. The left
retroperitoneum reveals no urinoma. Urology was consulted
intraoperatively who agreed with the management. The wound
was then closed and the patient was admitted to the Surgical
Intensive Care Unit. The patient did well in the Intensive
Care Unit. She had her pain controlled by the Acute Pain
Service. She was on Levaquin. She was given vaccines for
bacterial infections normally cleared by the spleen. The
patient was transferred to the hospital floor on [**2107-8-20**].
By hospital day number five, the patient was doing well. Her
pain was well-controlled and got out of bed without
difficulty. Her epidural catheter for pain control was
removed. On [**2107-8-21**], the patient had some left
substernal chest pain. Her electrocardiogram was normal and
a chest x-ray showed a dilated gastric bubble. A STAT
hematocrit was 26.2. The patient had a nasogastric tube
placed without complication. The patient was left on bowel
arrest and TPN was started for nutrition. By hospital day
number five, the patient was doing much better. She was able
to tolerate a diet and TPN was discontinued. On [**2107-8-26**], the patient had a follow-up ultrasound of her kidney
which showed no fluid collection. A repeat urinalysis showed
0-3 red blood cells. The Foley catheter was removed and the
patient will follow up with Urology as an outpatient.
By hospital day number 11, the patient was doing much better.
She was tolerating a normal diet. She was ambulating without
difficulty. Her vital signs are stable and she was afebrile.
She was discharged to home with Trauma Clinic follow-up.
DISCHARGE CONDITION: The patient was discharged in improved
condition.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES:
1. Grade 3 splenic laceration.
2. Motor vehicle accident.
3. Renal contusion.
4. Rib fractures of the 9th, 11th and 12th ribs.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], MD [**MD Number(1) 3599**]
Dictated By:[**Last Name (NamePattern1) 3600**]
MEDQUIST36
D: [**2107-11-17**] 18:57
T: [**2107-11-17**] 18:57
JOB#: [**Job Number 34925**]
|
[
"867.2",
"807.03",
"560.1",
"865.09",
"780.09",
"E816.1",
"511.9",
"868.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"58.41",
"99.15",
"54.19"
] |
icd9pcs
|
[
[
[]
]
] |
4341, 4421
|
4442, 4852
|
2445, 4319
|
692, 781
|
804, 2427
|
164, 636
|
659, 668
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,098
| 173,403
|
34256
|
Discharge summary
|
report
|
Admission Date: [**2106-3-31**] Discharge Date: [**2106-4-5**]
Date of Birth: [**2030-11-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Amoxicillin / Shellfish Derived
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional shortness of breath
Major Surgical or Invasive Procedure:
[**2106-3-31**] Aortic Valve Replacement(21mm [**Doctor Last Name **] Pericardial Valve)
History of Present Illness:
Mrs. [**Known lastname **] is a 75 year old female with known aortic stenosis
for the last several years. Serial echocardiograms have shown
progressive aortic stenosis. Over the last several months, she
has admitted to worsening exertional shortness of breath. She
has no history of syncope or CHF. In preperation for upcoming
aortic valve replacement, she underwent cardiac cathterization
which revealed single vessel coronary artery disease - 70%
lesion in the mid circumflex. Her coronary arteries were
otherwise normal. Her LVEF on ECHO is 60%. Preoperative carotid
ultrasound found no significant disease.
Past Medical History:
Aortic Stenosis
Coronary Artery Disease
History of GI Bleed(AV Malformation)- s/p Cauterization [**1-1**]
Hyperlipidemia
Gastritis, Hiatal Hernia
Urinary Incontinence
Diverticular Disease
Wrist Fracture Repair
Eye Surgery as Child
Social History:
40 pack year history of tobacco, quit 11 years ago. Admits to
only social ETOH. Married, and lives with her husband. [**Name (NI) **]
works part time at deli counter.
Family History:
Denies premature coronary artery disease.
Physical Exam:
Vitals: 138/63, 60, 16, 98%RA
General: WDWN obese female in no acute distress
HEENT: Oropharynx benign, EOMI, full dentures
Neck: Supple, no JVD
Lungs: CTA bilaterally
Heart: Regular rate and rhythm, normal s1s2, 4/6 SEM > carotids
Abdomen: Soft, nontender with normoactive bowel sounds
Ext: Warm, 1+ edema bilaterally
Pulses: 2+ distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted
Pertinent Results:
[**2106-3-31**] Intraop TEE:
PRE-BYPASS:
The left atrium is elongated. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The ascending aorta is mildly dilated. There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets are severely thickened/deformed. There is severe
aortic valve stenosis (area <0.8cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. The mitral valve leaflets are moderately thickened.
Mild (1+) mitral regurgitation is seen. The leaflets ratio is
close 1-1.5 and the c-[**Month (only) **] distance 1.6cm c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
predisposition.
Post_BYPASS:
Normal Right ventricular sytolic function. Overall LVEF 50-55%.
There is a bioprosthesis in the native aortic position, seated
well and functioning well with a peak and a mean gradient of 20
and 15 respectively.
[**2106-4-4**] 09:14PM BLOOD WBC-9.1 RBC-2.68* Hgb-7.6* Hct-23.6*
MCV-88 MCH-28.6 MCHC-32.4 RDW-14.9 Plt Ct-178
[**2106-4-5**] 05:20AM BLOOD WBC-8.8 RBC-2.98* Hgb-8.1* Hct-26.2*
MCV-88 MCH-27.3 MCHC-31.0 RDW-14.7 Plt Ct-197
[**2106-4-4**] 09:14PM BLOOD Glucose-95 UreaN-19 Creat-0.7 Na-135
K-4.5 Cl-99 HCO3-29 AnGap-12
[**2106-4-5**] 05:20AM BLOOD Glucose-92 UreaN-20 Creat-0.7 Na-136
K-5.3* Cl-101 HCO3-28 AnGap-12
[**2106-4-5**] 05:20AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.2
Brief Hospital Course:
Mrs. [**Known firstname **] was admitted and underwent aortic valve replacement
by Dr. [**Last Name (STitle) **]. For surgical details, please see seperate
dictated operative note. Following the operation, he was brought
to the CVICU for invasive monitoring. Within 24 hours, she awoke
neurologically intact and was extubated without incident. She
maintained stable hemodynamics and transferred to the SDU on
postoperative day two. On postoperative day three, she
experienced bouts of atrial fibrillation. Amiodarone therapy was
initiated with success back into a normal sinus rhythm. For the
remainder of her hospital stay, she remained in a normal sinus
rhythm. Beta blockade was advanced as tolerated. She required a
short course of antibiotics for a right arm cellulitis. Her
hospital course was otherwise uneventul. She continued to make
clinical improvements with diuresis and was medically cleared
for discharge to rehab on postoperative day five.
Medications on Admission:
Simvastatin 40 qd, MV, Prilosec 20 qod, Vesicare 1 qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days: Titrate accordingly, may need adjustment.
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days: Please stop when Lasix discontinued.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Aortic Stenosis - s/p AVR
Postoperative Atrial Fibrillation
Right Arm Cellulitis
Coronary Artery Disease
History of GI Bleed(AV Malformation)
Hyperlipidemia
Gastritis, Hiatal Hernia
Urinary Incontinence
Discharge Condition:
Good
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**2-27**] weeks, call for appt
Dr. [**Last Name (STitle) **] in [**12-27**] weeks, call for appt
Dr. [**Last Name (STitle) 17025**] in [**12-27**] weeks, call for appt
Completed by:[**2106-4-5**]
|
[
"999.2",
"451.84",
"682.3",
"424.1",
"562.10",
"414.01",
"999.39",
"272.4",
"427.31",
"E878.8",
"E879.8",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5831, 5898
|
3584, 4541
|
328, 419
|
6145, 6152
|
2007, 3561
|
6487, 6719
|
1514, 1557
|
4645, 5808
|
5919, 6124
|
4567, 4622
|
6176, 6464
|
1572, 1988
|
258, 290
|
447, 1059
|
1081, 1314
|
1330, 1498
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,251
| 165,287
|
15592+15593
|
Discharge summary
|
report+report
|
Admission Date: [**2154-11-15**] Discharge Date: [**2154-11-20**]
Date of Birth: [**2090-3-4**] Sex: M
Service:
ADDENDUM: Please add date of admission [**2154-11-15**] and date of
discharge [**2154-11-20**] to the previously dictated discharge
summary.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 10146**]
Dictated By:[**Last Name (NamePattern1) 43593**]
MEDQUIST36
D: [**2154-11-22**] 13:17
T: [**2154-11-22**] 13:34
JOB#:
Admission Date: [**2154-11-15**] Discharge Date: [**2154-11-22**]
Date of Birth: [**2090-3-4**] Sex: M
Service: [**Hospital1 **]/MEDICAL INTENSIVE CARE UNIT
CHIEF COMPLAINT: Lethargy.
HISTORY OF PRESENT ILLNESS: This is a 64 year-old Vietnamese
male with a history of anoxic brain injury from a V
fibrillation arrest that occurred five years prior and
diabetes mellitus brought by ambulance after family noticed
increases in lethargy, decrease in po intake and increasing
generalized weakness over the past one week. The patient was
also noted to have some urinary incontinence times two to
three days. The family denied nausea, vomiting, cough,
diarrhea, new rash, fevers or chills. The patient is very
difficulty to communicate with at baseline.
PAST MEDICAL HISTORY: 1. Anoxic brain injury five years ago
secondary to a V fibrillation arrest secondary to myocardial
infarction. 2. Diabetes mellitus.
MEDICATIONS: Klonopin 1 mg po b.i.d., Avandia the dose is
unknown apparent the patient's primary care physician [**Last Name (NamePattern4) **].
[**Last Name (STitle) 10145**] prescribed Avandia some time ago and it was
discontinued by the family for an unknown reason.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient with his family and is cared for
by his wife and sons.
REVIEW OF SYSTEMS: Please see history of present illness.
EMERGENCY DEPARTMENT COURSE: In the Emergency Department the
patient's finger stick blood glucose was 900. It was
measured at 624 in the serum. The patient's sodium was 173
corrected for hyperglycemia his sodium was 181. The patient
was minimally responsive with a temperature of 101.2. Workup
for the source of infection and mental status changes
resulted in the negative head CT, negative lumbar puncture,
negative urinalysis, negative chest x-ray. The patient was
given Ceftriaxone and 8 units of regular insulin in the
Emergency Room as well as hydrated.
PHYSICAL EXAMINATION: Temperature 101.8. Blood pressure
121/62. Respirations 24. Pulse ox 98% on room air.
General, the patient is somnolent, but opens eyes to sternal
rub. HEENT mucous membranes dry. No icterus. No pallor.
Supple neck. No bruits. Cardiovascular regular rate and
rhythm. No murmurs, rubs or gallops. No jugulovenous
distention. No peripheral edema. Pulmonary lungs clear to
auscultation. Abdomen soft, nontender, nondistended. No
palpable masses. Extremities warm, dry, 2+ dorsalis pedis
pulses, symmetric.
LABORATORIES ON ADMISSION: Sodium 172 corrected sodium 181,
potassium 3.4, chloride 130, bicarb 29, BUN 38, creatinine
2.2. The patient's baseline creatinine is apparently 1.0.
Serum blood glucose 624. Blood gas revealed pH of 7.34, PCO2
56 and PO2 of 85. Creatine kinase was 18, 100, 69, small
amount of acetone noted in the serum. Electrocardiogram
demonstrated normal sinus rhythm at 105 beats per minute,
normal axis.
HOSPITAL COURSE: 1. Diabetes mellitus: The patient
presented in nonketonic hyperosmolar coma, which resolved
with hydration with one quarter normal saline, because of the
hypernatremia and insulin drip. The patient was subsequently
switched to a regular insulin sliding scale, which was
subsequently advanced to Avandia 4 mg po q day and NPH 20
units q.a.m. with regular insulin sliding scale coverage.
Prior to being switched to the NPH and Avandia the patient
had several blood sugars in the 400s.
2. Hypernatremia: As stated above the patient's corrected
sodium on presentation was 181. His fluid deficit was found
to be 11 liters. His sodium was corrected at a rate of
approximately 1 milliequivalent an hour with hydration with
one quarter normal saline. The patient's sodium resolved to
normal levels within three days. After stopping intravenous
fluid after transfer to the floor the patient was found to
have a slowly rising sodium again. Renal Service who was
following the patient expressed concerned that this may be
due to diabetes insipidus as opposed to polyuria secondary to
ATN. Please see hospital course for acute renal failure
below. At the request of the Renal Service the patient's
intravenous fluids were stopped and urine and serum
osmolalities and sodiums were drawn at 0, 2 and 4 hours. The
results of this test appeared that the patient was able to
concentrate his urine and thus his polyuria and slowly
elevating hypernatremia with no supplemental fluids was
attributed to resolving polyuria from resolving ATN.
3. Acute renal failure: The patient's creatinine at the
time of admission was 1.8. His baseline is reportedly 1.0
per his primary care physician. [**Name10 (NameIs) **] creatinine subsequently
peaked in the MICU to 2.6 and resolved down to 20 after
transfer to the floor. Muddy brown casts were found on
examination of the urine and fractional excretion of sodium
was 6% both consistent with ATN. The patient's polyuria
gradually decreased after transfer to the floor with his
urine output down to roughly 2 liters on the day of
discharge. The acute renal failure was attributed to both a
prerenal state secondary to hyperglycemia and subsequent
diuresis and also to rhabdomyolysis. The patient's CK was
about [**2152**] on presentation, peaked at 11,000 and resolved
after transfer to the floor. It is unclear if his
rhabdomyolysis is as a result of his metabolic disarray or if
the patient's seized from having such an elevated sodium.
4. Fevers: The fever workup initiated in the Emergency Room
(please see Emergency Room course above) was done in addition
to pan culture. All results were negative and the patient
eventually quit spiking a fever and remained afebrile
throughout the rest of his hospitalization. Thought was
given to his fevers being a result of his metabolic disorder
in combination with his anoxic brain injury.
5. Neurological status: After treatment with hydration and
insulin drip for hypernatremia, hyperglycemia the patient's
mental status improved to baseline per his family.
DISCHARGE STATUS: The patient is stable for discharge to
either an extended care facility or to home with visiting
nurse. After discussion with the family it was decided that
the patient would not be appropriately cared for at home and
that he would be placed in an extended care facility. The
patient is currently on Avandia 4 mg po q day and 20 of NPH
insulin q.a.m. with a regular insulin sliding scale and has
achieved reasonable glucose control, but this will likely
need better titration as an outpatient and can be guided by
his primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10145**]. It is also
recommended that the patient have his BUN, creatinine and
sodium checked at least every other day for the first week of
his stay at this facility.
DISCHARGE MEDICATIONS: 1. Klonopin 1 mg po b.i.d. 2.
Insulin NPH 20 units subQ q.a.m. 3. Avandia 4 mg po q day.
4. Regular insulin sliding scale. 5. Metoprolol 50 mg po
b.i.d. 6. Protonix 40 mg po q day. 7. Tylenol 325 to 650
mg po q 4 to 6 hours prn.
DISCHARGE DIAGNOSES:
1. Nonketotic hyperosmolar coma.
2. Hypernatremia.
3. Acute renal failure secondary to prerenal causes and
rhabdomyolysis.
4. Acute tubular necrosis.
5. Rhabdomyolysis.
6. Anoxic brain injury secondary to V fibrillation arrest
secondary to myocardial infarction five years ago.
7. Anxiety.
8. Diabetes mellitus.
The patient may also benefit from long term physical therapy.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 10146**]
Dictated By:[**Last Name (NamePattern1) 43593**]
MEDQUIST36
D: [**2154-11-22**] 13:16
T: [**2154-11-22**] 13:36
JOB#: [**Job Number 45085**]
|
[
"348.3",
"276.2",
"276.0",
"728.89",
"250.20",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
7605, 8268
|
7343, 7584
|
3473, 7319
|
2509, 3040
|
1880, 2486
|
725, 736
|
765, 1305
|
3055, 3455
|
1328, 1775
|
1792, 1860
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,930
| 176,910
|
34982
|
Discharge summary
|
report
|
Admission Date: [**2125-9-27**] Discharge Date: [**2125-10-9**]
Date of Birth: [**2054-8-29**] Sex: F
Service: OTOLARYNGOLOGY
Allergies:
Lactose
Attending:[**First Name3 (LF) 7729**]
Chief Complaint:
Squamous Cell Carcinoma Left Pyriform Sinus
Major Surgical or Invasive Procedure:
1. Laryngoscopy.
2. Total laryngectomy and partial pharyngectomy.
3. Tracheoesophageal puncture.
4. Right modified radical neck dissection.
History of Present Illness:
The patient is a 71-year-old female with 2 prior known squamous
cell carcinomas involving the head and neck. The first was in
[**2121**]. This was a T3 N2B M0 squamous cell carcinoma of the left
tonsil which was treated with concomitant chemotherapy and
radiation. She did well until recently. In [**Month (only) 216**] of this year,
she was found to have a microinvasive squamous cell carcinoma
staged as T1 N0 M0 which was completely resected from the floor
of mouth. Several weeks after the surgery, she began to develop
odynophagia and clinically was found to have a tumor involving
the medial wall of the left piriform sinus. She underwent an
endoscopy and biopsy which revealed a poorly-differentiated
carcinoma. Given her prior radiation therapy and the
unwillingness of the radiation oncologist to give her primary
definitive radiation as the treatment, the only option was for a
total laryngectomy and partial pharyngectomy.
Past Medical History:
GERD
osteoporosis
tonsil cancer T3N2 treated [**2121**] - tonsilectomy and neck
dissection.
Social History:
Denies current EtOH or smoking
Family History:
Non-contributory
Physical Exam:
At the time of discharge:
VS: Afebrile, VSS
Constitutional: No acute distress, speaking with electrolarynx,
visible stoma.
Neck: Flat - staple lines c/d/i, no erythema or induration.
Stoma with red-rubber catheter at TEP site. Mild crusting around
suture line, moist.
CV: RRR, no murmurs
Resp: CTAB, no wheezes or crackles
Abd: Soft, nondistended, +BS
Ext: Warm, distal pulses palpable bilaterally
Skin: Face, neck and chest is normal
Musculoskeletal: Walking without assistance, normal to gait and
station
Spine, Pelvis and Extremities: Stable
Psychiatric: Normal to judgment, insight, memory, mood and
affect
Pertinent Results:
MICROBIOLOGY
[**2125-10-5**] 8:38 am SWAB Source: left stoma site.
GRAM STAIN (Final [**2125-10-5**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Preliminary):
STAPH AUREUS COAG +. MODERATE GROWTH.
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.
ENTEROCOCCUS SP.. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
MRSA SCREEN (Final [**2125-9-30**]): No MRSA isolated.
BARIUM SWALLOW STUDY - POD 11
IMPRESSION: Normal postoperative study demonstrating a
surgically created
tracheoesophageal fistula, without reflux of contrast into the
trachea and
without evidence of additional tracheoesophageal fistulae.
PATHOLOGY:
SPECIMEN SUBMITTED: Total Laryngectomy, Left inferior lateral
margin, Right Neck Level 2A, Right Neck Level 3, Right Neck
Level 4.
Procedure date Tissue received Report Date Diagnosed
by
[**2125-9-27**] [**2125-9-27**] [**2125-10-5**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/ttl
Previous biopsies: [**-9/3293**] MEDIAL WALL LEFT PIRIFORM
SINUS.
[**-9/2116**] CARCINOMA IN SITU ANTERIOR FLOOR OF MOUTH, RIGHT
FLOOR OF
[**Numeric Identifier 80013**] R. LATERAL TONGUE LESION (1 JAR)
DIAGNOSIS:
1. Lymph nodes, neck, right level 2A, excision:
Four lymph nodes with no carcinoma seen (0/4).
2. Lymph nodes, neck, right level 3, excision:
Two lymph nodes with no carcinoma seen (0/2).
3. Lymph nodes, neck, right level 4, excision:
Two lymph nodes with no carcinoma seen (0/2).
4. Hypopharynx, left inferior lateral margin, excision:
Unremarkable squamous mucosa. No carcinoma seen.
5. Larynx, total laryngectomy and partial pharyngectomy:
Invasive poorly differentiated carcinoma. See synoptic report.
MICROSCOPIC
Histologic Type:
Poorly differentiated carcinoma. See note.
Histologic Grade: G3: Poorly differentiated.
EXTENT OF INVASION
Primary Tumor: pT1: Tumor limited to one subsite of
hypopharynx and is 2 cm or less in greatest dimension.
Regional Lymph Nodes: pN0: No regional lymph node metastasis.
Lymph Nodes
Number examined: 8.
Number involved: 0.
Distant metastasis: pMX: Cannot be assessed.
Margins:
Uninvolved by tumor:
Distance from closest margin: 3 mm. Specified margin:
Lateral.
Lymphatic (small vessel) Invasion: Not identified.
Venous (large vessel) invasion: Note identified.
Perineural invasion: Present.
Note: Sections of the tumor demonstrate an ulcerated, poorly
differentiated carcinoma composed of nests and sheets of
atypical cells with large pleomorphic nuclei and occasional
prominent nucleoli. Numerous mitotic figures and focal necrosis
are identified. A focus suspicious for a squamous precursor
lesion (carcinoma in situ, slide L) with possible keratinization
is noted. Immunohistochemical staining shows that the tumor
cells are positive for cytokeratin cocktail (AE1/AE3 and CAM
5.2), CK5/6, and p63. Staining for neuroendocrine markers were
repeated and show focal staining with synaptophysin and
chromogranin. These immunophenotypic findings are suggestive of
both squamous and neuroendocrine differentiation. Although a
definite squamous carcinoma in situ component is not identified,
the morphologic and immunophenotypic features are consistent
with an invasive poorly differentiated carcinoma arising at this
site. Selected slides (L and immunohistochemical stains) were
reviewed with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 9885**].
CBC
[**2125-9-27**] 02:33PM [**Month/Day/Year 3143**] WBC-6.7 RBC-3.81 Hgb-10.1 Hct-31.1 Plt
Ct-182
[**2125-9-27**] 08:15PM [**Month/Day/Year 3143**] WBC-5.9 RBC-3.92 Hgb-10.4 Hct-31.7 Plt
Ct-115
[**2125-9-28**] 05:35AM [**Month/Day/Year 3143**] WBC-5.1 RBC-3.58 Hgb-9.9 Hct-29.1 Plt
Ct-121
[**2125-10-1**] 02:57AM [**Month/Day/Year 3143**] WBC-4.4 RBC-3.53 Hgb-9.5 Hct-28.2 Plt
Ct-138
[**2125-10-2**] 02:55AM [**Month/Day/Year 3143**] WBC-4.7 RBC-3.62 Hgb-10.0 Hct-29.3 Plt
Ct-151
[**2125-10-8**] 06:35AM [**Month/Day/Year 3143**] WBC-8.6 RBC-3.95 Hgb-10.8 Hct-32.5 Plt
Ct-321
CHEMISTRIES
[**2125-9-27**] 02:33PM [**Month/Day/Year 3143**] Glucose-92 UreaN-8 Creat-0.6 Na-136 K-3.8
Cl-103 HCO3-27 AnGap-10
[**2125-9-28**] 05:35AM [**Month/Day/Year 3143**] Glucose-153* UreaN-5* Creat-0.5 Na-132*
K-4.9 Cl-100 HCO3-25 AnGap-12
[**2125-9-30**] 03:50AM [**Month/Day/Year 3143**] Glucose-117* UreaN-5* Creat-0.4 Na-137
K-3.8 Cl-102 HCO3-23 AnGap-16
[**2125-10-2**] 02:55AM [**Month/Day/Year 3143**] Glucose-121* UreaN-11 Creat-0.4 Na-137
K-3.8 Cl-101 HCO3-27 AnGap-13
[**2125-10-8**] 06:35AM [**Month/Day/Year 3143**] Glucose-121* UreaN-18 Creat-0.6 Na-138
K-4.1 Cl-100 HCO3-29 AnGap-13
Brief Hospital Course:
The patient was admitted to the otolaryngology head and neck
surgery service on [**2125-9-27**] after undergoing a total laryngectomy
and partial pharyngectomy, tracheoesophageal puncture and right
modified radical neck dissection. She tolerated the procedures
well and without complication. She was transferred to the SICU
for immediate post-operative care and remained there until POD 7
at which time she was transferred to the floor for further care.
Neuro: Post-operatively, the patient received Dilaudid IV/PCA
with good effect and adequate pain control. When tube feeds were
started through the red-rubber catheter she was started on
crushed dilauded tabs with good effect. On POD 12 she began PO
clears and took dilaudid PO without problem. She was discharged
on liquid dilaudid for pain that could be taken by mouth or via
her feeding tube.
CV: The patient was stable from a cardiovascular standpoint; she
was on telemetry throughout her stay because of her new
laryngectomy stoma and the concern for desaturations - she did
not have any significant cardiovascular problems. [**Name (NI) **] [**Name2 (NI) **]
pressure and hear rate remained normal throughout her stay.
Pulmonary: The patient emerged from the operating room with a
new laryngectomy stoma. She was breathing on her own and was
transferred to the ICU for [**1-4**] nursing care. She was managed
with q1-2 hour suctioning of her secretions and was noted to
have several brief desaturations to the mid-80s while in the ICU
- extending her stay there for close stoma care and frequent
suctioning. Humidified O2 was placed over her stoma site at all
times and mucus crusting removed as needed. Chest x-rays
post-operatively did not show a pneumothorax. A chest x-ray on
POD 5 showed right sided atelectasis and chest PT was initiated.
The patient was also encouraged to get out to bed to ambulate,
she was seen by PT for the duration of her stay and did not have
any further desaturations. She began stoma care with teaching by
nursing staff and the speech and swallow team, she also began
work with her electrolarynx, which will continue as an
outpatient.
GI/GU: Post-operatively, the patient was given IV fluids and
then started on tube feeds through the red-rubber catheter
through her TEP site on POD 4. The tube was repositioned on POD5
and CXR confirmed its position. She continued on continuous tube
feeds without problem per nutrition recommendations. Her IV
fluids were discontinued on POD 6, her input and output were
continuously monitored. On POD 11 she had a barium swallow study
which did not reveal a leak or fistula, and she was started on
clear liquids, advancing to mechanical softs. She did not
experience any leak and was discharged on mechanical soft diet
with TF supplementation 3x/day.
ID: Post-operatively, the patient was started on IV clindamycin
following the procedure. On POD 8 a swab of her stoma site was
taken which grew 2+ MSSA resistant to clindamycin. She was
switched to ancef at that time. The redness around the stoma
site decreased by the time of her d/c. A MRSA swab was negative.
She was discharged on 10 days of duricef. Throughout her stay
she was afebrile, her temperature was closely watched for signs
of infection.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible. Physical therapy worked with the patient in the ICU
and on the floor to encourage ambulation.
At the time of discharge on POD#12, the patient was doing well,
afebrile with stable vital signs, tolerating a mechanical soft
diet, supplemented with tube feeds, ambulating, voiding without
assistance, and pain was well controlled. While she was
participatory in her laryngectomy stoma care, nursing staff, the
speech and swallow team as well as the ORL/HNS primary team felt
that she was not yet proficient in stoma care to be safe for
discharge home. This in combination with the necessary care of
her feeding tube, and administration of the feeds, warranted a
stay at a rehab facility. The patient will see Dr. [**Last Name (STitle) 1837**]
in follow up in [**7-13**] days.
Medications on Admission:
Fosamax, Anastrozole, Vit D, Prilosec
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Solution Sig: 325-650 mg PO Q4H
(every 4 hours) as needed for pain.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day) as needed for constipation.
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Hydromorphone 1 mg/mL Liquid Sig: [**2-7**] mL PO Q4H (every 4
hours) as needed for pain for 10 days.
Disp:*200 mL* Refills:*0*
5. Duricef 500 mg Capsule Sig: One (1) Capsule PO twice a day
for 10 days.
Disp:*20 Capsule(s)* Refills:*0*
6. Boost Plus Liquid Sig: One (1) can PO three times a day
for 4 weeks: Please continue diet suplementation as needed until
taking adequate calories by mouth.
Disp:*84 84* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 56223**]
Discharge Diagnosis:
Squamous Cell Carcinoma left pyriform sinus, status post total
laryngectomy
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to [**Hospital3 **] Hospital following a
laryngectomy for squamous cell carcinoma, your inpatient stay
was 12 days during which you had a steady recovery from your
operation and you made significant progress in learning how to
care for your new stoma. You are being discharged to a
[**Hospital 3058**] rehab facility in order to manage the more
complicated aspects of your continuing care - the tube feeds and
your stoma being most relevant.
You have received several print-outs which describe in detail
how to care for your stoma and what you should expect over the
next few months. You should read these carefully and continue
looking at the area with your new mirror as often as possible.
Care for your stoma includes keeping humidified air on it at ALL
TIMES, periodic moistening of the opening with a small amount of
saline and decrusting with forceps as needed to maintain the
airway's diameter. You should be doing this every 2 hours while
you are awake. When you awaken in the morning you will need to
take extra care in the removal of any crusts and use the suction
to bring up any thick mucus at the site. Please do not hesitate
to call the office with any questions about your stoma care. The
sutures at the site will dissolve on their own.
You continue to have a red-rubber catheter through your
tracheal-esophageal puncture site. This is providing nutrition
to you in addition to what you take by mouth. You should keep
this tube in place until your follow up appointment with Dr.
[**Last Name (STitle) 1837**], and should continue to receive feeds through it
while at the rehab and at home. You may slow the rate of feeds
if you are having loose stools. The tube is stitched in place
and the tape marks the level of insertion of the tube. It is
very important that the tube remained taped down with silk tape
to maintain its position. DO NOT REMOVE THE STITCHING AND
REPLACE THE TAPE ONLY WHEN NECESSARY, SECURING IT DOWN SO THAT
IT DOES NOT COME OUT.
You can take a mechanical soft diet by mouth - this means pureed
foods and liquids. You should eat any foods that you have to
chew.
It is important for you and those around you to know that you
cannot breathe from your mouth - you are a DEPENDENT NECK
BREATHER. This means that if anyone needs to place a breathing
tube, it must be done through the neck, the CANNOT place one
from your mouth or nose.
You should return to the ER if:
* You have difficulty breathing through the stoma or cannot
clear secretions at that site.
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Followup Instructions:
Please see Dr. [**Last Name (STitle) 1837**] in his clinic ([**Telephone/Fax (1) 6213**]. You
should see him in the next 7-10 days.
|
[
"530.81",
"041.11",
"733.00",
"519.01",
"148.1",
"V15.3",
"V10.02",
"518.0",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.42",
"96.6",
"30.4",
"31.95"
] |
icd9pcs
|
[
[
[]
]
] |
12701, 12749
|
7733, 11880
|
318, 460
|
12869, 12878
|
2268, 2594
|
16197, 16332
|
1603, 1621
|
11968, 12678
|
12770, 12848
|
11906, 11945
|
12902, 16174
|
1636, 2249
|
235, 280
|
2629, 7710
|
488, 1423
|
1445, 1538
|
1554, 1587
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,424
| 146,375
|
53919
|
Discharge summary
|
report
|
Admission Date: [**2130-11-22**] Discharge Date: [**2130-12-3**]
Date of Birth: Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 65 year old
male with past medical history of hypertension, diabetes
mellitus and hypercholesterolemia, who was admitted on
[**2130-11-22**], to the Medical Intensive Care Unit with the chief
complaint of fever and cough. He was found on admission to
be hypoxic and with bilateral infiltrates on chest x-ray,
diagnosed as heart failure versus pneumonia. He was treated
with Levofloxacin initially in the unit and improved rapidly,
was called out to the floor the next day, however,
transferred back to the Medical Intensive Care Unit the
following day for progressive hypoxia. At that point, his
antibiotics were Ceftriaxone and Azithromycin and he was
diuresed gently for question of congestive heart failure. An
echocardiogram on [**2130-11-27**], showed an ejection fraction of 30
to 35% and multiple wall motion abnormalities which were new
findings. His hypoxia slowly improved until he was stable in
room air. His course in the Medical Intensive Care Unit was
also complicated by acute renal failure and a mixed gap and
nongap acidosis. He was called out to the floor on [**2130-11-30**],
in stable condition.
PAST MEDICAL HISTORY:
1. Diabetes mellitus type 2.
2. Hypertension.
3. Hypercholesterolemia.
MEDICATIONS:
1. Glipizide 10 mg p.o. once daily.
2. Lipitor 10 mg p.o. once daily.
3. Diltiazem 120 mg p.o. once daily.
4. Actos 30 mg p.o. once daily.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives with wife at home,
enrolled in a day care program, immigrated from [**Male First Name (un) 1056**]
twenty years ago. Positive smoking history. Positive remote
alcohol history.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Examination on admission to the floor
revealed a temperature of 96.0, heart rate 64, blood pressure
110/60, oxygen saturation 95% in room air. In general, the
patient is easily arousible in no acute distress. Head,
eyes, ears, nose and throat - The pupils are equal, round,
and reactive to light and accommodation. Extraocular
movements intact. Moist mucous membranes. Jugular venous
pressure is seven centimeters. No lymphadenopathy. Cardiac
is regular rate and rhythm, II/VI systolic murmur at the left
lower sternal border, no gallops. The lungs revealed diffuse
expiratory wheezing. The abdomen is soft, nontender,
nondistended, no hepatosplenomegaly, normoactive bowel
sounds. Extremities revealed no edema.
LABORATORY DATA: White blood cell count 13.9, hematocrit
37.8, platelet count 327,000, differential 76% neutrophils,
17% lymphocytes. Sodium 142, potassium 4.0, chloride 108,
bicarbonate 21, blood urea nitrogen 43, creatinine 2.2,
glucose 256.
Chest x-ray on [**2130-11-30**], showed bilateral interstitial
infiltrates, improved from admission. Echocardiogram on
[**2130-11-27**], showed ejection fraction of 30 to 35%, regional
left ventricular wall motion abnormalities including an
akinetic apex. No valvular abnormality.
Electrocardiogram showed sinus tachycardia at 120 beats per
minute, normal axis and intervals, ST depressions in I and
aVL, minimal ST elevations in V2 and V3, ST depressions in V5
and V6, no old electrocardiogram for comparison.
HOSPITAL COURSE: Assessment is that of a 65 year old male
with hypertension and diabetes mellitus presenting with
pneumonia and questionable congestive heart failure.
1. Community acquired pneumonia - The patient was treated
with antibiotics, Levofloxacin initially and then switched to
Ceftriaxone and Azithromycin for progressive hypoxia. He
never required intubation while in the unit. He rapidly
improved over a few days and at discharge is stable in room
air.
2. Congestive heart failure - The patient had bilateral
interstitial infiltrates on examination which were read as
bilateral pneumonia versus congestive heart failure. An
echocardiogram was obtained on [**2130-11-27**], which showed an
ejection fraction of 30 to 35% and multiple wall motion
abnormalities including apical akinesis. This cardiomyopathy
has not been previously diagnosed. Given his low ejection
fraction, he was started on afterload reduction with Isordil
and Hydralazine. After his renal failure resolved, he was
transitioned to an ace inhibitor and his creatinine has been
stable on low dose ace inhibitor. He was also started on
beta blocker. His volume status throughout his admission was
near euvolemic and he was not diuresed after leaving the
unit. Consideration of anticoagulation for apical akinesis
was brought up, however, on discussion with the primary care
physician, [**Name10 (NameIs) **] was deemed that he was not an anticoagulation
candidate because of a fall risk. He will be discharged on
his new cardiac regimen to be titrated as an outpatient.
3. Acute renal failure - Multifactorial - The patient had
baseline renal insufficiency with a creatinine around 1.8.
His peak creatinine was 2.7 during this admission. The renal
failure was multifactorial. He was thought to be prerenal
given initial improvement with intravenous fluids. His CK
was elevated to around 3000 with an unclear etiology with
large blood on dipstick but no red blood cells on microscopy.
It was thought that he might have mild rhabdomyolysis as
well. His course was also complicated by urinary retention
secondary to Haldol which was given in the unit after an
episode of agitation. A Foley was placed temporarily but
after removal, the patient had been voiding on his own with
good urine output. At the time of discharge, his creatinine
is back to his baseline of 1.8.
4. Acidosis - The patient has mixed gap and nongap acidosis.
Upon admission, his gap acidosis was due to his evolving
peptic physiology at the time of his admission. His nongap
acidosis resolved after his renal failure resolved.
5. Diabetes mellitus - The patient is on Glipizide and
Actos. These were held temporarily due to renal failure and
congestive heart failure but will be resumed as an
outpatient.
6. Psychiatric issues - The patient has history of mild
dementia and agitation. He has been on Klonopin as an
outpatient and this was held during his hospitalization. He
did have an episode of agitation in the Medical Intensive
Care Unit which was blamed on Klonopin withdrawal and the
Klonopin was resumed with subsequent oversedation.
Therefore, on the floor, his Klonopin was held and he has had
no withdrawal symptoms. We will not discharge the patient on
Klonopin.
7. Disposition - The patient was evaluated by physical
therapy and deemed safe to return home with his wife. [**Name (NI) **] is
enrolled in a day care program and has done well with this
per the primary care physician.
8. Code Status - The patient was full code during this
hospitalization. The patient was discharged home in stable
condition.
DISCHARGE ACTIVITY: Ad lib.
DISCHARGE DIET: Diabetic diet.
DISCHARGE SERVICES: VNA for safety evaluation and medication
supervision.
MEDICATIONS ON DISCHARGE:
1. Zestril 2.5 mg p.o. once daily.
2. Toprol XL 25 mg p.o. once daily.
3. Glipizide 10 mg p.o. once daily.
4. Actos 30 mg p.o. once daily.
5. Aspirin 325 mg p.o. once daily.
DISCHARGE FOLLOW-UP: The patient is to follow-up with
primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 58216**] [**Name (STitle) 7537**].
Dictated By:[**Name8 (MD) 4925**]
MEDQUIST36
D: [**2130-12-3**] 13:42
T: [**2130-12-3**] 13:46
JOB#: [**Job Number 110596**]
|
[
"788.29",
"486",
"584.9",
"038.9",
"428.0",
"276.2",
"728.88",
"276.5",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
1819, 1837
|
7117, 7611
|
3364, 7091
|
1860, 3346
|
156, 1296
|
1318, 1588
|
1605, 1802
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,857
| 109,567
|
44678
|
Discharge summary
|
report
|
Admission Date: [**2141-12-23**] Discharge Date: [**2142-1-8**]
Date of Birth: [**2080-8-7**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3645**]
Chief Complaint:
central cord syndrome s/p fall
Major Surgical or Invasive Procedure:
ACDF with iliac crest bone graft C4-6
History of Present Illness:
Patient is a 61 y/o M s/p fall forward onto face, no LOC, now
with pain and weakness in RUE and hyperesthesias in BUE.
Past Medical History:
Alcoholism - drinks ~ [**11-25**] pints a day
Physical Exam:
Afebrile
Wound healing well
RUE: [**1-26**] deltoid, biceps, triceps. [**3-28**] WF, WE, FAb, FF
LUE: [**3-28**] deltoid, biceps, triceps, WF, WE, FAb, FF
Sensation: hyperesthesias C5-C7 BUE
BLE: [**3-28**] [**Last Name (un) 938**]/TA/GS
negative clonus, negative hoffmans.
Brief Hospital Course:
The patient was admitted to the floor after evaluation in the
emergency room. He began to undergo DT's prior to surgery, he
was transferred to the SICU and was intubated. He was
subsequently taken to surgery and returned intubated to the
SICU. He was extubated the following day. He continued to be
agitated and was kept and halodol and ativan. Subsequent to his
extubation the ICU team noted that the patient had increasing
trouble swallowing. An MRI was obtained. This showed anterior
hematoma, but no compression on the airway. For safety the
patient was re-intubated. He was extubated when an airleak was
noted around the ET tube. He was discharged to the floor when
stable in the ICU. He was advanced to a regular diet. HE was
dischareged to home once he was able to tolerate a diet, and was
evaluated by physical therapy.
Medications on Admission:
none
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain: do not drink alcohol, drive, or operate heavy
machinery while taking this medication.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Central cord syndrome C4-C6
Discharge Condition:
stable
Discharge Instructions:
You have undergone the following operation: Anterior Cervical
Decompression and Fusion
Immediately after the operation:
- Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit in a car
or chair for more than ~45 minutes without getting up and
walking around.
- Rehabilitation/ Physical Therapy:
o 2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can
tolerate.
o Isometric Extension Exercise in the collar: 2x/day x 10 times
perform extension exercises as instructed.
- Swallowing: Difficulty swallowing is not uncommon after this
type of surgery. This should resolve over time. Please take
small bites and eat slowly. Removing the collar while eating
can be helpful ?????? however, please limit your movement of your
neck if you remove your collar while eating.
- Cervical Collar / Neck Brace: You need to wear the brace at
all times until your follow-up appointment which should be in 2
weeks. You may remove the collar to take a shower. Limit your
motion of your neck while the collar is off. Place the collar
back on your neck immediately after the shower.
- Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry
then you can leave the incision open to the air. Once the
incision is completely dry (usually 2-3 days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
- You should resume taking your normal home medications.
- You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Follow up:
o Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o At the 2-week visit we will check your incision, take baseline
x rays and answer any questions.
o We will then see you at 6 weeks from the day of the operation.
At that time we will most likely obtain Flexion/Extension X-rays
and often able to place you in a soft collar which you will wean
out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1352**] in Two weeks. Call his office
at [**Telephone/Fax (1) 1228**] to confirm/schedule your appointment.
Please follow up With Dr [**Last Name (STitle) 11622**] regarding abnormal peripheral
smear.
Completed by:[**2142-1-8**]
|
[
"272.4",
"293.0",
"952.08",
"997.39",
"E885.9",
"E878.1",
"401.9",
"481",
"291.0",
"305.22",
"952.03",
"723.0",
"998.12",
"303.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.51",
"96.6",
"80.51",
"81.62",
"96.04",
"96.71",
"77.79",
"81.02"
] |
icd9pcs
|
[
[
[]
]
] |
2028, 2087
|
920, 1749
|
349, 389
|
2159, 2168
|
5055, 5335
|
1804, 2005
|
2108, 2138
|
1775, 1781
|
2192, 2280
|
621, 897
|
2554, 3393
|
4470, 5032
|
2313, 2536
|
279, 311
|
3405, 4458
|
417, 537
|
559, 606
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,003
| 177,592
|
41731
|
Discharge summary
|
report
|
Admission Date: [**2182-8-30**] Discharge Date: [**2182-9-7**]
Date of Birth: [**2126-7-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
metformin / Shellfish
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Grafting x2 (left internal mammary artery
grafted to left anterior descending artery/Saphenous vein
grafted to Obtuse Marginal) [**2182-8-30**]
History of Present Illness:
56 year old man who recently developed new onset chest pain.
Went to outside hospital this AM and underwent cardiac
catheterization which revealed complex left circumflex lesion at
OM branch and 90% RCA. Transferred to [**Hospital1 18**] for further care and
evaluation of revascularization.
Past Medical History:
insulin-dependent diabetes mellitus
Hypertension
Hyperlipidemia
s/p nerve stimulator placed in back
s/p C7 2 bones remov
Social History:
Lives with:alone
Occupation:part-time works at [**Company 17115**] in the meat department
Cigarettes: Smoked no [] yes [x] Hx: <1ppd x a few months quit
when he was 28
ETOH: < 1 drink/week [x]
Family History:
Uncle with CABG
Physical Exam:
Physical Exam
Pulse:52 Resp:20 O2 sat:100/RA
B/P Right:147/74 Left:141/78
Height: 5'8" Weight: 229 lbs
General: NAD, alert, cooperative
distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [X] Irregular [] no Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [] bowel sounds +
[]
Extremities: Warm [x], well-perfused [] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: +1 Left:+1
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left:+1
Radial Right:+2 Left: +2
Carotid Bruit Right: none Left:none
Pertinent Results:
[**2182-8-30**] Echo:
Left Ventricle - Septal Wall Thickness: *1.6 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.7 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 4.4 cm
Left Ventricle - Fractional Shortening: *0.23 >= 0.29
Left Ventricle - Ejection Fraction: 60% to 65% >= 55%
Left Ventricle - Stroke Volume: 59 ml/beat
Left Ventricle - Cardiac Output: 3.45 L/min
Left Ventricle - Cardiac Index: *1.68 >= 2.0 L/min/M2
Aorta - Sinus Level: 3.1 cm <= 3.6 cm
Aorta - Ascending: 2.7 cm <= 3.4 cm
Aorta - Arch: 2.7 cm <= 3.0 cm
Aortic Valve - LVOT VTI: 23
Aortic Valve - LVOT diam: 1.8 cm
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - A Wave: 4.9 m/sec
Mitral Valve - E/A ratio: 0.20
Mitral Valve - E Wave deceleration time: 165 ms 140-250 ms
PRE-BYPASS: No spontaneous echo contrast or thrombus is seen in
the body of the left atrium or left atrial appendage. Right
ventricular chamber size and free wall motion are normal. There
are three aortic valve leaflets. The mitral valve appears
structurally normal with trivial mitral regurgitation.
POST-CPB: Preserved LV function post cpb. Aortic contour is
normal post decannulation.
CXR [**9-6**]
SINGLE AP PORTABLE VIEW OF THE CHEST
REASON FOR EXAM: Colonic distention.
Comparison is made with prior study performed a day earlier.
Cardiomegaly is stable. There are low lung volumes. Bibasilar
atelectases
have increased. There is no pneumothorax. Left pleural effusion
is small.
Nerve stimulators and sternal wires are unchanged.
[**2182-9-7**] 07:50AM BLOOD WBC-10.9 RBC-3.42* Hgb-10.2* Hct-28.7*
MCV-84 MCH-29.8 MCHC-35.6* RDW-13.3 Plt Ct-433
[**2182-9-7**] 07:50AM BLOOD Glucose-151* UreaN-15 Creat-1.0 Na-133
K-4.5 Cl-96 HCO3-31 AnGap-11
[**2182-9-6**] 06:10AM BLOOD ALT-31 AST-34 LD(LDH)-269* AlkPhos-81
[**2182-9-6**] 06:10AM BLOOD Lipase-41
[**2182-9-7**] 07:50AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.1
Brief Hospital Course:
Admitted same day surgery and was brought to the operating room
for coronary artery bypass graft surgery. Please see operative
report for further surgical details. He tolerated the procedure
well and was transferred to CVICU. In the first twenty four
hours he was weaned from sedation, awoke neurologically intact
and was extubated without complications. He was started on
betablockers and diuretics, and later on post operative day one
was transferred to the floor. Physical Therapy was consulted
for evaluation of strength and mobility. He continued to
progress slowly and had issues with abdominal distention but
normal liver function tests. CT scan unremarkable with general
surgery consult. He was given an aggressive bowel regimen with
good results. Chest tubes and pacing wires removed per protocol.
On post operative day 8 he was ambulating with assistance,
tolerating a full diet and his incisions were healing well. He
continued to progress and was cleared for discharge to rehab at
[**Location (un) **] House on POD #8.All f/u appts were advised.
Medications on Admission:
Lantus 70 units HS
Atenolol 25mg Daily
Lipitor 80mg Daily
Acots 45mg Daily
Zestoretec 20/2.5mg [**Hospital1 **]
Lisopril 20 mg [**Hospital1 **]
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day for 2 weeks.
4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 10 days.
10. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO twice a day for 10
days.
11. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once
a day.
12. Lantus 100 unit/mL Solution Sig: Seventy Five (75) units
units Subcutaneous once a day.
13. insulin Sliding scale (see attached)
Humalog sliding scale
Breakfast Lunch Dinner Bedtime
120-159 mg/dL 2 Units 2 Units 2 Units 0 Units
160-199 mg/dL 4 Units 4 Units 4 Units 2 Units
200-239 mg/dL 6 Units 6 Units 6 Units 4 Units
240-280 mg/dL 8 Units 8 Units 8 Units 6 Units
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] House Nursing Home - [**Location 9583**]
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
insulin-dependent Diabetes mellitus
Hypertension
Hyperlipidemia
mild postop ileus
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance
Incisional pain managed with dilaudid and tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage
1+ Edema bilateral lower extremities
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:
Surgeon: Dr.[**Last Name (STitle) **] [**Telephone/Fax (1) 170**] - [**2182-10-2**] at 1:30pm
Cardiologist: Dr. [**Last Name (STitle) 42394**] [**9-16**] at 8:45am
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] in [**12-23**] 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:[**2182-9-7**]
|
[
"V58.67",
"560.1",
"401.9",
"414.01",
"V45.89",
"250.00",
"564.09",
"272.4",
"413.9",
"997.4",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
6598, 6686
|
3900, 4964
|
299, 468
|
6845, 7100
|
1911, 3877
|
7940, 8460
|
1162, 1180
|
5159, 6575
|
6707, 6824
|
4990, 5136
|
7124, 7917
|
1195, 1892
|
248, 261
|
496, 790
|
812, 934
|
950, 1146
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,157
| 196,194
|
51297
|
Discharge summary
|
report
|
Admission Date: [**2163-1-19**] Discharge Date: [**2163-2-17**]
Date of Birth: [**2086-11-3**] Sex: M
Service: VSU
SERVICE: Vascular surgery.
HISTORY OF PRESENT ILLNESS: 76 year-old male, status post
endovascular abdominal aortic aneurysm repair on [**1-12**]
at [**Hospital6 2561**]. Transferred to our institution for
ICU bed. The patient presented for an elective aortic
aneurysm repair that was complicated by intraoperative
bleeding secondary to left iliac artery injury at the outside
institution. Intraoperative hematocrit at the institution
was 11 with an estimated blood loss of 3 liters to 5 hour
case. Postoperatively, the patient was aggressively
resuscitated with packed red blood cells, FFP and
Crystalloid. The patient had a shocked liver with a
transaminase in the 7000's. Also, acute renal failure ensued.
The patient developed pulmonary edema, pseudomonal pneumonia
which was treated at the outside institution with Zosyn and
Cipro. The patient developed a septic shock picture on
[**1-16**] which required pressor support.
The patient also underwent hemodialysis at the outside
institution. The patient arrived at our institution on
[**2163-1-19**].
PAST MEDICAL HISTORY: Hypercholesterolemia, type II
diabetes, hypertension, colon cancer, coronary artery
disease, status post myocardial infarction, peripheral
vascular disease. First degree AV block, anemia.
PAST SURGICAL HISTORY: Colon resection for cancer. CABG.
Left femoral stent placement. Carotid endarterectomy.
Pacemaker.
MEDICATIONS ON ADMISSION: Lisinopril, Lipitor, Nifedipine,
Avandia, Lopressor.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: On presentation, temperature was
100.6; heart rate 81; blood pressure 109/34; respiratory rate
20, 92%. The patient was on assist control, 60%, 20 by 600
with PEEP of 20. CVP was 22. Pulmonary artery pressures were
62 over 31. The patient was sedated, with sluggish pupils.
Heart was regular rate and rhythm. He had decreased breath
sounds at bilateral bases. Abdomen was soft and distended.
There was 2+ edema with dopplerable PT and DP bilaterally.
The patient was admitted to the vascular surgery service.
A summary, in a concise fashion, is shown below in order of
systems.
HOSPITAL COURSE: Neurologically, the patient was sedated
with Propofol for prolonged periods of time as well as
Fentanyl and Ativan. When the patient was lightened from all
sedation, he intermittently moved his upper extremities but
never moved his lower extremities and also never followed
commands.
Cardiovascularly, the patient had intermittent uses of
Levophed for hypotension, particularly toward the end of his
hospital course when he became septic. The patient had
bigeminy, multiple PVC's and sporadic atrial fibrillation for
which he was started on heparin.
Pulmonary: The patient was vented on assist control, SIMV at
all times. He did not tolerate pressure support weans.
Gastrointestinal: The patient was initially started on tube
feeds with an abdominal CT scan early on admission in our
institution revealed question of ischemic colitis. Tube
feeds were stopped. TPN was initiated. The patient's abdomen
became distended the second week of [**Month (only) 404**] significantly.
He had an elevated white count of 36,000 as well as fevers
and hypotension. It was decided at this time to drain a
pancreatic pseudo cyst. Cultures from this were essentially
negative, however, the patient did began to have some
hemorrhagic episodes into the pancreatic pseudo cyst where
the percutaneous needle was placed. This required multiple
units of transfusion. At this time, heparin was
discontinued. The patient also had splenic infarct noted on
his CAT scan.
Genitourinary: The patient was initially started on CPVH
which was weaned off; however, at the end, the creatinine
increased and his urine output decreased. Hematologically,
he was on heparin for atrial fibrillation which was
discontinued toward the end of the admission.
Infectious disease: The patient was on broad spectrum
antibiotics through the entire course. He did have
pseudomonas and yeast in his sputum.
Endocrine: The patient was on insulin sliding scale and the
patient required insulin drip during the admission.
The patient became septic toward the end of the admission,
requiring increased pressors and his creatinine increased.
His urine output decreased. It was decided at this time,
after extensive discussions with the family, that further
care should not be instituted. The transplant surgery
service was willing to do an exploratory laparotomy and to
explore any pancreatic necrosis as well as any issues which
would have been found in the abdomen; however, in discussion
with the family, it was decided that no intervention would be
done. The patient remained comfort measures only and the
patient expired thereafter shortly on [**2163-2-19**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 5697**]
Dictated By:[**Name8 (MD) 368**]
MEDQUIST36
D: [**2163-2-20**] 15:58:00
T: [**2163-2-21**] 07:09:14
Job#: [**Job Number 106421**]
|
[
"998.11",
"427.31",
"518.84",
"V53.31",
"707.03",
"276.1",
"995.92",
"577.2",
"038.43",
"785.52",
"289.59",
"584.5",
"557.9",
"428.0",
"348.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"96.6",
"39.95",
"38.93",
"52.01",
"00.17",
"86.22",
"96.72",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
1566, 1658
|
2282, 5169
|
1437, 1539
|
1681, 2264
|
194, 1200
|
1223, 1413
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,782
| 143,267
|
26710
|
Discharge summary
|
report
|
Admission Date: [**2193-1-17**] Discharge Date: [**2193-1-25**]
Date of Birth: [**2143-12-6**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Brain mass
Major Surgical or Invasive Procedure:
Right craniotomy for tumor mass resection
History of Present Illness:
49 y/o male tx from [**Location (un) **] / [**Hospital1 **], with H/A today [**9-10**],
starting two weeks ago with less intensity. CT today at OSH
significant for R parietal mass 3.5cm W with 7mm of shift. Mr
[**Known lastname **] states he has occasional H/A's relieved with OTC meds. Only
recent change was two weeks ago.
Past Medical History:
HTN, anxiety, NIDDM diet controlled, dyslipidemia prostatitis
in past anxiety congenital bicuspid valve leak (treated with
meds), [**Doctor Last Name **] Mal seizures as teenager until age 46 when he was
declared not to have them by a neurologist
Social History:
Pt currently employeed by a collection comapany. 20 yr. work hx.
with same co. as sole financial support for his wife and two
children ages 8 and 12.
Physical Exam:
Gen: appears anxious when answering questions. appears slightly
unkempt appearance.
HEENT: Normocephallic, eyes equidistant, nose and mouth midline.
Mucous
membranes pink and moist.
CV/PV: soft systolic murmor auscultated over erb's point, pulses
palpable. Good capillary refill
Respiroatory: Chest expansion symmetrical and even. Lung sounds
clear.
GI: Abdomen distended, soft, non-tender. Positive bowel sounds
all four quads
GU: deferred
Skin: intact.
Neuro: Alert, oriented x 3. PERRLA, Cranial nerves intact. No
pronator drift, but slight left arm tremor on exertion. Naned 3
of 3 items in 5 minutes, names 5 of 5 objects. Reflexes 2+ all
four extremities, motor strength 5/5 in all four extremities.
Sensation intact, toes upgoing.
Pertinent Results:
[**2193-1-17**] 10:00PM PT-12.4 PTT-20.9* INR(PT)-1.1
[**2193-1-16**] 09:55PM GLUCOSE-134* UREA N-14 CREAT-1.0 SODIUM-140
POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-22 ANION GAP-15
[**2193-1-16**] 09:55PM CRP-11.8*
[**2193-1-16**] 09:55PM PHENYTOIN-<0.6*
[**2193-1-16**] 09:55PM WBC-10.9 RBC-4.59* HGB-13.6* HCT-38.9* MCV-85
MCH-29.6 MCHC-34.9 RDW-12.5
[**2193-1-16**] 09:55PM NEUTS-92.2* BANDS-0 LYMPHS-6.8* MONOS-0.8*
EOS-0.2 BASOS-0
[**2193-1-16**] 09:55PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2193-1-16**] 09:55PM PLT SMR-NORMAL PLT COUNT-265
[**2193-1-16**] 09:55PM SED RATE-44*
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **] M.
PRINCIPAL DIAGNOSIS: Right-sided temporal tumor.
PRINCIPAL PROCEDURE:
1. Right-sided craniotomy for resection.
2. Microscopic dissection for intraoperative image guidance.
3. Duraplasty using pericranial autograft.
MRA BRAIN W/O CONTRAST [**2193-1-17**] 12:09 AM
IMPRESSION: Large right superior temporal lobe and deep white
matter mass with surrounding edema, most likely representing
neoplasia.
CT HEAD W/O CONTRAST [**2193-1-23**] 9:40 AM
IMPRESSION:
Minimal improvement in the post-surgical changes in the right
frontotemporal region.
Minimal improvement in the midline shift and mass effect since
the prior examination from [**2193-1-21**].
Brief Hospital Course:
The patient is a 49-year-old male who recently presented with a
newly diagnosed right-sided contrast-enhancing multilobulated
mass. The patient has significant mass effect and swelling from
that lesion. A full work-up did not reveal a primary tumor
anywhere in his body. The patient does need a tissue diagnosis
as basis for further
treatment options. He was therefore counseled for open
resection. He consented. He was taken electively to the
operating room on [**2193-1-19**]. He did well post
operatively intially was awake, alert and orientated X3 no true
deficits noted a follow up head MRI showed The resection cavity
in the right superior temporal lobe is unchanged in appearance,
with air and blood products within it. There is mild peripheral
enhancement and enhancement extending along the dural surface in
the location of the right craniotomy defect. A deeper rounded 2
cm enhancing mass, located between the right posterior thalamus
and internal capsule, is unchanged. There is vasogenic edema
around the surgical site, which is not significantly changed in
the interval since the previous study. He was monitored in the
recovery room overnight and transferred to the floor on post op
day 1.
On post op day 2 he was found to be more lethargic a stat head
CT showed right uncal herniation from edema he was given 100 Gm
of Mannitol , Lasix, Steroids 10mg and increased to 8mg Q6 and
tranferred to the SICU. The following morning he became more
awake, alert and orientated X3, PERRLA, language was fluent,
visual fields full and had equal stength in all extemeties.
He was transferred to the step down unit on post op day 4, his
Mannitol was weaned to off on post op day 5 and steroids weaned
very slowly to a goal of 2mg [**Hospital1 **] (post discharge). A head Ct on
[**1-23**] showed minimal improvement of edema and midline shift. He
was tolerating a regular diet, has periods of headaches relieved
with Percocet and noted to have some edema at surgical site felt
to be appropriate by Dr [**Last Name (STitle) 65817**] no redness or drainage at site.
Physical therapy felt he would benefit from a course of acute
rehab.
He should continue on the Lamigotrine with a increase in 25mg Q
week until goal of 150mg [**Hospital1 **] is reached
Medications on Admission:
lisinopril 20 mg po daily
lipitor 10 mg po daily
baby ASA 81 mg po daily
Clonipin 1mg in am and 0.5mg QHS
Doxazosin 2 mg po daily
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
9. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
10. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO DAILY
(Daily).
11. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
14. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2)
Capsule PO BID (2 times a day).
15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
16. Dexamethasone 2 mg Tablet Sig: 1.5 Tablets PO Q8H (every 8
hours): continue until [**1-28**].
17. Dilantin 100 mg Capsule Sig: One (1) Capsule PO once a day:
give between [**Hospital1 **] dose.
18. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO three times
a day: start on [**1-29**] continue until brain tumor follow up.
Discharge Disposition:
Extended Care
Facility:
health alliance/[**Hospital **] rehabilitation center
Discharge Diagnosis:
Brain Mass
Discharge Condition:
Good
Discharge Instructions:
--If any fever greater than 101.5, wound swelling (more than
current), redndess or increasing pain, please call Dr[**Name (NI) 9034**]
office.
-If you experienc any increased headache, neck pain or fever,
please all Dr[**Name (NI) 9034**] office.
No driving until foloow up at brain tumor clinic
Followup Instructions:
Follow up at Brain tumor clinic [**2-4**] at 3:00pm [**Location (un) **]
[**Hospital Ward Name 23**] Building [**Hospital Ward Name 516**]
Completed by:[**2193-1-25**]
|
[
"746.4",
"348.5",
"250.00",
"401.9",
"427.69",
"300.00",
"272.0",
"780.39",
"293.9",
"191.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.12",
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
7434, 7514
|
3347, 5609
|
330, 374
|
7568, 7574
|
1940, 3324
|
7919, 8089
|
5790, 7411
|
7535, 7547
|
5635, 5767
|
7598, 7896
|
1182, 1921
|
280, 292
|
402, 728
|
750, 999
|
1015, 1167
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,362
| 195,396
|
33553
|
Discharge summary
|
report
|
Admission Date: [**2159-4-20**] Discharge Date: [**2159-4-25**]
Date of Birth: [**2080-12-27**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p All terrain vehicle crash
Major Surgical or Invasive Procedure:
[**2159-4-23**] IVC filter placement
History of Present Illness:
78 yo male driver of an ATV who struck tree, no helmet. He was
transported to an area hospital where he was found to have a
brain hemorrhage and was subsequently transferred to [**Hospital1 18**] for
further care.
Past Medical History:
Pacer
MI x2
CAD s/p stents
Osteoarthritis
s/p cholecystectomy
Family History:
Noncontributory
Physical Exam:
Initial Exam
BP:92/60 HR:67 RR:16 O2Sats:100%
Gen: Patient is awake, but agitated
HEENT: Has small laceration on left eyelid.
Pupils: PERRL EOMs-intact
Neck: In cervical collar, no point tenderness.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Slight dysarthria.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 mm bilaterally
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-11**] throughout.
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Pertinent Results:
[**2159-4-20**] 02:19PM GLUCOSE-132* UREA N-27* CREAT-1.1 SODIUM-145
POTASSIUM-4.5 CHLORIDE-118* TOTAL CO2-19* ANION GAP-13
[**2159-4-20**] 02:19PM WBC-10.4 RBC-3.35* HGB-10.3* HCT-30.0* MCV-89
MCH-30.7 MCHC-34.3 RDW-14.9
[**2159-4-20**] 02:19PM PLT COUNT-223
[**2159-4-20**] 01:14AM GLUCOSE-143* UREA N-29* CREAT-1.2 SODIUM-145
POTASSIUM-4.7 CHLORIDE-117* TOTAL CO2-19* ANION GAP-14
[**2159-4-20**] 01:14AM PT-13.2 PTT-25.2 INR(PT)-1.1
[**2159-4-19**] 09:25PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
CT HEAD W/O CONTRAST
IMPRESSION: Small right parietal subdural and subarachnoid
hemorrhages with slight associated mass effect. Continued
observation recommended.
CT C-SPINE W/O CONTRAST
IMPRESSION: Multilevel degenerative changes, but no evidence for
fracture.
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
IMPRESSION:
1. Displaced fractures of the superior and inferior pubic rami,
bilaterally.
2. Slightly displaced fractures of the right transverse
processes of L1 through L5.
3. No definite sacral fracture or SI joint diastasis. However,
the pelvic fracture pattern and numerous transverse process
fractures raise the possibility of the "open- book"
fracture-dislocation mechanism.
4. 3.6 cm infrarenal abdominal aortic aneurysm.
5. Mediastinal lipomatosis explains its "widened" appearance on
the radiograph.
ABD (SINGLE VIEW ONLY); ABDOMINAL FLUORO WITHOUT RADIO
FINDINGS: Single fluoroscopic spot view without radiologist
present demonstrates an inferior vena cava filter and a surgical
instrument at the same level of L1-2.
Brief Hospital Course:
He was admitted to the Trauma Service. Neurosurgery and
Orthopedics were consulted given his injuries. His subdural
hemorrhage was managed non operatively; he was loaded with
Dilantin and will remain on this for 10 days (stop date [**4-30**]).
Serial head CT scans were followed and remained stable. He will
need to follow up with Dr. [**Last Name (STitle) **] in 8 weeks for repeat CT head
imaging. As for his neurologic status he is awake; not fully
oriented; is oriented to himself and family. He was started on
low dose Zyprexa at hs because of increased confusion at night.
His orthopedic injuries were also managed non operatively. He
can be WBAT both lower extremities. An IVC filter was placed
because felt due to his orthopedic injuries he was at risk for
pulmonary embolus. He will require follow up with Dr. [**Last Name (STitle) 1005**],
Orthopedics, in 2 weeks.
Physical therapy was consulted and have recommended brain injury
rehab stay.
Discharge Medications:
1. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 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. Phenytoin 50 mg Tablet, Chewable Sig: Four (4) Tablet,
Chewable PO Q8H (every 8 hours).
5. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
7. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML
PO Q6H (every 6 hours) as needed for constipation.
10. Bisacodyl 5 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily) as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p All terrain vehicle crash
Right Subdural hematoma w/ 3mm shift
Bilateral Sup/Inf Pubic Rami fractures
Right Sacral fracture
Right L1-3,5 Transverse Process fractures
Discharge Condition:
Good
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **], Neurosurgery, in 1 month. Call
[**Telephone/Fax (1) 1669**] for an appointment; inform the office that a repeat
head CT scan will be needed for this appointment.
Follow up with Dr. [**Last Name (STitle) 1005**], Orthopedics, in 2 weeks, call
[**Telephone/Fax (1) 1228**] for an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
[
"V45.82",
"E821.0",
"852.21",
"412",
"441.4",
"808.2",
"414.01",
"805.4",
"805.6",
"V45.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"96.71",
"99.04",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
5366, 5436
|
3477, 4435
|
345, 384
|
5650, 5657
|
1870, 3454
|
5680, 6149
|
730, 747
|
4458, 5343
|
5457, 5629
|
762, 1084
|
276, 307
|
412, 627
|
1250, 1851
|
1099, 1234
|
649, 714
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,782
| 178,896
|
41699
|
Discharge summary
|
report
|
Admission Date: [**2165-10-29**] Discharge Date: [**2165-11-20**]
Date of Birth: [**2114-10-29**] Sex: M
Service: MEDICINE
Allergies:
metformin
Attending:[**First Name3 (LF) 3021**]
Chief Complaint:
Fever, neutropenia, hepatitis.
Major Surgical or Invasive Procedure:
[**2165-10-31**] Skin biopsy.
[**2165-10-31**] Bone marrow biopsy.
[**2165-11-1**] Bone marrow biopsy.
History of Present Illness:
51yo male with history of hypertension, hyperlipidemia,
rheumatoid arthritis and diabetes mellitus who presents to OSH
after syncopal event on [**10-26**].
.
He awoke on [**10-26**] and felt warm. His temperature at that time was
101.0 so he took two tylenol and went back to sleep. He awoke a
few hours later and again felt warm and "flush" and found his
temp to be 103.0. He got up to go to the bathroom and "the next
thing (he) knew" he was on the floor. He was found by his wife
after an unknown duration and came to quickly. Denies any
confusion. He his the right side of his face and has a large
abrasion there now. He was taken to his local ED where he was
admitted for further evaluation.
.
While at the OSH, he underwent an extensive work-up for his
syncope. During this process, he developed persistent fevers,
thrombocytopenia, leukopenia, and liver failure. He was
initially started on azithromycin and rocephin but was
transitioned to vanco and cefotaxmin to cover for CNS infection.
Neurology evaluated the patient given syncopal event and
underwent negative EEG and CT head. No LP was done as there was
no suspicion for on-going meningitis. He underwent an ECHO which
some LVH with normal EF and no pulmonary HTN. CT chest and CT
sinus were negative for any infection and he satted about 92% on
RA.
.
As mentioned, the patient was found to have acute elevation of
his liver enzymes. On admission, ALT was 89 and AST was 70. ALT
rose to 353 and then 1067 and AST rose to 472 and 1732. T-bili
and alk phos remained within normal limits. Hepatitis panel and
monospot studies were negative. He had no abdominal pain,
jaundice, nausea or vomiting. RUQ U/S did not show any
inflammation or ductal dilatation.
.
He also became leukopenic, which is of unclear etiology. There
was some concern that it could be secondary to Enabrel. WBC down
from 3.2 to 0.8 with ANC of 0.51. Hct stayed within normal
limits. In addition, thrombocytopenia develops as she went from
169 to 68. Retic count was 1%, INR 1.1, fibrinogen 240, d-dimer
3360. Smear showed leukopenia with left shift and normochromic,
normocytic anemia. There was no evidence of schistocytes, acute
leukemia, inclusion bodies or toxin granulation.
.
ID was consulted given fevers and underlying marrow suppression.
Cultures were negative and EBV is pending. He was continued
vancomycin and cefotaxime. Of note the patient denies any recent
travel, tick bites, or new rashes.
.
He is being transferred to [**Hospital1 18**] for further evaluation. On
arrival to [**Hospital1 18**], vital signs were T- 103.4, BP- 160/80, HR-
103, RR- 20, SaO2- 95% on RA. The patient reports feeling warm
but denies chest pain, shortness of breath, abdominal pain,
dizziness, LH, or syncope.
Past Medical History:
1. Diabetes Mellitus
2. Hypertension
3. Hyperlipidemia
4. RA
5. Obesity
6. Insomnia
7. Osteoarthritis
Social History:
Married. Does not smoke or use any drugs. Denies regular alcohol
use.
Family History:
Diabetes and hypertension on maternal side of his family. Colon
cancer- father.
Physical Exam:
ADMISSION EXAM:
VS: T- 103.4, BP- 160/80, HR- 103, RR- 20, SaO2- 95% on RA
GENERAL: Mildly distressed but resting. Appropriate.
HEENT: NC/AT, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no JVD.
HEART: Tachycardic, no MRG, nl S1-S2.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**6-6**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, gait deferred.
Pertinent Results:
ADMISSION LABS:
[**2165-10-30**] 09:35AM BLOOD WBC-0.8* RBC-4.02* Hgb-12.2* Hct-34.7*
MCV-86 MCH-30.4 MCHC-35.2* RDW-13.3 Plt Ct-30*
[**2165-10-30**] 09:35AM BLOOD Neuts-53 Bands-8* Lymphs-30 Monos-5 Eos-1
Baso-0 Atyps-0 Metas-3* Myelos-0
[**2165-10-30**] 09:35AM BLOOD PT-13.7* PTT-47.8* INR(PT)-1.2*
[**2165-10-30**] 05:10PM BLOOD Fibrino-155
[**2165-10-30**] 09:35AM BLOOD Ret Aut-0.9*
[**2165-10-30**] 09:35AM BLOOD Glucose-148* UreaN-16 Creat-1.0 Na-133
K-3.7 Cl-102 HCO3-21* AnGap-14
[**2165-10-30**] 09:35AM BLOOD Calcium-7.1* Phos-1.4* Mg-1.7
[**2165-10-30**] 05:15PM BLOOD Albumin-3.1* UricAcd-2.7* Iron-58
[**2165-10-30**] 05:15PM BLOOD calTIBC-207* VitB12-1567* Folate-19.0
Hapto-76 Ferritn-[**Numeric Identifier 1097**]* TRF-159*
[**2165-10-30**] 05:10PM BLOOD HIV Ab-NEGATIVE
[**2165-10-30**] 09:35AM BLOOD Acetmnp-NEG
.
[**2165-10-30**] CT CHEST/ABD/PELV:
1. Mild gallbladder wall hyperenhancement with surrounding band
of fat
stranding, portocaval lymph nodes, and presence of peritoneal
fluid might be explained by current episode of hepatitis.
However, if cholecystitis remains a consideration clinically a
right upper quadrant ultrasound might be considered.
2. Small pulmonary nodules are non specific and ahould be
followed up with a chest CT in 12 months as [**First Name8 (NamePattern2) **] [**Last Name (un) 8773**]
Society guidelines if the patient has no history of smoking or
malignancy.
3. Small bilateral pleural effusions are observed.
4. Mildly enlarged mediastinal lymph nodes were also present.
5. Left lobe liver hypodensity is too small to characterize.
.
BMBx [**2165-10-31**]: HYPERCELLULAR BONE MARROW WITH FOCAL STROMAL
DAMAGE, INCREASED APOPTOSIS AND OCCASIONAL HEMOPHAGOCYTIC
HISTIOCYTE. THESE FINDINGS, IN THE CLINICAL SETTING OF
PANCYTOPENIA, HEPATIC [**Month/Day/Year **], EXTREME HYPERFERRITINEMIA,
HYPOFIBRINOGENEMIA AND HYPERTRIGLYCERIDEMIA ARE CONSISTENT WITH
ACQUIRED HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS.
.
[**2165-11-4**] ECHO: LVEF: 55% IMPRESSION: Suboptimal image quality.
Normal biventricular cavity sizes with preserved global left
ventricular systolic function. Mild right ventricular free wall
hypokinesis.
.
[**2165-11-7**] LOWER EXTREMITY DOPPLER U/S: IMPRESSION: No evidence for
DVT.
.
[**2165-11-7**] MRI HEAD: IMPRESSION: Normal MRI of the head.
.
[**2165-11-7**] EEG: IMPRESSION: These findings are consistent with
initial non-convulsive status epilepticus, resolving with
treatment (IV levetiracetam), and improvement in the background
activity to moderate diffuse slowing consistent with a moderate
diffuse encephalopathy.
.
[**2165-11-12**] CT HEAD: FINDINGS: IMPRESSION: Normal study.
.
[**2165-11-13**] CXR: Tip of the new right PIC line is in the mid SVC
alongside a right internal jugular sheath. Widening of the
mediastinum is stable, and there is no tracheal displacement or
other finding to suggest that there is any mediastinal bleeding.
There is no pleural effusion and the lungs are clear.
.
[**2165-11-20**] 04:55AM BLOOD WBC-1.0*# RBC-3.18* Hgb-9.8* Hct-26.7*
MCV-84 MCH-30.8 MCHC-36.7* RDW-13.5 Plt Ct-44*
[**2165-11-11**] 03:49AM BLOOD Neuts-69.4 Lymphs-29.2 Monos-1.0* Eos-0.2
Baso-0.2
[**2165-11-18**] 09:30AM BLOOD PT-12.1 PTT-21.9* INR(PT)-1.0
[**2165-11-18**] 09:30AM BLOOD Fibrino-356
[**2165-11-4**] 01:58AM BLOOD Fibrino-104*
[**2165-11-18**] 09:30AM BLOOD Fibrino-356
[**2165-11-11**] 03:49AM BLOOD Ret Aut-0.7*
[**2165-11-1**] 09:32PM BLOOD FacVIII-59 Fact IX-41* Fact [**Doctor First Name 81**]-66
FacXIII-NORMAL
[**2165-11-2**] 05:22AM BLOOD ACA IgG-3.8 ACA IgM-12.0
[**2165-11-1**] 04:20PM BLOOD CD3%-73.61 CD3Abs-247 16/56%-0.49
16/56Ab-2
[**2165-11-20**] 04:55AM BLOOD Glucose-117* UreaN-18 Creat-0.5 Na-135
K-3.9 Cl-102 HCO3-28 AnGap-9
[**2165-11-20**] 04:55AM BLOOD Calcium-7.9* Phos-3.2 Mg-1.8
[**2165-11-14**] 05:04AM BLOOD Albumin-2.7* Calcium-7.8* Phos-3.9 Mg-2.1
Iron-147
[**2165-11-20**] 04:55AM BLOOD ALT-81* AST-25 LD(LDH)-365* AlkPhos-110
TotBili-1.4
[**2165-10-31**] 05:50AM BLOOD ALT-1211* AST-1850* LD(LDH)-2431*
CK(CPK)-936* AlkPhos-93 TotBili-0.5
[**2165-11-3**] 04:50PM BLOOD CK(CPK)-2685*
[**2165-11-12**] 04:03AM BLOOD ALT-111* AST-52* LD(LDH)-425* CK(CPK)-256
AlkPhos-111 TotBili-1.1
[**2165-11-18**] 09:30AM BLOOD Ferritn-[**2183**]*
[**2165-11-14**] 05:04AM BLOOD D-Dimer-[**Numeric Identifier 90624**]*
[**2165-10-31**] 05:50AM BLOOD Triglyc-344*
[**2165-11-1**] 10:45AM BLOOD Triglyc-276*
[**2165-11-8**] 03:17AM BLOOD Osmolal-322*
[**2165-10-30**] 09:35AM BLOOD TSH-1.5
[**2165-10-31**] 05:50AM BLOOD Smooth-NEGATIVE
[**2165-11-2**] 10:00AM BLOOD PSA-1.1
[**2165-10-31**] 05:50AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2165-10-31**] 05:50AM BLOOD RheuFac-234* CRP-80.6*
[**2165-11-3**] 05:32PM BLOOD Lactate-3.7*
[**2165-11-5**] 12:58AM BLOOD Lactate-1.2
[**2165-11-3**] 05:08AM BLOOD freeCa-1.08*
[**2165-11-10**] 04:00PM BLOOD freeCa-1.15
Brief Hospital Course:
51yo man with RA on etanercept, DM, and HTN who is was foung to
have [**Month/Day/Year **], pancytopenia, fevers, hyperferritinemia,
hypofibrinogenemia, and BMB confirming hemophagocytic
lymphohistiocytosis (HLH). Developed fever, pancytopenia,
[**Last Name (LF) **], [**First Name3 (LF) **] transferred to [**Hospital1 18**] [**2165-10-29**]. He was
intubated for agitation and airway protection [**2165-10-31**] after
becoming dyspneic, tachypneic, and having chest pain. Ferritin
was 57,602. BMB confirmed HLH. Started high-dose steroids (dex
20mg IV daily), IVIg 40g IV daily x4d, and on [**2165-11-4**] etoposide
150mg/m2 days 1,4,8,11. On [**2165-11-5**] he had 3 minutes of
seizure-like activity which resolved with benzodiazapines. EEG
initially showed frequent subclinical seizures. ICU course was
complicated by hypernatremia to 150 which improved with free
water boluses, agitation/delerium which improved with
levetiracetam and haloperidol, sinus tachycardia to HR 150, and
steroid-induced hyperglycemia. Extubated [**2165-11-8**]. MRI head
negative. He was transfused 5U pRBCs, cryoprecipitate for
hypofibrinogenemia. Abx were stopped [**2165-11-9**] despite fevers
(due to HLH). Dramatic improvement over this week.
.
# Febrile Neutropenia - Initially febrile when presented to
outside hospital, and with WBC of 3. He was started on vanc and
ceftriaxone. Became neutropenic down to WBC 0.8 prior to
transfer. On transfer he remained febrile up to 103 with relief
only from cooling blankets due to inability to take
acetaminophen or ibuprofen. Hem/onc was consulted for further
assistance and performed a bone marrow biopsy on [**2165-10-31**] which
was repeated [**2165-11-1**] due to inadequate specimen. Diagnosis HLH.
His antibiotic course included:
--vancomycin 1g q12hr - [**Date range (1) 90625**], [**11-1**]->approx. [**2165-11-9**]
--cefepime 2g q8hr - [**10-29**]->approx. [**2165-11-9**]
--doxycycline 100mg PO q12hr - [**10-30**]->approx. [**2165-11-9**]
--acyclovir 800mg q8hr - [**10-31**]->
- ciprofloxacin PO 750mg q12hr [**11-1**]->approx. [**2165-11-9**]
.
# Anemia - Initially his hematocrit was stable around 37 for
most of his hospitalization, but on [**11-1**] it dropped to 30 and
then subsequently to 26 later that day. His LDH was up, but
hapto was normal. This was assumed to be related to whatever
process was causing his pancytopenia.
.
# Thrombocytopenia - His platelet counts were initially normal
at the OSH and trended steadily downward to 60 on admission, and
then remained around 30.
Transfusions: Platelets - 1 bag - [**11-1**] (for PICC placement).
.
# Hepatitis - His LFTs were initially normal at the OSH, and
then began to increase, initially to ALT/AST ~400, then ~1200
but stable for two days. Then his ALT increased to 1700 and AST
to 4700. LDH continued to increase from [**2154**] to 2400 to 4300.
Bilirubin and coags remained normal. Ferritin continued to
elevate up to [**Numeric Identifier 36021**], likely acute phase reactant. Liver was
consulted for further evaluation.
.
# RA: Held etanercept. Initially concerned that this could
contribute to his pancytopenia but Rheumatology felt this
unlikely. Rheumatology was formally consulted and felt the most
likely diagnosis was HLH, and recommended starting IVIG, which
he received once.
.
# Diabetes: On U500 as an outpatient, with unclear glucose
levels or insulin requirements. Started on a regular insulin
sliding scale on this admission. Sugars initially
well-controlled in the 100s, then began to increase into the
300s.
.
# Hypertension: Held atenolol and benicar in the setting of
recent syncopal event and report of bradycardia at OSH.
Maintained on telemetry.
.
# Syncopal event- could have been vagal or secondary to
hypotension given high fevers. CT head, ECHO, EEG all negative
at OSH.
.
MICU course:
Patient transferred to MICU [**Location (un) 2452**] given new respiratory
symptoms and oxygen requirement. On arrival to the MICU, he
received IVIG (40mg over 4 days). He did not tolerate increased
rate and developed rigors and fevers, which could also have been
secondary to underlying disease process. He was treated with
tylenol and benadryl and tolerated the remained of the infusion.
His respiratory remained stable overnight. BPs were elevated
to SBP of 190. He was initially treated with hydral 5mg IV x 2
with good response. Given duration of illness and likelihood
that sepsis would have declared itself, we resumed his
beta-blockade with metoprolol 12.5mg [**Hospital1 **] with plans to resume
[**Last Name (un) **] if BPs were stable on [**11-2**]. He was started on PPI in the
setting of recent Hct drop and stools were guaiac-ed
(results**). RUQ U/S (with dopplers) showed no gallbladder
pathology with normal hepatic vasculature.
.
Heme/onc was consulted regarding his pancytopenia. A bone
marrow biopsy was done which revealed hypercellular bone marrow
with increased apoptosis and occasional hemophagocytic
histiocyte. It was felt that this was c/w acquired
hemophagocytic lymphohistiocytosis given his constellation of
symptoms. He was then transfered to the [**Hospital Unit Name 153**] for initation of
chemotherapy. Prior to transfer, the patient was noted to be
acutely agitated and had to be intubated for airway protection.
.
During his stay in the [**Hospital Unit Name 153**], the patient was noted to have
shaking episodes (low amplitude, all 4 extremities). An EEG was
performed, which was concerning for seizure activity. Neurology
was consulted who felt that he may have been having subclinical
seizures and he was started on antiepileptics. As his EEG
monitoring continued, this activity stopped and his
antiepileptics were discontinued.
.
His mental status also began to improve, albeit slowly. He was
able to be extubated without incident. The patient had a fall
out of bed that was unwitnessed. He was found at the side of
his bed, sitting on the floor. He denied hitting his head, and
there was no evidence of head trauma. A head CT was done which
did not reveal any abnormalities. Also during his ICU stay, the
patient required an insulin drip to adequately control his blood
sugars. This was felt to most likely due to steroids and his
DM. His insulin dose and sliding scale was uptitrated
accordingly and the insulin gtt was discontinued. He was then
transferred to the floor for further management.
.
# HLH: Steroids started [**2165-11-2**], IVIG x4d finished [**2165-11-6**],
cycle #1 etoposide per HLH-94 regimen started [**2165-11-4**], finished
[**2165-11-14**] (Days 1/4/8/11). Completed 2wks dexamethasone 20mg,
now on a slow taper.
- Continue etoposide 150mg/m2 qwk x6wks (Mondays), last given
[**2165-11-18**].
- Continue dexamethasone 10mg (5mg/m2) daily x2wks, then 5mg
(2.5mg/m2) x2wks, 2.5mg (1.25mg/m2) x1wk, then taper off over
1wk.
- Cyclosporine might be started week #9 pending re-evaluation.
- Follow CBC, fibrinogen, coags, LDH.
- Calcium and vitamin D to prevent bone loss while on steroids.
- PPI while on steroids.
- Continue TMP/SMX PPx.
- TMP-SMX for prophylaxis.
.
# Pancytopenia: Due to HLH and chemotherapy. Transfused 1U PLTs
[**2165-11-1**]. Transfused 8U pRBC previously and 2U pRBC [**2165-11-16**].
Trace positive stool guaic. Avoid NSAIDs and heparin with low
PLTs.
.
# Coagulopathy: PTT up to 71 (with Factor IX 41%) now
normalized. Transfused cryoprecipitate [**2165-11-4**] to keep
fibrinogen >100.
.
# [**Month/Day/Year 5779**]: Due to HLH. Hepatology consulted. Normal
hepatitis serologies from OSH. LFTs improving.
.
# Diabetes: Endocrinology consulted. Added NPH. Holding
insulin glargine until PO intake stabilizes. Increased sliding
scale per Endocrine.
.
# Respiratory failure: Extubated. Off O2.
.
# Seizure d/o and delirium: Due to HLH. MRI brain negative.
EEG confirmed seizure. Neurology consulted. Resolved.
Continued levetiracetam for seizure. Continued trazodone prn
sleep.
.
# Fever: Due to HLH. ID consulted. Abx stopped [**2165-11-9**].
Adenovirus PCR, analplasma (HGE) Ab, blastomycosis Ab,
coccidioides Ab, hepatitis E Ab, HHV-6 PCR, HSV-[**2-3**], histoplasma
Ab, leptospira Ab, parvovirus B19 Ab all negative.
.
# Thigh hematoma: Due to BM biopsy, coagulopathy, and
pancytopenia. Resolving.
.
# RA: Holding etanercept for now.
.
# Hypertension: Restarted olmesartan (initially held due to
syncope). Increased metoprolol to 25mg [**Hospital1 **]. Atenolol stopped.
.
# Hypernatremia: Due to osmotic diuresis with hyperglycemia,
resolved.
.
# FEN: Regular diabetic diet. Hypernatremia resolved with IV
fluids.
.
# DVT Prophylaxis: Pneumatic boots.
.
# Access: PICC.
.
# Precautions: Fall.
.
# Contact: Wife.
.
# Code: Full.
.
TRANSITIONAL:
# HLH: Etoposide 150mg/m2 IV weekly x5 more weeks, then
re-evaluate.
.
# Pulmonary Nodule: CT with Scattered pulmonary nodules
measuring up to 5 mm needs f/u CT in 12 months.
Medications on Admission:
1. Atenolol 25mg daily
2. Lipitor 40mg daily
3. Lasix 40mg daily
4. Benicar 20mg daily
5. Lovaza- 1gm- 2 cap in AM, 2 in PM
6. Vicotaz- 1.8u subcutaneous daily
7. U500 insulin- 14U in AM, 13U in PM
8. TriCor- 145mg PO daily
9. Enabrel
Discharge Medications:
1. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID.
2. calcium carbonate 200 mg calcium (500 mg) PO BID.
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY.
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H.
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID.
6. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY.
7. prochlorperazine maleate 5 mg Tablet Sig: 1-2 Tablets PO q8HR
PRN nausea.
8. ondansetron HCl 4 mg Tablet Sig: 1-2 Tablets PO q8HR PRN
nausea.
9. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
PRN Thrush.
10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H PRN pain.
11. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS PRN insomnia.
12. olmesartan 20 mg Tablet Sig: One (1) Tablet PO Daily.
13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID.
14. etoposide 20 mg/mL Solution Sig: One [**Age over 90 1230**]y (150)
mg/m2 Intravenous 1X/WEEK (ONCE PER WEEK) for 5 weeks: Mondays
x5 more weeks, then treatment to be determined. Plan is to give
this in Dr.[**Name (NI) 84404**] office.
15. dexamethasone 2 mg Tablet Sig: Five (5) Tablet PO DAILY
(Daily): 10mg (5mg/m2) daily x2wks (finishing [**2165-12-1**]), then
5mg x2wks, 2.5mg x1wk, then taper off over 1wk.
16. NPH insulin human recomb 100 unit/mL Sig: 12 Units SC qAM:
With breakfast.
17. insulin regular human 100 unit/mL Solution Sig: Per sliding
scale SC QID.
18. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
PRN Rash.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11252**] Rehab
Discharge Diagnosis:
1. Syncope (fainting).
2. Fever.
3. Pancytopenia (low blood counts).
4. Coagulopathy (bleeding disorder).
5. Hemophagocytic lymphohistiocytosis (HLH), bone marrow
disease.
6. [**Hospital 5779**] (liver dysfunction, hepatitis).
7. Altered mental status (delirium).
8. Generalized weakness.
9. Seizure disorder.
10. Rheumatoid arthritis.
11. Diabetes.
12. Hypertension (high blood pressure).
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital directly from another hospital
due to fainting (syncope), pancytopenia (low blood counts),
[**Hospital **], altered mental state, and fever. You were seen
by the Infectious Disease, Rheumatology, Neurology,
Endocrinology, Hepatology (Liver), Dermatology, and
Hematology/Oncology specialists. You needed transfusions of red
blood cells, platelets, and clotting factors for a coagulopathy
(bleeding disorder). Dermatology performed a skin biopsy of a
rash. Hematology performed a bone marrow biopsy; this confirmed
the diagnosis of HLH (hemophagocytic lymphohistiocytosis), a
bone marrow disease that destroys blood cells. This was treated
with etoposide (chemotherapy) and dexamethasone (steroids) and
you will need to continue these as an outpatient.
.
While you were in the hospital, your confusion and agitation
worsened when you were feeling short of breath. This required
intubation (ventilator/breathing machine support). During this
time, an EEG showed seizure activity, so you were started on a
seizure medication, levetiracetam (Keppra). As the steroids and
chemotherapy continued, you began feeling better, you did not
need the ventilator, fevers resolved, and the liver function
tests normalized. Your blood counts remain low, a result of the
HLH and chemotherapy, and you are continuing to need frequent
blood transfusions.
.
Initially, you should have your blood counts (CBC) checked every
other day and this can be spaced out if your need for
transfusions declines.
.
MEDICATION CHANGES:
1. Etoposide chemotherapy weekly for at least the next 5 weeks,
then additional therapy will be considered.
2. Dexamethasone tapered over then next six weeks.
3. Levetiracetam (Keppra) for seizure disorder.
4. Stop atenolol.
5. Metoprolol 2x a day.
6. Calcium and vitamin D supplements while you are on steroids
(dexamethasone).
7. Trimethoprim/sulfamethoxazole (Bactrim) SS (single strength)
once daily to prevent infections.
Followup Instructions:
HEMATOLOGY/ONCOLOGY
DR. [**First Name (STitle) **] CATCHER
APPOINTMENT: MONDAY [**2165-11-25**] AT 9:15AM
[**Hospital **] HEALTHCARE
[**Street Address(2) 90626**], [**Location (un) **], [**Numeric Identifier **]
PHONE [**Telephone/Fax (1) 90627**]
FAX [**Telephone/Fax (1) 90628**] (ATTENTION: [**Doctor First Name 6811**])
.
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2165-11-28**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3884**], MD [**Telephone/Fax (1) 3237**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2165-11-28**] at 3:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6575**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: NEUROLOGY
When: THURSDAY [**2165-12-12**] at 3:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 19249**], MD [**Telephone/Fax (1) 44**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"250.00",
"787.21",
"401.1",
"780.61",
"570",
"345.00",
"518.81",
"288.00",
"288.61",
"276.0",
"348.30",
"288.4",
"287.5",
"V85.41",
"790.4",
"272.0",
"401.9",
"349.82",
"780.52",
"782.1",
"458.9",
"780.09",
"285.9",
"275.3",
"714.0",
"729.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25",
"86.11",
"96.04",
"41.31",
"96.72",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
19823, 19876
|
9038, 17961
|
304, 409
|
20309, 20309
|
4151, 4151
|
22479, 23757
|
3404, 3485
|
18246, 19800
|
19897, 20288
|
17987, 18223
|
20484, 22008
|
3500, 4132
|
22028, 22456
|
234, 266
|
437, 3176
|
6765, 9015
|
4167, 6756
|
20324, 20460
|
3198, 3301
|
3317, 3388
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,481
| 169,071
|
44197
|
Discharge summary
|
report
|
Admission Date: [**2100-12-19**] Discharge Date: [**2100-12-20**]
Date of Birth: [**2057-11-8**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Amoxicillin / E-Mycin / Latex / Ondansetron /
Vancomycin / Levofloxacin / Zofran / Phenergan / Dilaudid /
Ceftriaxone / Sulfamethoxazole/Trimethoprim / Voriconazole /
Fluconazole / Caspofungin / Doxycycline / Propranolol /
Neurontin / Azithromycin / Xopenex Hfa / Optiray 300
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
fluconazole desensitization
Major Surgical or Invasive Procedure:
none
History of Present Illness:
43 yo female with extensive allergy history, atonic colon s/p
resection, and recurrent vaginal yeast infections treated
previously with caspofungin but now present again is being
admitted to MICU for fluconazole desensitization. Her target
dose is 800 mg.
Of note, the patient has had phlebitic reactions previously to
catheters left in place for IVs. She will need daily IVs placed
to receive her fluconzole infusions.
Currently, the patient is without complaints. She presents from
home without any issues.
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.
Past Medical History:
CVID - monthly IVIG
autonomic neuropathy
esophageal dysmotility
oral/genital ulcers ? Behcet's
colonic inertia s/p subtotal colectomy at [**Hospital3 14659**] in [**2093**]
atrophic vaginitis with recurrent yeast infections
sleep disorder characterized by non-REM narcolepsy, restless leg
syndrome, and periodic leg movements
Social History:
No tobacoo, alcohol and illict drugs.
Family History:
Non-contributory
Pertinent Results:
[**2100-12-19**] 08:27PM BLOOD WBC-5.9 RBC-3.91* Hgb-12.2 Hct-36.0
MCV-92 MCH-31.1 MCHC-33.9 RDW-12.4 Plt Ct-283
[**2100-12-19**] 08:27PM BLOOD Glucose-95 UreaN-10 Creat-0.8 Na-138
K-4.1 Cl-105 HCO3-27 AnGap-10
[**2100-12-19**] 08:27PM BLOOD ALT-9 AST-16 AlkPhos-41 TotBili-0.2
Brief Hospital Course:
43 yo female with multiple allergies, atonic colon s/p
resection, recurrent vaginal yeast infections who presents today
for fluconazole desensitization for treatment of her candidal
vaginitis
# Fluconazole Desensitization: Patient to receive target dose of
800 mg. She underwent fluconazole desensitization via protocol
as outlined by her outpatient providers. She received
diphenhydramine 25 mg and famotidine 20 mg IV x 1 given 20
minutes prior to infusion. She completed the course without any
difficulty. She will continue as an outpatient to complete her
course of daily fluconazole 800 mg. She will follow up with her
PCP and allergist as an outpatient. The post desensitization
form was faxed to her allergist's office.
# sleep disorder: cont concerta
Medications on Admission:
1) Diphenhydramine/Viscous lido/Maalox 5 mL Swish and spit up to
5x daily PRN oral ulcers
2) EpiPen PRN
4) Concerta 24H 36 mg daily
5) Sucralfate 1 gm topically QID PRN
Discharge Medications:
1. Methylphenidate 36 mg Tab,Sust Rel Osmotic Push 24hr Sig: One
(1) Tab,Sust Rel Osmotic Push 24hr PO daily ().
2. Fluconazole in Dextrose(Iso-o) 400 mg/200 mL Piggyback Sig:
Eight Hundred (800) mg Intravenous once a day for 14 days.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Fluconazole Desensitization
Yeast Vaginitis
Discharge Condition:
stable, ambulatory, normal metal status
Discharge Instructions:
You were admitted to [**Hospital1 18**] for fluconazole desensitization. You
tolerated the medication well without any significant side
effects. You will continue on this medication as an outpatient
per your outpatient providers.
Please continue all medications as prescribed.
Please keep all scheduled appointments.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 250**]
You Have an effusion scheduled on 7Feldberg on the [**Hospital Ward Name 516**]
today at 14:30pm.
Provider: [**Name10 (NameIs) 1248**],BED SEVEN [**Name10 (NameIs) 1248**] ROOMS Date/Time:[**2100-12-21**]
11:15
Provider: [**Name10 (NameIs) 1248**],BED SEVEN [**Name10 (NameIs) 1248**] ROOMS Date/Time:[**2100-12-22**]
8:15
Provider: [**Name10 (NameIs) 1248**],BED SEVEN [**Name10 (NameIs) 1248**] ROOMS Date/Time:[**2100-12-23**]
9:15
|
[
"112.1",
"V07.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3386, 3392
|
2139, 2906
|
579, 586
|
3499, 3541
|
1837, 2116
|
3910, 4468
|
1800, 1818
|
3126, 3363
|
3413, 3413
|
2932, 3103
|
3565, 3887
|
512, 541
|
614, 1378
|
3432, 3478
|
1400, 1729
|
1745, 1784
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,783
| 108,400
|
41717
|
Discharge summary
|
report
|
Admission Date: [**2180-12-8**] Discharge Date: [**2180-12-18**]
Date of Birth: [**2098-8-2**] Sex: F
Service: SURGERY
Allergies:
Codeine / Oxycodone / tramadol / Dicloxacillin
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
large bowel obstruction
Major Surgical or Invasive Procedure:
exploratory laparotomy, LOA, transverse colectomy (Right
colostomy, Left mucous fistula)
History of Present Illness:
82F with a recent admission for [**Last Name (un) 17147**] I diverticulitis
managed conservatively with antibiotics. While in house she had
two episodes of abdominal distension and bilious emesis
concerning for ileus versus partial bowel obstruction. They
subsequently resolved with NGT decompression and she was
ultimately discharged to rehab yesterday. At the time she was
passing flatus and moving her bowels. She now presents from
rehab
with worsening abdominal distension and several bouts of bilious
emesis. She has not passed flatus or moved her bowels since
leaving the hospital.
Past Medical History:
Past Medical History: diverticulitis, hypertension,
hyperlipidemia, DVT's, tubal pregnancy
Past Surgical History: cholecystectomy, appendectomy,
hysterectomy, ex lap for SBO, s/p ventral hernia repair
Social History:
Lives mostly alone, although granddaughter lives with her on the
weekends. No smoking, EtOH a few times a year, no illicits.
Family History:
Noncontributory
Physical Exam:
On presentation to [**Hospital1 18**]:
Vitals: 98.4 82 108/66 16 93 2L
GEN: A&O, uncomfortable
HEENT: No scleral icterus, dry membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, mildly distended, three large ventral hernias which
are non-reducible and mildly tender to palpation
Ext: 1+ edema bilaterally, Warm well perfused
Pertinent Results:
CT abd - Small-bowel obstruction secondary to a complex ventral
hernia with transition point evident in the right lower quadrant
with collapsed bowel leaving a ventral hernia as detailed above.
[**2180-12-8**] WBC-13.7* Hct-36.3 Plt Ct-407
[**2180-12-12**] WBC-19.8* Hct-37.5 Plt Ct-421
[**2180-12-14**] WBC-13.5* Hct-24.8* Plt Ct-233
[**2180-12-7**] Glucose-94 Creat-0.9 Na-137 K-4.5 Cl-97 HCO3-33*
AnGap-12
[**2180-12-13**] Glucose-97 Creat-1.2* Na-135 K-4.0 Cl-101 HCO3-25
AnGap-13
[**2180-12-14**] Glucose-88 Creat-1.1 Na-135 K-3.8 Cl-100 HCO3-27
AnGap-12
Brief Hospital Course:
82F with history sigmoid diverticulitis, multiple ventral
hernias and colonic obstruction, admitted to the ACS service on
[**2180-12-8**] from rehab with a large bowel obstruction. She was
taken to the operating room for transverse colectomy with
colostomy and mucous fistula and tolerated the procedure well.
She was admitted to the TICU intubated, on levophed, with low
UOP, and in afib. During the course of her short stay in the ICU
she was extubated, was fluid resuscitated, her pressors were
weaned, and her atrial fibrillation was controlled, initially
with an amio ggt, then by PO amio once she tolerated sips.
Events by day in the ICU were:
[**12-11**]: admitted TSICU, still intubated. on levophed.
[**12-12**]: bolus albumin PRN, UOP improved. amiodarone bolus for
a.fib w/ RVR. converted back to sinus at 11pm. left aline
replaced into radial artery (ulnar stopped drawing back).
episode of desaturation at 5pm, difficult to ventilate - CXR OK,
significant secretions, likely mucous plug - improved with
suctioning
[**12-13**]: Extubated in am. Received 20 IV lasix. Off pressors for
about 2 hours, hypotensive on transfer from bed to chair, back
in a-fib. Received 50 ml of 25% albumin, 150 mg bolus of
amiodarone and was re-started on levo 0.03. Converted back to
sinus. continued off levo.
On [**12-14**] she was transferred to the floor. That evening she was
noted to be tachycardic on telemetry and an ECG confirmed atrial
fibrillation. She converted back to NSR after IV metoprolol 5 mg
x 1. Her vital signs were routinely monitored and she remained
hemodynamically stable throughout the remainder of her hospital
course. Her amiodarone and diltizem were continued from her
prior hospitalization. However, her simvasatin was decreased
from 20 mg to 10 mg daily given the FDA recommendation to not
exceed 10 mg of simvastatin while taking either of diltiazem or
amio for risk of myopathy. She was instructed to follow up with
her primary care provider after discharge from rehab.
Her prior dose of coumadin for chronic afib was held
perioperatively, and restarted on [**12-17**]. Her INR at discharge on
[**12-18**] was 1.5 and she was ordered for 3mg of coumadin that
evening.
After transfer to the floor, she was noted to have gas and
liquid stool output in her ostomy bag. On [**12-15**] she was started
on a clear liquid diet. On [**12-16**] she was advanced to a regular
diet which she tolerated well. She continued to pass stool and
gas via her colostomy.
A foley catheter was placed perioperatively and removed on [**12-15**]
at which time she voided adequate amounts of urine without
difficulty.
Physical therapy was consulted to assess her mobility who
recommended discharge to rehab when medically stable.
She was started on IV vancomycin and zosyn empirically given
spillage intraoperatively. Her WBC was trended and decreased
appropriately from 19.8 initially postop to 7.4 on [**12-16**]. Her
antibiotics were completed on [**12-18**] and she continued to remain
afebrile.
On [**12-18**], she was discharged to rehab with 2 surgical drains in
place and instructions to follow up in the Acute Care Surgery
clinic in [**2-24**] weeks.
Medications on Admission:
enalapril, simvastatin, HCTZ, vitamin D
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) inj
Injection TID (3 times a day).
2. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
3. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
6. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
7. diltiazem HCl 120 mg Capsule, Extended Release Sig: Two (2)
Capsule, Extended Release PO DAILY (Daily).
8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
9. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. warfarin 3 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Hospital1 **]
Discharge Diagnosis:
Large bowel obstruction
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 with a bowel obstruction. You
were taken to the operating room because of this and underwent
transverse colectomy with colostomy and mucous fistula.
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.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-30**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*Your staples will be removed 10-14 days after your surgery.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
While you were in the hospital some changes were made to your
medications. Please follow up with your primary care provider
after leaving the rehab facility to discuss your current
medications.
Surgery Follow up Appointment:NEEDED
Acute Care Surgery Clinic
[**Hospital1 69**]
[**Hospital **] Medical Office Building
[**Hospital Unit Name 58920**]
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: ([**Telephone/Fax (1) 2537**]
***Note: Please call the number listed above to schedule a
hospital follow up appointment in 2 to 3 weeks from your
hospital discharge.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2180-12-18**]
|
[
"998.2",
"998.02",
"427.31",
"V58.61",
"038.9",
"V12.51",
"518.51",
"401.9",
"569.5",
"E878.3",
"V49.86",
"569.83",
"933.1",
"567.21",
"272.4",
"286.9",
"995.92",
"584.5",
"552.21",
"E915"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.03",
"53.61",
"45.74",
"54.59",
"99.15",
"46.75",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
6559, 6619
|
2424, 5594
|
329, 420
|
6687, 6687
|
1836, 2401
|
9461, 10174
|
1422, 1439
|
5684, 6536
|
6640, 6666
|
5620, 5661
|
6870, 8323
|
8339, 9438
|
1174, 1263
|
1454, 1817
|
266, 291
|
448, 1037
|
6702, 6846
|
1081, 1151
|
1279, 1406
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,261
| 137,339
|
52704
|
Discharge summary
|
report
|
Admission Date: [**2192-12-30**] Discharge Date: [**2193-1-17**]
Date of Birth: [**2122-6-23**] Sex: M
Service: Vascular Surgery
CHIEF COMPLAINT:
Left toe infection.
HISTORY OF PRESENT ILLNESS: The patient is a 70 year old
male with known peripheral vascular disease, status post left
femoral-popliteal bypass with a jump graft with a left second
toe amputation and revision, who now presents with a
gangrenous wound with involvement on the left third toe.
There is purulent discharge and breakdown of the incision.
He denies any constitutional symptoms. There is surrounding
erythema.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: NPH insulin, regular insulin
sliding scale, carvedilol, Synthroid, folate, aspirin,
amiodarone, simvastatin, Renagel, Nephrocaps, Epogen and
Coumadin.
PAST SURGICAL HISTORY: 1. Left leg bypass graft. 2.
Arteriovenous fistula placement. 3. Coronary artery bypass
grafting in [**2183**].
PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Type
2 diabetes mellitus.
PHYSICAL EXAMINATION: On physical examination, the patient
had a temperature of 99.1, pulse 97, blood pressure 70/40,
recheck 92/50, respiratory rate 18 and oxygen saturation 99%
in room air. General: Alert oriented male in no acute
distress. Head, eyes, ears, nose and throat: Unremarkable.
Chest: Clear to auscultation bilaterally. Cardiovascular:
Irregular rhythm with regular rate. Abdomen: Unremarkable.
Extremities: 1+ pitting edema or right lower extremity at
ankle, Dopplerable graft flow and Dopplerable dorsalis pedis
and posterior tibialis pulses bilaterally, there is erythema
around the second toe amputation site and it is warm to
touch.
HOSPITAL COURSE: The patient was given intravenous Levaquin
500 mg and intravenous Flagyl 500 mg in the Emergency Room.
He was transferred to the vascular service for continued
care.
The patient was followed by the renal service and underwent
dialysis on his regular dialysis days. He did require
transfusion of packed red blood cells on [**2193-1-9**].
On [**2193-1-10**], the patient underwent a jump graft,
popliteal to peroneal bypass with left transmetatarsal
amputation without complications and was transferred to the
Vascular Intensive Care Unit for continued monitoring and
care.
The patient was transferred from the Vascular Intensive Care
Unit on [**2193-1-11**]. He continued to do well. He was
followed by the renal service. Physical therapy saw him and
began nonweightbearing ambulation to the right foot. He
would have to remain nonweightbearing for a total of 30 days
from the date of surgery.
The initial dressing was removed on postoperative day number
one. There were areas of necrosis on the anterior incision
and transmetatarsal amputation site. This was monitored.
Dr. [**Last Name (STitle) **] saw the patient on [**2193-1-17**] and felt that
the wound was a viable wound and that it would not require
any other surgical intervention at this time, and that the
normal saline wet-to-dry dressings to the T-section of the
transmetatarsal amputation with dry sterile dressings daily
and strict nonweightbearing on the extremity with follow-up
in two weeks. He would continue with ciprofloxacin until
seen by Dr. [**Last Name (STitle) **].
The patient did undergo a venous duplex study on [**2193-1-16**] which was negative for deep vein thrombosis. At the
time of discharge, his blood sugars were under adequate
control.
The patient would be transferred to a rehabilitation facility
which had capabilities of hemodialysis. His ceftazidime was
discontinued prior to discharge. The Flagyl was discontinued
and he was sent out on ciprofloxacin 250 mg daily.
DISCHARGE MEDICATIONS:
NPH insulin 14 units q.a.m. and 12 units q.h.s. with regular
insulin sliding scale at breakfast, lunch and dinner:
breakfast-glucose less than 120 no insulin, 121 to 150 one
unit, 151 to 200 two units, 201 to 250 three units, 251 to
300 four units, 301 to 350 five units, greater than 351 six
units; lunch-glucose less than 120 no insulin, 121 to 150 one
unit, 151 to 200 two units, 201 to 250 three units, 251 to
300 four units, 301 to 350 five units, greater than 351 six
units; dinner-glucose less than 120 no insulin, 121 to 150
one unit, 151 to 200 two units, 201 to 250 three units, 251
to 300 four units, 301 to 350 five units, greater than 351
six units; bedtime-no insulin unless glucose is greater than
300, 301 to 350 one unit, greater 351 two units.
Coumadin 5 mg started on [**2193-1-15**]; it was held until
the decision was made regarding any further surgical
intervention; patient should continue on his normal Coumadin
dose of 4 mg p.o.q.d.; PT/INR should be checked on a daily
basis, goal INR 2 to 2.5; patient is on Coumadin for chronic
atrial fibrillation.
Colace 100 mg p.o.b.i.d.
Tylenol #3 one to two tablets p.o.q.4-6h.p.r.n. pain.
Ciprofloxacin 250 mg p.o.q.d.
Heparin 5,000 units s.c.b.i.d. until patient is ambulating
independently.
Nephrocaps one p.o.q.d.
Amiodarone 200 mg p.o.q.d.
Aspirin 81 mg p.o.q.d.
Tums three p.o.t.i.d. with meals.
Amphojel 30 cc p.o.t.i.d. with meals.
Zantac 150 mg p.o.q.d.
Synthroid 100 mcg p.o.q.d.
DISCHARGE INSTRUCTIONS: Dressings to left transmetatarsal
amputation site at the T, normal saline wet-to-dry with dry
sterile dressing on the transverse incision. This should be
done on a daily basis. The patient is strict
nonweightbearing.
DISCHARGE DIAGNOSES:
1. Left foot ischemia, status post jump graft, popliteal to
peroneal bypass with left transmetatarsal amputation.
2. Hypertension, controlled.
3. Diabetes mellitus, controlled.
4. Hypothyroidism, controlled.
5. Chronic atrial fibrillation, on amiodarone and Coumadin.
6. Chronic renal insufficiency with end-stage renal disease,
on hemodialysis.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 19472**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2193-1-17**] 14:42
T: [**2193-1-17**] 14:46
JOB#: [**Job Number **]
|
[
"583.81",
"585",
"250.70",
"427.31",
"401.9",
"250.40",
"707.15",
"443.81",
"785.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.12",
"39.49",
"39.95",
"84.11"
] |
icd9pcs
|
[
[
[]
]
] |
5468, 6103
|
3745, 5202
|
688, 840
|
1746, 3722
|
5227, 5447
|
864, 981
|
1088, 1728
|
163, 184
|
213, 661
|
1004, 1065
|
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