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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
8,847
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|
25108
|
Discharge summary
|
report
|
Admission Date: [**2143-12-7**] Discharge Date: [**2143-12-12**]
Date of Birth: [**2081-6-5**] Sex: F
Service: NEUROSURGERY
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
s/p fall with head trauma
Major Surgical or Invasive Procedure:
Left craniotomy for left frontal mass resection
History of Present Illness:
62 year old female wiht head trauma s/p fall in shower
complaining of right upper and lower extremity weakness times
five days
Past Medical History:
Right eye gloucoma/cataract
HTN
SLE
Fibromyalgia
Social History:
noncontributory
Family History:
noncontributory
Physical Exam:
expired [**2143-12-12**] @1802
Pertinent Results:
[**2143-12-7**] 03:00AM WBC-12.9* RBC-4.09* HGB-13.7 HCT-37.9 MCV-93
MCH-33.6* MCHC-36.3* RDW-12.6
[**2143-12-7**] 03:00AM ALBUMIN-4.2 CALCIUM-10.2
[**2143-12-7**] 03:00AM LIPASE-34
[**2143-12-7**] 03:00AM ALT(SGPT)-11 AST(SGOT)-16 LD(LDH)-154 ALK
PHOS-90 AMYLASE-52 TOT BILI-0.4
[**2143-12-7**] 07:05AM FIBRINOGE-433*
[**2143-12-7**] 07:05AM PT-13.5* PTT-27.2 INR(PT)-1.2
[**2143-12-7**] 07:05AM PLT COUNT-218
[**2143-12-7**] 07:05AM GLUCOSE-165* UREA N-21* CREAT-1.0 SODIUM-142
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-24 ANION GAP-18
Brief Hospital Course:
Patient was admitted [**2143-12-12**] after severeal days of right upper
and lower extremity weakness ultimately leading to lost of
balance and head trauma s/p fall in shower. Head Ct in outside
hospital revealex left frontal mass confirmed by repat CT in
[**Hospital1 18**]. Dilantin loading dose 1gm to be followed by 100mg TID was
initiated. Additionally Decadron 4mg Q6 hours along with MRI of
the Head with and without contrast, Chest/Abdominal/Pelvic CT,
bone scan, ESR, CRP, CEA ere added for work up. MRI revealed
Left frontal lobe mass along the medial aspect of the brain
suggestive of a primary neoplasm glioblastoma appears more
likely than oligodendroglioma. Pateint was preop and consented
for resection of frontal lobe mass. Procedure was peformed
[**2143-12-10**] without complication and transfered to PACU. Please see
operative report for details. Postoperative day 2 [**2143-12-12**] @
1802 patient expired after suffering an episode of pulseless
electrical activity (PEA). Family was notified and refused
option of autopsy for death evaluation.
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2143-12-12**]
|
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15,062
| 177,464
|
44311
|
Discharge summary
|
report
|
Admission Date: [**2194-3-16**] Discharge Date: [**2194-3-21**]
Service:
HISTORY OF PRESENT ILLNESS: Patient is an 81-year-old male
with a past medical history of coronary artery disease and
CRI, who was recently admitted to [**Hospital1 190**] on [**3-8**] through [**3-10**] for a urinary tract
infection and hypernatremia, who is now found at nursing home
to be less responsive and hypotensive. The patient had been
admitted on [**2194-3-8**]. Urinalysis in the Emergency Room
revealed greater than 50 white cells, and patient was started
on Levaquin 250 po q day for a 14 day course. Urine culture
was negative. The patient was also hyponatremic, and he was
treated with free water boluses. For his change in mental
status, a MRI was performed which showed no acute
cerebrovascular accident.
Since hospitalization, the patient continued to exhibit
confusion, although this improved until the morning of
presentation for the current admission with hypotension with
a blood pressure of 60/palpable and unresponsiveness.
In the Emergency Room, the patient's vital signs were
temperature of 97.2, blood pressure 84/76, pulse 123,
respiratory rate 34, O2 saturation 94% on 100% face mask. A
Foley catheter was placed which drained frank pus. A femoral
line was attempted x2 and a left subclavian cordis line was
inserted. The patient was hypotensive to a blood pressure of
76/42, and was started on Neo-Synephrine drip. Cultures were
obtained. The patient was treated with Flagyl 500 mg IV,
Levaquin 500 mg IV, ceftriaxone 2 grams IV. Potassium in the
Emergency Department was 6.3, so the patient was treated with
calcium gluconate, insulin, and D50. He received 4 liters of
normal saline and was admitted to the MICU.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post coronary artery bypass
graft x2 in [**2182**] with a myocardial infarction in [**2181**].
2. Meningioma of the sphenoid ridge with a right frontal
craniotomy in [**2188**], suspected residual was seen on [**11-23**].
3. Cerebrovascular accident with a left facial droop.
4. CRI with baseline creatinine of 2.0.
5. Dementia.
6. Hypercholesterolemia.
7. Status post hemorrhoidectomy.
8. Peptic ulcer disease.
9. [**Doctor Last Name 3646**]-[**Doctor Last Name **] while a WWII POW.
10. Eczematous dermatitis.
11. Diabetes type 2.
12. Hypertension.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Levaquin 250 mg po q day on day 9 of 14.
2. Baby aspirin.
3. Pyridoxine.
4. Prozac 5 mg q day.
5. Zyrtec 10 mg q day.
6. Atarax 25 mg q hs.
7. Had been on Elavil and Lopressor, which was discontinued
on [**2193-3-11**] secondary to a rash.
EXAMINATION ON ADMISSION: Vital signs: Temperature 97.2,
blood pressure 100/39, O2 saturations 99%. General: The
patient was awake, alert, answering questions appropriately
in no acute distress. Pupils are equal, round, and reactive
to light. Moist mucous membranes. Conjunctivae were pale.
The neck was supple with 8 cm of jugular venous pressure. He
was clear to auscultation bilaterally with no wheezes, rales,
or rhonchi. Regular, rate, and rhythm, normal S1, S2 with no
murmur appreciated. Abdomen was soft, full, nondistended,
and nontender. Skin: Positive cyanosis, but intact
capillary refill. Neurologic: Was responsive, following
commands. Rectal was positive for guaiac.
LABORATORIES ON ADMISSION: White count 21.4, hematocrit
38.0, platelets 636. INR of 1.5. Sodium 150, potassium 6.3,
chloride 113, bicarb 19, BUN 62, creatinine 4.8, glucose 185,
calcium 8.5, magnesium 2.3, phosphorus 5.3. Urinalysis
showed greater than 50 white cells with many bacteria,
moderate leukocyte esterase, and positive nitrates. ALT was
45, AST 66, alkaline phosphatase 126, T bilirubin 0.4,
amylase 41, albumin 3.2.
Chest x-ray in the Emergency Room showed central venous line
with tip in the left brachiocephalic vein, no pneumothorax.
Shows near total resolution of previously identified left
lower lobe opacity.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit for likely urosepsis and hypertension
likely secondary to urosepsis and acute renal failure likely
prerenal secondary to volume depletion. The patient was
weaned off pressors while in the MICU. The patient was
treated for a resistant E. coli urinary tract infection with
Zosyn and patient responded well and was hemodynamically
stabilized.
The patient's hematocrit dropped while in the MICU with no
identified source of bleeding. The patient was transfused
with 2 units packed red blood cells due to his history of
coronary artery disease. Patient's acute renal failure
gradually improved throughout his hospital course.
The patient was evaluated by the GI Service, and watchful
waiting for the guaiac positive stool was recommended at that
time. No further imaging or endoscopy was performed. The
patient's hematocrit remained stable, and there were no
further signs of GI bleeding.
The patient was restarted on his Lopressor ramping up towards
his goal of his original outpatient dose as tolerated. Blood
and urine cultures were all negative throughout the [**Hospital 228**]
hospital course, so the patient was continued to be treated
for presumed resistant urinary tract infection with Zosyn.
A swallow study was completed, and diet was adjusted for
nectar thick liquid. The patient had loose bowel movements
which were Clostridium difficile negative x3. A renal
ultrasound was performed to rule out a perinephric abscess in
the setting of persistent urinary tract infection and this
ultrasound was negative for perinephric abscess, masses, or
stones.
The patient was transferred to the Medicine floor in stable
condition. While on the floor, the patient continued to
complain of diffuse pruritic rash which had been noted since
admission. This had been reportedly worked up previously and
had been sustained to be eczematous rash. A Derm consult was
ordered, and a diagnosis of Norwegian scabies was made based
on skin scrapings. The patient was treated with Lindane
lotion. The nursing home, where the patient had been a
resident, was notified, and they acknowledged that they had
an outbreak of Norwegian scabies and were aware of the
problem. [**Name (NI) **] had been in close contact with the patient
were notified through the Infection Control Service, and were
recommended to use Lindane or Prometh to prevent contraction
of Norwegian scabies.
The patient was accepted for transfer back to [**Hospital 100**] Rehab
Nursing Home, where he had been previously been a resident.
DISCHARGE DIAGNOSES:
1. Urosepsis.
2. Norwegian scabies.
3. Coronary artery disease status post coronary artery bypass
graft x2.
4. Meningioma status post craniotomy.
5. Cerebrovascular accident with a left facial droop.
6. Chronic renal insufficiency.
7. Acute renal failure resolved.
8. Peptic ulcer disease.
9. Diabetes type 2.
10. Hypertension.
11. High cholesterol.
12. Dementia.
DISCHARGE MEDICATIONS:
1. Fluoxetine 10 mg po q day.
2. Zosyn 2.25 grams IV q8h through [**2194-3-29**].
3. Lopressor 50 mg po bid.
4. Protonix 40 mg po q day.
5. Lindane lotion 60 mg td x1 dose to be given [**2194-3-27**].
6. Colace 100 mg po bid.
7. Senna two tablets po q hs.
8. Multivitamin one capsule per day.
9. Hydroxyzine 25 mg po q4-6h prn.
FOLLOWUP: The patient was to followup with his primary care
physician, [**Name10 (NameIs) **] was to have repeat dose of Lindane for
Norwegian scabies as described above.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 45008**]
Dictated By:[**Name8 (MD) 29946**]
MEDQUIST36
D: [**2194-6-18**] 16:08
T: [**2194-6-20**] 21:40
JOB#: [**Job Number **]
|
[
"584.9",
"585",
"276.0",
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"250.00",
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
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6987, 7714
|
2415, 2671
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4009, 6578
|
111, 1743
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|
1765, 2389
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,239
| 196,733
|
9895
|
Discharge summary
|
report
|
Admission Date: [**2150-4-16**] Discharge Date: [**2150-4-24**]
Date of Birth: [**2080-5-6**] Sex: M
Service: SURGERY
Allergies:
Gluten
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
potential liver transplant
Major Surgical or Invasive Procedure:
[**2150-4-16**] liver transplant
History of Present Illness:
69 y.o. h/o M s/p AVR [**6-17**] for calcific aortic valve disease
on [**Month/Year (2) **] with hepatitis C genotype 1 and HCC s/p ethanol ablation
of a 2.5-cm lesion in segment VI [**2149-4-10**] then chemoembolization
[**2149-4-23**]. Surveillance CT scans have been negative for
recurrence.
He was in process of getting chest/abd CT today, but this was
aborted once liver offer was made today. He had already had 1
bottle of po contrast otherwise has been npo. Last CT was [**1-19**].
ROS: + urinary frequency without pain/burning/urgency/hematuria
or cloudy foul smelling urine. Denies HA, dizziness, fever,
chills, recent infections, cp, cough, sob, orthopnea, PND,
indigestion, abd pain, constipation/diarrhea, joint pain.
Past Medical History:
hepatitis C
hepatocellular cancer
severe aortic stenosis
celiac disease
prostate cancer
-treated with hormone therapy and radiation
R leg skin lesion
-biopsied at [**Hospital1 2177**] last week, results unknown
[**2150-4-16**] liver transplant
Social History:
Lives alone, h/o tobacco (quit) and alcohol use (last alcohol 7
months ago), h/o drug use (quit)
Family History:
nc
Physical Exam:
Temp 97.2 HR 68 reg BP 143/86 RR 18, WT 60.2kg, Height 5'7"
A&O, no scleral icterus, mildly anxious, talkative/pleasant
No thrush, upper/lower dentures, [**Last Name (un) **]
2+ carotids, no bruits,no TM, no LAD
Lungs clear
Cor s1S2 nl, sys murmur
abd soft, non-tender/non-distended, no HSM
vasc 2 + femoral pulses,
ext no cce, 2+ bilat DPs
skin bronze appearing, no rashes, scattered macules on back
Pertinent Results:
[**2150-4-23**] 05:30AM BLOOD WBC-5.9 RBC-2.76* Hgb-9.3* Hct-26.6*
MCV-96 MCH-33.7* MCHC-35.1* RDW-16.2* Plt Ct-203
[**2150-4-20**] 05:17AM BLOOD PT-14.1* PTT-30.4 INR(PT)-1.2*
[**2150-4-23**] 05:30AM BLOOD Glucose-116* UreaN-12 Creat-0.5 Na-134
K-4.0 Cl-102 HCO3-27 AnGap-9
[**2150-4-23**] 05:30AM BLOOD ALT-161* AST-81* AlkPhos-87 TotBili-0.3
Brief Hospital Course:
On [**2150-4-16**], he underwent liver transplant. Surgeon was Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. Induction immunosuppession was given. HBIG was given
intraop during the anhepatic phase for donor that was HBV+. He
was sent to the SICU postop where he was extubated. He remained
hemodynamicaly stable and was transferred out of the SICU on pod
2.
LFTs improved. JP drains initially had high output. Liver duplex
on postop day 1 was normal. HBAb titers and HBsAg were done
daily. HBsAg remained negative. Antibody titers were >450. Five
days of HBIG were given postop. Lamivudine was also started on
day one. This continued. Per Hepatology, he would only need to
continue on Lamivudine once discharged home.
Diet was advanced and tolerated. He was ambulating and was
cleared by PT for discharge for home. The JPs were removed and
insertion sites sutured.
He required sliding scale insulin for hyperglycemia, but this
improved with steroid taper. He was instructed to monitor his
glucoses and record these results.
Prograf was started on postop day 1. This was titrated per
trough levels. On the day of discharge, his level was 12.3. Dose
was decreased to 3mg [**Hospital1 **], cellcept was 1 gram [**Hospital1 **].
He was discharged to home in stable condition. VNA services were
arranged to assist with glucose monitoring and continuation of
medication teaching.
Medications on Admission:
Allergies: wheat/gluten
[**Last Name (un) 1724**]: Flomax 4mg [**Last Name (LF) **], [**First Name3 (LF) **] 81mg qd, trazodone 50mg HS,
clotrimazole
5x/day (doesn't take)
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
7. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
10. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
12. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
13. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
HCV cirrhosis
HCC
Discharge Condition:
good
Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, inability to take any of your medications,
worsening abdominal pain/distension, jaundice, incision/drain
site redness/bleeding or drainage
Please empty JP drain and record outputs. Bring record of drain
outputs to next appointment in the Transplant office
Check your blood sugars twice daily
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7167**], RD Phone:[**Telephone/Fax (1) 3681**]
Date/Time:[**2150-4-28**] 1:00
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2150-4-30**]
10:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2150-4-30**]
11:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2150-4-24**]
|
[
"998.31",
"E878.2",
"V10.46",
"446.29",
"571.5",
"579.0",
"070.70",
"V01.79",
"790.29",
"155.0",
"V43.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"50.59",
"00.93",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
5133, 5191
|
2297, 3701
|
292, 327
|
5253, 5260
|
1928, 2274
|
5699, 6276
|
1486, 1490
|
3924, 5110
|
5212, 5232
|
3727, 3901
|
5284, 5676
|
1505, 1909
|
225, 254
|
355, 1088
|
1110, 1355
|
1371, 1470
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,916
| 161,187
|
6090
|
Discharge summary
|
report
|
Admission Date: [**2170-11-29**] Discharge Date: [**2170-12-25**]
Date of Birth: [**2085-2-15**] Sex: F
Service: MEDICINE
Allergies:
erythromycin / Penicillins
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Percutaneous coronary intervention with BMS placement x 2
Intubation
Central Line
Arterial Line
History of Present Illness:
85 yr old female patient of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8579**] with hx of CAD, CABG
[**2131**] and stenting in [**2162**] as well as left leg angioplasty [**2158**],
s/p right leg stents [**2-28**], also has a left common femoral
aneurysm (still present after thrombin injection), on coumadin
for PAF, who presents for elective cardiac catheterization
tomorrow. Patient has experienced recent increased exertional
angina. Symptoms occur often at nighttime, where she has noticed
that she develops chest discomfort when she moves pillows around
on her bed. She notes relief of the pain with one nitroglycerin
or rest. She has had an abnormal stress test on [**2170-11-19**], which
showed a fixed inferior defect but a reversible antero-apical
defect.. EF is noted to be 41%. Dr. [**Last Name (STitle) 8579**] has requested
Mucomyst administration prior and after cath.
.
Currently, patient reports no chest pain, shortness of breath,
nausea or vomiting. She is without any pain at the current time.
She reports no recent fevers or chills.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock 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,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension.
2. CARDIAC HISTORY:
-CAD s/p CABG in [**2131**].
-PERCUTANEOUS CORONARY INTERVENTIONS: RCA, LAD ostial vein graft
in [**2162**]; left SFA angioplasty in 8/99.
-PACING/ICD: None.
3. OTHER PAST MEDICAL HISTORY:
CHF EF 41% on [**2170-11-19**] stress test
Paroxysmal atrial fibrillation
COPD
DJD
Peripheral vascular disease (s/p PTCA stent R SFA [**2-/2170**], PTCA
stent L SFA [**2158**])
spinal stenosis
Social History:
SOCIAL HISTORY: Lives in [**Location **] in [**Hospital3 **] facility.
Has her own apartment. Has daughter [**Name (NI) 23875**] [**Name (NI) 23876**]
(daughter-HCP): [**Telephone/Fax (1) 23877**] (cell), [**Telephone/Fax (1) 23878**] (home)
-Tobacco history: Denies currently, significant past history, 2
pks/day for many years
-ETOH: Denies currently, social drinker previously
-Illicit drugs: none
Family History:
Father who died of coronary artery disease.
Physical Exam:
On presentation:
VS: T=96.3 BP=146/58 HR=76 RR=18 O2 sat=92%RA
GENERAL: AAOx3, NAD. Mood, affect appropriate. Appears
comfortable
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 3 cm above clavicle.
CARDIAC: RR, normal S1, S2. 2/6 SEM loudest at LUSB. No thrills,
lifts. No S3 or S4 noted.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.
EXTREMITIES: 2+ pitting edema present up to knees bilaterally.
Venous stasis changes present bilaterally.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas noted.
PULSES:
Right: 2+ DP 2+ PT 2+
Left: 2+ DP 2+ PT 2+
Pertinent Results:
On presentation:
[**2170-11-29**] 07:45PM BLOOD WBC-4.5 RBC-2.90* Hgb-8.5* Hct-26.2*
MCV-90 MCH-29.1 MCHC-32.3 RDW-15.3 Plt Ct-218
[**2170-11-29**] 07:45PM BLOOD PT-12.4 PTT-25.5 INR(PT)-1.0
[**2170-11-29**] 07:45PM BLOOD Glucose-132* UreaN-59* Creat-1.8* Na-139
K-4.1 Cl-107 HCO3-24 AnGap-12
[**2170-11-29**] 07:45PM BLOOD Calcium-9.2 Phos-4.2 Mg-2.2
.
On discharge:
wbc: 6.8
hgb: 7.3
hct: 22.4
plt: 420
Na: 136, K: 4.1 CL: 104 bicarb; 24 BUN: 31 Cr: 1.1
ca: 8.9 P: 3.1 Mg: 1.9
.
.
Microbiology:
URINE CULTURE (Final [**2170-12-22**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
Blood cultures - all negative except for 2 sets pending on d/c
C. diff toxins - neg x 2
Respiratory cx - yeast and mold
.
Imaging:
.
[**11-30**] Cardiac Cath:
1. Coronary angiography in this right dominant system
demonstrated
a 50% lesion in the LMCA. The LAD was totally occluded and
filled via
vein graft. The Lcx had a mid 50-60% discrete lesion. The RCA
had a mid
60-70% discrete instent restenosis.
2. Graft angiography demonstrated a svg to the mid LAD witha
70%
proximal lesion, instent restenosis with evidence of thrombus.
3. Resting hemodynamics revealed elevated right and left sided
filling
pressures with a pcwp of 25mmHG and RVEDP of 20mm Hg. Moderate
pulmonary hypertension was present with a PAP of 63mm Hg.
Cardiac
output was normal at 4L/min. There was severe systolic
hypertension at
163mmHg while on a nitroglycerine drip.
.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease of the native arteries.
Left
main disease, and instent restenosis of SVG-LAD graft.
2. Severe systolic hypertension with evidence of diastolic
dysfunction.
3. Moderate pulmonary hypertension.
.
[**11-30**] TTE: The left atrium and right atrium are normal in cavity
size. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is low normal (LVEF 50%) secondary to inferior
posterior hypokinesis. Right ventricular chamber size is normal.
with depressed free wall contractility. 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 to moderate ([**12-23**]+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion. There is an anterior space
which most likely represents a prominent fat pad.
.
[**12-1**] CXR: As compared to the previous radiograph, the inferior
vena cava
catheter has been removed. The remaining monitoring and support
devices are
in unchanged position. Minimal retrocardiac atelectasis, the
presence of a
small left pleural effusion cannot be excluded. Unchanged
borderline size of the cardiac silhouette without evidence of
overt pulmonary edema.
.
[**12-15**] CXR: As compared to the previous examination, there is no
relevant
change. Moderate cardiomegaly without signs of overt pulmonary
edema.
Moderate tortuosity of the thoracic aorta. No pleural effusions.
No focal
parenchymal opacity suggesting pneumonia.
[**12-19**]: UE venous US:
IMPRESSION: Non-occlusive thrombus seen adherent to the PICC
line within the left basilic vein extending into the left
subclavian vein.
[**12-24**] Renal US:
1. No renal abscess or son[**Name (NI) 493**] signs of pyelonephritis.
Please note that
a normal ultrasound does not exclude the diagnosis of
pyelonephritis.
2. Benign simple-appearing right renal cyst.
3. Bilateral renal calcifications likely representing vascular
calcifications
and tiny crystals with no evidence of obstructing stones or
hydronephrosis.
Brief Hospital Course:
85 yr old female patient of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8579**] with hx of CAD, CABG
[**2131**] and stenting in [**2162**] as well as left leg angioplasty [**2158**],
s/p right leg stents [**2-28**], also has a left common femoral
aneurysm (still present after thrombin injection), on coumadin
for PAF, who presents for elective cardiac catheterization after
worsening angina.
.
# Coronary artery disease and catheterization complications -
Patient admitted for pre-hydration prior to catheterization.
Taken to the cardiac cath lab on [**2170-11-30**]. There was total
occlusion of her LAD with 70% in-stent restenosis and evidence
of thrombus in her proximal SVG-LAD. PTCA/stenting of her LAD
venous graft was complicated by graft perforation into the
thorax without evidence of tamponade after the procedure. She
was intubated and remained stable enough to deliver 2
overlapping DES to the venous graft with occlusion of the
perforation. She was transfused 4 units pRBC in total, with
stable pressures on dopamine gtt and transferred to the CCU for
post-procedure monitoring. Post-procedure TTE did not show
evidence of pericardial effusion. She was continued on home dose
clopidigrel 75mg, which should be continued for 12 months. She
should be instructed aspirin 325mg indefinitely. B-blocker and
[**Last Name (un) **] to be restarted (as described below).
.
# Ventilator Associated Pneumonia: She developed fevers while
being intubated. She was pan-cultured and given meropenem +
vancomycin for a 7 day course. Sputum grew sparse mold, without
any pathogens. After initial difficulty weaning her from the
ventilator, she was succesfully extubated on [**12-9**]. She is now
on room air.
.
#. Urinary tract infection: Weeks into the hospitalization,
while on the regular medical floor, the patient became acutely
lethargic and cultures were taken. Urinalysis was highly
suggestive of infection and she was empirically started on
Cipro. Her urine culture grew E.coli, resistant to Cipro, and
her antibiotic regimen was changed to Cefpodoxime for a course
of 3 more days (total of 7). Renal ultrasound was obtained to
r/o abcess which was negative for abscess or pylo
.
#. Left wrist and hand cellulitis with LUE DVT: Her wrist and
thenar eminence became quite swollen, erythematous, and painful
on movement. She was empirically started on vancomycin for
coverage, which was changed to dicloxacillin/bactrim. A LUE
ultrasound revealed a non-occlusive thrombus in the basilic vein
with extension in the subclavian. This was associated with the
PICC line in this location, so it was removed promptly. She was
not started on heparin due to ongoing melenotic stools as well
as a hematocrit in the low 20s. Wrist cellulitis improved on
discharge
.
# Hypernatremia: Na+ rose in setting of poor PO intake. While
she was refusing to take anything by mouth, she was given D5W.
When she began to eat small amounts again, her Na+ normalized to
the normal range at discharge.
.
# Nutrition: After extubation, PO intake was markedly decreased,
as patient refused to eat. In discussions with the daughter,
she strongly refused feeding tube and states this is against
patient's wishes. She has continued to need a lot of
encouragement to eat and drink, stating that if she had food she
liked, she would eat more. Her mental status continued to
improve with mild increases in PO intake, so the decision was
made to monitor her nutritional status as an outpatient.
.
# Delirium: Patient developed worsening MS [**First Name (Titles) 151**] [**Last Name (Titles) 23879**]
delirium following extubation. This continued despite correction
of her hypernatremia and treatment of her VAP. She was treated
with haldol with little effect and [**Doctor First Name **] modifications. She
gradually became more conversant, but continued to be
intermittently confused. She should have Olanzipine if needed in
the evenings to prevent any agitation. Aprazolam and gabapentin
have been discontinued upon discharge. Though her nutritional
status remains poor, we have decided (in conjunction with the
family) to avoid NG or PEG tube feedings and allow her to
increased her diet as tolerated. Her UTI and left hand
cellulitis caused another acute change in her mental status,
which improved with proper treatment of these infections.
.
# Acute Kidney Injury - Patient's renal function initially
deteriorated following catherization, likley secondary to
contrast nephropathy. Baseline Cr thought to be 1.6 or so. She
was extensively diuresed with lasix and metolazone, and her
kidney function eventually improved and she had good urine
output. She was started on her home dose of lasix, but her
creatinine bumped once again and her losartan and lasix were
held.
.
# Scleral/conjunctival hemorrhages: She developed sigificant
bilateral eye hemorrhages during admission, likely related to
anticoagulation + coughing while intubated. She gradually
improved without issue.
.
# Paroxysmal atrial fibrillation: Now in sinus consistently. Her
CHADS2 = 3, and given her risk of bleeding is relatively low and
she is a potential fall risk, we decided to hold off on
coumadin. She will continue on ASA and plavix as above.
.
# COPD: She was intubated s/p catheterization. When she was
extubated, she was continued on Spiriva per home dose.
.
# Hyperlipidemia: Crestor was initially held given [**Last Name (un) **], but then
restarted once patient was extubated and able to tolerates POs,
and her renal function improved.
.
# Hypertension: Losartan and and metoprolol (increased to 100mg
daily) continued on discharge. She was also started on low-dose
Amlodipine 5mg. Her home dose of Lasix was also restarted when
kidney function improved.
.
# GERD: While intubated and s/p intubation, her PPI was changed
to Lansoprazole which she should continue.
Medications on Admission:
Aspirin 81 mg PO daily
Plavix 75 mg daily
Crestor 5 mg daily 000
Toprol XL 25 mg daily
Losartan 25 mg PO daily
Lasix 40 mg daily
Nitroglycerin 0.4 mg PO PRN
Spiriva 18 mcg PO daily
Omeprazole 20 mg daily
Gabapentin 200 mg TID
Folic acid 1 mg daily
Xalatan 0.005% daily
Celebrex 200 mg PO daily
Alprazolam 0.5 mg PO BID
Premarin 0.625 mg daily
Discharge Medications:
1. aspirin 325 mg Tablet [**Last Name (un) **]: One (1) Tablet PO DAILY (Daily).
2. clopidogrel 75 mg Tablet [**Last Name (un) **]: One (1) Tablet PO DAILY
(Daily).
3. rosuvastatin 5 mg Tablet [**Last Name (un) **]: One (1) Tablet PO DAILY
(Daily).
4. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
[**Last Name (un) **]: One (1) Tablet Sustained Release 24 hr PO once a day.
5. nitroglycerin 0.4 mg Tablet, Sublingual [**Last Name (un) **]: One (1) tablet
Sublingual every 5 min for total of 2 tabs as needed for chest
pain.
6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device [**Last Name (un) **]:
One (1) Cap Inhalation DAILY (Daily).
7. folic acid 1 mg Tablet [**Last Name (un) **]: One (1) Tablet PO DAILY (Daily).
8. latanoprost 0.005 % Drops [**Last Name (un) **]: One (1) Drop Ophthalmic HS (at
bedtime): both eyes.
9. white petrolatum-mineral oil 56.8-42.5 % Ointment [**Last Name (un) **]: One
(1) Appl Ophthalmic PRN (as needed) as needed for eye
irritation: both eyes.
10. docusate sodium 100 mg Capsule [**Last Name (un) **]: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
11. senna 8.6 mg Tablet [**Last Name (un) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. amlodipine 5 mg Tablet [**Last Name (un) **]: One (1) Tablet PO DAILY (Daily).
13. heparin (porcine) 5,000 unit/mL Solution [**Last Name (un) **]: One (1)
syringe Injection twice a day.
14. acetaminophen 325 mg Tablet [**Last Name (un) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
15. mirtazapine 15 mg Tablet [**Last Name (un) **]: One (1) Tablet PO HS (at
bedtime).
16. losartan 25 mg Tablet [**Last Name (un) **]: One (1) Tablet PO DAILY (Daily).
17. ascorbic acid 500 mg Tablet [**Last Name (un) **]: One (1) Tablet PO BID (2
times a day).
18. ferrous sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Last Name (un) **]: Five
(5) ml PO BID (2 times a day).
19. polyethylene glycol 3350 17 gram/dose Powder [**Last Name (un) **]: One (1)
packet PO DAILY (Daily).
20. cefpodoxime 100 mg Tablet [**Last Name (un) **]: Two (2) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
21. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] Nursing & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
Coronary Artery Disease
Paroxysmal Atrial fibrillation
diabetes mellitus type 2
Hypertension
Chronic Obstructive pulmonary disease
Peripheral Vascular disease
Hypernatremia
conjunctival Hemorrhage
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 had chest pain and a complicated cardiac catheterization to
find out the cause of your chest pain. The vein graft to a heart
artery was opened using a bare metal stent but a small
perforation developed and was closed with two Grafmaster covered
stents. You required a breathing machine for low oxygen and
medicine to keep your blood pressure up. Antibiotics were given
for pneumonia, a urinary tract infection, and a skin infection
involved your left hand and wrist. You have slowly recovered and
need rehabilitation to get stronger. It is very important that
you eat as much as possible.
.
We made the following changes to your medicine:
1. Increase aspirin to 325 mg daily
2. Increase Metoprolol to 100 mg daily
3. Start colace, miralax and senna to prevent constipation
4. Start amlodipine to lower your blood pressure
5. Start Heparin injections to prevent blood clots
6. Start tylenol as needed for pain
7. Stop taking Gabapentin, Celebrex, Aprazolam and Premarin
8. Start an eye ointment for dry eyes
9 change Omeprazole to Lansoprazole to protect your stomach
10. Start Mirtazipine to help your appetite
12. Start vitamin c and Iron to help your anemia
13. finish a 7 day course of Cefpodoxime to treat your urinary
infection and the cellulitis on your left arm.
Followup Instructions:
Name: [**Last Name (LF) 8579**], [**First Name7 (NamePattern1) 518**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: ASSOCIATES IN INTERNAL MEDICINE
Address: [**State 8536**], [**Apartment Address(1) 23880**], [**Location (un) **],[**Numeric Identifier 23881**]
Phone: [**Telephone/Fax (1) 23882**]
Appt: [**1-3**] at 2:45pm
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48,314
| 129,631
|
42404
|
Discharge summary
|
report
|
Admission Date: [**2191-6-24**] Discharge Date: [**2191-7-20**]
Date of Birth: [**2144-1-6**] Sex: M
Service: MEDICINE
Allergies:
simvastatin / Tricor
Attending:[**First Name3 (LF) 3918**]
Chief Complaint:
Admission for scheduled allogeneic SCT for MDS
Major Surgical or Invasive Procedure:
[**2191-6-24**] Right internal jugular vein tunneled triple-lumen
catheter placement by IR
[**2191-6-24**] Left internal jugular temporary triple-lumen catheter
placement by IR
History of Present Illness:
Mr. [**Known lastname 91831**] is a 47-year-old gentleman with history of
myelodysplasia with refractory anemia and excess blasts (RAEB)
who presents for admission for a scheduled allogeneic stem cell
transplant. He has been doing well. No current complaints.
Of note he has a skin graft in the leg after that is somewhat
discolored so he was seen by dermatology, who biopsed the
lesion. The biopsy showed some evidence of a recent ecchymosis
but no evidence of active infection (special stains for
microorganisms were negative) and felt that the patient could go
forward with transplant at this point. He also had a recent eye
stye which was treated by I and D then a 40 day course of
tobradex.
ROS
[+] per HPI
[-] fevers, sweats, chills, recent infection, sore throat, chest
pain, shortness of breath, cough, abdominal pain, nausea,
vomiting, or diarrhea.
Past Medical History:
MDS with refractory anemia
Hypercholesterolemia
history of staph infection in leg wound
pilonidal cyst s/p drainage
[**Known lastname **] polyps
EtOH abuse
surgery right arm after tree climbing accident as a child
ONCOLOGIC HISTORY: [**Known firstname **] [**Known lastname 91831**] is a 47 year old man with
transfusion dependent MDS (RAEB-2) who was diagnosed in 2/[**2190**].
He has received no chemotherapy but has required red cell and
platelet support. Mr. [**Known lastname 91831**] had a repeat marrow on [**2191-4-18**], that showed approximately 15% blasts, but still consistent
with an MDS. As this was thought to be some progression towards
leukemia in the interim before transplant it was decided to give
him a cycle of Dacogen. He started Dacogen on [**2191-5-2**].
Social History:
He has been married for 15 years. He is a self-employed
carpenter who is currently on a leave. He has a 27-year-old
daughter who is healthy. He has been a pack per day smoker for
32 years, he quit drinking alcohol in [**2179**] with one relapse in
[**1-/2191**] after being told that he needed a stem cell transplant.
H/o DUI x 2.
Family History:
His father has [**Name2 (NI) 499**] cancer. His mother is alive and well. He
has a full sister who is healthy and a half brother who is also
healthy. Maternal grandfather died from [**Name2 (NI) 499**] cancers.
Maternal grandmother died from a heart condition. His paternal
grandmother died from bone cancer in her 70s.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS T: 97.7 BP:102/68 P:55 RR:16 Pox: 100% RA
GEN: AAOx3, NAD
HEENT: PERRL, 5mm lesion on left eye, non-erythematous, EOMI,
MMM, no thrush, no OP erythema or lesions
NECK: supple, no LAD, no JVD
CVS: RRR, no m/r/g
LUNGS: reg resp rate, breathing unlabored, lungs clear to
auscultation bilaterally, no w/r/r
ABD: soft, NT, ND, NABS
ext: 2+ pulses, no c/c/e, 2cm skin graft present on right leg,
discolored skin surrounding graft, no erythema
Skin: no rashes, lesion on left leg, healing wound above right
ankle
Neuro: CN 2-12 intact, no focal deficits, strength 5/5 in UE and
LE bilat.
DISCHARGE PHYSICAL EXAM:
VS: T98.2, BP 98/60, HR 70, RR 16, 100% RA
GEN: AAOx3, NAD
HEENT: PERRL, left eye lesion resolved, conjunctiva injected,
EOMI, MMM, no thrush, no OP erythema or lesions
NECK: supple, no LAD, no JVD
CVS: RRR, no m/r/g
LUNGS: reg resp rate, breathing unlabored, lungs clear to
auscultation bilaterally, no w/r/r
ABD: soft, NT, ND, NABS
ext: 2+ pulses, no c/c/e
Skin: no rashes, 2cm skin graft present on right leg,
hyperpigmented skin surrounding graft, no erythema
Neuro: CN 2-12 intact, no focal deficits, strength 5/5 in UE and
LE bilat. Pins and needles sensation over right forearm, no
extension distal to wrist, reproducible with ulnar nerve
palpation
Pertinent Results:
ADMISSION LABS:
[**2191-6-24**] 09:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2191-6-24**] 09:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2191-6-24**] 09:45AM UREA N-14 CREAT-0.8 SODIUM-142 POTASSIUM-5.0
CHLORIDE-108 TOTAL CO2-31 ANION GAP-8
[**2191-6-24**] 09:45AM ALT(SGPT)-35 AST(SGOT)-41* LD(LDH)-364* ALK
PHOS-73 TOT BILI-1.0 DIR BILI-0.2 INDIR BIL-0.8
[**2191-6-24**] 09:45AM ALBUMIN-4.7 CALCIUM-9.2 PHOSPHATE-4.2
MAGNESIUM-2.2 URIC ACID-5.3
[**2191-6-24**] 09:45AM WBC-1.9* RBC-2.70* HGB-8.9* HCT-26.5* MCV-98
MCH-32.8* MCHC-33.6 RDW-21.7*
[**2191-6-24**] 09:45AM NEUTS-52 BANDS-0 LYMPHS-46* MONOS-0 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-3*
[**2191-6-24**] 09:45AM PT-11.8 PTT-34.2 INR(PT)-1.1
[**2191-6-23**] 10:12AM ALT(SGPT)-36 AST(SGOT)-35 LD(LDH)-323* ALK
PHOS-72 TOT BILI-1.1
RELEVENT LABS:
[**2191-7-17**] 09:22AM BLOOD tacroFK-5.3
[**2191-7-18**] 08:53AM BLOOD tacroFK-6.7
[**2191-7-20**] 09:35AM BLOOD tacroFK-6.9
DISCHARGE LABS:
[**2191-7-20**] 12:00AM BLOOD WBC-7.5 RBC-3.83* Hgb-11.5* Hct-34.5*
MCV-90 MCH-30.0 MCHC-33.4 RDW-18.7* Plt Ct-147*
[**2191-7-20**] 12:00AM BLOOD Neuts-66 Bands-3 Lymphs-11* Monos-8 Eos-4
Baso-0 Atyps-0 Metas-5* Myelos-2* Promyel-1*
[**2191-7-20**] 12:00AM BLOOD PT-12.0 PTT-27.8 INR(PT)-1.1
[**2191-7-20**] 12:00AM BLOOD Glucose-106* UreaN-11 Creat-0.6 Na-134
K-4.3 Cl-98 HCO3-28 AnGap-12
[**2191-7-20**] 12:00AM BLOOD ALT-26 AST-18 LD(LDH)-285* AlkPhos-76
TotBili-0.6
[**2191-7-20**] 12:00AM BLOOD Albumin-3.7 Calcium-8.4 Phos-3.9 Mg-1.6
PERTINENT MICRO:
[**2191-7-18**]: HHV6 PCR, CMV VL negative
[**2191-7-18**]: EBV [**Numeric Identifier 91832**] H
[**2191-7-11**]: EBV PCR undetectable
PERTINENT IMAGING:
Head CT [**2191-7-2**] for headache & thrombocytopenia
IMPRESSION: Small fluid within the sphenoid sinus. No acute
intracranial hemorrhage.
TTE [**2191-7-4**]
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. Due to the eccentric nature of the
regurgitant jet, its severity may be significantly
underestimated (Coanda effect). The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Normal regional and global biventricular systolic
function. Mild mitral regurgitation directed anteriorly.
Compared with the prior study (images reviewed) of [**2191-6-6**], the
degree of mitral regurgitation has increased. The other findings
are similar.
Liver Ultrasound [**2191-7-6**] for elevated LFTs
IMPRESSION:
1. Coarsened echotexture of the liver and spleen along with
borderline
splenomegaly. These findings are non-specific. No ascites.
2. 6 mm angiomyolipoma in the left kidney.
CT abd [**2191-7-9**] for elevated LFTs & neutropenic fever
IMPRESSION:
1. No CT explanation for patient's symptoms.
2. Borderline splenomegaly is nonspecific.
3. Liver cysts as seen on ultrasound.
CT chest [**2191-7-10**] for hypotension & neutropenic fever
FINDINGS: The thyroid gland is homogeneous. The lungs are
clear. There is no consolidation, effusion or pneumothorax.
The airways are patent to the subsegmental level. Heart size is
normal. A left-sided central catheter terminates in low SVC. A
right-sided central catheter terminates at the cavoatrial
junction. There is no supraclavicular, mediastinal, hilar or
axillary adenopathy. Limited views of the upper abdomen
redemonstrate two cysts in the right lobe of the liver. Other
visualized intra-abdominal structures are unremarkable. There
are no concerning lytic or sclerotic bone lesions.
Skin biopsy [**7-15**]
The changes are not well developed. The keratinocyte apoptosis
may be the result of recent cytotoxic therapy. Possible
diagnostic considerations include early evolving drug eruption,
viral exanthem, and graft versus host disease. If the eruption
progresses, rebiopsy of a more developed lesion may be further
revealing.
Brief Hospital Course:
47 yo M with history of myelodysplasia with refractory anemia
and excess blasts admitted for allogeneic stem cell transplant.
Course was complicated by neutropenic fever, atrial fibrillation
with rapid ventricular response, drug rash, and blepharitis.
# Myelodysplastic syndrome: 47M with transfusion dependent MDS
(RAEB-2) diagnosed in [**2190-12-29**]. He had previously received
no chemotherapy but required red cell and platelet support.
Patient had a repeat marrow on [**2191-4-18**], that showed
approximately 15% blasts, but still consistent with an MDS. As
this was thought to be some progression towards leukemia in the
interim before transplant it was decided to give him a cycle of
Dacogen which was started on [**2191-5-2**]. Transplant was delayed for
question of right shin skin graft infection (evaluated by
dermatology) and left eye stye. Patient underwent ablative
Flu/Bu/ATG, followed by allogenic MUD SCT, with CMV negative
recipient, CMV positive donor. Day 0 was [**2191-6-30**].
Overnight following transfusion of graft, patient became febrile
and developed atrial fibrillation with RVR as discussed below,
as well as on a second occasion (D+12) just prior to
engraftment. Tacrolimus levels were monitored closely, patient
received prophylaxis with acyclovir and micafungin, and neupogen
was stopped upon engraftment. Dexamethosone was given in a
three-day pulse for suspected engraftment syndrome. Antibiotics
for neutropenic fever were stopped following engraftment as
discussed below.
- Continue Acyclovir and antifungal prophylaxis
- Continue 2mg [**Hospital1 **] Tacrolimus, goal level [**4-7**]
- Follow up in hematology/oncology clinic
# Neutropenic fever: No source identified on CT of chest
([**2191-7-10**]) or CT abdomen/pelvis ([**2191-7-9**]). Antibiotic course was
as follows :cefepime8/3-8/11, meropenem [**7-10**], aztreo [**Date range (1) 19818**],
flagyl [**Date range (1) 19818**], vancomycin [**Date range (1) 91833**]. Antibiotics were stopped
following engraftment and patient was stable and afebrile
thereafter. All blood and urine cultures were negative.
# Afib with RVR: Transfusion reaction vs. infection vs. volume
depletion vs. nicotine bolus. On the night following graft
infusion patient was tachycardic and febrile to 103F, with
pressures 80s/50s, responsive to fluids. Several hours later,
and EKG for persistent tachycardia showed Afib with RVR. Patient
was noted to have nicotine patch was was noted to be in place on
arm, with likely increased absorption during fevers, which would
predispose to this rhythm. Rate control was not achieved
following IV metoprolol and IV diltiazem. He was transferred to
the ICU for further management, including pressors briefly and
diltiazem drip. He was transferred back to BMT service on PO
metoprolol in normal sinus rhythm. One one other occasion
patient had similar episode (Day +12) requiring another brief
stay of similar course in the ICU. At time of discharge patient
was in normal sinus rhythm, stable on PO metoprolol.
- Discharged on 25mg PO metoprolol tartrate Q8H
- Will follow up as outpatient with [**Hospital1 18**] cardiology clinic
[**2191-8-4**]
#Rash: Likely drug rash vs. associated with high fevers.
Erythematous blanchable rash on abdomen and back, petechial rash
over anterior thighs. Resolved following discontinuation of
cefepime, worsened with meropenem, improved on aztreonam and
following resolution of fevers. Developed a second rash
following engraftment with transient papules over thorax on mid
axillary line bilaterally. Dermatology was consulted, took
biopsy out of concern for possible skin graft-versus host
disease. Biopsy showed early changes with keratinocyte apoptosis
(possible result of recent chemotherapy), possible evolving drug
eruption, viral exanthem, and graft versus host disease.
- If the eruption progresses, rebiopsy of a more developed
lesion may be further revealing
- Will need suture removal [**2191-7-28**]
# Blepharitis: likely due to recent immune reconstitution,
possible reaction to normal flora, vs conjunctival GVHD.
Edematous upper eyelids likely causing conjunctival irritation.
Patient was evaluated by ophthalmology.
- Erythromycin ointment, fluorometholone drops for one week
following discharge
- Artificial tears for symptom relief
has changes in vision
Chronic Issues:
# Skin graft right shin: Concern for infection on admission.
Lesion was evaluated by dermatology and biopsied. Cultures were
negative and pathology showed scar tissue with red cell
extravasation and abundant hemosiderin deposits, no signs of
infection to delay transplant. Lesion was noted to darken during
nadir, lightened following engraftment.
#Hypercholesterolemia: Fish oil was held during this admission
for risk of myelosuppression.
#Left eye chalazion: Small hyperpigmented lesion was noted on
left eye lower lid. Patient has remote history of full course of
antibiotics for this stye. It was monitored on physical exam
daily throughout his hospitalization. Ophthalmology was
consulted when patient complained of increased tenderness around
the area during neutropenic nadir, and had five day course of
erythromycin ointment.
Transitional issues:
- Will need suture removal on [**2191-7-28**] from left chest
skin biopsy
- Tacrolimus dose 2mg PO Q12H
- Target Tacrolimus dose 5-10
- Patient will be followed closely by outpatient
hematology/oncology
- Continuation of metoprolol to be determined by outpatient
cardiologist
- Will need to start bactrim for PCP prophylaxis on [**Name9 (PRE) **] +30
- Positive EBV titer from [**2191-7-18**]
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Lovaza *NF* (omega-3 acid ethyl esters) 2 g Oral [**Hospital1 **]
2. nepafenac *NF* 0.1 % OU DAILY:PRN inflammation
3. Lorazepam 1 mg PO UNDEFINED anxiety
4. Tobramycin-Dexamethasone Ophth Oint 1 Appl LEFT EYE QID
Discharge Medications:
1. Lorazepam 1 mg PO BID:PRN anxiety
RX *lorazepam 1 mg 1 tablet by mouth twice a day Disp #*60
Tablet Refills:*0
2. Acyclovir 400 mg PO Q8H
RX *acyclovir 400 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Tablet Refills:*2
3. Ursodiol 300 mg PO BID
RX *ursodiol 300 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*2
4. Multivitamins 1 TAB PO DAILY
5. Gabapentin 300 mg PO Q8H
RX *gabapentin 300 mg 1 capsule(s) by mouth every eight (8)
hours Disp #*90 Capsule Refills:*2
6. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
7. Fluconazole 200 mg PO Q 12H
RX *fluconazole [Diflucan] 200 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*60 Tablet Refills:*2
8. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth every
twelve (12) hours Disp #*30 Capsule Refills:*0
9. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**11-29**] tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
10. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
11. Tacrolimus 1 mg PO Q12H
RX *tacrolimus 0.5 mg 2 capsule(s) by mouth every twelve (12)
hours Disp #*120 Capsule Refills:*2
12. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron HCl 8 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*2
13. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*2
14. Fluorometholone 0.1% Ophth Susp. 1 DROP BOTH EYES TID
Duration: 1 Weeks
RX *fluorometholone [FML S.O.P.] 0.1 % 1 drop(s) in each eye
three times a day Disp #*1 Bottle Refills:*0
15. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES [**Hospital1 **] Duration:
1 Weeks
RX *erythromycin 5 mg/gram (0.5 %) 1 drop(s) in each eye twice a
day Disp #*1 Bottle Refills:*0
16. Artificial Tears Preserv. Free 1-2 DROP BOTH EYES PRN
dryness
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Therapies
Discharge Diagnosis:
Primary diagnosis: myelodysplastic syndrome
Secondary diagnosis: atrial fibrillation with rapid ventricular
response
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 91831**],
It was a pleasure taking part in your care during your
hospitalization at [**Hospital1 18**]. You came to the hospital for stem
cell transplant for your myelodysplastic syndrome. When your
white blood cell counts were very low, you had fevers and were
treated with antibiotics, though no infection was found. During
those fevers you experienced a rapid irregular heart rhythm
called atrial fibrillation which resolved after going to the
intensive care unit for a medicine called diltiazem to slow your
heart down. When your heart rate was normal and your cell counts
had recovered we stopped the antibiotics. You were stable and
able to be discharged soon after. It is very important that you
follow up with the hematology/oncology clinic at the
appointments listed, and with a new cardiologist as follow up
for your atrial fibrillation.
You will need your stitches from your skin biopsy removed on
[**2191-7-28**] by one of your outpatient providers.
Followup Instructions:
Please attend the following appointments which have been
scheduled for you.
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2191-7-21**] at 8:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13863**], RN [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: BMT CHAIRS & ROOMS
When: THURSDAY [**2191-7-21**] at 8:30 AM
Department: BMT/ONCOLOGY UNIT
When: FRIDAY [**2191-7-22**] at 8:30 AM [**Telephone/Fax (1) 447**]
Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2191-8-4**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37140**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]
Completed by:[**2191-7-20**]
|
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icd9cm
|
[
[
[]
]
] |
[
"38.97",
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icd9pcs
|
[
[
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16497, 16566
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3588, 4245
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,201
| 117,424
|
25910
|
Discharge summary
|
report
|
Admission Date: [**2193-5-2**] Discharge Date: [**2193-5-6**]
Date of Birth: [**2112-8-6**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
BRBPR, lightheadedness
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy (EGD) [**2193-5-3**]
Colonoscopy [**2193-5-3**]
Colonoscopy [**2193-5-6**]
History of Present Illness:
80 year-old woman with HCV cirrhosis and IVDU admitted with
rectal bleeding. Patient has had BRBPR since Tuesday morning. It
started out as thick and dark with streaks of red. She continued
to have her usual [**4-18**] BMs daily with the same black stools with
streaks of blood. BEcause she was feeling dizzy when she stood
up, she decided to go to PCP [**Name Initial (PRE) 1262**]. PCP referred her to our
ED but she didnt want to go yesterday but decided to come today.
On exam in the ED initial vs:T:98 HR:86 BP:164/74 RR:16 O2Sat100
She had maroon stool, guaiac +++ on rectal exam. 2 EJ PIVs were
inserted. She had an NG lavage that returned no blood. She
remained hemodynamically stable in ED. Pressures 140s systolic
or better for majority of time in ED. Sat 95% RA and stable. Gi
was consulted and recommended serial hcts only. No scope today
unless profuse bleeding.
On the floor, patient had no complaints. She denies nausea and
vomiting. She has no h/o GIB and a colonscopy in [**2186**] was wnl
per her report. She has been taking advil 2tabs twice daily for
back pain for the last few months and before that was on
naproxen. She denies ETOH use.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bladder
habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
COPD followed by Dr. [**Last Name (STitle) **]
Cervical Spondylosis
HCV
Med non-compliance
HTN
GERD
Hypothyroid
Osteoporosis
S/P bilateral hip replacement
CKD, baseline Cr 1.1
Social History:
She lives alone but her son is involved in her care. She smokes
currently but does not drink. She has a prior history of IVDU
and is on methadone. Her methadone administrator is [**First Name8 (NamePattern2) 2048**]
[**Last Name (NamePattern1) 1968**] ([**Telephone/Fax (1) 64437**]).
Family History:
Father with emphysema
Physical Exam:
Vitals: T:99.3 PO BP:167/72 P:77 R: 18 O2: 98%Ra
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dryMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2193-5-2**]
LACTATE-1.7 K+-4.4
GLU-99 UREA N-27* CR-1.2* SODIUM-137 POTASSIUM-5.3* CHLORIDE-99
CO2-31
cTropnT-<0.01
WBC-8.3 RBC-3.88* HGB-12.1 HCT-35.8* MCV-92 PLT-148*
NEUTS-71.0* LYMPHS-17.6* MONOS-7.6 EOS-3.2 BASOS-0.6
PT-11.3 PTT-20.9* INR(PT)-0.9
EGD [**2193-5-3**]:
Impression: Normal mucosa in the esophagus
Erythema and nodularity in the antrum compatible with antral
gastritis Normal mucosa in the duodenum
A few scattered non bleeding AVMs were noted in the second part
of duodenum
Small hiatal hernia
Otherwise normal EGD to third part of the duodenum
Colonoscopy [**2193-5-3**]: !Procedure was incomplete due to poor prep!
Impression: Stool in the colon
Normal mucosa in the colon up to 40 cm
Diverticulosis of the sigmoid colon
Otherwise normal colonoscopy to descending colon
Colonoscopy [**2193-5-6**]:
Grade 2 internal hemorrhoids
Diverticulosis of the transverse colon, descending colon,
sigmoid colon and distal ascending colon
Otherwise normal colonoscopy to cecum
Discharge labs:
[**2193-5-6**] 05:31AM BLOOD WBC-5.5 RBC-3.16* Hgb-10.2* Hct-29.7*
MCV-94 MCH-32.2* MCHC-34.3 RDW-14.1 Plt Ct-122*
[**2193-5-6**] 05:31AM BLOOD Glucose-85 UreaN-11 Creat-1.0 Na-140
K-3.4 Cl-100 HCO3-34* AnGap-9
[**2193-5-6**] 05:31AM BLOOD Calcium-9.0 Phos-2.5* Mg-1.6
Brief Hospital Course:
Mrs. [**Last Name (STitle) 64438**] is an 80 yo F with h/o HCV, COPD, and GERD
admitted with BRBPR.
# LGIB: NG lavage negative. BRBPR possibly from diverticular
bleed. She remained hemodynamically stable and the bleed had
resolved by the time she was admitted to the [**Hospital Unit Name 153**]. EGD revealed
antral gastritis and a colonoscopy showed diverticulosis (bowel
prep was not adequate, so a complete study could not be
performed). She was treated with IV PPI [**Hospital1 **]. The patient was
observed over the weekend and had stable Hct between 28-31. She
had a repeat colonoscopy on [**5-6**] which showed diverticulosis but
no active bleed was found. No bleeding lesions were seen. She
was restarted on a regular diet and tolerated this well prior to
discharge. She was transitioned to Pantoprazole 40mg daily on
discharge. She was also instructed to stop naprosyn given her
EGD report with antral gastritis. She can follow up with her
PMD regarding restarting naprosyn in the future.
She has follow up appointment scheduled with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26211**] on
[**5-14**] with CBC check at that time as well. She will also
follow up with GI in [**2193-5-16**].
# HCV: Previously followed by Dr. [**Last Name (STitle) **]. Coags normal
indicating good liver synthetic function.
# HTN: Lisinopril intially held for GIB, restarted when BP
stable. This was restarted at her home dose on the floor.
# H/O IVDU: Has been on methadone for 40 years. She was
continued on her methadone dose of 120mg daily.
# COPD: Advair was continued
# Hypothyroidism: Levothyroxine was continued
# Osteoporosis: Vitamin D and calcium was restarted on discharge
# GERD: As above, the pt was started on IV pantoprazole 40mg
[**Hospital1 **], then transitioned to 40mg daily
# Smoking dependence: Nicotine patch
# Code status: RESUSCITATE but DO NOT INTUBATE (confirmed with
patient).
The patient was encouraged to either be entirely full code or
DNR/DNI. She will discuss further with her son at a later time
and reconsider.
Medications on Admission:
(Per note from [**Hospital1 778**] Health on [**2193-5-2**])
Protonix 40mg daily
Methadone 125mg daily
Levoxyl 137mcg daily
Lisinopril 10mg [**Hospital1 **]
Fosamax 70mg weekly
Loratadine 10mg daily
Colace 200mg [**Hospital1 **]
MVI
Proair HFA 108mcg 2 puffs q4-6hrs prn SOB
Advair 500-50 [**Hospital1 **]
Naproxen 375mg Q8h
Atrovent 17mcg 1-2 puffs q6hrs prn
Oscal D3 500/200 daily
Tylenol 1000mg q6hrs prn pain
Lexapro 10 vs 20 vs 30 daily
Discharge Medications:
1. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Methadone 40 mg Tablet, Soluble Sig: Three (3) Tablet,
Soluble PO DAILY (Daily).
5. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Please take this medication 2 hours after your calcium.
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily): Please take this medication in the
afternoon 2 hours after your calcium. Please note, that you
should not take this medication at the same time as your thyroid
and calcium medictions.
Disp:*30 Tablet(s)* Refills:*0*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
11. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: [**2-16**]
puffs Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
12. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain: Do NOT exceed 2grams of Tylenol in 24
hours .
13. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
15. loratidine Sig: One (1) once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Diverticulosis
GI bleed
Hepatitis C
COPD
Hypertension
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 for evaluation and management of GI bleed. An
endoscopy was performed on [**2193-5-3**] that revealed gastritis
(inflammation in the lining of your stomach), but no bleeding.
A colonoscopy was attempted but not completed on [**2193-5-3**] because
of incomplete bowel prep. A repeat colonoscopy was performed on
[**2193-5-6**] that revealed diverticulosis and this is the likely
source of your GI bleed. Your diet was advanced after your
colonoscopy and you tolerated this well.
Medication changes:
1. Please stop taking Naproxen as you had inflammation on your
EGD. Naproxen can worsen this. Please discuss this with your
primary care doctor at your next visit.
Followup Instructions:
Name: [**Last Name (LF) 26211**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital6 5242**] CENTER
Address: [**Last Name (un) **], [**Location (un) **],[**Numeric Identifier 6425**]
Phone: [**Telephone/Fax (1) 64439**]
Appointment: [**2193-5-14**] 9:20am
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2193-6-12**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 10314**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
|
[
"V43.64",
"535.40",
"305.1",
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"562.12",
"455.0",
"403.90",
"537.82",
"553.3",
"530.81",
"496",
"585.9",
"733.00",
"070.54",
"285.9",
"304.01",
"276.7",
"721.0",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"96.34",
"38.93",
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
8611, 8668
|
4356, 6439
|
292, 395
|
8767, 8767
|
3056, 4047
|
9657, 10337
|
2493, 2516
|
6931, 8588
|
8689, 8746
|
6465, 6908
|
8947, 9447
|
4063, 4333
|
2531, 3037
|
9467, 9634
|
230, 254
|
1606, 1976
|
423, 1588
|
8782, 8923
|
1998, 2175
|
2191, 2477
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,156
| 143,133
|
29805
|
Discharge summary
|
report
|
Admission Date: [**2144-12-30**] Discharge Date: [**2145-1-12**]
Date of Birth: [**2122-5-22**] Sex: M
Service: SURGERY
Allergies:
Bupropion
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
S/p 30 foot fall
Major Surgical or Invasive Procedure:
Closure facial lacerations
History of Present Illness:
22M s/p suicide attempt jumped from 30' +LOC by report,
ambulatory on scene
Past Medical History:
schizoaffective, bipolar, MR, ADHD, TBI, past suicide attempt
Social History:
group home, previous suicide attempts
Family History:
non contributory
Pertinent Results:
[**2144-12-30**] 07:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2144-12-30**] 07:50PM WBC-12.8* RBC-4.80 HGB-16.2 HCT-46.9 MCV-98
MCH-33.8* MCHC-34.6 RDW-13.4
CHEST SINGLE VIEW ON [**1-2**]
FINDINGS: The lungs are clear without infiltrate or effusion. No
significant change compared to the film from the prior day.
[**2144-12-31**] Radiology CT UP EXT W/O C
FINDINGS: There has been satisfactory reduction of the
previously seen
perilunate dislocation. Beam hardening artifact from patient
positioning and overlying cast obscures fine osseous detail and
obscures assessment of the
adjacent soft tissues. Allowing for this, there is a minimally
displaced
fracture of the radial styloid and a tiny minimally displaced
fracture
fragment off the dorsal ulnar lip of the distal radius. The
distal ulna is
intact. The scaphoid and capitate are intact. The lunate appears
intact
though there is a tiny, 1 mm ossific density is seen volar and
superior to the lunate (402B, 55), representing a tiny
intra-articular loose body, a discrete donor site not
appreciated. Carpal bones are otherwise unremarkable.
Visualized portion of the hand is normal. No radiopaque foreign
bodies are
appreciated.
IMPRESSION:
1) Satisfactory reduction.
2) Minimally displaced fractures of the radial styloid and
dorsal ulnar lip of the distal radius.
3) Tiny (1 mm) intra-articular loose body adjacent to the
lunate, without a definable donor site.
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Study Date of
[**2144-12-30**] 8:02
NON-CONTRAST CT OF THE FACIAL BONES: The paranasal sinuses are
normally
pneumatized and aerated, with minimal mucosal thickening in the
left maxillary
antrum. There is no fracture involving the orbital walls or
walls of the
sinuses. The palate, maxilla, and mandible are intact. Plate and
screws
within the apex of the mandible is intact, from prior trauma.
There is
extensive gas and tiny foreign bodies along the periosteal
surface of the
mandible consistent with trapped air and foreign bodies from the
patient's
chin degloving injury. The mandible itself is intact. The globes
are normal.
There is also a soft tissue laceration involving the upper lip
and extending
into the inferior nares.
IMPRESSION: Soft tissue lacerations and injury involving the
upper lip,
inferior nares, and chin, with no evidence of fracture. Small
foreign bodies
along the anterior aspect of the mandible.
Brief Hospital Course:
He was admitted to the trauma service. His facial lacerations
were repaired in ED by Plastic Surgery. He was started on Unasyn
for empiric coverage of facial lacerations which was later
changed to Augmentin which will continue for 5 more days after
discharge. He was transferred to Trauma SICU for close
monitoring; serial hematocrits were followed; admission Hct 46
has remained stable between 35-40 over course of hospitalization
with most recent one 37.1 on [**1-4**]. The left lunate dislocation
was reduced at bedside with plans for operative intervention
once other injuries were stabilized.
The L2 spinous process fracture was managed non operatively;
his pain was controlled with prn Percocet initially. he was
later changed to Tylenol and prn Oxycodone.
Psychiatry was consulted early on and he was placed on 1:1
sitters immediately. He was started on prn Haldol; his Depakote
was withheld pending surgery to repair his wrist. Depakote level
was checked and was 71.
On [**1-6**] he was taken to the operating room for ORIF of his left
wrist (lunate dislocation). There were no intraoperative
complications. Postoperatively he has done well. His blood
pressure (130/70) and heart rate (84) have been stable. His
temperature in 99.1 low grade which is expected postoperatively.
Serum electrolytes and hematocrits have also remained stable.
He developed fever on HD#11 temperature max reached 101.4. He
was cultured; there was concern for possible collection in his
abdomen given his significant abdominal trauma. He underwent CT
of the abdomen and pelvis; no collections were identified.
His fevers defervesced and he is afebrile at this time. His
final urine culture was negative and his chest imaging did not
reveal any pleural or pericardial effusions. His WBC was 3.8 on
[**1-11**] and was repeated on [**1-12**] and was 4.0. Because of side
effects associated with Depakote of pancytopenia and
thrombocytopenia his Depakote was stopped per recommendation of
Psychiatry.
He is tolerating a regular diet and is ambulating independently
with a steady gait. As for his behavior he has been cooperative
with care. He is therefore deemed medically clear for discharge
to an inpatient Psychiatric facility.
For follow up care he will need to be seen by Trauma and Plastic
Surgery.
Medications on Admission:
Zonisamide 300 mg [**Hospital1 **]
Depakote ER 1500 mg HS
Abilify 15 mg daily
Seroquel 50 mg q4 PRN agitation
Geodon 40 mg [**Hospital1 **]
Discharge Medications:
1. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day as needed for constipation.
2. Haldol Sig: 1-2 MG PO every 4-6 hours as needed for
agitation.
3. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO three
times a day for 2 days.
4. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane TID (3 times a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**5-3**]
hours as needed for fever or pain.
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Hospital1 1559**] ([**Location (un) **] Campus 8 South)
Discharge Diagnosis:
s/p ~30 ft fall/jump (suicide attempt)
Grade IV Liver laceration
Grade III Right Renal Laceration
Bilateral pulmonary contusions
L2 spinous process fracture
Perilunate dislocation
Facial lacerations
Left ulnar radius fracture
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, apin
adequately controlled
Discharge Instructions:
You were admitted to the hospital for injury to your liver,
kidney, lungs, spine, and hand. Return to the ED for any of the
following:
*Fevers
*Abdominal pain
*Chest pain
*Shortness of breath
*Increasing pain
*Dizziness, lightheadness, or fainting
*Nausea or vomiting
*Numbness, tingling, or weakness
*Any other concerning symptoms.
Because of the injury to your liver you should AVOID any contact
sports or activity that may cause injury to your abdominal area.
Followup Instructions:
Follow up in 2 weeks with Trauma Surgery. Call [**Telephone/Fax (1) 6429**] for
an appointment.
Follow up in 1 week with Plastic Surgery. Call [**Telephone/Fax (1) 3009**] for
an appointment.
**You may also follow up in the Plastic and Trauma surgery
clinics at [**Hospital6 15083**]. These appointments will need to
be made by the inpatient psychiatric facility that you will be
going to.
If there are any difficulties scheduling any of the above
appointments please call [**First Name8 (NamePattern2) 17148**] [**Last Name (NamePattern1) 2819**], NP, Trauma Surgery at
[**Telephone/Fax (1) 67547**].
|
[
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"907.0",
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icd9cm
|
[
[
[]
]
] |
[
"86.59",
"21.81",
"79.32",
"24.32",
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icd9pcs
|
[
[
[]
]
] |
6253, 6355
|
3083, 5376
|
286, 314
|
6625, 6705
|
612, 3060
|
7220, 7828
|
575, 593
|
5567, 6230
|
6376, 6604
|
5402, 5544
|
6730, 7197
|
230, 248
|
342, 419
|
441, 504
|
520, 559
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,500
| 122,033
|
45453
|
Discharge summary
|
report
|
Admission Date: [**2171-9-15**] Discharge Date: [**2171-9-26**]
Date of Birth: [**2111-6-29**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
ESLD due to HCV cirrhosis and hepatocellular carcinoma, awaiting
liver transplantation
Major Surgical or Invasive Procedure:
[**2171-9-16**] Orthotopic liver transplant from deceased donor with
portal vein to portal vein anastomosis, donor celiac axis to
recipient right hepatic artery anastomosis, and bile duct to
bile duct anastomosis over an 8-French T-tube
[**2171-9-19**] Right-sided diagnostic and therapeutic thoracentesis
History of Present Illness:
60 year-old male with HCV cirrhosis and hepatocellular
carcinoma, who presented for a liver transplant. His liver
disease was asymptomatic other than edema and ascites. He
reported feeling well, and denied any fevers, chills, or recent
illnesses. He was recently hospitalized was for a potential
transplant, which did not occur.
Past Medical History:
Transplant Hx:
59-year-old male with cirrhosis secondary to hepatitis C and
hepatocellular carcinoma. He underwent a RFA of three lesions in
[**2170-10-12**] for HCC. The patient had a bone scan in [**2170**],
which revealed no evidence of osseous metastases, but there was
mild uptake in the region of the spleen. His alpha feta protein
has been regularly checked and remains stable around 4. He had
an upper endoscopy on [**2169-3-1**] revealing three cords of grade 2
varices.
.
PMH:
-Hepatitis C virus associated cirrhosis with a prior history
of interferon therapy over five years ago.
-Hepatocellular carcinoma by biopsy in [**2170-8-11**]. Initial
abdominal CT showed three separate lesions in the liver. He had
radiofrequency ablation in [**2170-10-12**]. Most recent CT of the
abdomen on [**2171-1-31**] shows stable 1.4 cm lesion at the
dome and stable prior radiofrequency ablation foci.
PSH:
-back injury s/p surgery ~[**2157**]
-knee injury s/p surgery [**2141**]
-appendectomy
Social History:
Lives with wife, smokes 2 cigarettes/day, quit EtOH 35 years
ago, no drug use.
Family History:
"mother died in her sleep"
father with DM, now deceased.
Physical Exam:
(on admit)
Gen: NAD
HEENT: no icterus
CVS: RRR
Pulm: CTA b/l
Abd: soft, nontender, mildly distended, +BS, hepatomegaly 1-2 cm
below costal margin in midclavicular line, no splenomegaly
appreciated, + fluid wave
Ext: 2+ pitting edema b/l LE to the shins, no clubbing/cyanosis
Pertinent Results:
[**2171-9-15**] 04:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2171-9-15**] 04:12PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2171-9-15**] 04:13PM PT-15.0* PTT-37.1* INR(PT)-1.4*
[**2171-9-15**] 04:13PM WBC-2.8* RBC-3.33* HGB-12.1* HCT-34.9*
MCV-105* MCH-36.3* MCHC-34.5 RDW-15.0
[**2171-9-15**] 04:13PM PLT COUNT-57*
[**2171-9-15**] 04:13PM ALBUMIN-3.4 CALCIUM-8.9 PHOSPHATE-4.5
MAGNESIUM-2.0
[**2171-9-15**] 04:13PM ALT(SGPT)-72* AST(SGOT)-119* ALK PHOS-65 TOT
BILI-1.0
[**2171-9-15**] 04:13PM GLUCOSE-124* UREA N-13 CREAT-1.2 SODIUM-140
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-32 ANION GAP-10
[**2171-9-15**] 09:02PM freeCa-1.01*
Brief Hospital Course:
Admitted on [**2171-9-15**] and underwent an orthotopic liver transplant
from deceased donor
with portal vein to portal vein anastomosis, donor celiac axis
to recipient right hepatic artery anastomosis and bile duct to
bile duct anastomosis over an 8-French T-tube on [**2171-9-16**]. He
tolerated the procedure well with no immediate complications and
was brought to the SICU for post-operative management. Liver US
on POD#0 revealed patent hepatic vasculature, with no
perihepatic fluid collections and 90cm/sec velocity in the donor
main portal vein. The patient was extubated following arrival to
ICU and immunosuppression was initiated per protocol - FK 2mg
daily, MMF 2g daily, and a steroid taper. Antibiotics (nystatin,
valcyte, fluconazole) were initiated according to protocol.
Post-operatively, he remained stable hemodynamically stable.
Once in the ICU, he was weaned off propofol, with RISBI 44, good
cough and gag, and was subsequently extubated without incident
on POD#0. JP drain output was sero-sanginous and T-tube output
bilious. On POD#0, PAC was discontinued and CVL placed. Foley
and NG tube remained in place. The patient was given oxycodone
and dilaudid for pain. He required oxygen following extubation
(coo-aersol tent and 5L nasal cannula) and was unable to be
weaned over 24 hours. On attempted wean, he was noted to desat
to 85-88%. On POD#2, the patient was noted to have crackles on
expiration and coarse breath sounds. A CXR revealed low lung
volumes, but aside from mild atelectasis at the left base, was
essentially clear. Repeat xray demonstrated persistent
small-to-moderate right pleural effusion and associated
atelectasis. Chest PT was initiated at this time, as well as
aggressive pulmonary toilet. Physical therapy was consulted to
assist with getting the patient out of bed. On POD#2, due to LE
swelling and shortness of breath, a bilateral lower extremity
U/S was also obtained, with no evidence of DVT with bilateral
lower extermities. An ECHO was obtained on [**9-19**], with no
significant intrapulmonary shunting, but symmetric LVH. 48hrs
following extubation, the patient continued to require oxygen
and was unable to be weaned without desatting to mid-80%. As a
result, CT chest was obtained on [**9-18**], which revealed an interval
slight increase in moderate/large right pleural effusion.
Interventional pulmonology was consulted and the patient
underwent a right-sided diagnostic and therapeutic thoracentesis
with removal of 800cc bloody fluid. A CT chest was then
completed which revealed atelectasis and/or pneumonic
consolidation in the right lower lobe, with new multifocal
ground-glass opacities in the upper lobes. Differential
diagnosis included pulmonary hemorrhage, less likely viral
infection, drug reaction or aspiration pneumonitis. The
patient's respiratory status improved following thoracentesis.
The patient received a bronchoscopy on [**9-20**], which revealed
small amount of mucoid secretions. During the procedure, BAL was
obtained for fungal, viral and bacterial cultures with an
immunocompromised protocol. Bronchial washings were found to be
negative for malignancy, with negative cultures to date. Per ID
recommendations, the patient was placed on ciprofloxacin,
bactrim, fluconazole, levofloxacin, zosyn, and vancomycin while
cultures were pending. On [**9-21**], the patient's NG tube was
removed and he was placed on clear liquids, which he tolerated
well. He was determined stable for transfer to the floor. At
this time, vancomycin, ciprofloxacin, and zosyn were
discontinued, as there was no evidence of bacterial pneumonia.
Fluconazole, bactrim, and valycte were continued per protocol.
On POD#7, the patient received a cholangiogram, which
demonstrated a cyanotic area at the level of the anastomosis
probably due to mild edema, with a small amount of contrast
material passing into the jejunum. Upon transfer to the floor,
he was tolerating a regular diet, ambulating independently,
urinating without difficulty, and reported adequate pain control
on oral dilaudid. The medial JP drain was pulled on POD#9.
Discharge planning and patient teaching were initiated and a
decision was made to discharge on POD #10. FK level was 12.1 on
[**2171-9-26**] and the patient was given Tacrolimus 1mg po bid. Empty
your drain bulb and record amounts at least twice daily, more
often as needed. He was instructed to bring a record of the
drain output with to his next clinic appointment and to measure
and record his blood sugars daily. He will have labwork done
every Monday and Thursday following discharge.
Medications on Admission:
Lasix 40 mg [**Hospital1 **]
Nadolol 20 mg QD
Mycelex 10 mg QD,
Aldactone 100 mg QD
Percocet 10/325 1 tab q6h prn back/knee pain
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Trimethoprim-Sulfamethoxazole 80-400 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. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
7. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
twice a day.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*2*
9. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed.
Disp:*60 Tablet(s)* Refills:*0*
11. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
HCC cirrhosis and hepatocellular carcinoma s/p OLT
Discharge Condition:
stable
Discharge Instructions:
Please call Dr.[**Name (NI) 1381**] office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, inability to take any of your medications,
abdominal distension or diarrhea, jaundice, incision/drain site
redness/bleeding or drainage or any concerns.
No heavy lifting
[**Month (only) 116**] shower, pat incision dry
Empty your drain bulb and record amounts at least twice daily,
more often as needed. Bring a record of the output with you to
the transplant clinic visit.
Measure and record blood sugars daily. Bring a record of the
readings with you to the transplant clinic visit
Have labwork done every Monday and Thursday
Do not drive if taking narcotic pain medication
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2171-10-3**] 10:30
[**Name6 (MD) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2171-10-3**] 11:20
[**Name6 (MD) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2171-10-10**] 11:40
|
[
"518.0",
"V18.0",
"571.5",
"782.3",
"070.54",
"511.9",
"155.0",
"997.3",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"87.54",
"00.93",
"99.04",
"50.59",
"99.05",
"34.91",
"96.6",
"96.56",
"33.22",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
9101, 9159
|
3334, 7922
|
401, 708
|
9254, 9263
|
2566, 3311
|
9993, 10357
|
2197, 2256
|
8101, 9078
|
9180, 9233
|
7948, 8078
|
9287, 9970
|
2271, 2547
|
275, 363
|
736, 1069
|
1091, 2084
|
2100, 2181
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,872
| 139,593
|
610
|
Discharge summary
|
report
|
Admission Date: [**2193-11-18**] Discharge Date: [**2193-11-26**]
Date of Birth: [**2154-4-7**] Sex: M
Service: MEDICINE
Allergies:
Oxycodone
Attending:[**Male First Name (un) 4578**]
Chief Complaint:
.
Right patellar fracture
.
Major Surgical or Invasive Procedure:
.
1. open reduction internal fixation for right patellar fracture
.
2. Cardiac catheterization
.
History of Present Illness:
CC:[**CC Contact Info 4714**].
HPI: 39 yo M w h/o G6PD deficiency, DM2, s/p ORIF (intubated
during procedure) for R patella fx. Post-surgical course
complicated by 02 desat to the 80's on RA and post-op pain. Pt.
required 6L FM 02 to incr. sats to the 90's. Additionally, EKG
showed diffuse ST depressions and TWI. Pt. was transferred to
the [**Hospital Unit Name 153**] for observation and management of hypoxia. The pt. had
an epidural placed for pain control which has now been d/c'd. He
is now transferred to [**Hospital Unit Name 196**] for further workup of EKG changes and
possible cardiac catheterization. He denies any chest pain or
SOB during this hospitalization.
.
ROS: Pt. denies headaches, SOB, CP(although he does describe a
few episodes of chest pain with excercise and at rest in the
past). Denies N/V, denies diarrhea, admits to constipation and
reflux as inpatient.
.
Past Medical History:
.
- OSA(newly diagnosed)
- G6PD deficiency
- DM 2
- h/o genital herpes
- R patella fx: occurred while playing basketball on [**11-8**].
Underwent ORIF of R knee on [**11-18**] due to non-[**Hospital1 **].
- s/p repair of R ruptured patellar tendon in [**2185**]
.
Social History:
.
SOCIAL HISTORY: He is currently working as a realtor. He does
not smoke, never smoked in the past, but does drink alcohol
socially.
.
Family History:
.
FAMILY HISTORY:
No fam hx of CAD or cancer.
.
Physical Exam:
.
PHYSICAL EXAM:
Vitals: 140/84 68 100%RA FS 153
Gen: NAD, AAOx3
HEENT: EOMI, PERRL
Cardio: distant heart sound, normal S1/S2, no murmurs.
Resp: CTA bilat. no wheezes, crackles
Abd: NT/ND, BS normoactive
Ext: R knee immobilizer in place, 1+ edema on right. L leg
non-edematous.
.
Pertinent Results:
.
EKG: NSR@ 79, nl axis, nl intervals, <1mm STE in V1, V2, STD in
II, III, aVF, V4-V6, TWF in I, TWI in II, III, V3-V6
.
IMAGING:
CXR: bilateral airspace disease (R>L) c/w pulm edema vs.
aspiration
.
XRAY RIGHT KNEE, THREE VIEWS [**2193-11-8**]: There is a transverse
fracture through the lower third of the patella with
approximately 2.3 cm of distraction. There are several adjacent
bony fragments. A large knee effusion is present. Bony
mineralization is normal. No radiopaque foreign bodies are
identified. There is diffuse generalized edema in the
surrounding soft tissues. The distal femur and proximal tibia
are intact. The alignment of the knee is preserved.
IMPRESSION: Transverse fracture of the right patella as above.
.
Right LE Duplex, [**2193-11-23**]:
Limited study. No evidence of deep venous thrombosis within the
right common femoral, proximal superficial femoral and calf
veins.
.
ECHO, [**2193-11-19**]:
The left atrium is mildly elongated. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal.
Tissue velocity imaging demonstrates an E/e' <8 suggesting a
normal left ventricular filling pressure (<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Preserved global and regional biventricular systolic
function.
.
Cardiac cath, [**2194-11-25**]:.
1. Selective coronary angiography of this right dominant system
revealed
no angiographically apparent coronary artery disease. The LAD,
LCX, and
RCA were patent without disease. The LMCA had 20% ostial
stenosis.
2. Limited hemodynamics demonstrated LVEDP of 13mmHg.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
.
Brief Hospital Course:
39 yo M w h/o G6PD deficiency, DM2, s/p ORIF (intubated during
procedure) for R patella fx. Post-surgical course complicated by
02 desat to the 80's on RA and post-op pain with EKG changes.
MICU course:
**Enzymes consistently negative. Cards to do cardiac
catheterization for concern for left main disease. Of note
t-wave abnormalities persisted throughout his stay in the unit.
Patient was started on aspirin, lipitor, acei, and beta-blocker.
**Patient had low-grade fever that orthopedics attributed to
knee operation. Patinet was kept on Cefazolin per orthopedics.
**Hematology consulted regarding the safety of asa and G6PD
deficiency. They felt that it was OK to give a trial of the ASA
and then assess. HCT was stable.
**Elevated creatinine was attributed to large muscle mass and
not believed to be due to any pathologic process in the setting
of a normal GFR.
**Oxygen requirement decreased during his stay and it was not
believed to have had a PE given the short surgery and clinical
improvement.
.
Hospital Course:
#) Hypoxia: The patient desatted to the 80's on RA and required
6L 02 after surgery. His O2 requirement gradually decreased and
eventually was 100% 02 sat on RA. Chest xray showed mild pulm.
edema and elevated left hemi-diaphragm. His O2 requirement was
thought initially to be [**1-31**] oversedation from pain medications
in the post-operative setting along with history of obstructive
sleep apnea. His O2 requirement improved quickly and PE was not
thought to be likely.
.
#) EKG changes: The patient's EKG showed diffuse fixed 1mm ST
elevations and TWI that persisted on followup EKGs. However, it
was unclear whether these changes are new (no EKGs on record in
our records or [**Hospital1 2177**]). The patient has been asymptomatic and
denies any chest pain or SOB. He does report mild chest pain a
few weeks back while excercising and at rest. He was monitored
on telemetry and seen by the cardiology consult who felt his EKG
findings were concerning for possible left main disease. He was
transferred to the cardiology service for cardiac
catheterization. His cardiac enzymes were cycled and were
negative, and he was monitored on telemetry. He was started on
an aspirin, BB, statin, and ACEI during his hospitalization and
continued upon discharge. His cardiac cath showed no evidence
of coronary disease but concern for possible compression of the
left main root, possibly anomalous coronary anatomy. He was
scheduled for an outpatient cardiac MRI to further evaluate this
possibility and follow up in cardiology clinic.
.
#) Elevated Creatinine: The patient was admitted with a Cr of
1.6. Records obtained from [**Hospital1 2177**] show his baseline crt. is 1.5.
His calculated CrCl was normal and the elevated Cr was thought
to be [**1-31**] the patient's large muscle mass.
.
#) HTN: The patient had no history of documented HTN. However,
the patient had SBP in the 160's while at [**Hospital1 18**]. He was started
on a BB and ACEI given his EKG changes and concern for cardiac
disease.
.
#) Type II DM: The patient's outpatient oral hypoglycemics were
stopped upon admission and he was maintained on an insulin
sliding scale. He was briefly put on Glargine for control of
elevated blood sugars but this was discontinued before his
discharge.
.
#) Fevers: The patient had fevers to 101 in the post-operative
period. His fever curve trended down. Blood and urine cultures
were negative. A chest xray showed evidence of atelectasis and
the patient was encouraged to continue incentive spirometry. A
right lower extremity Duplex was negative for DVT. He was
continued on Cefazolin per recommendations of the orthopedic
service. This was discontinued and the patient had no further
fevers.
.
#) s/p ORIF of left patellar fracture: The patient was followed
by the orthopedic surgery service. He was fitted with a brace
for the right leg and was scheduled for followup in 2 weeks with
orthopedics for further adjustment of the brace. He was given a
short course of pain medication for his right knee pain after
surgery and he will followup with orthopedics in 2 weeks.
.
#) G6PD deficiency: Stable during this hospitalization. Sulfa
drugs were avoided, as were dietary triggers.
Hematology/oncology was called before starting aspirin but they
felt that the patient had a low likelihood of hemolysis with
aspirin. The patient was started on aspirin and monitored for
signs and lab evidence of hemolysis. His hematocrit was stable
and he tolerated the aspirin well. He was continued on an
aspirin as an outpatient.
.
#) FEN: Cardiac heart-healthy, G6PD deficiency diet
.
#) Code: Full Code
Medications on Admission:
.
MEDS (home):
Glyburide 5mg qd
.
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. HYDROmorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain for 7 days.
Disp:*35 Tablet(s)* Refills:*0*
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
.
Primary:
1. patellar fracture s/p ORIF
.
Secondary:
1. diabetes type II
2. hypertension
3. G6PD deficiency
.
.
Discharge Condition:
.
stable. hypoxia resolved.
.
Discharge Instructions:
.
1. Please continue to take your new blood pressure medications
as prescribed.
2. Please continue physical therapy as instructed.
3. Attend you follow up appoinments as below.
.
If you experience any numbness or tingling or weakness in your
lower extremity or if you have fevers, chills, shortness of
breath, chest pain or other worrisome symptoms please seek
medical attention.
.
Followup Instructions:
.
Please followup with orthopedics for your patellar fracture:
Provider: [**Name10 (NameIs) **] GATES, RNC MSN Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2193-12-3**] 10:10
.
You have an appointment scheduled to see your primary care
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) 4715**], at [**Hospital6 **] on
Monday, [**12-2**] at 8:30am.
.
Completed by:[**2193-11-26**]
|
[
"250.40",
"401.9",
"733.82",
"338.18",
"271.0",
"583.81",
"E929.9",
"327.23",
"905.4",
"822.0",
"518.0",
"E927",
"518.4",
"794.31",
"519.4",
"799.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.36",
"37.22",
"03.90",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
9562, 9568
|
4206, 5221
|
303, 402
|
9725, 9757
|
2145, 4129
|
10187, 10631
|
1797, 1829
|
8945, 9539
|
9589, 9704
|
8886, 8922
|
5238, 8860
|
4146, 4183
|
9781, 10164
|
1861, 2126
|
236, 265
|
430, 1322
|
1344, 1609
|
1643, 1763
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,713
| 163,414
|
50320
|
Discharge summary
|
report
|
Admission Date: [**2150-4-20**] Discharge Date: [**2150-4-27**]
Date of Birth: [**2096-10-22**] Sex: F
Service: NEUROLOGY
Allergies:
Ativan
Attending:[**First Name3 (LF) 5831**]
Chief Complaint:
confusion, headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Known firstname **] [**Known lastname **] is a 53 year-old woman who was brought into the ED by
her husband after she was confused and not making sense this
morning at home. She has a notable history of paraplegia
secondary to motor-vehicle accident in [**2142**] with T1/2 cord
injury. She was recently hospitalized from [**4-14**] - [**4-16**] after
she developed yellow productive sputum with a likely right lower
lobe consolidation. She was treated w/ Vancomycin, cefepime and
azithromycin for a healthcare associated pneumonia (HCAP) and
discharged on [**4-16**]. She was also found to have a multidrug
resistant klebsiella UTI and was started on Vanc/Zosyn for a 14
day course.
Her husband and primary caregiver at home felt that the evening
prior to admission she was at her baseline which they describe
as
communicative, pleasant and with mobility in her upper
extremities. On [**4-20**] she awoke stating that she had a bad
headache (further description unobtainable) and she was no
longer
making sense. She continued to repeat phrases and was not
following commands. She was brought into the ED. During her time
in the ED she was noted to have a seizure for around 1 minute
which consisted of deviation of the head to the right with eyes
to the right. She also had tonic contraction of both arms. This
resolved spontaneously and was then given 2 mg of Versed (hx of
adverse reaction to Ativan). Her caregiver reports that she had
one seizure in the past, around 1 year ago in the setting of
multiple medication discontinuation (including - baclofen).
She also has a history of PRES in the setting of a MICU
admission
in [**2147-12-3**] in which systolic blood pressures were greater than
160s. She had binocular vision loss during the episode and MRI
with occipital lobe FLAIR hyperintensities.
She is unable to provide any additional history. Her husband
states that at home her blood pressure typically run in the
90s-110s systolic.
Past Medical History:
# T1 to T2 paraplegia status post a motor vehicle accident.
# Recurrent pneumonia (followed by pulm - Last [**2149-4-9**])
- Per pulm, recurrent pneumonia likely from pulmonary toilet
issues secondary to neuromuscular disease with improvement with
consistent and aggressive bronchopulmonary therapy.
- Prior sputum cultures + for MRSA, pan-sensitive Klebsiella,
and Pseudomonas.
# Recurrent UTIs in the setting of urinary retention requiring
straight catheterization
# COPD
# hepatitis C
# anxiety
# DVT in [**2142**] -IVC filter placed in [**2142**]
# Pulmonary nodules
# Hypothyroidism
# Chronic pain
# Chronic gastritis
# Anemia of chronic disease
# S/p PEA arrest during hospitalization in [**2147-10-3**]
Social History:
Lives at home with husband and 2 adolescent children.
- Tobacco: 35-pack-years, has tried to quit but smokes
intermittently.
- Alcohol: Denies.
- Illicits: Denies.
Family History:
Mom - lung cancer
Dad - healthy
Physical Exam:
afebrile; 116-190s/70s-110s P 90s R 30s SpO2 95% facemask
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: continuously repeating phrases "yes, ok, yes,
ok". Not following simple appendicular or midline commands.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 5 to 2mm and sluggish. blinks to threat b/l.
Funduscopic exam revealed no papilledema, exudates, or
hemorrhages.
III, IV, VI: eyes midline and will track to the left, not moving
past midline to the right
V: reacts to stimuli on both sides of face
[**Year (4 digits) **]: No facial droop, facial musculature symmetric.
VIII: reacts to auditory stimuli b/l
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: unable to test
XII: unable to test
-Motor: diminished bulk in LE, flaccid tone in LE.
No adventitious movements, such as tremor, noted. Has b/l
movements of arms that are purposeful and symmetric, some
resistance b/l at the triceps. No movement of legs (chronic)
-Sensory: reacting to stimuli on UE b/l
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 0 0
R 2 2 2 0 0
Plantar response was muted bilaterally.
-Coordination: unable to test
-Gait: unable to test given paraplegia
.
Exam on discharge:
.
Unchanged except for the following Mental status exam: Alert,
oriented X3, language normal, attention: able to recite months
of year backwards, short-term memory: [**4-5**] words @ 5minutes,
slight perseveration,
Pertinent Results:
Labs on admission:
[**2150-4-20**] 09:45AM PT-12.5 PTT-29.9 INR(PT)-1.2*
[**2150-4-20**] 09:45AM PLT COUNT-218#
[**2150-4-20**] 09:45AM NEUTS-79.0* LYMPHS-14.4* MONOS-2.9 EOS-3.1
BASOS-0.6
[**2150-4-20**] 09:45AM WBC-9.1 RBC-3.84* HGB-10.0* HCT-33.7*# MCV-88
MCH-26.0* MCHC-29.7* RDW-16.4*
[**2150-4-20**] 09:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2150-4-20**] 09:45AM ALBUMIN-3.8 CALCIUM-9.2 PHOSPHATE-3.8#
MAGNESIUM-2.3
[**2150-4-20**] 09:45AM LIPASE-16
[**2150-4-20**] 09:45AM ALT(SGPT)-30 AST(SGOT)-22 ALK PHOS-78 TOT
BILI-0.2
[**2150-4-20**] 09:45AM GLUCOSE-119* UREA N-9 CREAT-0.5 SODIUM-146*
POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-40* ANION GAP-11
[**2150-4-20**] 09:51AM LACTATE-1.0
[**2150-4-20**] 10:17AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2150-4-20**] 10:17AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2150-4-20**] 10:17AM URINE UHOLD-HOLD
[**2150-4-20**] 10:17AM URINE HOURS-RANDOM
[**2150-4-20**] 12:16PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-1100*
POLYS-45 LYMPHS-45 MONOS-10
[**2150-4-20**] 12:16PM CEREBROSPINAL FLUID (CSF) WBC-9 RBC-3*
POLYS-43 LYMPHS-45 MONOS-12
[**2150-4-20**] 12:16PM CEREBROSPINAL FLUID (CSF) PROTEIN-79*
GLUCOSE-71
[**2150-4-20**] 12:35PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2150-4-20**] 12:35PM URINE HOURS-RANDOM
Imaging studies:
.
[**2150-4-20**]
CT_HEAD
IMPRESSION: Significant motion artifact limits evaluation. White
matter
hypodensity in the left parietal lobe may represent sequela of
prior event of PRES.
.
NOTE ADDED AT ATTENDING REVIEW: Although the left frontal
hypodensity might be a sequelum of prior PRES, the MR
examination of [**2147-12-29**] did not demonstrate abnormality in
this location. Further, there is loss of grey white contrast,
but no atrophy, as might be expected if this were an old lesion.
These findings raise concern of acute-subacute infarction, or
perhaps swelling after a seizure. MR is recommended for further
evaluation. This revised interpretation was noticed at 5:25 pm,
and discussed by telephone, by Dr. [**Last Name (STitle) **], with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 22924**]
of the Emergency Department at 5:30pm.
[**2150-4-19**]
EEG
IMPRESSION: This is an abnormal portable EEG due to the presence
of
frequent left temporal and left hemisphere sharp and slow wave
discharges occurring for a few seconds at a time at 1 Hz
indicative of
an epileptogenic focus in this region. However, the study was
severely
limited by abundant and frequent movement artifact during the
majority
of the study, and the rightsided electrodes were most severely
affected. The background was otherwise slow and disorganized
reaching
up to a maximum of [**6-7**] Hz posteriorly indicative of a moderate
to
severe encephalopathy. Given the above findings, we suggest 24
bedside
EEG monitoring for further diagnosis.
[**2150-4-24**]
CT-HEAD
IMPRESSION: Hypodensities in bilateral occipital, left temporal,
and left
frontal lobes are not significantly changed since the prior
exam, and may
represent PRES or post-seizure changes. MRI is recommended for
further
evaluation.
Brief Hospital Course:
Ms. [**Known lastname **] is 53 yo woman with T1-T2 level paraplegia since [**2142**],
with previous history of episode of PRES, was in [**Hospital1 **] with
pneumonia and UTI last week, home for 4 days when she developed
headache and confusion. She came in to ER, was hypertensive to
SBP of 170's-180's and DBP in 110-120 range, had a focal seizure
and severe encephalopathy.
On [**2150-4-20**] she was admitted to the ICU and her hypertension was
treated with nicardipine IV. She was loaded with [**Date Range 13401**] for
possible seizures. She was given Acyclovir empirically for
possibility of HSV encephalitis and underwent a lumbar puncture.
She was treated empirically for MDR UTI and possible PNA with
Vancomycin/Cepefime/Flagyl.
She underwent NCHCT which showed hypodensities consistent with
PRES with possibility of acute-subacute infarct.
Given her overall improvement, she was transfered to the floor
on [**2150-4-22**].
She remained afebrile and her BP was well controlled. Her CSF
did not show HSV and Acyclovir was discontinued. Her other ABx
were also stopped.
On [**2150-4-22**], she had an extended routine EEG which did not show
electrographic seizures or clear spikes. Her [**Date Range 13401**] was
continued for seizure prophylaxis as she did not have any other
episodes concerning for seizure.
To evaluate the hypodensity seen on previous scan, she was
ordered for MRI brain but refused. She was then ordered for a
repeat NCHCT which showed stable changes consistent with PRES.
She will be discharge home to resume her typical pre-admission
home services.
Transitional issues:
.
1. PRES: this is the second episode since [**2147**]. Given her
paraplegia, she is at risk for dysautonomia and hypertensive
crises which have required inpatient hospitalizations for BP
control. Her BP is somewhat labile and attempts to start low
dose BP control meds (lisinopril) have led to significant
hypotension. Going forward, she might benefit from BP cuff with
PRN BP control at home. She should continue her typical home
care to limit pain, constipation or other triggers of
hypertension.
.
2. Pulmonary function: she has chronic recurrent PNA and
followed by Pulmonary service. She has PFTs tomorrow and ongoing
home chest-PT which she will continue on discharge.
.
3. Sleep apnea: during this hospitalization, she had several
episodes of desaturations (80s) at night despite being on 2LNC.
It is [possible that her likely sleep apnea is contributing to
HTN. We will recommend a sleep study as outpatient.
.
4. Seizures: these were likely provoked by PRES. For the moment,
she will remain on [**Name (NI) 13401**] prophylactically until neurology
follow-up.
Medications on Admission:
albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Name (NI) **]: One (1) Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
baclofen 10 mg Tablet [**Name (NI) **]: Two (2) Tablet PO BID (2 times a
day).
baclofen 10 mg Tablet [**Name (NI) **]: One (1) Tablet PO Once Daily at 4
PM.
calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
[**Name (NI) **]: Two (2) Tablet, Chewable PO twice a day.
citalopram 40 mg Tablet [**Name (NI) **]: One (1) Tablet PO once a day.
6. ipratropium bromide 0.02 % Solution [**Name (NI) **]: One (1) Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
7. levothyroxine 112 mcg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY
(Daily).
8. clonazepam 1 mg Tablet [**Name (NI) **]: One (1) Tablet PO three times a
day as needed for anxiety.
9. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Name (NI) **]:
Three (3) Adhesive Patches, Medicated Topical DAILY (Daily).
10. methadone 5 mg Tablet [**Name (NI) **]: One (1) Tablet PO TID (3 times a
day).
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Name (NI) **]: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
12. oxybutynin chloride 5 mg Tablet [**Name (NI) **]: One (1) Tablet PO Once
Daily at 4 PM.
13. oxybutynin chloride 5 mg Tablet [**Name (NI) **]: Two (2) Tablet PO BID
(2 times a day).
14. polyethylene glycol 3350 17 gram Powder in Packet [**Name (NI) **]: One
(1) Powder in Packet PO DAILY (Daily).
15. pregabalin 100 mg Capsule [**Name (NI) **]: One (1) Capsule PO TID (3
times a day).
16. simvastatin 10 mg Tablet [**Name (NI) **]: One (1) Tablet PO once a day.
17. sucralfate 1 gram Tablet [**Name (NI) **]: One (1) Tablet PO TID (3 times
a day).
18. oxycodone 5 mg Tablet [**Name (NI) **]: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
19. trazodone 100 mg Tablet [**Name (NI) **]: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
20. azithromycin 250 mg Tablet [**Name (NI) **]: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
21. prednisone 10 mg Tablet [**Name (NI) **]: Two (2) Tablet PO once a day:
Friday, then 1 tablet daily Saturday/Sunday.
Disp:*4 Tablet(s)* Refills:*0*
22. vancomycin 500 mg Recon Soln [**Name (NI) **]: 1250 (1250) mg Intravenous
Q 12H (Every 12 Hours) for 23 doses.
Disp:*23 inj* Refills:*0*
23. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback
[**Name (NI) **]: One (1) Intravenous Q8H (every 8 hours) for 32 doses.
Disp:*32 inj* Refills:*0*
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Name (NI) **]: One (1) Inhalation Q6H (every 6 hours) as
needed for dyspnea.
2. baclofen 10 mg Tablet [**Name (NI) **]: Two (2) Tablet PO BID (2 times a
day).
3. baclofen 10 mg Tablet [**Name (NI) **]: One (1) Tablet PO Q 24H (Every 24
Hours).
4. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
[**Name (NI) **]: Two (2) Tablet, Chewable PO twice a day.
5. citalopram 20 mg Tablet [**Name (NI) **]: Two (2) Tablet PO DAILY (Daily).
6. ipratropium bromide 0.02 % Solution [**Name (NI) **]: One (1) Inhalation
Q6H (every 6 hours) as needed for dyspnea.
7. levothyroxine 112 mcg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY
(Daily).
8. clonazepam 1 mg Tablet [**Name (NI) **]: One (1) Tablet PO TID (3 times a
day).
9. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Name (NI) **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
10. methadone 5 mg Tablet [**Name (NI) **]: One (1) Tablet PO TID (3 times a
day).
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Name (NI) **]: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
12. oxybutynin chloride 5 mg Tablet [**Name (NI) **]: Two (2) Tablet PO BID
(2 times a day).
13. oxybutynin chloride 5 mg Tablet [**Name (NI) **]: One (1) Tablet PO Q24H
(every 24 hours).
14. polyethylene glycol 3350 17 gram Powder in Packet [**Name (NI) **]: One
(1) Powder in Packet PO DAILY (Daily).
15. pregabalin 25 mg Capsule [**Name (NI) **]: Four (4) Capsule PO TID (3
times a day).
16. simvastatin 10 mg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY
(Daily).
17. sucralfate 1 gram Tablet [**Name (NI) **]: One (1) Tablet PO three times
a day.
18. oxycodone 5 mg Tablet [**Name (NI) **]: One (1) Tablet PO Q8H (every 8
hours) as needed for Pain.
19. trazodone 50 mg Tablet [**Name (NI) **]: Two (2) Tablet PO HS (at
bedtime) as needed for anxiety.
20. acetaminophen 650 mg/20.3 mL Solution [**Name (NI) **]: One (1) PO Q6H
(every 6 hours) as needed for headache.
21. levetiracetam 500 mg Tablet [**Name (NI) **]: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*3*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA
Discharge Diagnosis:
Encephalopathy
PRES syndrome
seizure
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 the hospital for confusion and headaches
and were found to have very high blood pressure. You also may
have had a seizure.
You confusion was thought to be the result of either high blood
pressure or the result of an infection. Both your high blood
pressure and possible infection were treated and you improved.
The antibiotics were stopped. An anti-seizure medication was
started.
You were closely monitored over the next several days and your
condition improved every day.
You should follow up with the neurologist once you leave the
hospital.
You should follow up with the Pulmonary doctor once you leave
the hospital given the concern for sleep apnea. You may benefit
from a sleep study to ensure that your oxygen level does not
decrease at night. You should continue respiratory therapeutic
maneuvers every day.
During your hospitalization, you were noted to have several high
blood pressure readings. You should discuss starting a
medication to help treat this.
Please note the following medication changes
START
- [**Hospital1 13401**] (to help prevent seizures, this medication might be
stopped by your neurologist in the future)
STOP:
-
Please continue taking all your other medication as prescribed
by your physicians.
Followup Instructions:
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2150-4-30**] at 1:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: THURSDAY [**2150-4-30**] at 1:30 PM
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2150-4-30**] at 1:30 PM
With: DRS. [**Name5 (PTitle) 4013**] & [**Doctor Last Name **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: Neurology
When: [**2150-5-13**] 02:30p
With: [**Doctor Last Name 43**],[**Doctor Last Name **]
Where: SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] NEUROLOGY UNIT CC8
|
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"244.9",
"300.00",
"348.39",
"599.0",
"305.1",
"041.3",
"780.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
15730, 15781
|
8283, 9872
|
289, 296
|
15862, 15862
|
4973, 4978
|
17322, 18140
|
3209, 3242
|
13565, 15707
|
15802, 15841
|
10992, 13542
|
16040, 17299
|
3733, 4719
|
3257, 3594
|
9893, 10966
|
230, 251
|
324, 2277
|
4738, 4954
|
4993, 6445
|
15877, 16016
|
2299, 3011
|
3027, 3193
|
6462, 8260
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,934
| 100,662
|
31027
|
Discharge summary
|
report
|
Admission Date: [**2134-5-23**] Discharge Date: [**2134-5-28**]
Date of Birth: [**2056-9-12**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Acute stroke
Major Surgical or Invasive Procedure:
IV-TPA
History of Present Illness:
Reason for consult: Code Stroke
History of Present Illness: 76 year old right handed woman with
history of CAD s/p CABG in [**2117**]'s, htn, hyperchol, who was
feeling well until 11 a.m. today when she told her husband she
was going out shopping but her speech sounded slurred. She
walked upstairs and about 15 minutes later her husband heard a
thump. He found her lying on the bathroom floor, mumbling
incoherently, with her right leg crossed over her left. He
called his daughter who came over to the house, then she called
EMS.
Husband reports no recent systemic illness, followed by Dr.
[**Last Name (STitle) 16958**] for cardiology, told everything was fine recently.
Husband not aware of any prior history of arrhythmia, no prior
stroke.
Review of systems: No known recent fever, weight loss, cough,
rhinorrhea, chest pain, palpitations, vomiting, diarrhea, or
rash. She does sometimes feel short of breath with exertion.
Past Medical History:
Past Medical History:
Hypertension
CAD s/p CABG in [**2117**]
Hypercholesterolemia
Social History:
Social History: Lives with husband.
Family History:
Family History: Non contributory
Physical Exam:
Examination:
T 95.4 HR 96, irregular BP 128/68 RR 18 Pulse Ox 100% on
RA initially
General appearance: 76 year old woman in C-spine collar lying
quietly in bed in NAD, with eyes open
HEENT: NC/AT, wearing C-spine collar
CV: Iregular rate rhythm without audible murmurs, rubs or
gallops. No carotid bruits audible.
Lungs: Crackles at bases
Abdomen: Soft, nontender, nondistended, no hsm or masses
palpated
Extremities: no clubbing, cyanosis or edema
Mental Status: Awake and alert, with eyes open. Mute, does not
produce any sound or speech. Does not reliably follow any
commands, does not mimic commands.
Cranial Nerves: Left pupil is round and reactive to light, right
is surgical. Blinks to threat bilaterally. Optic disc margins
are sharp on funduscopic exam. Extraocular movements are full
without gaze preference initially, then after 20-30 minutes she
developed a left gaze preference. There is no nystagmus.
+corneals. Right UMN facial droop. +gag.
Motor System: Initially no movement of right arm, occasional
flexion of right leg to noxious stimuli on either side. Moves
left arm and leg vigorously antigravity. Normal tone.
Reflexes: Deep tendon reflexes are 2+ and symmetric. Plantar
response extensor on right initially, later mute.
Sensory: Responds more vigorously to noxious stimuli on the
left,
readily but less vigorously in right leg, no response to
pinprick
in right arm.
Coordination, Gait: Could not assess
Pertinent Results:
[**2134-5-27**] 06:00AM BLOOD WBC-7.8 RBC-3.78* Hgb-11.6* Hct-34.0*
MCV-90 MCH-30.6 MCHC-34.0 RDW-14.2 Plt Ct-139*
[**2134-5-23**] 01:40PM BLOOD Neuts-78.1* Bands-0 Lymphs-14.5*
Monos-4.3 Eos-2.2 Baso-0.9
[**2134-5-27**] 06:00AM BLOOD Glucose-109* UreaN-11 Creat-0.6 Na-141
K-3.5 Cl-104 HCO3-29 AnGap-12
[**2134-5-24**] 02:47AM BLOOD ALT-17 AST-23 LD(LDH)-185 CK(CPK)-34
AlkPhos-48 TotBili-0.5
[**2134-5-27**] 06:00AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.9
[**2134-5-23**] 05:47PM BLOOD %HbA1c-5.7
[**2134-5-23**] 05:47PM BLOOD Triglyc-86 HDL-43 CHOL/HD-3.0 LDLcalc-68
LDLmeas-75
CTA [**2134-5-23**]:
CONCLUSION: No evidence of infarction on the non-contrast CT
scan.
Profound prolongation of mean transit time throughout the left
middle cerebral artery distribution. The blood volume appears
largely preserved, although somewhat decreased in the anterior
temporal lobe.
Occlusion of the left middle cerebral artery during its M1
course, just distal to the origin of an anterior temporal
branch.
CT head [**2134-5-24**]:
FINDINGS: There is mild prominence of the ventricles and sulci
in an atrophic pattern. There is no evidence of hemorrhage or
acute infarction.
There is a tiny focal hypodensity in the left putamen,
suggesting an old lacunar infarction. There have been no
significant changes since the head CT of [**2134-5-23**].
CXR [**2134-5-27**]:
There is significant improvement in previously demonstrated
severe pulmonary edema being now of a mild degree. Bilateral
pleural effusions are again noted. The heart size is markedly
enlarged but stable and the patient is after CABG.
CONCLUSION: No evidence of hemorrhage or recent infarction.
CT C-spine [**2134-5-24**]:
FINDINGS: Alignment is normal. No fractures are identified.
There are mild degenerative changes in the cervical spine that
cause mild narrowing of the spinal canal but no suggestion of
spinal cord compression. Noncontrast CT has limited intraspinal
soft tissue resolution and cannot evaluate the possibility of
disc, hematoma, or other soft tissue abnormalities inside the
spinal canal. There are large bilateral pleural effusions,
incompletely evaluated on this study.
CONCLUSION: No evidence of fracture or subluxation
Echocardiogram [**2134-5-24**]:
The left atrium is elongated. No left atrial mass/thrombus seen
(best excluded by transesophageal echocardiography). Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Regional left ventricular wall motion is
normal. [Intrinsic left ventricular systolic function is likely
more depressed given the severity of mitral regurgitation.] The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Moderate to severe (3+)
mitral
regurgitation is seen. There is moderate pulmonary artery
systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Moderate to severe mitral regurgitation. Preserved
global and
regional biventricular systolic function. Moderate pulmonary
artery systolic hypertension. No left atrial mass/thrombus seen.
Right knee x-ray [**2134-5-27**]:
Degenerative changes of the right knee including medial
compartment joint space narrowing. No definite fracture is seen;
previous finding reflected a projecting osteophyte.
Chondrocalcinosis.
Brief Hospital Course:
Hospital Course:
1. Neurology: Patient received IV TPA in ED for NIHSS of 15 and
admitted to Neurology ICU for observation and post-IV TPA
protocol. Patient was noted to have no neurological deficits
within 24 hours. She was noted to have atrial fibrillation on
admission and stroke was thought to be cardioembolic in
etiology. The patient was started on heparin and coumadin. Once
INR was therapeutic heparin discontinued and patient continued
on Coumadin 3 mg po qday. She was transferred to the floor once
medically stable. Lipid panel TG 86, HDL 43, and LDL 75, Hgb A1c
5.7%. She worked with PT/OT once her knee pain improved.
2. CV: Echocardiogram done and showed moderate to severe mitral
regurgitation and moderate pulmonary hypertension. She was
treated with Lasix as needed for moderate to severe pulmonary
edema which improved to mild pulmonary edema on repeat CXR. She
was ruled out for MI with cardiac enzymes x 3.
3. Respiratory: Patient was on oxygen nasal cannula during the
duration of hospitalization which was thought to be related to
pulmonary edema. She was treated with intermittent Lasix.
4. FEN/GI: Tolerated regular diet.
5. MSK: Patient had a fall after stroke. She had C-spine CT
which was read as no evidence of fracture. She complained of
right knee pain. X-rays showed that there was DJD but no
evidence of fracture. She was placed in knee immobilizer and
worked with PT/OT.
6. Rehab: Given's patient's deconditioning during this hospital
stay, it was though she would benefit from inpatient
rehabilitation.
Medications on Admission:
Medications:
Simvastatin 40 mg daily
Welchol 625 mg daily
Norvasc 5 mg daily
Atenolol 100 mg daily
Semprex D 8,60 mg daily
Isosorbide dinitrate 20 mg daily
Zetia 10 mg daily
Evista 60 mg
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Atenolol 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
8. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime): titrate based on INR goal [**2-6**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care Center
Discharge Diagnosis:
stroke
Discharge Condition:
stable
Discharge Instructions:
Follow up with appointments as below.
Take all medications as instructed.
Followup Instructions:
Neurology [**Hospital 4038**] Clinic. [**Hospital Ward Name 23**] [**Location (un) **], [**Hospital1 18**]. Provider:
[**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2134-6-29**] 11:00
AM. Please call to confirm appointment
Call your PCP after discharge from rehabilitation and make an
appointment to follow up with them.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
"434.11",
"427.31",
"416.8",
"401.9",
"428.0",
"424.0",
"715.36",
"272.0",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
8864, 8929
|
6416, 6416
|
329, 337
|
8980, 8989
|
3004, 6393
|
9111, 9610
|
1499, 1518
|
8197, 8841
|
8950, 8959
|
7985, 8174
|
6433, 7959
|
9013, 9088
|
1533, 1991
|
1138, 1306
|
277, 291
|
426, 1118
|
2166, 2985
|
2006, 2150
|
1350, 1413
|
1445, 1466
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,320
| 115,468
|
1087
|
Discharge summary
|
report
|
Admission Date: [**2153-9-26**] Discharge Date: [**2153-9-29**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2167**]
Chief Complaint:
Cough, fever & change in mental status; incidental finding of
maroon stool
Major Surgical or Invasive Procedure:
none
History of Present Illness:
89 yo M with a history of prostate CA and Alzheimer's dementia
who presents after home nurses noted he appeared unwell,
incidentally noted to have maroon, guaiac positive stool. Of
note, the patient has had several recent admissions to [**Hospital1 18**] and
consultations with Gerontology since his wife suffered a recent
stroke.
.
The patient's daughter reports that he lives at home with 24
hour PCA. He was noted to have a non-productive cough for
approximately 1.5 weeks. He was prescribed cough suppresent but
his symptom persisted. On the day of admission he was noted to
appear shaky and generally unwell by his home nurses, including
shakiness and weakness. His PCP was called who referred him to
the ED.
.
In the ED, T 102.8 HR 105 BP 122/64 RR 26 O2Sat 97%2L NC. He was
felt to have 2 possible sources of infection including lung and
urine and received ceftriaxone 1g and Azithromycin 500mg as well
as acetaminophen 650mg. A foley catheter was placed. While
having a diaper change in the ED, the patient was incidentally
found to have maroon, grossly (and confirmed on testing) guaiac
positive stool. He was hemodynamically stable with baseline Hct.
The pateint was admitted to the [**Hospital Unit Name 153**] & transferred to 11R on
[**2153-9-27**].
.
ROS: Patient's daughter denies home fevers, chills, nightsweats,
headaches, blurry vision, chest pain, shortness of breath,
abdominal pain, nausea, vomiting, diarrhea, dysuria, lower
extremity edema or weight gain. The patient of note has a long
history of guaiac positive stool by the report of his daughter.
She does not know if his stool is normally maroon in color. At
baseline A&Ox2.
.
Past Medical History:
Alzheimer's dementia, has had wandering & aggitation
h/o Prostate Ca, s/p XRT ([**2149**]), followed by Urology ([**Name8 (MD) **],MD)
CKD, Stage 3 (baseline creatinine ~1.0)
GERD
Anxiety
Depression
Severe degenerative disease in the lumbar spine
Anemia
h/o Diverticulum
h/o Colonic polyps
Internal hemorrhoids
Social History:
Patient is a retired dentist. Lives at home with 24H PCA's. Son
[**Name (NI) **]. [**Name (NI) **] [**Known lastname 7078**], Chief, Division of Oral Medicine, Department
of Surgery, [**Company 2860**]), is primary contact & HCP: [**Telephone/Fax (3) 7079**]. Patient had been living with wife independently at
home until recently. Wife [**Doctor First Name **] - second marriage; patient's
first wife & mother of children died ~ 30 years ago) was
visiting her family in [**State 7080**] and had a stroke (? [**Month (only) **]
[**2153**]). Wife is currently living in [**State 7080**] and
participating in outpatient rehab. Patient has services through
JCFS.
.
Patient is dependent in all ADLs & IADLs.
Family History:
NC
Physical Exam:
ADMISSION PE:
============
T 99.2F 76 103/47 23 92% 6L
Gen: Elderly gentleman. NAD.
HEENT: PERRL.
CV: RRR. Normal S1 and S2. No M/R/G.
Pulm: Upper airway congestion. Possible small amount of left
base rhonchi. Otherwise clear to auscultation.
Abd: Soft, nontender. No organomegaly.
Ext: No edema.
Neuro: A&Ox1. Moving all extremities.
Pertinent Results:
ADMISSION LABS:
==============
[**2153-9-26**] 05:36PM URINE HOURS-RANDOM CREAT-186 SODIUM-39
POTASSIUM-82 CHLORIDE-46
[**2153-9-26**] 05:36PM URINE OSMOLAL-699
[**2153-9-26**] 05:36PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2153-9-26**] 02:49PM URINE HOURS-RANDOM
[**2153-9-26**] 02:49PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.022
[**2153-9-26**] 02:49PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2153-9-26**] 02:49PM URINE RBC-0-2 WBC->50 BACTERIA-FEW YEAST-NONE
EPI-0
[**2153-9-26**] 02:49PM URINE EOS-POSITIVE
[**2153-9-26**] 03:05PM PT-14.6* PTT-27.7 INR(PT)-1.3*
[**2153-9-26**] 03:02PM LACTATE-2.7*
[**2153-9-26**] 02:49PM GLUCOSE-153* UREA N-35* CREAT-1.3* SODIUM-142
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-28 ANION GAP-12
[**2153-9-26**] 02:49PM ALT(SGPT)-33 AST(SGOT)-21 LD(LDH)-195
CK(CPK)-72 ALK PHOS-72 AMYLASE-106* TOT BILI-0.5
[**2153-9-26**] 02:49PM LIPASE-18
[**2153-9-26**] 02:49PM CK-MB-NotDone
[**2153-9-26**] 02:49PM CALCIUM-9.0 PHOSPHATE-1.8* MAGNESIUM-2.1
[**2153-9-26**] 02:49PM ETHANOL-NEG bnzodzpn-NEG barbitrt-NEG
[**2153-9-26**] 02:49PM WBC-9.7# RBC-3.99* HGB-10.9* HCT-33.3* MCV-83
MCH-27.2 MCHC-32.6 RDW-14.2
[**2153-9-26**] 02:49PM NEUTS-89* BANDS-2 LYMPHS-5* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2153-9-26**] 02:49PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2153-9-26**] 02:49PM PLT SMR-NORMAL PLT COUNT-152
.
MICROBIOLOGY:
============
[**2153-9-27**] URINE (Catheter) - Legionella Urinary Antigen,
PRESUMPTIVE POSITIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
IMAGING:
=======
[**2153-9-27**] CHEST (PORTABLE AP) - Feeding tube terminates in the
proximal stomach. Patchy bibasilar opacities, slightly improved
on the left. Although possibly related to atelectasis,
aspiration should also be considered.
.
SPEECH & SWALLOW:
================
RECOMMENDATIONS:
1. Safest recommendation continues to be NPO, however patient's
family understands and is willing to accept risks of aspiration
(patient not yet made CMO) and continue po intake, suggest small
sips of honey thick liquids and puree consistencies;
2. Pills crushed with small bites of puree at home;
3. Monitor hydration as patient at risk of dehydration on
thickened liquids.
.
DISCHARGE LABS:
==============
none
Brief Hospital Course:
# Cough, question of PNA per CXR, Urine legionella screen
positive, fever to 102 in ED & looked unwell to 24H PCA.
Currently patient afebrile & o2 sats stable on RA. Family
desires treatment of any infectious process. Continue
levofloxacin q48h renally dosed for total treatment of 14 days.
Afebrile on discharge.
.
# Urinary Tract Infection
U/A positive on admission, initially placed on Macrodantin, C&S
returned ENTEROCOCCUS SP >100,000 Organisms/ml, sensitive to
Ampicillin, Nitrofurantoin & Vancomycin; resistant to
TETRACYCLINE. Patient continued/placed on ampicillin and has
five days of treatment to complete after discharge.
.
#Dementia
Increase in behavioral symptoms since wife had recent stroke &
is no longer in home, despite 24H PCAs in house. Past recent
[**Hospital1 18**] admissions for wandering, aggitation: has had Psych & [**Last Name (un) **]
consultaions. Reportedly with poor orientation at baseline.
Oriented to self (name & DOB) during this admission. Goals for
patient, per disscussions with family & HCP, now palliation.
Family will pursue home Hospice services and continue 24H PCAs.
Family to discuss w/ primary care physician utility of
continuing medications such as namenda and aricept given current
status. Would also be reasonable to consider [**Doctor Last Name 360**] for
secretions, should they become copious and bothersome to
patient, such as scopolamine. Use as needed low dose risperidal
for agitation.
# Failed swallow study x's 2
The patient continues to present with overt aspiration and had
pulled out a pedi-NGT that had been placed. After discussion
with family & with HCP by Dr [**Last Name (STitle) **] via TC: no more NGT's, no
g-tubes to be placed and the patient will be offered food for
comfort, with the accepted risk of aspiration.
.
# Guaiac positive stool.
Hemodynamically stable, GI was consulted and per discussion with
the family, the patient would likely not want further work-up
for this issue. This has been discussed by their report in the
past with the patient's PCP. [**Name10 (NameIs) **] Hct 32.8 on [**2153-9-28**].
.
# Anemia
Baseline of 30-35. B12 474 (low normal) and folate 14.0 on
[**2153-7-19**]. Current drop in HCT thought due to GIB, but now
stablized. No further W/U at this time.
.
# Acute on chronic renal failure
Cr 1.3 on presentation up from baseline of 1.0, but came down to
0.9 with hydration. IVF were repleted.
# Code Status: DNR/DNI, treat infections with antibiotics, to
consult hospice at home.
Medications on Admission:
Namenda (Memantine) 10 mg PO BID
Aricept (Donepezil) 10 mg PO QD
Risperidone 1mg PO QHS
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Donepezil 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO q48h for 6
doses.
Disp:*6 Tablet(s)* Refills:*0*
6. Memantine 10 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Ampicillin 250 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 5 days.
Disp:*15 Capsule(s)* Refills:*0*
8. Risperdal 0.25 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for agitation.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
ADMITTING DIAGNOSIS:
===================
Pneumonia, Legionella (Positive Serogroup 1 Antigen Urinary
Screen)
Urinary Tract Infection, Enterococcus Sp
Lower GI Bleed
.
SECONDARY DIAGNOSIS:
===================
Alzheimer's dementia, has had wandering & aggitation
CKD, Stage 3 (baseline creatinine ~1.0)
GERD
Anxiety
Depression
Severe degenerative disease in the lumbar spine
Anemia
h/o Prostate Ca, s/p XRT ([**2149**]), followed by Urology ([**Name8 (MD) **],MD)
h/o Diverticulum
h/o Colonic polyps
Internal hemorrhoids
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital with a fever, cough and a
decline in your level of alertness. It was found that you had a
pneumonia and a urinay tract infection and have been started on
antibiotics.
.
Your family is going to arrange for additional professional help
to assist you in having the best quality of life.
.
Please take all of your medications as prescribed.
.
Contact your Primary Care Provider [**Name Initial (PRE) **]/or your other health
profesionals for any health-related concerns.
Followup Instructions:
Please notify your Primary Care Provider that you are back home.
.
Nutrition:
1. Safest recommendation continues to be nothing by mouth,
however as patient's family understands and is willing to accept
risks of aspiration, suggest small sips of honey thick liquids
and puree consistencies;
2. Pills crushed with small bites of puree at home;
3. Monitor hydration as patient at risk of dehydration on
thickened liquids.
.
Family will be contacting and arranging for home hospice
services upon discharge. Contact information will be provided by
Case Management.
Completed by:[**2153-9-29**]
|
[
"599.0",
"285.1",
"331.0",
"V10.46",
"578.9",
"482.84",
"041.04",
"722.52",
"585.3",
"294.11",
"287.5",
"530.81",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9295, 9301
|
5941, 8432
|
337, 343
|
9865, 9873
|
3479, 3479
|
10423, 11014
|
3102, 3106
|
8571, 9272
|
9322, 9322
|
8458, 8548
|
9897, 10400
|
5896, 5918
|
3121, 3460
|
223, 299
|
371, 2029
|
9510, 9844
|
3495, 5880
|
9343, 9489
|
2051, 2364
|
2380, 3086
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,541
| 172,727
|
17787
|
Discharge summary
|
report
|
Admission Date: [**2114-2-13**] Discharge Date: [**2114-3-13**]
Date of Birth: [**2089-1-25**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 25-year-old
woman without a significant past medical history found down
in the shower after her roommate heard her yell out. She was
unable to speak shortly thereafter and was unable to move her
right side.
MEDICATIONS ON ADMISSION: Medications at home included only
oral contraceptive pills.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed her temperature was 97.6, blood pressure was 178/63,
heart rate was 80, respiratory rate was 12. She was sedated
and paralyzed. Pupils were reactive. The left pupil was
larger than the right by 2 mm. Her chest was clear to
auscultation. Her respiratory rate was regular. Her chest
was clear. The abdomen was soft and nondistended. Positive
bowel sounds. Extremity examination revealed no edema.
PERTINENT LABORATORY VALUES ON PRESENTATION: Her
laboratories revealed sodium was 145, potassium was 3.7,
chloride was 113, bicarbonate was 22, blood urea nitrogen was
10, creatinine was 0.7, and blood glucose was 127.
HOSPITAL COURSE: On arrival to the hospital, the patient
was obtunded and vomiting. A computed tomography showed a
large left intraparenchymal hematoma extending from the basal
ganglion to the internal capsule into the periventricular
[**Known lastname **] matter, and positive blood in the ventricles, with 4 mm
of midline shift (from left to right). A ventricular drain
was placed under high pressure, and the patient was taken to
the operating room for a decompressive craniectomy.
In the operating room, she had 2 liters of fluid, 2 units of
fresh frozen plasma, 1 unit of packed red blood cells, and a
urine output of 2800 cc. She arrived from the Postanesthesia
Care Unit with a drain in placed, sedated, paralyzed, and
intubated.
The patient was on a Fentanyl drip, Nipride, cefazolin, and
famotidine.
She was admitted to the Neurologic Surgical Intensive Care
Unit status post a hematoma evacuation and craniectomy. She
tolerated the procedure well. There were no intraoperative
complications.
Postoperatively, she remained intubated, sedated, and
paralyzed. She had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain in place. Her
pupils continued to be reactive. The left frontal area where
a bone flap was removed remained soft and not under any
tension. Her vital signs remained stable.
On [**2114-2-14**], [**2113**] the patient was taken to the
angiogram suite where an arteriovenous malformation was found
being fed from the left anterior choroidal artery and to a lessr
extent from the left posterior cerebral artery. The anterior
choroidal artery harbored a feeding artery aneurysm which was
felt to be the rupture site. She had a second endovascular
procedure where the anterior choroidal artery was catheterized
and the aneurysm was occluded using NBCA injection without
intraprocedural complications.
On [**2114-2-16**], the patient was off sedation. Her
pupils were 3 mm down to 2 mm and reactive. Her cranial
defect was soft. She was localizing with her left upper
extremity and withdrawing her lower extremities. She spiked
a temperature to 101.5 on [**2-16**] and was fully cultured.
The patient was receiving Cephazolin for the drain
prophylaxis. No other antibiotics at that time.
On [**2114-2-18**], the patient grew out gram-negative rods in
her sputum. She was started on levofloxacin.
On [**2114-2-20**], the patient's pupil were 4 mm down to 3 mm
and symmetric. She was moving left side spontaneously and
localizing on the right throughout her lower extremities.
She did open her right eye spontaneously. The patient was on
levofloxacin and ceftazidime for gram-positive cocci in pairs
in the sputum and also in the urine.
[**2114-2-23**], the patient had a tracheostomy and
percutaneous endoscopic gastrostomy tube placed without
complications. She continued to remain neurologically the
same. The pupils were 4 mm down to 3 mm. She was moving her
left side spontaneously. She opened the right eye more than
the left eye and withdrew on the right side. She continued
to have vent drain in place and was continued on levofloxacin
and ceftazidime for heavy growth of gram-positive cocci in
her sputum.
Cerebrospinal fluid cultures were sent periodically
throughout her Intensive Care Unit stay; all of which were
negative for organisms.
She also had periodic computed tomography scans which showed
improvement and reabsorption blood with no new hemorrhages
present.
On [**2114-3-6**], the patient was taken back to the
operating room and had her cranial defect repaired. She also
had a ventriculoperitoneal shunt placed without
intraoperative complications.
The patient was then transferred to the regular floor.
Neurologically, she remained unchanged. She was opening her
right eye and was attentive. She was moving the left side
spontaneously. The right side withdrew to pain. She was
followed by Physical Therapy and Occupational Therapy and
will require long-term acute rehabilitation.
MEDICATIONS ON DISCHARGE: (Medications on discharge
included)
1. Zantac 150 mg p.o. b.i.d.
2. Heparin 5000 units subcutaneously q.12h.
3. Artificial Tears one to two drops both eyes as needed.
4. Colace 100 mg p.o. b.i.d.
CONDITION AT DISCHARGE: The patient's condition on discharge
was stable.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up with Dr. [**Last Name (STitle) 1132**] in one month
2. The patient will need to receive stereotactic radiosurgery
of the remnant AVM fed by the PCA.
3. The patient will require staple removal on postoperative
day 10 from her shunt. She had a shunt placed on [**2114-3-9**]. Her staples should come out on [**2114-3-19**].
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2114-3-12**] 08:20
T: [**2114-3-12**] 08:32
JOB#: [**Job Number 49400**]
|
[
"431",
"482.83",
"331.4",
"430",
"518.81",
"780.6",
"785.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.72",
"01.39",
"02.06",
"02.34",
"43.11",
"31.1",
"96.6",
"96.04",
"38.91",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
5259, 5470
|
426, 1220
|
1239, 5232
|
5568, 6184
|
5485, 5535
|
173, 399
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,872
| 139,712
|
13339
|
Discharge summary
|
report
|
Admission Date: [**2168-3-4**] Discharge Date: [**2168-3-13**]
Date of Birth: [**2085-8-12**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
OSH transfer w/ respiratory failure and shock
Major Surgical or Invasive Procedure:
intubation, mechanical ventilation
History of Present Illness:
[**Initials (NamePattern4) **] [**Known lastname 1124**] is an 82 YOF with a PMH significant for aggressive
metestatic breast cancer to liver, lymph nodes, and possibly
lung metastasis recently started on xeloda ([**2168-2-19**]) who has
been declining over the past few weeks with increased fatigue,
decreased PO, and weight loss, as well as ascites requiring Q 2
week paracentesis. She was in her normal state of health until
last night when she had brown emesis x 2. Early the morning of
[**2168-3-4**] she had emesis again and was dizzy and weak on her way
back from the bathroom. Her daughter helped her to bed and
noted she was tachypneic so she called her brother who is a MD
and then ended up calling EMS. When they arrived they noted her
O2 sats were in the 70s. They brought her to [**Hospital3 **].
.
Of note, on [**2-19**] pt underwent paracentesis which revealed 145
WBC. per OMR, on [**2-25**] Dr. [**Name (NI) **] documented that there was
1 positive ascitic fluid culture (coag negative staph) with plan
to monitor for possible evidence of infection and treat with
antibiotics if indicated. The day prior to her presentation she
reportedly was feeling well.
.
At the OSH the patient had CXR and CT scan which revealed "acute
on chronic" PEs and probable aspiration PNA. Hct 39.1 and many
bacteria and WBC on UA. She was not started on heparin gtt
given concern for GI bleed with hemetemesis. She was given
clindamycin and levoquin, 2 L IVF and was transfered to [**Hospital1 18**]
where here care is.
.
In the ED, patient was found to be in respiratory distress with
tachypnea 36 and O2 sats 94% on NRB. Initially patient was DNI,
but conversation was held w/ oncologist, daughter, and son (on
phone) about end of life issues and per son, pt wanted to pursue
aggressive treatment so she was made full code. She was
intubated, R IJ placed, given 4 L NS, OG tube placed and
returned 600 cc of dark coffee grounds. GI was called to see
her and recommended urgent EGD for risk assessment of starting
anticoagulation. CT scan showed large amount of stool in the
[**Hospital1 499**], mult liver mets, ascites, obscure known pulm lesions, but
no other pathology. Pt was given vanc, Zosyn, and started on
levophed gtt. Labs were significant for WBC 14, 25% bands, Hct
34.2 (down from 37), INR 1.3, elevated AST 120, trop 0.07,
lactate 2.2. UA showed 20 WBC, 50 RBC, few bacteria, lg blood,
nitrite neg, mod leuks. Urine and blood cultures were obtained.
ABG 7.48/33/84.
.
On the floor in the [**Hospital Unit Name 153**] the patient was sedated and intuibated
and unable to answer ROS. She had her right IJ pulled halfway
out and was not receiving her levophed gtt. Her BP was in the
50s systolic. She was started on vasopressin then levophed
peripherally until central access was reestablished. She had
her right IJ replaced. Her ventilator was set at Assist
Control, Fi)2 100%, 500 by 16.
.
.
Past Medical History:
Past Medical History:
1. Breast cancer (estrogen sensitive tumor), s/p lumpectomy 15
years ago and recently normal mammogram 7/[**2167**].
2. Metestatic breast cancer - diagnosed [**2167-11-30**] after RUQ
U/S was obtained for abd pain and slight elevated LFTs, and pt
found to have lesions. MRI confirmed new liver lesions in
addition to those that were previously seen on MRI in [**2166**] and
thought to be hemangiomas. Biopsy [**2168-1-26**] revealed metastases
c/w the patient's previously resected breast primary, which was
strongly positive for estrogen receptor. [**2-12**] she underwent
brain MRI and PET-CT
which showed no evidence of brain metastasis, but multiple bone,
liver, lymph nodes and possibly lung metastasis.
3. Sarcoid with substantial parenchymal disease
radiographically, but had problems in the past tolerating
prednison so was followed twice yearly by Dr [**Last Name (STitle) 575**] twice a
year.
4. HTN
5. s/p bilateral hystero-salpingo-oophorectomy
6. osteopenia
.
Social History:
The patient lives in [**Location 1456**] [**State 350**] with her husband who
is 86 years old and has congestive heart failure. She does not
smoke or drink alcohol. Her daughter is a lawyer and her son is
a cardiothoracic surgeon.
.
Family History:
Ashkenazi [**Hospital1 **] descendant. Sister died of [**Hospital1 499**] cancer at
age 72. Father had [**Name2 (NI) 499**] cancer, died at age 82 of CHF. Two of
her father's brothers had prostate cancer.
Physical Exam:
VS: Temp: 98.4 BP: 55/30 HR: 64 RR: 20 O2sat 95%
GEN: not alert, sedated/ventilated
HEENT: PERRL,anicteric, dry MM, no supraclavicular or cervical
lymphadenopathy, no jvd, right IJ half way pulled out
RESP: diffuse rhonci
CV: RR, S1 and S2 wnl, no m/r/g
ABD: multiple masses, firm abdomen, + BS, rectum impacted with
hard brown stool
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
Brief Hospital Course:
Ms. [**Known lastname 1124**] was an 82 YOF with aggressive newly recurrent breast
cancer who was initially transferred from OSH were she presented
with hematemesis and respiratory distress and was found to have
acute on chronic PE, likely aspiration pneumonia and UTI. On
admission to our ICU Pnt was intubated and sedated for resp
distress and pressors were started for shock. Her hospital
course was complicated by septic and cardiogenic shock,
respiratory failure, GI bleeding and paroxismal atrial
fibrilation. On the evening of [**3-12**] after meeting with patient??????s
family, due to the patient??????s poor prognosis and the perceived
futility of further medical intervention and in accordance with
the wishes of the patient??????s HCP and family members patient??????s
goals of care were changed to CMO. She was subsequently
extubated and morphine drip was started for comfort. The patient
expired shortly thereafter with her family at the bedside. Her
death was pronounced on [**2168-3-13**] at 00:45.
Medications on Admission:
Medications at home:
Atenolol 50 mg Q day
Folic acid, vit B6, vit B 12 Q day
Lasix 20 mg Q day
Megace 625 mg/ml 5 ml Q day
ondansetron 4 mg TID PRN
aspirin 81 mg
Calcium carbonate 400 mg Q day
alendronate Q wk
Vit D 3 [**2157**] unit Q day
Xeloda 1500 mg [**Hospital1 **] (7 days on/off)
.
Allergies: NKDA
Discharge Disposition:
Expired
Discharge Diagnosis:
NA
Discharge Condition:
NA
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2168-3-13**]
|
[
"276.0",
"578.0",
"427.31",
"401.9",
"507.0",
"197.0",
"V10.3",
"785.51",
"599.0",
"038.9",
"196.9",
"198.5",
"415.19",
"789.51",
"518.81",
"197.7",
"785.52",
"995.92",
"416.2",
"560.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.91",
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
6630, 6639
|
5253, 6273
|
337, 373
|
6685, 6689
|
6740, 6773
|
4616, 4823
|
6660, 6664
|
6299, 6299
|
6713, 6717
|
6320, 6607
|
4838, 5230
|
252, 299
|
401, 3326
|
3370, 4347
|
4364, 4600
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,346
| 172,069
|
36041
|
Discharge summary
|
report
|
Admission Date: [**2128-12-20**] Discharge Date: [**2128-12-23**]
Date of Birth: [**2098-2-12**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
open depressed skull fracture
Major Surgical or Invasive Procedure:
Fracture repair and epidural evacuation
History of Present Illness:
HPI: 30F s/p fall from horse; possible brief LOC; found sitting
up, "groggy" but with GCS 15; Ox3; moving all 4 ext; large right
temporo-zygomatic skin laceration; CT head at OSH shows
depressed
right temporal fracture; transferred to [**Hospital1 18**] for trauma and
neurosurgical evaluation;
Past Medical History:
PMHx: s/p C-section 12 yrs prior;
Social History:
Social Hx: next of [**Doctor First Name **]: mother: [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 81798**]; has 2
children;
Family History:
not available
Physical Exam:
PHYSICAL EXAM:
83 122/66 15 100
Right temporal/zygomatic laceration, deep; no CSF or brain
tissue
seen
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension. No dysarthria
or
paraphasic errors.
II: Pupils equally round and reactive to light, to
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing: not tested
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-5**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Pertinent Results:
CTA OF THE HEAD AND NECK: The carotid and vertebral arteries and
their major
branches are patent with no evidence of dissection. No
significant mural
irregularity or flow-limiting stenosis is noted. The distal
intracervical
portion of the right internal carotid artery measures 5.3 mm on
the right side
and the distal intracervical portion of the left internal
carotid artery
measures 4.8 mm.
The patient is status post repair of depressed right temporal
bone fracture
with an unchanged 3-mm depressed fracture fragment. Fracture of
the
lateral wall of the right sphenoid sinus extends into the
carotid groove and
the carotid canal of the petrous temporal bone; however, this
segment of the
right ICA is unremarkable. There is diffuse opacification of the
right
sphenoid sinus with high density material, most likely blood.
Mild mucosal
thickening of the posterior ethmoidal air cells and the left
sphenoid sinus is
also noted.
IMPRESSION:
1. Normal CTA of the head and neck with no evidence of
dissection.
2. Stable post-surgical appearance of depressed right temporal
bone fracture.
Unchanged fracture of the sphenoid sinus which extends into that
carotid
canal, with unremarkable appearance of the petrous (horizontal)
segment of
that ICA.
Post op CT:
IMPRESSION:
1. Status post repair of depressed right temporal bone fracture.
A 5-mm
fragment remains displaced intracranially by 2 mm. Small amount
of
pneumocephalus.
2. The surgical hardware results in streak artifact, which may
obscure a
small epidural collection noted on the prior CTA.
3. Unchanged fracture of the sphenoid sinus and sphenoid bone,
with extension
to the carotid canal.
Brief Hospital Course:
Pt was admitted to the hospital through the emergency department
for right open/depressed skull fracture repair after fall from
horse.
Pt was seen in the ED and brought to the OR emergently for
fracutre repair and wound washout. She was then put in the ICU
for close observation. Her exam remained stable and post op
imaging/CT was stable.
A CTA of the head was repeated to eval for right carotid injury
as sphenoid fracture extends to the right carotid canal, no
disruption of the Carotid artery was noted.
OMFS consult was called on hospital day #2 as pt was complaining
of right jaw pain with limited mobility. She had dedicated CT
of the mandible and sinus which were negative for fracture.
Their recommendations included NSAIDS for edema and pain, and
f/u with personal Dentist once the facial swelling has subsided.
She was seen by PT and OT and deemed safe and independant for
discharge home.
Medications on Admission:
Medications prior to admission: occasional Ibuprofen
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*40 Capsule(s)* Refills:*0*
2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
depressed right temporal bone fracture / repaired
sphenoid [**Doctor First Name 362**] fracture extending through right carotid canal
Discharge Condition:
neurologically intact
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in __10__days for removal of your
staples or sutures.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2128-12-23**]
|
[
"E884.9",
"801.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.02"
] |
icd9pcs
|
[
[
[]
]
] |
4704, 4710
|
3433, 4343
|
353, 394
|
4888, 4912
|
1757, 3410
|
6188, 6636
|
945, 961
|
4447, 4681
|
4731, 4867
|
4369, 4369
|
4936, 6165
|
991, 1082
|
4401, 4424
|
283, 315
|
422, 719
|
1097, 1738
|
741, 777
|
793, 929
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,657
| 164,590
|
13516
|
Discharge summary
|
report
|
Admission Date: [**2143-4-4**] Discharge Date: [**2143-4-8**]
Date of Birth: [**2112-11-14**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Watermelon / Almond Oil
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
Upper GIB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
30M h/o DMI, hypertension, GERD, h/o erosive gastritis admitted
to [**Hospital1 18**] on [**4-4**] with hyperglycemia (though without an anion
gap), vomitting, and hypertension, was treated on the general
medical floor initially, then transferred to the ICU when he
developed hematemesis.
ED course was significant for HTN, with a BP 180/117 and
hyperglycemia with FSBG of 305. Pt's initial presentation [**4-4**]
with hyperglycemia, thought to be due to viral URI and vomitting
along with not taking insulin because he had no syringes. When
he developed hematemesis he was transferred to ICU. GI team was
consulted, and as hct was stable and there was no further
vomitting, EGD deferred to outpt. ICU course complicated by
acute renal failure. Renal ultrasounds showed no hydronephrosis
ROS: Mild sore throat; negative f/c; Feels thirsty
Past Medical History:
1. Type I diabetes mellitus, uncontrolled. Last HbA1c 10.8
[**2142-5-3**]. Followed by Dr. [**Last Name (STitle) 9835**] at [**Last Name (un) **]. Complicated by
gastroparesis, nephropathy.
2. Erosive gastritis per EGD [**2137**]. Noncompliant with GI follow
up for EGD after [**2141**] hospitalization/elopement. Noncompliant
with PPI.
3. Hypertension, uncontrolled
4. Chronic renal insufficiency, baseline 1.5
5. Gastroesophageal reflux disease
6. Depression
Social History:
Works at [**Company 2475**] in office services. Lives with girlfriend in
[**Location (un) 686**]. Smokes approx 5 cigarettes/week. Usually rare EtOH.
Family History:
Mr. [**Known lastname 21822**] has 4 brothers and 5 sisters, all with no known Hx
of diabetes or significant medical problems. His [**Name2 (NI) **] are
alive and well. He reports that his grandfather had Diabetes,
but he isn??????t sure what type.
Physical Exam:
VS: T 98 PO, BP 150/80, HR 90, RR 20, O2 sat 100 RA, FSBG 63
Gen: Alert, no acute distress
HEENT: PERRL, extraocular motions intact, anicteric, mucous
membranes dry
Neck: No JVD, no cervical lymphadenopathy
Chest: Clear to auscultation bilaterally, no rales
CV: Normal S1/S2, RRR, no murmurs
Abd: Soft, nontender, nondistended, with normoactive bowel
sounds
Extr: No edema. 2+ DP pulses bilaterally
Neuro: Alert and oriented x 3, no asterixis
Skin: No rash
Pertinent Results:
[**2143-4-4**] 09:17PM GLUCOSE-176* UREA N-28* CREAT-2.8* SODIUM-143
POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-21* ANION GAP-18
[**2143-4-4**] 09:17PM LD(LDH)-279* CK(CPK)-517*
[**2143-4-4**] 09:17PM CK-MB-3 cTropnT-<0.01
[**2143-4-4**] 09:17PM CALCIUM-9.2 PHOSPHATE-4.0 MAGNESIUM-1.5*
[**2143-4-4**] 09:17PM WBC-8.8 RBC-3.71* HGB-10.7* HCT-30.5* MCV-82
MCH-28.9 MCHC-35.1* RDW-12.5
[**2143-4-4**] 09:17PM WBC-8.8 RBC-3.71* HGB-10.7* HCT-30.5* MCV-82
MCH-28.9 MCHC-35.1* RDW-12.5
[**2143-4-4**] 10:55AM URINE RBC-[**11-28**]* WBC-0-2 BACTERIA-RARE
YEAST-NONE EPI-0-2
[**2143-4-4**] 10:55AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2143-4-4**] 10:55AM URINE UHOLD-HOLD
[**2143-4-4**] 10:55AM URINE UHOLD-HOLD
[**2143-4-4**] 11:23AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2143-4-4**] 11:23AM URINE HOURS-RANDOM
[**2143-4-4**] 09:30AM GLUCOSE-282* UREA N-29* CREAT-2.7* SODIUM-140
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-23 ANION GAP-17
[**2143-4-4**] 09:30AM AST(SGOT)-30 LD(LDH)-280* CK(CPK)-509* ALK
PHOS-101 TOT BILI-0.4
[**2143-4-4**] 09:30AM LIPASE-43
[**2143-4-4**] 09:30AM CK-MB-3 cTropnT-<0.01
[**2143-4-4**] 09:30AM ALBUMIN-3.9 CALCIUM-9.3 PHOSPHATE-3.0
MAGNESIUM-1.6
[**2143-4-4**] 09:30AM ALBUMIN-3.9 CALCIUM-9.3 PHOSPHATE-3.0
MAGNESIUM-1.6
[**2143-4-4**] 09:30AM ACETONE-NEGATIVE
[**2143-4-4**] 09:30AM WBC-11.9*# RBC-4.08* HGB-12.3* HCT-33.4*
MCV-82 MCH-30.1 MCHC-36.7* RDW-12.5
[**2143-4-4**] 09:30AM NEUTS-93.3* LYMPHS-2.7* MONOS-3.7 EOS-0.1
BASOS-0.2
[**2143-4-4**] 09:30AM NEUTS-93.3* LYMPHS-2.7* MONOS-3.7 EOS-0.1
BASOS-0.2
[**2143-4-6**] 3:38 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
ISOLATED FROM ONE SET ONLY SENSITIVITIES PERFORMED ON
REQUEST..
Anaerobic Bottle Gram Stain (Final [**2143-4-8**]):
REPORTED BY PHONE TO DR. [**First Name (STitle) **] AT 2120 ON [**4-8**]..
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Brief Hospital Course:
1)Hematemesis: Resolved spontaneously, GI team evaluated pt and
felt that GI bleed was likely due to known gastritis vs possible
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tears. Hct remained stable.
2)Acute renal failure: Creatinine was 2.6 on presentation. No
hydronephrosis by ultrasound. Given pt's sense of thirst,
possible pre-renal from hypovolemia, IV fluids to be bolued and
creatinine rechecked. Given that on arrival to general medicine
floor he had lost IV access. Urine lytes were sent. No evidence
of volume overload. A CPK was checked which was markedly
elevated after being transferred out of the [**Hospital Unit Name 153**]. The patient
was given aggressive IVF once IV access was obtained. On the
night of discharge the patient stated he did not want further
treatment and signed out AMA. He was deemed competent to make
his decision by the moonlighting physician. [**Name10 (NameIs) **] that evening
the microlab called the moonlighter to say he had a positive
blood cx with GPC (see results above). This was deemed a
possible contaminant but the patient was called and instructed
to return to the ER for further evaluation. Two messages were
left on the patient's phone.
3)Hypertension, benign: Pt presented initially with hypertensive
urgency, better controlled now on home medication of amlodopine
10 mg daily, and Toprol 200 mg daily.
4)Diabetes Mellitus type 1, uncontrolled with complications:
Giving smaller dose of standing insulin than he is on at home
due to his acute renal failure. Treat with NPH. He was given
NPH 40 units in ICU [**4-6**] pm and had FSBG of 27 in the morning of
[**4-7**].
Medications on Admission:
# Amlodipine 10 mg daily
# Toprol XL 200 mg daily
# Insulin NPH 30 units subcutaneous in the morning; 60 units
Subcutaneous at bedtime.
# Humalog 10 units subcutaneous [**Hospital1 **]
Discharge Medications:
1. Amlodipine 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
2. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
[**Hospital1 **]: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Simethicone 80 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
Disp:*40 Tablet, Chewable(s)* Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Metoclopramide 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Discharge Disposition:
Home
Discharge Diagnosis:
hypertension
hyperglycemia
GI bleed
Discharge Condition:
sable
Discharge Instructions:
Please be sure to take your insulin every day, call the clinic
and ask to speak to the triage nurses at [**Telephone/Fax (1) 250**] if you
ever run out of any medicine or syringes. Call your PCP with
any confusion, headache, vomitting, or other concerning
symptoms. Please be sure to continue the omeprazole (Prilosec)
to protect your stomach so you do not bleed.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2143-5-14**] 3:30
|
[
"536.3",
"311",
"403.90",
"V15.81",
"V58.67",
"578.0",
"079.99",
"465.9",
"535.40",
"250.63",
"250.43",
"584.9",
"305.1",
"583.81",
"530.7"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7289, 7295
|
4676, 6342
|
307, 314
|
7375, 7383
|
2600, 4312
|
7799, 7947
|
1856, 2107
|
6578, 7266
|
7316, 7354
|
6368, 6555
|
7407, 7776
|
2122, 2581
|
4356, 4653
|
258, 269
|
342, 1187
|
1209, 1672
|
1688, 1840
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,021
| 104,946
|
15657
|
Discharge summary
|
report
|
Admission Date: [**2177-10-13**] Discharge Date: [**2177-11-17**]
Date of Birth: [**2177-10-13**] Sex: M
Service: NEONATOLOGY
HISTORY: This is the 1.315 kg product of a 28 [**1-9**] week twin
gestation, born to a 27-year-old GI P0-II mother. Prenatal
screens notable for maternal blood type A positive, antibody
surface antigen negative, group B strep unknown. This is a
Ultrasound at 23 weeks showed size discordance, attributed to
twin-twin transfusion syndrome. Subsequent ultrasound showed
increasing oligohydramnios but good biophysical profiles.
The mother completed steroid therapy. These patients were
delivered by cesarean section. Twin I emerged apneic but
minutes.
1. Respiratory: The child was intubated and given 2
doses of surfactant, and rapidly weaned to CPAP and then
nasal cannula. Intermittently the child had to go back on
CPAP for increased spelling. He was started on caffeine and
subsequently weaned onto nasal cannula on DOL #16 and onto RA on
DOL#34. He is currently on caffeine. He has occasional spells.
2. Fluids, electrolytes and nutrition: He was initially
nil by mouth and started on intravenous fluids. His
feeds were advanced as tolerated .He is currently tolerating
150 cc/kg of PE28 with ProMod po/pg.
3. Infectious Disease: The patient had started antibiotics.
Culture were negative at 48 hours, and these were
discontinued. When he had increased spells, repeat CBC and
blood cultures were done, but no further antibiotics were
started. He is currently off all antibiotic therapy.
4. Cardiovascular: He never required blood pressure
support, although he did have a murmur and was given a course
of indomethacin. His murmur persisted. An echocardiogram
was performed, which showed that he had a mild biventricular
outflow obstruction, probably secondary to hypovolemia, but
no structural heart disease and no duct. Repeat ECHO on DOL#28
revealed improved but mild biventricular hypertrophy, which will
need to be followed as an outpatient at the Cardiology Clinic.
5. Hematology: He received a blood transfusion of 50 cc/kg
since his hematocrit was relatively low and his
echocardiogram was consistent with hypovolemia. He did
require phototherapy for hyperbilirubinemia, however, at this
time, he is off of phototherapy, with normal bilirubin
levels.
6. Neurology: HUS on [**10-15**] and [**10-23**] were within normal limits
Follow up HUS on [**2177-11-13**] revealed caudothalamic groove cyst
PHYSICAL EXAMINATION: He is 2.170kg, he is non-dysmorphic.
His cardiac examination shows a II/VI systolic murmur, regular
rate and rhythm. His lung examination is clear bilaterally.
His abdomen is soft and nondistended. The rest of his physical
examination is within normal limits.
CONDITION AT THE TIME OF THIS SUMMARY: Stable.
FOLLOW UP
1. Paediatric Cardiology in mid [**Month (only) **] to F/U biventricular
hypertrophy- parents will need to call for appointment
2. ROP screen on [**2177-11-19**]
MEDICATION
Caffeine 15mg po/pg qd
Vit E 5 IU po/pg qd
Ferrinsol 0.15cc po/pg qd
DIAGNOSIS LIST:
1. Prematurity
2. Status post twin-twin transfusion
3. Mild apnea of prematurity
4. Status post rule out sepsis
5. Mild biventricular hypertrophy
6. Right subependymal cysts with resolved bilateral germinal
matrix haemorrhages
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 50-477
Dictated By:[**Name8 (MD) 45197**]
MEDQUIST36
D: [**2177-10-31**] 17:56
T: [**2177-11-1**] 00:00
U: [**2177-11-17**] 09:00
JOB#: [**Job Number 35882**]
|
[
"774.2",
"V31.01",
"770.81",
"429.3",
"765.15",
"746.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"99.83",
"96.04",
"03.31",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
2507, 3584
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,651
| 166,558
|
46713
|
Discharge summary
|
report
|
Admission Date: [**2158-11-18**] Discharge Date: [**2158-11-21**]
Date of Birth: [**2111-4-11**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Serax
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
CC:[**CC Contact Info 99151**]
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
Femoral line placemenent
History of Present Illness:
The patient is a 47 year old man with history of polysubstance
abuse (EtOH, hx of heroin) who initially presented with cough
and chest pain. At that time an EKG was unremarkable and an CXR
was w/o acute process. The patient left AMA prior to further
evaluation was done. After about an hour outside the hospital
the patient called EMS stating that he just took a high dose of
his phenobarbital and was worried about himself. On arrival to
the ED his vitals were T 97.5 HR 78 bp 135/78 RR 16 97%RA. He
was awake and stated to the ED staff that he did not want to
kill himself but that he was "just trying to get high." He was
alert and able to walk around the ED and able to order his own
meal. When the ED attending went to evaluate him he was found to
be minimally responsive. He awoke only to sternal rub. He was
intubated for airway protection (with etomidate and succinyl
choline) without significant decline in his blood pressure per
report. A femoral line was placed for IV access. Serum EtoH was
101. Urine tox was + for benzos, barbituates. An OG tube was
placed and charcoal was administered. He received IVF to
alkalinize the urine.
Admitted to the [**Hospital Unit Name 153**].
Past Medical History:
1. MI in [**2156**]
2. Longstanding EtOH abuse w/ h/o DT's, multiple admissions for
withdrawal +/- seizures, multiple falls while intoxicated.
3. Seizure disorder - since age 12 due to head trauma - h/o
absence, partial, and complex seizures; no h/o status
epilepticus. Since adulthood, seizures have been related to EtOH
use or EtOH withdrawal.
4. S/P R lower lobectomy in [**2156-4-2**] for lung CA. No
chemo/radiation.
5. Hepatitis C (untreated)
6. S/P 2nd & 3rd toe amputations [**2-3**] frostbite
Social History:
Mr. [**Known lastname 4318**] is originally from [**State 350**] and spent the last
one year in [**State 1727**] doing painting contract work with his brother.
[**Name (NI) **] returned to [**Location 86**] 3 months ago and has been living alone in
a rooming house in [**Location (un) 583**]. Mr. [**Known lastname 4318**] is divorced and has a
22 year old daughter.
-EtOH: Started drinking at age 15. He has been hospitalized
multiple times for withdrawal seizures and has had DT's x2. For
the past few weeks, he has been drinking 24-36 beers and [**1-3**]
pint vodka per day. The longest he has been sober is 2 yrs from
[**2146**]-[**2147**].
-Smoking: ~40 pack year history. 2pack/day for 20 years. Quit in
[**2156-4-2**] when diagnosed and treated for lung cancer.
-Illicit Drugs: used cocaine, heroin > 15 years ago; [**Hospital1 18**]
records indicate h/o phenobarbital abuse
-Admits to high risk heterosexual activity
Family History:
-Mother (d. 77) ?????? MI; h/o IDDM, HTN
-Father (d. 81) ?????? MI, Alzheimer's Disease, alcoholic
-Brother ?????? recovering alcoholic, h/o heroin abuse
-Brother ?????? recovering alcoholic
-Sister ?????? grew out of absence seizure disorder
Physical Exam:
Vitals: 97.2 67 155/93 20 100%
vent: AC 650 x 14 PEEP 5 FIO2 0.5
Gen: intubated and sedated. thin. chronically ill appearing
HEENT: ETT in place. dry mucous membranes. PERRL
Neck: EJ fills to thryoid cart
Chest: clear anterior and lat. small chest tube scars to right
lat chest
CV: reg tachy S1/S2 no m/r/g
Abd: flat, soft, NT active bowel sounds. no HSM
Ext: clentched left hand. no c/c/e. 2+ DP bilat
Skin: warm, small abrasions to both knees
Neuro:
-MS: arouses to voice
-CN: pupils reactive, gag reflex present
-Motor: moving all 4 ext spontaneously
-DTR: trace at biceps & patellars
Pertinent Results:
[**2158-11-18**] 09:11AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2158-11-18**] 09:11AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2158-11-18**] 09:11AM URINE bnzodzpn-POS barbitrt-POS opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2158-11-18**] 09:11AM URINE HOURS-RANDOM
[**2158-11-18**] 03:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2158-11-18**] 03:20PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.004
[**2158-11-18**] 03:20PM URINE bnzodzpn-POS barbitrt-POS opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2158-11-18**] 03:20PM URINE GR HOLD-HOLD
[**2158-11-18**] 03:20PM URINE HOURS-RANDOM
[**2158-11-18**] 03:20PM URINE HOURS-RANDOM
[**2158-11-18**] 04:06PM PT-11.9 PTT-34.6 INR(PT)-1.0
[**2158-11-18**] 04:06PM PLT COUNT-361
[**2158-11-18**] 04:06PM NEUTS-47.2* LYMPHS-42.3* MONOS-5.0 EOS-4.0
BASOS-1.4
[**2158-11-18**] 04:06PM WBC-4.4 RBC-3.58* HGB-9.8* HCT-30.4* MCV-85#
MCH-27.3 MCHC-32.1 RDW-17.3*
[**2158-11-18**] 04:06PM ASA-NEG ETHANOL-101* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-POS tricyclic-NEG
[**2158-11-18**] 04:06PM PHENOBARB-94* PHENYTOIN-LESS THAN
[**2158-11-18**] 04:06PM OSMOLAL-319*
[**2158-11-18**] 04:06PM FOLATE-7.5
[**2158-11-18**] 04:06PM ALBUMIN-4.4
[**2158-11-18**] 04:06PM LIPASE-34
[**2158-11-18**] 04:06PM ALT(SGPT)-58* AST(SGOT)-68* AMYLASE-33 TOT
BILI-0.2
[**2158-11-18**] 04:06PM estGFR-Using this
[**2158-11-18**] 04:06PM GLUCOSE-75 UREA N-10 CREAT-0.7 SODIUM-140
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-27 ANION GAP-15
[**2158-11-18**] 04:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2158-11-18**] 04:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2158-11-18**] 04:35PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.002
[**2158-11-18**] 04:35PM URINE bnzodzpn-POS barbitrt-POS opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2158-11-18**] 04:35PM URINE HOURS-RANDOM
[**2158-11-18**] 07:49PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2158-11-18**] 07:49PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2158-11-18**] 07:59PM LACTATE-3.9*
[**2158-11-18**] 07:59PM TYPE-ART PO2-288* PCO2-43 PH-7.42 TOTAL
CO2-29 BASE XS-3
Brief Hospital Course:
The patient is a 47 year old man with hx of polysubstance abuse,
distant seizure d/o, hepatitis, and lung cancer s/p resection
presenting with alcohol/phenobarbitol ingestion complicated by
depressed mental status requiring airway protection, now
extubated
.
# Altered Mental Status: likely secondary to phenobarb ingestion
given markedly elevated level complicated by EtOH and benzos. CT
head negative for intracranial bleeding. Phenobarbital level is
trending down as of time pt. left ama. AMS resolved and
successfuly extubated. At time of leaving AMA, pt. fully alert
and oriented, states that he understands my recommendation that
he stay in hospital for further evaluation and treatment, but
wishes to leave against medical advice.
.
# Phenobarbital overdose: Phenobarbital level is decreasing.
Received charcol treatment. Urine was also alkalanized to
enhance excretion. Recommendation made that he change to
another anti-epileptic, and [**Month/Day/Year **] input sought regarding
this, however, pt. left ama before [**Month/Day/Year **] could come to
review the case and evaluate pt.
.
# Respiratory Failure - secondary to altered mental status from
above. no evidence of hypoxia or hypercarbic respiratory
failure. successfuly extubated as mentioned above. At time of
leaving ama, pt. breathing comfortably, saturations on room air
98%.
.
# EtOH Addiction - patient at high risk for DTs given long
history of EtOH addiction and concurrent primary seizure
disorder. Was maintained on valium prn ciwa greater than 10.
At time of discharge, VSS, minimally tremulous. Again, pt
stated understanding that he at high risk of recurrent seizure,
and that he wants to leave despite this risk. I have
recommended evaluation by [**Month/Day/Year **] for recommendations for
anti-epileptic medication other than phenobarbital, but pt.
unwilling to wait for evaluation.
.
# Seizure d/o - no evidence for active seizures at time of d/c
ama.
Medications on Admission:
- Phenobarbital 60mg TID
- Phenytoin 400mg daily
- ASA 81mg daily
Discharge Medications:
None given as pt. left against medical advice.
Discharge Disposition:
Home
Discharge Diagnosis:
alcohol intoxication
alcohol withdrawal
phenobarbital overdose
seizure disorder
Discharge Condition:
AF VSS, withdrawing from alcohol.
Discharge Instructions:
You were admitted because of alcohol intoxication and overdosing
on your phenobarbital. You were intubated and extubated safely.
You are at very very high risk of withdrawing from alcohol,
DT's and even death if you do not either stay here or go to a
drug rehabilitation center for detox. You stated that you
understood this risk and are willing to accept this. You will
need to sign out against medical advice because we strongly
disagree with your decision. We also feel that you need to
change your anti-seizure meds from phenobarbital to dilantin
(which other providers have told you) because you are clearly
abusing the phenobarbital. Please see the provider of these
medications for a firm regimen.
Followup Instructions:
with your PCP [**Last Name (NamePattern4) **] [**1-3**] weeks
|
[
"303.01",
"276.2",
"969.4",
"E980.3",
"345.90",
"518.82",
"E849.0",
"280.9",
"967.0",
"070.70",
"291.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
8646, 8652
|
6514, 6783
|
309, 374
|
8776, 8812
|
3950, 6491
|
9571, 9636
|
3082, 3326
|
8575, 8623
|
8673, 8755
|
8484, 8552
|
8836, 9548
|
3341, 3931
|
239, 271
|
402, 1593
|
6798, 8458
|
1615, 2120
|
2136, 3066
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,392
| 182,162
|
23647
|
Discharge summary
|
report
|
Admission Date: [**2191-1-18**] Discharge Date: [**2191-1-27**]
Date of Birth: [**2128-6-20**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3127**]
Chief Complaint:
Diabetic Ketoacidosis
Major Surgical or Invasive Procedure:
Cardiac Catheterization
Past Medical History:
PMH:
1. Type II diabetes X 25 yrs: [**2190-4-1**] HgbA1C 9.5, since which
his insulin regimen has been adjusted multiple times.
- c/b nephropathy, peripheral neuropathy, and gastroparesis
2. s/p Left TMA ~ 5 years ago secondary to gangrene.
3. Anemia: Unknown baseline. HCT [**3-20**] 31.3.
4. ESRD: secondary to diabetes and hypertension. On hemo
dialysis (MWF) since [**2184**]. Since moving here from [**State 531**], he
has seen Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] of nephrology at [**Hospital1 60484**].
5. Hypertension.
6. s/p discectomy at age 40 yrs.
7. GERD
Social History:
lives in [**Hospital3 11148**] [**Hospital3 **] Center. Prior heavy ETOH, quit
8 years ago. TOB: 50 pk yr h/o smoking. No illicits.
Family History:
Fa--DM, CABG, Mo--CVA
Pertinent Results:
[**2191-1-18**] 07:30AM BLOOD Glucose-977* UreaN-106* Creat-15.8*
Na-138 K-5.5* Cl-81* HCO3-18* AnGap-45*
[**2191-1-18**] 11:04AM BLOOD Glucose-806* UreaN-103* Creat-15.9*
Na-139 K-4.8 Cl-81* HCO3-24 AnGap-39*
[**2191-1-19**] 10:20PM BLOOD CK-MB-21* MB Indx-4.4 cTropnT-13.52*
[**2191-1-19**] 04:09PM BLOOD CK-MB-37* MB Indx-4.5 cTropnT-15.41*
[**2191-1-18**] 04:40PM BLOOD CK-MB-130* MB Indx-8.7* cTropnT-7.83*
[**2191-1-18**] 11:04AM BLOOD CK-MB-81* MB Indx-8.6* cTropnT-3.59*
[**2191-1-18**] 09:26PM BLOOD CK-MB-130* MB Indx-7.8*
Brief Hospital Course:
Upon presentation to the emergency room for hypotension and
diabetic ketoacidosis, immediately admitted to the intensive
care unit for close monitoring. Upon admission, many tests,
including cardiac enzymes were drawn which revealed CK-MB
peaking at 130 and Troponin peaking at 15 [NSTEMI]. Cardiology,
as well as Renal, was immediately consulted. Cardiac working
including an angiogram reveal 2-vessel disease.
A CT of the abdomen done on day two showed pancolitis without
evidence of intra-abdomenal abscess colections. His
electrolytes and blood sugars quickly normalized with
hemodialysis and insulin drip/sliding scale. He stayed in the
Intensive Care Unit for five days total, and was then
transferred to the cardiac floor. There, he was continued to be
closely monitored with telemetry. On day nine of his
hospitalization, he had a successful angioplasty of the right
coronary artery.
Feeling well and doing well, he was discharged on the [**1-27**], [**2191**] good condition. His intructions for follow up was very
throrough and specific.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6.
Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose
AS DISCUSSED WITH [**Last Name (un) **] DIABETIC CENTER
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8.
PT WAS RECENTLY DISCHARGED BEFORE COMING BACK TO THE HOSPITAL
AND SHOULD HAVE ENOUGH MEDICATIONS.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Diabetic Ketoacidosis s/p right colectomy [**2191-1-11**]
Two vessel coronary artery disease.
Discharge Condition:
Good
Discharge Instructions:
Please follow directions as discussed previously by Dr.
[**Last Name (STitle) **]/Attending Surgeon/Cardiologist.
Please take medications as prescribed and read warning labels
carefully. If signs of infections such as fever greater than
101.4 F, purulent discharge from wound or cardiac catheter
entrance site (groin), increased pain and redness at wound/groin
site, please call or go to the emergency room. If there is
bleeding from groin cathether entrance site call/go to the ER.
Remember to call for a follow up appointment (bellow) with Dr.
[**Last Name (STitle) **] and the Cardiologist. Light activities until seen in
clinic. [**Month (only) 116**] sponge bathe or take shower if shower hose can be
directed to minimize getting wounds wet. No baths. If you
still have staples, they will be addressed during your follow up
visit. If you have steri-strips, do not peel them off-it may
take off the scab. Trim the edges if necessary. Peel
Otherwise, they will fall off on their own after about a week.
Absolutely no smoking because tobacco will slow/inhibit wound
healing.
Followup Instructions:
Please call Dr.[**Name (NI) 4838**] office for a follow-up appointment([**Telephone/Fax (1) 10248**].
Also, please follow-up your Cardiologist (as previously
described by the Cardiac Team)([**Telephone/Fax (1) 2037**].
Please call the [**Last Name (un) **] Diabetic Center for a follow up
appointment [**Telephone/Fax (1) 2378**].
Please continue to follow up with your Renal/Dialysis Team.
Completed by:[**2191-2-2**]
|
[
"585.6",
"403.91",
"250.40",
"414.01",
"250.10",
"410.71",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.07",
"37.22",
"00.45",
"38.93",
"00.66",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
3637, 3695
|
1795, 2858
|
337, 363
|
3833, 3840
|
1238, 1772
|
4976, 5400
|
1196, 1219
|
2881, 3614
|
3716, 3812
|
3864, 4953
|
275, 299
|
385, 1029
|
1045, 1180
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,214
| 188,480
|
28461
|
Discharge summary
|
report
|
Admission Date: [**2118-2-7**] Discharge Date: [**2118-2-14**]
Date of Birth: [**2059-1-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
Abdominal pain and fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
59 y/o male with a h/o GBM s/p partial resection and
chemoradiation and cholangiocarcinoma currently completing
second cycle of gemcitabine and cisplatin who presented with
lower abdominal pain and fever the day of admission. Pt states
he has been doing fairly well until yesterday when he developed
a fever. In the ED, he was noted to have temp of 103 and he was
pan-cultured and started on IV cefepime. He was noted to be
hemodynamically stable without obvious source of infection on
clinical examination. No urinary tract symptoms. No GI symptoms.
CT abdomen done in ER was negative. U/A was negative. Pt was
admitted for further management of his pain and the fever.
.
ROS: Pt denies recent N/V/D. Pt admits to sick contacts but
denies recent travel. Pt denies any urinary symptoms. Pt denies
rash or joint complaints.
Past Medical History:
GBM
Cholangiocarcinoma
Emphysema, dx [**2111**]
h/o 'hepatitis' contracted in a lab (on the job) treated with
abx for 2 years in the [**2080**]'s
Sigmoid colon perforation - s/p resection with colostomy [**9-1**]
Renal insufficiency
Social History:
50 pack-year smoking history but has recently quit smoking.
EtOH: 4 beers/wk, in the past up to 1 case beer/week. Works as a
blacksmith in a steel foundry x 35 years, many people at work
with lung disease but also many smokers. Married with two
daughters, one son.
Family History:
No known h/o cancers; father deceased (unknown age) CAD, mother
deceased (unknown age) CVA; 2 brothers, 3 sisters, reportedly
healthy, 3 children reportedly healthy
Physical Exam:
PE:
Vitals:
T 98.5 HR 75 BP 112/62 RR 16 96%RA
General: WD/WN 59 y/o male in NAD.
HEENT: NC/AT. PERRLA. EOMI. MM dry. OP with evidence of thrush.
Neck: No LAD or JVD.
CV: Normal S1, S2 without m/r/g.
Pulm: CTAB without wheezes or crackles.
Abdomen: Soft, NT/ND with normoactive BS. No rebound or
guarding. Stoma intact.
Ext: No c/c/e. 2+ DP B/L.
Pertinent Results:
[**2118-2-6**] CT Abdomen and Pelvis
Interval appearance of increased amount of ascites, which still
remains small. No evidence of obstruction or perforation.
Otherwise, similar appearance of the abdomen and pelvis to
examination of four days prior.
.
[**2118-2-6**] CXR
No acute cardiopulmonary process identified.
.
[**2118-2-8**] Abdominal U/S
Heterogeneous appearance of the right lobe of the liver
consistent with known history of cholangiocarcinoma. Gallbladder
edema likely attributable to liver dysfunction as there is no
evidence of cholecystitis. Trace ascites.
.
[**2118-2-8**] LENIs
No evidence of DVT.
.
[**2118-2-10**] CXR
No acute cardiopulmonary process. No evidence of free air.
.
[**2118-2-10**] KUB
No evidence for obstruction or free intraperitoneal air.
.
[**2118-2-6**] WBC-1.9*# RBC-2.95* Hgb-10.2* Hct-30.7* Plt Ct-301#
[**2118-2-11**] WBC-9.5 RBC-3.04* Hgb-9.5* Hct-28.4* Plt Ct-444*
[**2118-2-11**] Neuts-67 Bands-3 Lymphs-3* Monos-15* Eos-0 Baso-1
Atyps-0 Metas-4* Myelos-5* Promyel-2*
[**2118-2-9**] Gran Ct-3350
[**2118-2-6**] Glucose-194* UreaN-16 Creat-0.7 Na-136 K-4.2 Cl-103
HCO3-23
[**2118-2-11**] Glucose-111* UreaN-15 Creat-0.6 Na-138 K-3.4 Cl-108
HCO3-23
[**2118-2-11**] ALT-19 AST-29 LD(LDH)-306* AlkPhos-193* TotBili-1.6*
[**2118-2-8**] Lipase-21
[**2118-2-11**] Albumin-2.0* Calcium-7.5* Phos-1.7* Mg-2.3
[**2118-2-8**] TSH-5.3*
[**2118-2-8**] T3-145 Free T4-1.2
[**2118-2-7**] Lactate-2.3*
Brief Hospital Course:
59 y/o male with a h/o GBM and cholangiocarcinoma who recently
completed cisplatin and gemcitabine chemotherapy who presented
with fever to 103 at home and lower abdominal pain. The
following issues were addressed during this admission.
.
1. Fever
The pt was admitted after spiking a temp to 103 at home. During
this admission, workup was started to discern the etiology for
his fever. Several sets of blood cultures were sent. One bottle
returned at positive for coag negative staph. He was given one
day of vancomycin but this was stopped when blood culture was
consistent with contamination. CXR and clinical exam revealed no
evidence of pulmonary process. U/A and urine cultures were
negative. Pt was initially started on cefepime. On hospital day
#1, pt had no further fevers and coverage was changed to
cipro/Flagyl for better abdominal coverage. The night of
hospital day #1, pt spiked another temperature and became
tachycardic, subsequently transferred to the [**Hospital Unit Name 153**] for concern
for developing sepsis. Pt was stabilized in the [**Hospital Unit Name 153**] and no
infectious source was found. Pt continued to have low-grade
temperatures. He was transferred to the oncology floor. All
cultures were negative and no infectious source was identified.
The most likely etiology for pt's fevers was secondary to
inflammation in his abdomen from his known malignancy. Pt was
continued on empiric cefepime. Abdominal U/S revealed no
evidence of cholecystitis and only trace ascites. There was
discussion of possibly draining his ascites. Surgery was
consulted. After full discussion with the primary oncology team
and surgery, it was determined that paracentesis would be
extremely risky. Pt declined paracentesis.
.
Given pt's worsening functional status, a family meeting with
Dr. [**Last Name (STitle) 3274**] occurred and the pt and his family agreed that if
the pt did not improve over the next couple days that pursuing
comfort measures would be the pt's desire. On [**2118-2-11**], the pt
and family decided to pursue comfort measures only. The pt
passed away with his family at his side on [**2118-2-14**].
Medications on Admission:
Keppra 1000 mg PO BID
Famotidine 20 mg PO TID
Ativan 0.5 mg TID PRN
Compazine 10 mg Q8H PRN nausea
Olanzapine 5 mg QHS PRN
ISS
Discharge Medications:
Pt expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Cholangiocarcinoma
Discharge Condition:
None
Discharge Instructions:
Pt expired.
Followup Instructions:
None
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
Completed by:[**2118-2-18**]
|
[
"038.9",
"V10.85",
"707.03",
"V44.3",
"492.8",
"585.9",
"156.1",
"285.22",
"995.93",
"789.5",
"707.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6106, 6115
|
3755, 5893
|
339, 345
|
6178, 6185
|
2300, 3732
|
6245, 6392
|
1752, 1918
|
6071, 6083
|
6136, 6157
|
5919, 6048
|
6209, 6222
|
1933, 2281
|
275, 301
|
373, 1197
|
1219, 1453
|
1469, 1736
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,678
| 167,651
|
15017+56598
|
Discharge summary
|
report+addendum
|
Admission Date: [**2103-1-29**] Discharge Date: [**2103-2-6**]
Date of Birth: [**2033-9-7**] Sex: M
Service: VSU
CHIEF COMPLAINT: Thoracoabdominal aneurysm.
HISTORY OF PRESENT ILLNESS: This is a 69-year-old gentleman
with a 6.3 cm thoracoabdominal aneurysm, who has extensive
COPD and prior right and left lung surgery and was not felt
to be a candidate for open thoracoabdominal aneurysm repair.
The patient now is admitted for endovascular repair of his
thoracoabdominal aneurysm.
PAST MEDICAL HISTORY: Status post right iliofemoral conduit
placement on [**2102-12-12**] and SMA iliorenal right and
left bypasses with ligation of the origin of the SMA and
right and left renal arteries in [**2097**]; small-cell carcinoma
of the parotid gland, status post chemotherapy and radiation;
history of lung carcinoma, status post wedge resection of the
left upper lobe on [**2100-1-18**] and right lower lobe
superior segmentectomy on [**2100-2-9**]; history of
hypertension; history of peripheral vascular disease; history
of carotid stenosis; history of depression; history of
abdominal aortic aneurysm; history of hyperlipidemia; history
of being a 96-pack-year smoker - has not smoked in 2 years;
history of COPD with an FEV-1 of 42%; history of chronic
kidney disease, stage II to III.
ALLERGIES: Univasc; Lipitor; vitamin E; Ambien.
MEDICATIONS ON ADMISSION: Vicodin 5/500 b.i.d., hydralazine
50 mg q.i.d., albuterol 90 mcg q.i.d., fluoxetine 40 mg
daily, Prilosec 20 mg daily, aspirin 325 mg daily, metoprolol
75 mg t.i.d., simvastatin 80 mg daily, ipratropium/albuterol
18/103 mcg 2 puffs q.i.d., fluticasone 110 mcg puffs b.i.d.,
isosorbide mononitrate 60 mg daily, Ultram 25 mg daily,
Flexeril 10 mg at bedtime.
SOCIAL HISTORY: He is retired and has a former history of
alcohol abuse and former tobacco use. He has not smoked since
___________ and previously had 96- to 100-pack-year smoking.
He lives in [**Location 149**] and has been in [**Location (un) 86**] for 2 or 3 months,
staying with friends in [**Location (un) 2030**].
FAMILY HISTORY: Positive for [**Location (un) 499**] cancer - his mother at
the age of 43 and his brother with [**Name2 (NI) 499**] cancer at the age of
37.
PHYSICAL EXAMINATION: VITAL SIGNS: 97.2; 67; 18; blood
pressure 102/68; O2 sat 97% on room air. GENERAL APPEARANCE:
No acute distress. HEENT: Exam was unremarkable. There was
no lymphadenopathy. CARDIOVASCULAR: Regular rate and rhythm,
with a systolic ejection murmur at the left lower sternal
border. LUNGS: Clear to auscultation bilaterally. ABDOMEN:
Unremarkable exam. EXTREMITIES: No peripheral edema.
NEUROLOGICAL: Exam is nonfocal.
HOSPITAL COURSE: The patient was admitted to the vascular
service for prehydration prior to anticipated endovascular
repair on [**2103-1-29**]. The procedure was cancelled
secondary to the patient's elevated creatinine of 2.7. The
renal service was consulted. The impression was that they do
not feel that the patient was in ATN or had
glomerulonephritis based on the urine slide. AIN is possible
in the setting of new antibiotics with minimal WBCs on the
urine. There is concern that the renal ultrasound shows no
flow in the left kidney and there is no flow on it either on
[**2102-12-22**]. There most likely is a vascular etiology to
worsening renal function with possible prerenal etiology.
Urine lytes __________ suggest prerenal, but this was after
1.2 L of fluid. Recommendations at the time were to monitor
the creatinine, continue IV fluids, do a nuclear isotope
scan, monitor the LDH, hold off on surgery, and hold the
lisinopril.
His preoperative chest x-ray demonstrated small left lower
lobe changes. The pulmonary service was requested to review
the films and assess for increased respiratory risk for
planned procedure. They felt that this should not put him at
any increased risk from a pulmonary complication and would
continue his current COPD regimen.
The patient was continued on an IV bicarbonate drip and fluid
resuscitated with a steady improvement in his creatinine,
which on admission was 2.7, and by [**2103-2-2**] it was
1.4. The patient proceeded to angio for endovascular repair
of his thoracoabdominal aneurysm. The patient had an EVAR
with a TAG and coil embolization of the celiac artery. The
patient tolerated the procedure well and was transferred to
the PACU in stable condition.
Postoperatively, the patient was weaned off of his vent. He
was followed by the pain service postoperatively. He was
transferred to the unit on [**2103-2-3**] for blood
pressure control and he was extubated at that time. His nitro
was weaned on postoperative day #1, and his diet was
advanced. His IV fluids were Hep-Locked. Subcu heparin was
instituted, and the patient was transferred to the SICU for
continued monitoring and care. His lumbar drain was
discontinued. His renal function continued to improve. On
postoperative day #2, there were no overnight events. Pain
was adequately controlled. His IV fluids were Hep-Locked.
Ambulation was begun, and physical therapy was requested to
evaluate the patient for discharge planning. The patient's
creatinine remained stable at 1.6 with good urinary output.
When medically stable, the patient will be discharged to home
with services for monitoring of his blood pressure.
DISCHARGE MEDICATIONS: Simvastatin 80 mg daily, metoprolol
tartrate 75 mg b.i.d., albuterol 90 mcg actuation aerosol 1
to 2 puffs q.6 hours p.r.n. for wheezing, fluoxetine 40 mg
daily, Protonix 40 mg daily, ipratropium bromide 17 mcg
actuation aerosol 2 puffs q.i.d., fluticasone 110 mcg
actuation aerosol 2 puffs b.i.d., isosorbide mononitrate 60
mg daily, nicotine patch 14 mg/24 hours daily, aspirin 325 mg
daily, hydralazine 50 mg q.6 hours, hydrocodone/acetaminophen
5/500 tablets 1 to 2 q.4 to 6 hours p.r.n. for pain.
DISCHARGE DIAGNOSES:
1. Thoracoabdominal aneurysm.
2. History of supraventricular tachycardia with
interventricular conduction delay arrest - resuscitated.
3. History of pneumonia ([**2103-1-24**]) - treated.
4. History of small-cell carcinoma, status post ___________
chemotherapy and radiation therapy.
5. History of lung carcinoma, status post left upper lobe
wedge resection and a right lower lobe superior
segmentectomy ([**2100-1-18**] and [**2100-2-9**]).
6. History of right iliofemoral conduit placed with an
superior mesenteric artery iliorenal, right and left,
artery bypass grafts and ligation of the origin of the
superior mesenteric artery and the right and left renal
arteries ([**2102-11-13**]).
7. History of carotid disease.
8. History of depression.
9. History of abdominal aortic aneurysm.
10.History of hyperlipidemia.
11.History of tobacco use (96+ pack years - discontinued in
__________).
12.History of chronic kidney disease, stage II to III.
13.History of postoperative blood loss anemia, transfused.
DISCHARGE INSTRUCTIONS: The patient may ambulate essential
distances and may shower, but take no tub baths. He should
continue all medications as directed and do no driving until
seen in follow-up by Dr. [**Last Name (STitle) **]. He should call our
office if he develops a fever of greater than 101.5 or if the
wound sites develop redness, drainage, or swelling.
MAJOR SURGICAL PROCEDURES: EVAR, TAG, and coil embolization
of the celiac artery on [**2103-2-2**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 6039**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2103-2-5**] 12:13:59
T: [**2103-2-5**] 14:22:48
Job#: [**Job Number 43935**]
Name: [**Known lastname 7998**],[**Known firstname 33**] Unit No: [**Numeric Identifier 7999**]
Admission Date: [**2103-1-29**] Discharge Date: [**2103-2-19**]
Date of Birth: [**2033-9-7**] Sex: M
Service: SURGERY
Allergies:
Univasc / Lipitor / Vitamin E / Ambien
Attending:[**First Name3 (LF) 726**]
Addendum:
Continued from [**2-7**]:
Pt with extended hospital stay from previous DC Summary.
CHART THINNED:
To note pt on admission his blood pressure was consistantly in
the 180's. Pt on minimal blood pressure medications. When
started on blood pressure medications the pts blood pressure was
very difficult to control.
because of this a cardiology consult was obtained. the worked
with us to control pt BP. On Dc pt to have VNA services for BP
monitering. VNA is to call pt PCP id BP pressure is a problem
Pt experieinced tachycardia with with decrease in blood
pressure. Whe this happened pt was ambulatory, he stated that he
could not feel his legs, acute onset bilateral lower extremity
weakness. This was thought to be due to hypoperfused cord
syndrome. Nuerology consult was obtained.
NUEROLOGY RECOMMENDATIONS:
1. obtain MRI of the T & L spine without contrast
2. Keep SBP > 120 as allowed by his recent procedure
3. Limited narcotics use
MRI IMPRESSION:
1. Questionable minimal signal abnormality within the [**Doctor Last Name **]
matter of the distal thoracic spinal cord and conus which could
be the sequela of cord ischemia. Given the equivocal finding,
clinical followup to ensure symptomatic resolution is
recommended.
2. Heterogeneous marrow signal which could represent chronic
disease or anemia.
3. Mild degenerative changes involving the lumbar spine as
detailed above which are similar to [**2101**].
4. Bilateral pleural abnormalities and thoracoabdominal aortic
aneurysm, status post repair, are better evaluated on recent CT
of the torso.
We also got a Nuerosurgery consult:
Pt did not require any surgical intervention. The agreed with
Nuerology.
Imprssion below:
[**2103-2-2**] who had episode of bilateral leg paralysis and sensory
loss [**2103-2-11**] in setting of systolic blood pressure in the 90's.
MRI and physical findings show no indication for surgical
decompression or spinal angiogram. Would recommend relative
volume expansion and relative increase in MAP as tolerated.
Pt hypertensive meds were adjusted accordingly. When pt
medication was adjusted to keep SBP greater then 120. Pt did not
experience any lower extremity weakness.
[**2-10**]: Pt experienced SOB and chest pain:
Pt ruled out for MI
A CAT scan was obtained, impression below:
IMPRESSION:
1. No evidence of pulmonary embolism or aortic dissection.
2. Status post repair of thoracoabdominal aortic aneurysm. No
evidence of contrast extravasation to suggest endoleak. No
evidence of rupture.
3. Left renal artery conduit occlusion again seen, with absence
of perfusion in the left kidney.
4. Increase in moderate-to-large bilateral pleural effusions,
right greater than left with associated atelectasis. Evidence of
pulmonary edema.
5. Nodular opacities at the right base again possibly
representing atelectasis or inflammatory change since they are
new from [**2102-12-21**]. Attention will be paid on follow-up imaging.
Pt also had some pain issues:
A Pain consult was obtained, pt started on Tizanidine. This seem
to improve pt's pain. As this medication was titrated pt became
lethargic. The medication was adjusted accordingly. Pt ot be
discharged on low dose. ON DC pt pain is well controlled.
Because of the above issues pt watched over the weekend1/5 and
[**2-18**]. Pt stable for DC
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - MACU
[**First Name11 (Name Pattern1) 168**] [**Last Name (NamePattern4) 730**] MD [**MD Number(2) 731**]
Completed by:[**2103-2-19**]
|
[
"441.7",
"496",
"272.4",
"V10.11",
"V15.3",
"584.9",
"443.9",
"585.9",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.44",
"00.46",
"39.50",
"88.42",
"39.90",
"39.71",
"00.41"
] |
icd9pcs
|
[
[
[]
]
] |
11348, 11572
|
2087, 2229
|
5866, 6909
|
5342, 5845
|
1390, 1748
|
2692, 5318
|
6934, 11325
|
2252, 2674
|
152, 180
|
209, 508
|
531, 1363
|
1765, 2070
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,007
| 173,668
|
2935
|
Discharge summary
|
report
|
Admission Date: [**2113-1-30**] Discharge Date: [**2113-2-6**]
Date of Birth: [**2040-3-14**] Sex: M
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11304**]
Chief Complaint:
left renal mass
Major Surgical or Invasive Procedure:
Robotic left partial nephrectomy- Dr. [**Last Name (STitle) 14114**] [**2113-1-30**]
History of Present Illness:
Mr. [**Known lastname 3614**] is a 72 year old male with HTN, COPD, CHF, HL, CAD s/p
MI with stent placement in [**2097**], here with post-operative
hypoxia. He underwent right partial nephrectomy for a 6 cm
renal mass concerning for renal cell carcinoma.
Intraoperatively, he received 6 L of IVFs. Post-operatively, he
was noted to desat to 80s on 4LNC.
.
Upon arrival to the [**Hospital Unit Name 153**], his vitals were RR 20, HR 91, BP
96/55, 95% on 4LNC. The patient reports his breathing is
comfortable, though patient is tachypneic. He denies cough,
pleuritic chest pain, chest pressure. He reports increased
abdominal pain with deep inspiration.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denied chest pain or tightness, palpitations. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain.
Past Medical History:
HTN
Hyperlipidemia
CHF, most recent echo with [**Last Name (LF) 14115**], [**First Name3 (LF) **] of 60% in [**Month (only) **] by report
COPD with moderate obstructive disease on PFTs
CAD, s/p MI [**17**] years ago
Type 2 diabetes, insulin dependent
Scoliosis
Social History:
Patient has a 1.5 PPD for 15 years smoking history, but quit 25
years ago. Denies current alcohol use. Patient lives with his
daughter who is his health care proxy. [**Name (NI) **] is a retired
upholsterer.
Family History:
Patient denies family history of cardiac or pulmonary disease.
Physical Exam:
Vitals: HR 81, BP 100/60, 96% on 4LNC,
General: Alert, oriented, tachypneic
HEENT: Sclera anicteric, oropharynx clear
Neck: supple, JVP difficult to assess
Lungs: coarse breath sounds at right base, but lung exam limited
due to patients diffuculty sitting upright
CV: distant heart sounds, Regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: soft, multiple surgical scars with come tenderness
diffusely, bowel sounds present, no rebound tenderness or
guarding
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
137 | 105 | 16 /
--------------- 121
5.2 | 24 | 1.1 \
.
\ 11.0 /
14.6 ----- 203
/ 33.8 \
Brief Hospital Course:
Patient was admitted to Urology after undergoing robotic left
partial nephrectomy. No concerning intraoperative events
occurred; please see dictated operative note for details. The
patient received perioperative antibiotic prophylaxis. The
patient was transferred to the floor from the PACU in stable
condition. On POD0, pain was well controlled on PCA, hydrated
for urine output >30cc/hour, and provided with pneumoboots and
incentive spirometry for prophylaxis. However, the patient was
noted to have increasing post-operative hypoxia.
Intraoperatively, he received 6 L of IVFs and was noted to desat
to 80s on 4LNC post-operatively, prompting transfer to the [**Hospital Unit Name 153**]
for interval managment.
.
The patient's exam and presentation were most consistent with
respiratory compromise that was multifactorial and secondary to
his known COPD, scoliosis, and splinting from surgery-associated
pain. His oxygen saturation and breathing improved with
bronchodilator therapy and he was transferred back to the
surgical service on POD2.
.
On POD 3, the patient ambulated, was restarted on home
medications, basic metabolic panel and complete blood count were
checked, pain control was transitioned from PCA to oral
analgesics, diet was advanced as tolerated. On POD5, JP and
urethral catheter (foley) were removed without difficulty. The
patient passed a void trial with voided volumes greater that
post void residuals. The remainder of the hospital course was
relatively unremarkable. The patient was discharged in stable
condition, eating well, ambulating independently, voiding
without difficulty, and with pain control on oral analgesics. On
exam, incision was clean, dry, and intact, with no evidence of
hematoma collection or infection. The patient was given explicit
instructions to follow-up in clinic with Dr. [**Last Name (STitle) 3748**] in 3 weeks.
Medications on Admission:
Atenolol 25 mg daily
Lipitor 20 mg daily
Lasix 20 mg daily
Lisinipril 5 mg daily
Aspirin 325 mg daily
Multivitamin daily
Albuterol
Atrovent
Discharge Medications:
1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for break through pain only (score >4)
.
Disp:*50 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheeze, SOB.
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
6. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily). Capsule(s)
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8300**] VNA
Discharge Diagnosis:
right renal mass
Discharge Condition:
Stable
Discharge Instructions:
-You may shower but do not bathe, swim or immerse your incision.
-Do not eat constipating foods for 2-4 weeks, drink plenty of
fluids
-Do not lift anything heavier than a phone book (10 pounds) or
drive until you are seen by your Urologist in follow-up
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthough pain >4.
Replace Tylenol with narcotic pain medication. Max daily
Tylenol dose is 4gm, note that narcotic pain medication also
contains Tylenol (acetaminophen)
-Do not drive or drink alcohol while taking narcotics
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication,
discontinue if loose stool or diarrhea develops.
-Resume all of your home medications, except hold NSAID
(aspirin, and ibuprofen containing products such as advil &
motrin,) until you see your urologist in follow-up
-Call your Urologist's office today to schedule/confirm your
follow-up appointment in 3 weeks AND if you have any questions.
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incision, call your doctor or
go to the nearest ER
-Call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3748**] to set up follow-up appointment and if
you have any urological questions. [**Telephone/Fax (1) 3752**]
Followup Instructions:
Please contact Dr.[**Name (NI) 11306**] office to arrange/ confirm follow
up.
Completed by:[**2113-2-6**]
|
[
"V58.67",
"189.0",
"737.34",
"401.9",
"414.01",
"799.02",
"496",
"458.29",
"V15.82",
"518.0",
"272.4",
"412",
"V45.82",
"560.1",
"250.00",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.4",
"17.42"
] |
icd9pcs
|
[
[
[]
]
] |
5600, 5659
|
2632, 4509
|
330, 416
|
5720, 5728
|
2512, 2609
|
7159, 7266
|
1847, 1911
|
4699, 5577
|
5680, 5699
|
4535, 4676
|
5752, 7136
|
1926, 2493
|
275, 292
|
1123, 1319
|
444, 1105
|
1341, 1603
|
1619, 1831
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,669
| 176,392
|
6166
|
Discharge summary
|
report
|
Admission Date: [**2116-2-2**] Discharge Date: [**2116-2-28**]
Date of Birth: [**2043-7-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
mitral valve repair via right thoracotomy [**2-20**]
cardiac cath
colonoscopy
upper endoscopy
dental extraction
History of Present Illness:
72M h/o sCHF (EF 35%); CAD s/p CABG x2; LCx stent [**2110**]; 4+MR;
s/p BiV ICD; recurrent pAF w/ RVR s/p AV node ablation; DM2,
presented to the ED with SOBx 2 days, as well as with one
recorded temperature at home to T 100. Of note, pt had been
discharged on [**2116-1-11**] after undergoing AV node ablation, and had
denied respiratory distress during [**1-23**] EP outpatient follow-up;
at that time, ICD had been interrogated and found to be WNL.
(On this presentation, however, pt stated that he had been SOB
since his latest discharge.)
.
Pt also reported that he had been coughing x3 days, producing
white phelgm, and had been in contact with a granddaughter
recently [**Name2 (NI) **] with influenza.
.
ROS: Positive for SOB, increased peripheral edema x1day,
decreased ability to sleep given SOB, and decreased exercise
tolerance. Negative for chest pain, abd pain, N/V, changes in
urinary/bowel habits, myalgias/arthralgias.
.
ED course:
# Vitals: O2sat 91 on RA, mid 80s on RA with conversation, 96 on
2L
# Meds: Furosemide 40mg IV (excreted 400cc urine), levofloxacin
Past Medical History:
# CAD s/p inferior MI, CABG x2 ([**2080**], [**2100**]: SVG to OM, SVG to
LAD, patent in [**2110**]), LCx stent [**2110**]
# Systolic CHF [**12-28**] ischemic CM (EF 35%) s/p BiV ICD [**2110**],
replaced [**2114**]
# HTN
# 4+ MR
# h/o paroxysmal atrial fibrillation s/p cardioversion [**2114**], s/p
AV node ablation [**2115**]
# COPD: No home O2
# DM2
# Hypercholesterolemia
# Chronic renal insufficiency
# GERD
Social History:
# Personal: Lives with wife, has 2 sons. [**Name (NI) 24075**]-speaking only.
# Professional: Retired construction worker.
# Tobacco: Smoked maximum 4ppd
# Alcohol: Social
# Recreational drugs: None
Family History:
Noncontributory
Physical Exam:
VITALS: T 96.8, BP 100/50, HR 70, RR 20, O2sat 95 on 2L, FS 245
HEENT: NCAT, OP clear, MMM, no LAD
NECK: JVP elevated to ear. No carotid bruits.
CHEST: Bilateral rales 3/4 up. Apices clear. No rhonchi,
wheezes.
CARDIAC: RRR, S1S2, 2/6 SEM @ apex.
ABDOMEN: Soft, NT/ND, BS+, no HSM
EXT: BLE to ankles, 1+ B DP.
NEURO: A&Ox3
Pertinent Results:
Studies/imaging:
# EKG: V-paced at rate 69
# CXR: Mild cardiogenic pulmonary edema although no definite
focal
infection is visualized. Repeat radiography after appropriate
diuresis is helpful to assess for underlying infection.
.
ECHO [**2116-2-4**]:
Conclusions
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. There is moderate regional left ventricular
systolic dysfunction with severe hypokinesis/akinesis of the
inferior, inferolateral and inferoseptal walls, and hypokinesis
of the apex, c/w multivessel CAD. [Intrinsic left ventricular
systolic function is likely more depressed given the severity of
valvular regurgitation.] Right ventricular chamber size is
normal. with mild global free wall hypokinesis. The aortic root
is mildly dilated at the sinus level. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are mildly thickened. A very eccentric, posteriorly
directed jet of [**Location (un) **] (4+) mitral regurgitation is seen, likely
on the basis of the posteromedial papillary muscle dysfunction.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Dilated left ventricle with moderate regional
systolic dysfunction, c/w multivessel CAD. Severe secondary
mitral regurgitation. Moderate tricuspid regurgitation. Moderate
pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2115-12-25**],
mitral and tricuspid regurgitation are more severe and pulmonary
pressures are higher. The other findings are similar.
Findings disscussed with Dr. [**Last Name (STitle) 24076**] at 1140 hours on the day of
the study.
.
C.CATH Study Date of [**2116-2-11**]
COMMENTS:
1. Coronary angiography of this right dominant system revealed
three
vessel coronary disease. The LMCA had mild disease. The LAD was
totally
occluded proximally with the distal vessel filling via a patent
SVG. The
LCX had a widely patent stent supplying OM2 which filled by a
patent
SVG. The RCA was known to be totally occluded and therefore was
not
selectively engaged.
2. Venous conduit arteriography revealed widely patent SVG-LAD
and
SVG-OM1.
3. Resting hemodynamics revealed an RASP of 11 mm Hg, RVEDP of
18 mm Hg,
PASP of 43 mm Hg, and PCWP of 21 mm Hg. The cardiac output was
4.0 and
the index 2.3.
4. Left ventriculography was deferred.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. [**Hospital1 **]-ventricular diastolic dysfunction.
3. Patent SVG-LAD, SVG-OM1.
.
CHEST (PRE-OP PA & LAT) [**2116-2-12**] 3:14 PM
FINDINGS: In comparison with study of [**2-2**], there is again
enlargement of the cardiac silhouette in this patient who has
undergone a previous CABG procedure with intact sternal sutures.
Defibrillator device remains in place. Prominence ill-defined
interstitial markings is consistent with the clinical diagnosis
of vascular congestion.
.
[**2116-2-2**] 12:05PM BLOOD WBC-8.3 RBC-3.61* Hgb-8.5* Hct-29.2*
MCV-81* MCH-23.5* MCHC-29.1* RDW-19.4* Plt Ct-232
[**2116-2-9**] 05:00AM BLOOD WBC-6.3 RBC-3.65* Hgb-9.2* Hct-29.8*
MCV-82 MCH-25.3* MCHC-30.9* RDW-20.0* Plt Ct-143*
[**2116-2-17**] 06:43AM BLOOD WBC-6.2 RBC-3.68* Hgb-9.2* Hct-30.3*
MCV-83 MCH-25.0* MCHC-30.3* RDW-19.4* Plt Ct-153
[**2116-2-28**] 05:20AM BLOOD WBC-6.6 RBC-3.30* Hgb-8.8* Hct-28.2*
MCV-85 MCH-26.7* MCHC-31.3 RDW-18.7* Plt Ct-162
[**2116-2-2**] 01:05PM BLOOD PT-36.2* PTT-32.7 INR(PT)-3.9*
[**2116-2-9**] 05:00AM BLOOD PT-14.4* PTT-26.5 INR(PT)-1.3*
[**2116-2-17**] 06:43AM BLOOD PT-14.1* PTT-59.0* INR(PT)-1.2*
[**2116-2-28**] 05:20AM BLOOD PT-30.1* PTT-33.9 INR(PT)-3.1*
[**2116-2-2**] 12:05PM BLOOD Glucose-193* UreaN-53* Creat-1.8* Na-134
K-5.5* Cl-97 HCO3-23 AnGap-20
[**2116-2-9**] 05:00AM BLOOD Glucose-151* UreaN-23* Creat-1.4* Na-141
K-3.7 Cl-103 HCO3-30 AnGap-12
[**2116-2-18**] 09:30AM BLOOD Glucose-263* UreaN-19 Creat-1.5* Na-135
K-4.1 Cl-102 HCO3-25 AnGap-12
[**2116-2-28**] 05:20AM BLOOD Glucose-145* UreaN-27* Creat-1.5* Na-138
K-5.6* Cl-102 HCO3-27 AnGap-15
[**2116-2-25**] 02:51AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.2
Brief Hospital Course:
He was taken to cardiac cath and found to have three vessel
disease. He was Iron deficient by labs and given the concern for
GI bleed, though stool guaiac was documented as negative, he was
taken to colonoscopy and EGD, which showed no source of bleed.
His Plavix was held upon admission in anticipation for
cardiothoracic surgery. His Coumadin was discontinued and he was
maintained on heparin drip once GI bleed was ruled out until
surgery. On [**2-17**] he had three teeth extracted. He was then
taken to the operating room on [**2-20**] where he underwent a mitral
valve repair via right thoracotomy. Please see operative report
for surgical details Following surgery he was transferred to the
CVICU for invasive monitoring in stable condition. He was given
48 hours of vancomycin as he was in the hospital preoperatively.
Later on op day he was weaned from sedation, awoke
neurologically intact and extubated. He was restarted on
Coumadin for his atrial fibrillation. Also started on beta
blockers and diuretics and gently diuresed towards his pre-op
weight. He remained in the ICU for pulmonary toilet. Chest tubes
and epicardial pacing wires were removed per protocol. On [**2-24**],
post-op day four, he underwent right thoracentesis for 250 cc.
He was transferred to the floor on post-op day five. He worked
with physical therapy for strength and mobility. He continued to
slowly recover and was discharged to home with vna services and
the appropriate medications and follow-up appointments. Dr.
[**Last Name (STitle) 1911**] will follow his INR and adjust Coumadin
accordingly.
Medications on Admission:
Atorvastatin (Lipitor) 20 mg daily
Furosemide 60 mg [**Hospital1 **]
Glyburide 5 mg [**Hospital1 **]
Ranitidine (Zantac) 150 mg [**Hospital1 **]
Warfarin 2 mg daily
ASA 81mg daily
Clopidogrel 75 mg daily
Toprol XL 150 mg daily
Imdur 30 mg daily
Spironolactone 25 mg daily
Discharge Medications:
1. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*1*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*1*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. 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*
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*1*
7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
Disp:*1 * Refills:*2*
10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 * Refills:*2*
11. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 4 weeks.
Disp:*65 Tablet(s)* Refills:*0*
12. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day for 1
doses: Titrate dose as directed by the office of Dr.
[**Last Name (STitle) 1911**].
Disp:*40 Tablet(s)* Refills:*1*
13. Outpatient Lab Work
INR to be drawn Saturday with results faxed to [**First Name4 (NamePattern1) 2808**]
[**Location (un) 24077**], RN in the office of Dr. [**Last Name (STitle) 1911**]
[**Telephone/Fax (1) 14926**].
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Primary:
severe mitral regurgitaion now s/p Mitral Valve Repair
coronary artery disease
chronic systolic heart failure
anemia
.
Secondary:
# h/o paroxysmal atrial fibrillation
- s/p cardioversion [**3-2**]
- s/p AVJ ablation [**2116-1-10**]
# COPD
# amio lung toxicity
# HTN
# Diabetes type 2
# Hypercholesterolemia
# Chronic renal insufficiency
# GERD
Discharge Condition:
Stable
Discharge Instructions:
1)Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
2)Please shower daily. No baths. Pat dry incisions, do not rub.
3)Avoid creams and lotions to surgical incisions.
4)Call cardiac surgeon if there is concern for wound infection.
5)No driving for at least one month.
Followup Instructions:
Dr. [**First Name (STitle) 679**] 2 weeks
Dr. [**Last Name (STitle) 1911**] 2 weeks
Dr. [**First Name (STitle) **] 4 weeks
Please fax INR results to [**First Name4 (NamePattern1) 2808**] [**Location (un) 24077**], RN at the office
of Dr. [**Last Name (STitle) 1911**] [**Telephone/Fax (1) 14926**]. Confirmation e-mailed from
[**Doctor Last Name 2808**] on [**2116-2-27**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2116-2-28**]
|
[
"V45.02",
"V45.81",
"416.8",
"496",
"401.9",
"413.9",
"523.40",
"428.23",
"427.31",
"403.90",
"280.9",
"535.50",
"414.01",
"585.9",
"562.10",
"211.4",
"428.0",
"272.0",
"424.0",
"250.00",
"424.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.49",
"37.23",
"38.93",
"35.23",
"23.19",
"88.56",
"88.72",
"45.23",
"45.13",
"39.61",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
10673, 10724
|
6874, 8465
|
338, 451
|
11120, 11128
|
2616, 5149
|
11510, 12004
|
2232, 2249
|
8787, 10650
|
10745, 11099
|
8491, 8764
|
5166, 6851
|
11152, 11487
|
2264, 2597
|
279, 300
|
479, 1563
|
1585, 1999
|
2015, 2216
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,600
| 197,900
|
14523
|
Discharge summary
|
report
|
Admission Date: [**2103-6-23**] Discharge Date: [**2103-6-27**]
Date of Birth: [**2072-11-21**] Sex: F
Service: MEDICINE
Allergies:
tramadol
Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
Hypoxic respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Name14 (STitle) 42893**] is a 30 year old G2P1 woman at 22 wks +2 d
gestation who was transferred from [**Hospital1 189**] with dyspnea and
concern for CHF. Her symptoms began 2-3 days ago suddenly, and
she has had progressive DOE. She would now get out of breath by
any movement. She reports orthopnea last night, had to sleep in
a chair, because she felt SOB lying flat.
At [**Hospital1 189**], she was found to have O2 sat of 73% on RA and was
placed on a non-rebreather. Chest x-ray there showed pulmonary
edema raising concern for acute CHF. She was given 20 mg of IV
furosemide, 70 mg of Lovenox, and 5 mg of IV NTG. Troponin there
was negative. She was transferred to [**Hospital1 18**] for further
management.
In the ED, initial vs were: T 97, HR 86, BP 107/67, RR 24, O2
sat 95% on NRB. She was placed on BIPAP and continued on nitro
gtt for preload reduction. She was briefly taken off of BIPAP
and was noted to have O2 sat 88% on 6L. She had repeat CXR
showing reportedly "fluid". EKG showed SR, no ST changes, + TWI
in III and V1-V3. Cardiology consult was called and performed
bedside echocardiogram, which revealed preserved EF and normal
systolic function. CTA was ordered to rule out PE. She was
noted to breathe comfortably on BIPAP but was mildly somnolent
during her ED stay. She did not receive antibiotics as she did
not demonstrate evidence of infection (no fever, chills, sputum,
leukocytosis). The OBGYN team was consulted and recommended
admission to ICU with verification of due date and prenatal
records. Bedside ultrasound of the uterus showed good fetal
movement. Gas prior to transfer was 7.43/33/138/23.
On the floor, she reports breathing is slightly better. + cough
but no sputum production. No pleuritic chest pain but has sharp
pain in her throat when she takes in deep breath. Also feel
that her hearing is muffled and feels that she hears echos. Has
mild nausea, no vomiting. No recent travel or sick contact,
although [**Name2 (NI) 18933**]'s sister has MRSA. Has not been hiking or been
in standing water.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, lumps or bumps. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denied
chest pain or tightness, palpitations. Denied vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denied arthralgias or
myalgias.
Past Medical History:
- HBV
- HCV
- Kidney stones
- Depression
- Cholecystectomy
- seizure while on Ultram, last one was 2 years ago, no
neurological work up (per patient)
- H/o IV drug use on methadone
Social History:
- unemployed
- Currently living with parents, planning to move in with
[**Name2 (NI) 18933**]
- has an 11 yo son
- Denies alcohol
- Smokes 1ppd
- Reports history of heroin use but has not used anything since
[**Month (only) 404**] this year per patient
Family History:
- [**Name (NI) 12237**] COPD
- Father - unprovoked PE
- no family history of bleeding disease
Physical Exam:
Physical Exam on Arrival
Vitals: T:96.5 BP:99/74 P:79 R: 22 O2: 93% 40% non-rebreather
General: Alert, oriented, uncomfortable
HEENT: Sclera anicteric, mucous membrane dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: diminished bibasilar lung sound, diffused crackles
throughout, R> L, no wheeze or rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmur, no rub,
no gallops
Abdomen: soft, non-tender, gravid, 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:
[**2103-6-23**] 11:45AM BLOOD WBC-8.1 RBC-3.14* Hgb-10.5* Hct-29.0*
MCV-92 MCH-33.4* MCHC-36.2* RDW-14.2 Plt Ct-101*
[**2103-6-27**] 06:20AM BLOOD WBC-3.4* RBC-2.96* Hgb-9.5* Hct-26.9*
MCV-91 MCH-32.0 MCHC-35.2* RDW-13.4 Plt Ct-122*
[**2103-6-23**] 11:45AM BLOOD Neuts-88.6* Lymphs-8.7* Monos-1.7*
Eos-1.0 Baso-0
[**2103-6-26**] 05:30AM BLOOD Neuts-69.2 Lymphs-25.8 Monos-3.4 Eos-1.6
Baso-0
[**2103-6-26**] 05:30AM BLOOD PT-14.2* PTT-26.1 INR(PT)-1.2*
[**2103-6-24**] 12:54PM BLOOD Fibrino-834*
[**2103-6-24**] 03:29AM BLOOD ESR-80*
[**2103-6-25**] 07:45AM BLOOD FetlHgb-0
[**2103-6-25**] 04:55AM BLOOD FetlHgb-0
[**2103-6-24**] 03:29AM BLOOD ACA IgG-PND ACA IgM-PND
[**2103-6-27**] 06:20AM BLOOD Glucose-78 UreaN-22* Creat-0.7 Na-138
K-3.8 Cl-107 HCO3-26 AnGap-9
[**2103-6-23**] 11:45AM BLOOD Glucose-96 UreaN-9 Creat-0.6 Na-138 K-4.3
Cl-106 HCO3-20* AnGap-16
[**2103-6-27**] 06:20AM BLOOD ALT-24 AST-28 AlkPhos-110* TotBili-0.2
[**2103-6-23**] 11:45AM BLOOD ALT-42* AST-102* LD(LDH)-513* CK(CPK)-29
AlkPhos-134* TotBili-0.4
[**2103-6-26**] 05:30AM BLOOD ALT-24 AST-35 LD(LDH)-271* AlkPhos-111*
TotBili-0.2
[**2103-6-23**] 11:45AM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-336*
[**2103-6-24**] 03:29AM BLOOD CK-MB-2 cTropnT-<0.01
[**2103-6-27**] 06:20AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.7
[**2103-6-23**] 11:45AM BLOOD Albumin-3.2* Calcium-8.9 Phos-3.4 Mg-1.6
[**2103-6-25**] 04:55AM BLOOD Cryoglb-PND
[**2103-6-24**] 03:29AM BLOOD Hapto-117
[**2103-6-23**] 11:45AM BLOOD HCG-[**Numeric Identifier 42894**]
[**2103-6-24**] 03:29AM BLOOD ANCA-NEGATIVE B
[**2103-6-24**] 03:29AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2103-6-24**] 03:29AM BLOOD CRP-193.0*
[**2103-6-24**] 03:29AM BLOOD HIV Ab-NEGATIVE
[**2103-6-24**] 03:29AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2103-6-23**] 03:07PM BLOOD Type-ART pO2-138* pCO2-33* pH-7.43
calTCO2-23 Base XS-0 Intubat-NOT INTUBA Comment-NON-INVASI
[**2103-6-23**] 03:07PM BLOOD Lactate-0.8
[**2103-6-23**] urine legionella negative
[**2103-6-23**] 7:03 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal aspirate.
**FINAL REPORT [**2103-6-27**]**
Respiratory Viral Culture (Final [**2103-6-27**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final [**2103-6-25**]):
Greater than 400 polymorphonuclear leukocytes;.
Specimen inadequate for detecting respiratory viral
infection by DFA
testing.
Interpret all negative results from this specimen with
caution.
Negative results should not be used to discontinue
precautions.
Refer to respiratory viral culture results.
Reported to and read back by [**Last Name (LF) **], [**First Name3 (LF) **] ([**Numeric Identifier 27796**]) ON [**2103-6-25**]
AT 11:54AM.
[**2103-6-24**] CMV serology IgG and IgM negative
Time Taken Not Noted Log-In Date/Time: [**2103-6-24**] 11:11 am
HBV Viral Load (Final [**2103-6-26**]):
Greater than 110 million IU/mL.
Performed using the Cobas Ampliprep / Cobas Taqman HBV
Test.
Linear range of quantification: 40 IU/mL - 110million
IU/mL.
Limit of detection: 10 IU/mL.
Time Taken Not Noted Log-In Date/Time: [**2103-6-24**] 11:11 am
HCV VIRAL LOAD (Final [**2103-6-26**]):
4,790 IU/mL.
Performed using the Cobas Ampliprep / Cobas Taqman HCV
Test.
Linear range of quantification: 43 IU/mL - 69 million
IU/mL.
Limit of detection: 18 IU/mL.
Rare instances of underquantification of HCV genotype 4
samples by
[**Doctor Last Name **] COBAS Ampliprep/COBAS TaqMan HCV test method used
in our
laboratory may occur, generally in the range of 10 to 100
fold
underquantitation. If your patient has HCV genotype 4
virus and if
clinically appropriate, please contact the molecular
diagnostics
laboratory ([**Telephone/Fax (1) 6182**]) so that results can be confirmed
by an
alternate methodology.
[**2103-6-24**] BLOOD CULTURE - NO GROWTH TO DATE AT THE TIME OF
DISCHARGE
[**2103-6-26**] 10:00 am POST-[**Month/Day/Year **] VIRAL CULTURE Site: LUNG
POST [**Month/Day/Year **] FETAL LUNG [**Known lastname 42895**], BABY.
POST-[**Name2 (NI) **] VIRAL CULTURE (Preliminary): NO VIRUS
ISOLATED.
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD)
(Preliminary):
Brief Hospital Course:
30 F G2P1 who presents hypoxic respiratory distress.
Hypoxic respiratory distress. Hypoxic to 73% on RA upon
presentation, she was intially treated with broad spectrum
antibiotics. In addition the patient was 22 weeks pregnant and
1 day after admission she suffered a spontaneous abortion of the
fetus. Her symptoms began to improve around this time but it is
unclear if the abortion led to a quicker improvement. She was
noted to have thrombocytopenia, anemia (not hemolytic) and LFT
elevations. Her LFTs normalized by discharge. [**Doctor Last Name 13675**] thought this
was not HELLP and hematology though that the patient did not
have any hemolysis. The patient underwent a CTA with a poorly
timed contrast bolus without clear evidence of PE. Her CXR had
diffuse infiltrates as did her CTA which was consistent with
widespread lung injury / ARDS. The patients echo was normal.
CMV serologies and blood cultures were negative, urine
legionella negative. She was diuresed as she improved and this
sped up her recovery. The post [**Doctor Last Name 18001**] on her fetus revealed
likely placental abruption causing cessation of blood supply
causing a myocardial infarction. The patient was informed of
these results by the pathologist. She was supported by social
work. The patient's pancytopenia stabilized and she was
discharged home when she was able to be weaned off oxygen and
was 97% on room air upon discharge. There was not a clear
unifying diagnosis for the patient's presentation. It is
possible she had an atpyical bacterial versus viral pneumonia
which led to ARDS and she was discharged to complete a 7 day
course of levofloxacin. In addition given the history of drug
use it is possible substance abuse such as heroin could have led
to ARDS however she denies recent use of heroin. The pathology
of the fetus did not reveal any bacterial or viral infection.
In regards to the pancytopenia it is possible this was related
to HCV infection versus acute illness and the patient should
have a CBC repeated next week in f/u with her PCP. [**Name10 (NameIs) **] she is
still pancytopenic she should follow up with hematology.
Anaplasma serologies were sent and pending at the time of
discharge.
Medications on Admission:
- Fluoxetine 20 mg PO daily
- Trazodone 100 mg PO QHS
- Methadone 10 mg x 11 tablets PO daily
- Prenatal vitamin PO daily
Discharge Medications:
1. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. methadone 10 mg Tablet Sig: Eleven (11) Tablet PO DAILY
(Daily).
3. trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
4. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 3 days: start on [**2103-6-28**].
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
ARDS, acute respiratory failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with acute respiratory
failure, possibly due to a viral or bacterial infection, however
no exact cause could be found. You improved and should take 3
additional days of antibiotics. Please make your appointment
with you PCP next week.
Followup Instructions:
Name: Dr [**Last Name (STitle) 7493**] (works with Dr [**Last Name (STitle) 42896**]
Location: FAMILY CARE OF [**Hospital1 **]
Address: [**Location (un) 26406**], [**Hospital1 **],[**Numeric Identifier 26407**]
Phone: [**Telephone/Fax (1) 26408**]
Appt: [**7-4**] at 10:45am
|
[
"644.21",
"287.5",
"486",
"649.31",
"285.9",
"272.0",
"V27.1",
"648.91",
"070.70",
"647.61",
"304.01",
"648.21",
"518.81",
"284.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"99.11",
"73.59"
] |
icd9pcs
|
[
[
[]
]
] |
11452, 11458
|
8674, 10899
|
299, 306
|
11553, 11553
|
3954, 8651
|
11999, 12278
|
3233, 3328
|
11071, 11429
|
11479, 11479
|
10925, 11048
|
11704, 11976
|
3343, 3935
|
231, 261
|
2419, 2743
|
334, 2401
|
11498, 11532
|
11568, 11680
|
2765, 2947
|
2963, 3217
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,610
| 114,792
|
20317
|
Discharge summary
|
report
|
Admission Date: [**2110-11-14**] Discharge Date: [**2110-11-26**]
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is an 81 year old
female with a history of chronic obstructive pulmonary
disease, hypertension, no known coronary artery disease who
was in her usual state of health until the afternoon of
admission when she experienced the sudden onset of substernal
chest pain after arranging grocery bags. The pain was 10 out
of 10 with associated shortness of breath, but no nausea,
vomiting or diaphoresis. Her husband called emergency
medical services.
REVIEW OF SYSTEMS: Positive paroxysmal nocturnal
dyspnea/orthopnea times four to five years, dyspnea on
exertion with heavy lifting.
In the Emergency Department the patient received beta blocker
Nitroglycerin and heparin bolus.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease, etiology felt to
be from emphysema from a history of multiple pneumonias as a
teenager.
2. Hypertension.
3. Lupus.
4. Osteoporosis.
5. Total abdominal hysterectomy.
ALLERGIES: Morphine causes nausea.
MEDICATIONS: Fosamax, Advair, Singular, Prednisone,
Albuterol prn, Plaquenil.
FAMILY HISTORY: Mom died in 60s of heart disease,
grandmother died at 62 of heart disease.
SOCIAL HISTORY: No tobacco, occasional alcohol. Lives in
[**Location 745**] with husband. She worked as a former bookkeeper and
secretary.
PHYSICAL EXAMINATION: General: Patient in mild respiratory
distress, pursed lip breathing, using accessory muscles.
Vital signs, 95.6, 105, 88/56. Head, eyes, ears, nose and
throat: Pupils equal, round and reactive to light,
oropharynx clear. Neck, jugulovenous pressure approximately
9 cm, no thyromegaly. Cardiovascular, tachycardiac, regular
rhythm, S1 and S2, positive S3. Pulmonary, decreased
breathsounds with bibasilar rales, diffuse wheezes. Abdomen,
positive bowel sounds, soft, nontender, nondistended.
Extremities, no cyanosis, clubbing or edema. 2+ pedal pulses
bilaterally. Neurological, alert and oriented times three
moving all extremities, symmetric deep tendon reflexes.
LABORATORY DATA: White count 6.5/40.8/274. Potassium 4.9,
BUN 17, creatinine 0.7, creatinine kinase 125, troponin less
than 0.01. Electrocardiogram, sinus tachycardia, 128
beats/minute, 3 to [**Street Address(2) 5366**] elevations in V1 through V6, [**Street Address(2) 28585**] elevation in AVL.
HOSPITAL COURSE: 1. Coronary artery disease. Upon arrival
the patient was taken immediately to the Catheterization
Laboratory for anterior ST elevation myocardial infarction.
The catheterization revealed - 1. One vessel coronary artery
disease with a 95% left anterior descending thrombotic lesion
involving the first major diagonal intervened upon with a
hepacoat stent. Also found was a 60% distal right coronary
artery lesion that was not intervened upon. 2. Increased
right-sided and left-sided pressures, with RAV of 19, RV
51/21, PCWP 35. 3. The procedure was complicated by a
profound hypotensive episode, requiring Dopamine and
intra-aortic balloon pump. After the procedure the patient
was transferred to the CCU. The patient did well in the CCU.
A cardiac regimen of beta blocker and ACE was titrated and
intra-aortic balloon pump was discontinued without incident.
The patient was subsequently transferred to the floor. While
on the floor, the patient experienced a hypotensive episode
with systolic pressures in the 70s and responded to fluid
bolus. Etiology was felt to be secondary to medications. At
the time of discharge, the patient's antihypertensive regimen
consisted of Captopril 6.25 b.i.d. and Coreg 12.5 b.i.d.,
attempts at higher doses of Captopril were limited by her
blood pressure. At the time of discharge, systolic pressures
ranged 90 to 110 and heartrate was 90 to 100, the patient
remained chest pain free throughout her stay.
2. Congestive heart failure - Post procedure, the patient
had an echocardiogram which revealed - A. Ejection fraction
of 25 to 30% with apical akinesis and severe hypokinesis of
the anterior septum and anterior wall. She had normal right
ventricular function. B. Moderate to severe (3+) tricuspid
regurgitation, trivial mitral regurgitation, no aortic
stenosis or aortic regurgitation. Moderate pulmonary
hypertension was also noted. After her catheterization the
patient was continued on heparin and was eventually started
on Coumadin for prophylaxis of left ventricular thrombus.
The patient was maintained on prn diuretics with stable
respiratory status and oxygen saturations until the day prior
to admission where she experienced worsening shortness of
breath felt to be secondary to pulmonary edema. Therefore
the patient was initiated on a standing dose of Lasix prior
to discharge.
3. Rhythm - The patient experienced transient episode of
atrial fibrillation during stay with no further recurrence.
She was in normal sinus rhythm at the time of discharge.
4. Gastrointestinal - After hypotensive episode on the
floor, the patient experienced the onset of abdominal pain
and small amount of lower gastrointestinal bleeding. Her
abdominal pain persisted and a gastrointestinal consult was
obtained secondary to concerns for ischemic colitis.
Gastrointestinal consult agreed with concern for an ischemic
event and recommended computerized tomography scan of the
abdomen. Computerized axial tomography scan revealed a
thickened wall of the descending limb of the colon consistent
with colonic ischemic but did not reveal any pneumatosis or
free air. General Surgery was consulted and recommended
observation of hemodynamics, intravenous fluids, and triple
antibiotics. The patient's antihypertensives were
discontinued at this time. She was started on Ampicillin,
Levofloxacin and Flagyl and was transferred back to the CCU
for closer monitoring. Heparin and Coumadin were also
discontinued at this time secondary to the lower
gastrointestinal bleeding. The patient's clinical status
rapidly improved with resolution of her abdominal pain. She
remained abdominal pain-free throughout the rest of the stay.
At the time of discharge she was tolerating a p.o. diet, was
guaiac negative, and had her antihypertensive regimen
reinstituted without further onset of abdominal pain.
5. Pulmonary - The patient maintained stable oxygen
saturations throughout her stay. She experienced some
episodes of shortness of breath which were responsive to her
metered dose inhalers and nebulizers. Additionally she
experienced an episode of shortness of breath as previously
described and this was felt to be secondary to pulmonary
edema which responded to intravenous Lasix.
6. Renal - The patient's creatinine remained stable
throughout the stay with baseline of 0.5 to 0.6 at the time
of discharge.
7. The patient was found to have a left adnexa cystic lesion
on computerized tomography scan done when evaluated for
ischemic colitis. Radiology recommended this be followed up
with a pelvic ultrasound. Ultrasound was not done at the
time of discharge, and it is recommended follow up as an
outpatient. A Physical therapy consult was obtained who felt
the patient had decreased mobility, endurance and balance,
and therefore recommended acute rehabilitation. The patient
was screened and subsequently discontinued to [**Hospital1 **] for
cardiac rehabilitation.
CODE STATUS: The patient is full code.
CONDITION ON DISCHARGE: The patient discharged in stable
condition without supplemental oxygen requirement. The
patient was discharged to [**Hospital **] Rehabilitation Facility.
DISCHARGE DIAGNOSIS:
1. Anterior ST elevation myocardial infarction status post
PCI of left anterior descending.
2. Congestive heart failure.
3. Ischemic colitis.
4. Chronic obstructive pulmonary disease.
5. Cystic mass of left adnexa.
DISCHARGE MEDICATIONS:
1. Aspirin 325 p.o. q. day
2. Plavix 75 mg p.o. q. day
3. Captopril 6.25 mg p.o. b.i.d.
4. Carvedilol 12.5 mg p.o. b.i.d.
5. Digoxin 0.125 mg p.o. q. day
6. Lasix 20 mg p.o. q. day
7. Lipitor 10 mg p.o. q. day
8. Prednisone 5 mg p.o. q. day
9. Plaquenil 200 mg p.o. q. day
10. Atrovent inhaler
11. Albuterol prn
12. Flovent
13. Serevent
14. Protonix 40 mg p.o. q. day
15. Colace prn
16. Senna prn
FOLLOW UP PLAN: The patient is to call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
office for follow up upon discharge from rehabilitation.
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 21980**]
Dictated By:[**Name6 (MD) 54516**]
MEDQUIST36
D: [**2110-11-26**] 07:46
T: [**2110-11-26**] 07:59
JOB#: [**Job Number 54517**]
|
[
"410.11",
"998.0",
"411.0",
"428.0",
"458.29",
"414.01",
"557.9",
"578.9",
"695.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.44",
"99.20",
"88.56",
"36.01",
"36.06",
"37.61",
"37.23",
"99.60"
] |
icd9pcs
|
[
[
[]
]
] |
1177, 1253
|
7841, 8645
|
7597, 7818
|
2414, 7394
|
1419, 2396
|
597, 808
|
120, 577
|
830, 1160
|
1270, 1396
|
7419, 7576
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,624
| 100,775
|
2426
|
Discharge summary
|
report
|
Admission Date: [**2147-1-5**] Discharge Date: [**2147-1-18**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8684**]
Chief Complaint:
Difficulty Breathing
Major Surgical or Invasive Procedure:
Cardiac cath
trans-esophageal echo
Dual chamber biv pacemaker placement
ICD placement
intubation
History of Present Illness:
81 year old male with a history of hypertension, hypothyroidism,
and a pacemaker x 5 years for complete heart block; presents
with sudden onset of shortness of breath this morning ([**2147-1-5**])
at 5am. He was awakened out of sleep with difficulty breathing
that improved when he sat up. He called his son on the phone,
then called the fire department and was subsequently taken to
the [**Hospital1 18**] Emergency Department.
.
He admits to having orthopnea and PND. He denies chest pain,
dizziness, syncope, headaches, cough, fevers/chills, or
nausea,vomiting,or diarrhea. The patient states that he has
experienced some exertional dyspnea in the past. He admits that
he has a limited activity level due in part to dyspnea, but he
mainly complains of bilateral lower extremity pain with walking,
that improves with rest. He describes this pain as arthritis in
his knees and hips, but also has pain in both calves as well.
.
On admission he stated that he feels a lot better since being in
the hospital on oxygen.
Past Medical History:
Hypertension
Hypothyroidism
Pacemaker (biventricular) x 5 years
Complete heart block
Social History:
A retired car salesman and WWII vet. He states that he drinks
alcohol socially, he smokes [**1-2**] pack per day for 60 years. He
lives alone, his wife passed in [**Month (only) 116**]. He has 2 sons and 3
daughters all of whom live nearby.
Family History:
No known cardiac disease
Physical Exam:
On admission:
vitals: T 98.9, HR 65 paced, BP 144/61, O2sat 96%ra, 98%2L
General appearance: Elderly man, comfortable alert and oriented
x 3, in no apparent distress.
HEENT: AT-NC, CN II-XII grossly intact, EOM-intact, no facial
asymmetry
Neck: supple, no masses, no tenderness, carotid pulses 2+
bilaterally, no carotid bruits, no JVP
Pulm: clear to auscultation, no crackles, no wheezes
CV: occasional early beats, no S3, no murmurs, no extra heart
sounds appreciated
Abdomen: Obese, soft non-tender, non-distended, no organomegaly,
no masses or bulges.
Ext: 2+ bilateral lower extremity edema. Weak dp pulses
bilaterally, no pt pulses. Dry flaky skin on dorsal tibial
surface, no chronic venostasis changes.
Pertinent Results:
[**2147-1-5**] 07:45AM GLUCOSE-116* UREA N-22* CREAT-1.3* SODIUM-141
POTASSIUM-5.7* CHLORIDE-106 TOTAL CO2-24 ANION GAP-17
[**2147-1-5**] 07:45AM PHOSPHATE-3.9 MAGNESIUM-1.8
[**2147-1-5**] 07:45AM WBC-5.4 RBC-4.59* HGB-14.1 HCT-41.1 MCV-90
MCH-30.7 MCHC-34.2 RDW-14.6
[**2147-1-5**] 07:45AM NEUTS-70.6* LYMPHS-22.5 MONOS-6.0 EOS-0.7
BASOS-0.1
[**2147-1-5**] 07:45AM PLT COUNT-159
[**2147-1-5**] 07:45AM PT-14.8* PTT-26.0 INR(PT)-1.5
[**2147-1-5**] 07:45AM CK(CPK)-193*
[**2147-1-5**] 07:45AM cTropnT-0.05*
[**2147-1-5**] 07:45AM CK-MB-6
[**2147-1-5**] 02:30PM CK(CPK)-132
[**2147-1-5**] 02:30PM cTropnT-0.05*
[**2147-1-5**] 02:30PM CK-MB-5 proBNP-2746*
[**2147-1-5**] 02:30PM ALT(SGPT)-22 AST(SGOT)-21 ALK PHOS-71 TOT
BILI-1.1
[**2147-1-5**] 02:30PM POTASSIUM-4.5
[**2147-1-5**] 02:55PM K+-4.6
[**2147-1-5**] 07:45AM D-DIMER-1240*
.
Brief Hospital Course:
81 yo male, initially admitted for SOB/CHF exacerbation;
hospital course discussed by problem.
# Dyspnea- he had been ruled out for a PE by CTA done in the ED.
The patient appeared to fluid overloaded in likely CHF
exacerbation by exam and by CXR. The patient was diuresed
effectively with IV Lasix. He also had a troponin leak up to
.06, peak CK in 300's. An echo was done which showed global
hypokinesis and an EF of 15%. Cardiology was consulted, and the
patient underwent a P-MIBI, which revealed LV enlargement and a
mild, fixed defect of inferior wall. Cardiac cath was discussed
with and subsequently performed on the patient, which
demonstrated no CAD, but severely depressed LVEF. The patient's
ACE was increased, and a statin, low-dose beta-blocker, and
Lasix were initiated, with an improvement in his symptoms.
Given the patient's low EF, a EP consult was obtained for
possible ICD placement. Prior to pacer/ICD placement, the
patient underwent a TEE to evaluate for possible atrial
thrombus, none was found.
.
On [**1-11**], the patient had a [**Hospital1 **]-ventricular pacemaker and ICD
placed, but EP studies on [**1-13**] showed that the RV lead was not
in the correct position. The patient had been started on
anticoagulation for Afib/flutter, so FFP was given to reverse
his INR in preparation for EP re-positioning of RV lead.
However, the patient became acutely SOB and hypertensive while
in EP lab. The patient was intubated and given 40 mg IV Lasix,
and nitroglycerin and the EP procedure was completed. He was
then transferred from to the CCU for CHF and ventilator
management.
.
While in the CCU, the patient the patient became tachy and
hypotensive, required dopamine for 24 hours to maintain
pressure. Cardiac enzymes were repeated, and an echo was
repeated to rule out tamponade. The patient improved with
aggressive diuresis, was successfully weaned off pressors and
extubated. Although the patient had one temperature spike
during the CCU, no infectious source was found, and he received
48 hours of empiric antibiotics following the EP procedure. The
patient was transferred back to the medicine floor and remained
hemodynamically stable and afebrile, with no further episodes of
chest pain or shortness of breath.
.
# CHB- his pacemaker was upgraded to dual chamber [**Hospital1 **]-ventricular
pacer along with the ICD. He will be followed in the device
clinic, with his first appointment on [**2147-1-20**].
.
# h/o a-fib/aflutter- He was rate controlled with Lopressor,
titrated up to a dose of 25 mg [**Hospital1 **], given that his blood
pressure tolerates this. He was also started on Coumadin,
initially mg, titrated down to 2.5 mg every evening. INR
monitoring will be required on a daily basis to ensure correct
dosing for a target range of 2.0-3.0
.
# L upper extremity edema- Following his stay in the CCU, the
patient's LUE was noted to be edematous and an ultrasound was
obtained which confirmed a DVT. The patient was already on
Coumadin, but a heparin drip was started as his INR at that time
was subtherapuetic.
.
# hypothyroidism- He was continued on his current dose of
Levoxyl, and thyroid studies were done which showed an elevated
TSH and low free T3, however no medication changes were made
during this acute exacerbation of CHF.
.
# Hypertension- The patient's blood pressure remained well
controlled following the procedure and his stay in the CCU. A
number of new medications (beta blocker, Lasix, ACE increase)
were started to help optimize his cardiac health, however, these
may need to be tailored to prevent hypotension. The patient was
ruled out for both tamponade and infection as potential causes
of hypotension.
.
# FEN- The patient was placed on fluid restriction of 1.5L per
day and tolerated a low sodium/cardiac diet well. His
electrolytes were carefully monitored in the setting of
diuresis, with occasional K+/Mg repletion.
.
The patient was evaluated by physical therapy, who recommended
the patient be admitted to a rehab facility. This was discussed
with both the patient and his family, including his HCP; and he
was subsequently discharged to [**Hospital 100**] Rehab for further
rehabilitation. The patient will need follow-up with the
EP/device clinic as described above.
Medications on Admission:
aspirin 325 mg PO daily
Lisinopril 5 mg PO daily
Levothyroxine 112 mcg PO daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*30 Patch 24HR(s)* Refills:*0*
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
CHF, both diastolic and systolic dysfunction
complete heart block
atrial fibrillation
hypertension
hypothyroidism
Discharge Condition:
good
Discharge Instructions:
You have been started on three new medications that are listed
below. Please take these and all of your medications as
instructed. Please DO NOT start taking the warfarin until
tomorrow night. Warfarin is a medication that keeps your blood
thin and to prevent blood clots. However, you have an increased
risk of bleeding while on this medication, particularly after
any type of fall or injury.
Please call your doctor if you develop any chest pain, shortness
of breath, fevers, chills, or vomiting.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2147-1-20**]
11:00
.
You will need to make a follow-up appointment with Dr. [**Last Name (STitle) **]
after your discharge. Please call [**Telephone/Fax (1) 12483**] for an
appointment.
|
[
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icd9cm
|
[
[
[]
]
] |
[
"88.72",
"96.04",
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"00.51",
"37.26",
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icd9pcs
|
[
[
[]
]
] |
8660, 8745
|
3481, 7753
|
282, 381
|
8903, 8910
|
2592, 3458
|
9461, 9741
|
1819, 1845
|
7883, 8637
|
8766, 8882
|
7779, 7860
|
8934, 9438
|
1860, 1860
|
222, 244
|
409, 1433
|
1874, 2573
|
1455, 1542
|
1558, 1803
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,630
| 150,082
|
51685
|
Discharge summary
|
report
|
Admission Date: [**2190-3-10**] Discharge Date: [**2190-3-31**]
Date of Birth: [**2137-12-9**] Sex: M
Service: SURGERY
Allergies:
Celebrex
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
complicated diverticulitis
Major Surgical or Invasive Procedure:
1. Sigmoid colectomy.
2. Resection of colovesicular fistula.
3. Splenic flexure mobilization
4. Cystoscopy stent placement.
5. Partial cystectomy of colovesical fistulous tract
6. Cystotomy closure.
History of Present Illness:
51-year-old gentleman who was admitted in
[**Month (only) 216**] with a diverticular perforation and diverticular abscess.
He was initially treated with antibiotics at [**Hospital 5871**] Hospital
and
ultimately transferred here where a percutaneous drain was
placed
and continued on antibiotics. He did suffer from a long bout
ileus. His drain was actually repositioned at one point with
resultant improvement in his symptoms.
Past Medical History:
PMHx: colonoscopy >10 yrs ago, HTN, hyperlipidemia, ETOH abuse,
pancreatitis, legionella PNA, diverticulosis
[**Doctor First Name **] Hx: AVR/MVR
Social History:
Tobacco: Current 1PPD
ETOH: daily though able to stop at any point without
consequences
Family History:
non contributory
Physical Exam:
Temp 98 HR 64 BP 122/80 RR 16 RA 98%
He is alert, oriented, in no acute
distress. Sclerae are anicteric. Oropharynx is clear. Neck is
supple without lymphadenopathy, jugular venous distension.
Neck:
There are no nodules. Lungs are clear bilaterally. Heart is
regular. He does have a mechanical heart valve sound. His
abdomen is soft, nontender, and nondistended. No masses, no
hernias, no costovertebral angle or spinal tenderness.
Extremities are without edema. Neurologic exam is grossly
nonfocal.
Pertinent Results:
[**2190-3-10**] 04:26PM HCT-37.0*
[**2190-3-10**] 04:26PM GLUCOSE-144* UREA N-25* CREAT-1.8* SODIUM-140
POTASSIUM-5.4* CHLORIDE-105 TOTAL CO2-23 ANION GAP-17
[**2190-3-10**] 04:26PM CALCIUM-9.6 PHOSPHATE-4.7* MAGNESIUM-1.4*
[**2190-3-10**] 09:08PM HCT-34.1*
[**2190-3-11**] Renal Ultrasound : No evidence of hydronephrosis
bilaterally.
[**2190-3-19**] Cystogram : Normal cystogram study, with no evidence of
bladder leak.
Brief Hospital Course:
Mr. [**Known lastname 1968**] was admitted to the hospital following a laparoscopic
conversion to open sigmoidectomy and cholecystic fistula repair.
Neuro - His pain was well controlled postoperatively with a
dilaudid PCA. Once the patient was tolerating POs, he was
transitioned to dilaudid PO with dilaudid IV for breakthrough.
He was otherwise fully neurologically intact throughout his
hospital course. On discharge his pain was well controlled and
he was without any focal neurologic deficits.
CV - Initially postoperatively the patient was hypotensive with
systolic pressure in the 70s. He was transferred to the ICU
where he was started on pressors. A transthoracic echo
demostrated an ~35% ejection fraction on dopamine. Cardiac
enzymes were sent on POD1 and were negative x 3. A cardiology
consult was obtained and it was their belief that the patient
was not in cardiogenic shock given the fact that his extremities
continued to be well perfused and his lungs remained clear to
auscultation. It was their opinion that his decreased EF was
likely due to the stress of surgery. On POD3 he was able to be
weaned from pressors. He remained normotensive for the
remainder of his hospital course. As he progressed on the
Surgical floor his blood pressure was in the 120-130/70 range
with a heart rate in the 60's. His pre admission ACE inhibitor
was not resumed to to his ATN and his carvadilol was also not
resumed due to his heart rate. Dr. [**Last Name (STitle) **] will re evaluate in a
few weeks.
Pulm - The patient was extubated in the OR without incident.
Initially postoperatively in the PACU the patient had
significant wheezing which required frequent combivent nebulizer
treatments. He oxygen saturations were maintained at > 92% with
facemask. By POD2 the patient's wheezing had resolved and by
POD3 the patient was maintaining his O2 sats > 92% on room air.
For the remainder of his hospital course his pulmonary function
was stable. He was encouraged to work with his incentive
spirometer 10x/hour which he did. At the time of discharge he
was on room air and breathing comfortably.
Renal - Postoperatively the developed acute renal failure. A
renal consult was obtained and their opinion that his low UOP
was likely secondary to dehydration and acute tubular necrosis
which was a likely consequence of intraoperative hypotension in
combination with abdominal compartment insuflation. He required
one session of CVVH to address hyperkalemia and hypercalcemia.
Over the next 3 days the patient was carefully bolused with
fluides and by POD3, his urine output had returned to [**Location 213**]
(>40 cc/hr) and his creatinine had returned to baseline (1.1).
His urine output was adquate for the remainder of his hospital
course and his renal function was stable.
GI - After extubation Mr. [**Known lastname 1968**] was gradually started on a
clear liquid diet. His diet was not advanced for 5-6 days as he
was very slow to pass flatus. Finally he was able to be
advanced after return of bowel function and he was tolerating a
regular diet without difficulty. Unfortunately he developed
BRBPR in the setting of IV heparin and Coumadin. He required 4
blood transfusions and heparin and coumadin were discontinued
for 48 hours. He was seen by the gastroenterology service for a
possible colonoscopy but he stopped bleeding and his hematocrit
was stable at 29 therefore the colonoscopy was postponed to a
later date as an out patient. His anticoagulation was resumed.
He ws tolerating a regular diet at the time of discharge.
GU - Post operatively he had hematuria requiring bladder
irrigation and his foley catheter was in place for 10 days.
Following a cystogram which revealed no leak he had a voiding
trial which was successful and he continued to void without any
hematuria or other symptoms at the time of discharge.
ID - On post op day # 4 his abdominal wound was warm and
cellulitic. The culture grew out multi drug resistent Ecoli
which was treated with Zosyn and local care. The wound was
opened and he underwent local treatment with saline wet to dry
dressing changes. His dressing changes were increased to TID as
he had a persistent fibrinous base which needed debridement.
Eventually the solution was changed to 1/4 str Dakin's solution
moist to dry dressings TID. He will continue this treatment for
1 week then follow up with Dr. [**Last Name (STitle) **].
HEME - At the time of discharge he had been on Lovenox and
Coumadin for 1 week without any BRBPR and he had a stable
hematocrit. His INR was 1.8 and he will take 12.5 mg of
Coumadin tonight and tomorrow night and an INR will be drawn
Friday by the VNA. Dr.[**Name (NI) 29343**] office was notified to resume
dosing his coumadin on Friday [**2190-4-2**].
After a long protracted stay, Mr. [**Known lastname 1968**] was discharged to home
on [**2190-3-31**] with VNA services and will follow up with Dr.
[**Last Name (STitle) **] next week. He will bring the VAC in with him for this
appointment.
Medications on Admission:
BENAZEPRIL - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth once a day
CARVEDILOL [COREG] - (Prescribed by Other Provider) - 12.5 mg
Tablet - 1 Tablet(s) by mouth once a day
PEG 3350-ELECTROLYTES - 236 gram-22.74 gram-6.74 gram-5.86
gram-2.97 gram Recon Soln - 1 bottle by mouth as directed
SIMVASTATIN [ZOCOR] - (Prescribed by Other Provider) - 40 mg
Tablet - 1 Tablet(s) by mouth once a day
UNKNOWN BLOOD PRESSURE PILL - (Prescribed by Other Provider) -
Dosage uncertain
WARFARIN [COUMADIN] - (Prescribed by Other Provider) - Dosage
uncertain
Medications - OTC
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other
Provider) - Dosage uncertain
--------------- ---------------
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. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*2*
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: as
directed by Dr. [**Last Name (STitle) **]. Take 12.5 mg on [**3-31**] and [**4-1**].
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
7. Lovenox 100 mg/mL Syringe Sig: One Hundred (100) mg
Subcutaneous twice a day.
Disp:*14 syringes* Refills:*3*
8. 1//4 STR Dakins solution Sig: One (1) application three
times a day: Dampen the Kerlix gauze with this solution, then
sqeeze excess out.
Disp:*1 liter* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary diagnosis
1. Sigmoid diverticulitis.
2. Colovesicular fistula.
3. Bilat ureteral stents
4. Cardiogenic shock
5. ATN
6. Acute blood loss anemia due to GI bleed
7. Abdominal wound infection
Secondary diagnoses
1. Hypertension
2. Hypercholesterolemia
3. ETOH abuse
4. Pancreatitis
5. Legionella pneumonia
6. Diverticulosis
7. S/P AVR/MVR (mechanical) for RF
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Please call your doctor or return to the emergency room if you
have 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.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**10-22**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
Keep the VAC dressing intact to 125 mm suction
Notify Dr. [**Last Name (STitle) **] if the wound is more painful or has
increased redness.
Please call the doctor if you have increased pain, swelling,
redn
Followup Instructions:
Dr. [**Last Name (STitle) **] in 2 weeks
Call Dr. [**Last Name (STitle) 3748**] at [**Telephone/Fax (1) 3752**] for a follow up appointment in 2
weeks
Call Dr. [**Last Name (STitle) **] for a follow up appointment in [**1-9**] weeks. He will
also follow your INR
Call Dr. [**Last Name (STitle) 174**] at [**Telephone/Fax (1) 68666**] for a follow up appointment in
[**3-11**] weeks. You will need a colonoscopy once you have recovered
from this hospitalization and he will discuss with you the
timing.
Completed by:[**2190-3-31**]
|
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icd9cm
|
[
[
[]
]
] |
[
"59.8",
"57.81",
"57.83",
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] |
icd9pcs
|
[
[
[]
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] |
9153, 9202
|
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|
295, 496
|
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|
1816, 2253
|
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|
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1282, 1797
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229, 257
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10974, 11224
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524, 956
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9624, 9733
|
978, 1127
|
1143, 1233
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,306
| 128,416
|
13172
|
Discharge summary
|
report
|
Admission Date: [**2158-10-15**] Discharge Date: [**2158-10-20**]
Date of Birth: [**2097-8-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 2080**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
intubated [**10-14**] extubated [**10-16**]
History of Present Illness:
51M h/o AF on coumadin, CHF, HL, hyperthyroidism, no known DM
found down by fam at 245p. EMS took him to [**Hospital3 **],
found to be in RAF with rate in 130s but also had FSBS of 850
and hyponatremic to 120. WBC 14. Trop positive there. taken to
[**Hospital3 3583**], T100, FSGS 800s, in RAF rate 100s. Intubated at
[**Hospital1 46**] for respiratory protection and given 10 then 30mg dilt,
insulin + gtt @ 2/hr, 8mg ativan, 4mg morphine and started on
propofol gtt. CT Head there negative.
Here at [**Hospital1 18**] ED in sinus rhythm with rate 85 BP 188/92. Tm
while in ED 100. On exam was intubated and sedated on vent. Trop
was 0.05 in setting of creatinine 1.1 (1.3 at OSH). Glucose was
down to 200s per EMS reports but 634 here. Tox screens negative.
Leukocytosis here. Got pCXR ETT in good placement with possible
aspiration vs MFPNA. Received ceftri 2g at OSH and 500 azithro
plus 500 flagyl here. Also got 10units IV insulin and on
3units/hr gtt. For troponin leak got 325mg asa. Blood and urine
cultures pending. EKG AF 93 NA QTc 443 QRS 112 ST dep V5-6. no
prior.
VS prior to transfer: HR93 171/46 100 on AC 550X18 100% Fio2
peep 5.
.
On the floor, intubated sedated, not following commands.
Past Medical History:
HL
CHF
Hypothyroidism
Afib on coumadin
gout
Arthritis
Asthma
OSA on CPAP at home (unknown settings)
ETOH use (3 drinks nightly) no h/o withdrawal
knee, shoulder, and hip replacements
left lung resection for unknown reasons (family doesnt know)
Social History:
smoker
Family History:
unknown
Physical Exam:
Vitals: T: 98.4 ax BP: 138/73 P:99 irreg R: 18 O2:100 on 550X18
100% peep 5
General: Obese. Intubated, sedated on propofol
HEENT: Sclera anicteric, dryMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: irregularly irregular normal S1 + S2, no murmurs, rubs,
gallops, non-displaced PMI
Abdomen: obese soft, non-tender, non-distended, bowel sounds
present,
GU: foley
Ext: warm, well perfused, no edema
Neuro: PERRL, withdraws to painful stimuli bilaterally upper and
lower extremities
Pertinent Results:
CTA chest [**2158-10-15**]
FINDINGS: Patient is intubated with the endotracheal tube ending
3.4 cm above the carina. There is no aortic dissection or
evidence of pulmonary embolism. The ascending aorta is enlarged
measuring up to 5.1 cm in diameter. The main pulmonary artery is
also prominent, measuring up to 4.4 cm in diameter. There is
moderate cardiomegaly. Fat density is noted within the
interatrial septum, most likely due to lipomatous hypertrophy.
Patient is status post left upper lobectomy. Suture material is
noted at the left hilum. There are dense calcifications also
noted at the left lung base along the diaphragm, likely related
to prior surgery. There is minimal atelectasis in the remaining
left lobe. A 2-mm pulmonary nodule is noted within the right
middle lobe. Dependent atelectasis is noted posteriorly in the
right. There is no mediastinal, hilar, or axillary
lymphadenopathy. Visualized aspects of the upper abdomen
demonstrate diffuse fatty infiltration of the liver. Remainder
of the visualized upper abdomen is unremarkable.
BONE WINDOWS: No concerning osseous lesions are identified. Mild
degenerative changes are noted throughout the visualized spine.
IMPRESSION:
1. No pulmonary embolism or aortic dissection. Prominent
ascending aorta
measuring up to 5.1 cm. Prominent main pulmonary artery
measuring up to 4.4 cm, suggesting pulmonary hypertension.
2. 2-3 mm nodule in right middle lobe for which no follow up is
needed if low risk (no underlying malignancy or smoking). If
not, recommend follow up CT in 12 months.
3. Cardiomegaly.
4. Status post left upper lobectomy.
5. Diffuse fatty deposition in the liver.
.
Echo [**2158-10-16**]
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild global left
ventricular hypokinesis (LVEF = ?40 %). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Right ventricular chamber size is normal. with
mild global free wall hypokinesis. The ascending aorta is
moderately dilated. The aortic valve leaflets are mildly
thickened (?#). There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal.Trivial mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is an anterior space which most likely represents a
prominent fat pad.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with mild global hypokinesis c/w diffuse
process (toxin, metabolic, tachycardia, etc. - cannot excluded
multivessel CAD). Dilated ascending aorta.
.
[**2158-10-15**] 12:33AM BLOOD WBC-14.9* RBC-5.02 Hgb-16.4 Hct-45.7
MCV-91 MCH-32.7* MCHC-35.9* RDW-14.5 Plt Ct-273
[**2158-10-15**] 12:33AM BLOOD Neuts-86.7* Lymphs-8.3* Monos-3.9 Eos-0.4
Baso-0.6
[**2158-10-15**] 12:33AM BLOOD PT-28.5* PTT-29.9 INR(PT)-2.8*
[**2158-10-15**] 12:33AM BLOOD Glucose-634* UreaN-25* Creat-1.1 Na-128*
K-3.8 Cl-85* HCO3-27 AnGap-20
[**2158-10-15**] 12:33AM BLOOD ALT-93* AST-93* CK(CPK)-74 AlkPhos-163*
TotBili-0.5
[**2158-10-15**] 12:33AM BLOOD cTropnT-0.05*
[**2158-10-15**] 12:33AM BLOOD Albumin-4.1 Calcium-8.9 Phos-4.2 Mg-2.0
[**2158-10-15**] 04:43AM BLOOD Digoxin-0.4*
[**2158-10-15**] 12:33AM BLOOD TSH-1.9
.....
Discharge Labs
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2158-10-20**] 06:48 7.6 4.73 15.4 44.6 94 32.6* 34.6 14.9 278
.
BASIC COAGULATION PT PTT Plt Ct INR(PT)
[**2158-10-20**] 06:48 278
[**2158-10-20**] 06:48 16.0* 23.2 1.4*
.
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2158-10-20**] 06:48 171*1 18 0.8 140 3.8 101 28 15
.
LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD LDLcalc
[**2158-10-20**] 06:48 168 312*1 21 8.0 85
Brief Hospital Course:
51yo M with h/o DM and AF on coumadin presenting with AMS found
to have HONC and RAF admitted to ICU for insulin gtt.
.
# Respiratory Failure: Patient intubated [**3-21**] AMS to protect
airway. CXR revealed widened mediastinum and likely CHF although
cannot r/o MF PNA. CT done and showed lobectomy and RLL
pneumonia. Given concern for CAP vs. aspiration PNA, treated
with CTX/azithro/flagyl. Patient's MS improved and was able to
be extubated on HD 2. Flagyl was d/c's on day [**5-24**] of treatment
due to small likelihood this was aspiration. Completed 6 days
of treatment with CTX and azithromycin. The patient will finish
a full 7 day course with po levofloxacin following discharge.
.
# HONK / Diabetes Mellitus: Patient has no known h/o DM but FSBS
in 800s at OSH with neurologic and electrolyte abnormalities
consistent with HHS. Unclear etiology of this although may be
first presentation of his DM2. Insulin gtt was started,
electrolytes monitored and repleted. Patient never developed an
anion gap. gtt discontinued on [**10-17**] and pt started on insulin
sliding scale. HbA1C was 11.9% for an estimaged average glucose
of 295. Discharged on metformin, lantus, and humalog sliding
scale with sugars well controlled from 150s - 220s. Will have
VNA for diabetes / finger stick and insulin administration
teaching.
.
# Demand ischemia: Patient has elevated trop with lateral ST
changes on EKG and no prior to compare with but in setting of AF
with RVR so more likely demand than ACS. HR controlled with
labetalol IV which will also help bring down BP. TTE done that
did not show any wall motion abnormalities, but did show reduced
EF with global hypokinesis. Patient should follow-up with
cardiology. He is discharged on metoprolol for rate control.
.
# Hyponatremia: Hypovolemic hyponatremia likely in setting of
HHS however corrected Na is 136 so actually likely [**3-21**]
hyperosmoloar state and only pseudo-hyponatremia.
.
# Atrial fibrillation: Presented in sinus rhythm with good rate
control. Coumadin held initially in case of procedures.
Restarted on [**10-17**] with INR of 2.0. Digoxin held given K
fluctuation while in HHS. Heart rate was increasing so
diltiazem was increased to 60mg qid. As patient had TTE that
showed reduced EF, he was started on a beta blocker instead, and
diltiazem was discontinued. Digoxin continued to be held as
patient was stabilized on regimen.
.
# Hyperthyroidism: Unclear when last TSH drawn and could be
precipitant of HHS if out of control. TSH normal and
levothyroxine continued.
.
# Chronic systolic CHF: Unclear if diastolic or systolic. Though
based on echo from [**10-16**] likely systolic. Patient only on lasix
and Dig (which could be for AF not CHF). Judicious use of fluids
once HONK well-treated given patient presented hypo-euvolemic.
Initially, lasix and zaroxylin held given recent [**Last Name (un) **] and needing
hydration for HONK and being down for at least 1 day. This was
restarted after the patient was extubated. He was started on
Ace-I, beta-blocker prior to discharge and should follow up
starting Ace-I with chem-7 in one week. On outpatient basis,
should likely be started on a statin as well. He may also
benefit from follow-up ECHO.
.
# AMS / Alcohol Withdrawal: Patient was agitated night after
being extubated, combative and required restratints. These were
removed in the morning. He then became very tearful and
distressed in the afternoon, which resolved without support. He
also discussed paranoid delusions (thought he was being
videotaped or in a moviem thought room decoration was changing)
and some visual hallucinations. On discharge the patient was no
longer [**Doctor Last Name **] on a CIWA scale for greater than 36 hours.
.
# Code Status: Initially unknown and patient intubated. Family
came in. Patient is DNR but ok to "I". No blood products as
patient is a Jehovah's witness.
Medications on Admission:
Warfarin 5mg daily
Zaroxolyn 5 mg daily
Allopurinol 300mg daily
Levothyroixine 0.025mg daily
Lasix 20mg [**Hospital1 **]
digoxin 0.125mg daily
Diltiazem CD 120 daily
Albuterol 2 putts Q6H PRN
Discharge Medications:
1. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
4. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO twice
a day.
Disp:*120 Tablet(s)* Refills:*2*
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) for 7
days: Apply to lower back and change daily.
Disp:*7 Adhesive Patch, Medicated(s)* Refills:*0*
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily). Tablet, Chewable(s)
9. Insulin Glargine 100 unit/mL Solution Sig: Twenty Four (24)
Units Subcutaneous at bedtime.
Disp:*720 Units* Refills:*2*
10. Humalog 100 unit/mL Solution Sig: 0-16 Units Subcutaneous
four times a day as needed for high blood sugar: Please check
fingersticks prior to meals and administer insulin per sliding
scale.
Disp:*1500 Units* Refills:*2*
11. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 1 days.
Disp:*1 Tablet(s)* Refills:*0*
12. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puffs Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
13. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
14. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
15. Metolazone 5 mg Tablet Sig: One (1) Tablet PO once a day.
16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for pain.
17. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours for 7 days: Do not drive or operate heavy machinery while
taking oxycodone.
Disp:*15 Tablet(s)* Refills:*0*
18. Outpatient Lab Work
Chem 7, INR
Please fax to Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 30795**]
19. Glucometer plus strips and lancets
Please provide patient with glucometer x1, lancets x120, and
glucometer strips x120
Discharge Disposition:
Home With Service
Facility:
Bayada nurses Inc
Discharge Diagnosis:
Primary Diagnoses: Community Acquired Pneumonia, Hyperosmolar
Hyperglycemic Nonketotic Coma, Alcohol Withdrawal
.
Secondary Diagnoses: Systolic Heart Failure, Atrial
Fibrillation with Rapid Ventricular Response, Alcohol
Dependence, Type II Diabetes Mellitus, Obstructive Sleep Apnea,
Hypothyroidism, Hypertension, Back Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for high blood sugar due to
undiagnosed diabetes that was likely worsened by pneumonia.
Your high blood sugar was treated with IV fluids and insulin.
You will need to continue taking lantus insulin at night, and
check your sugars four times a day and to take humalog insulin
as directed by your sliding scale. You were also started on
metformin, a pill which should help control your sugar and in
time lessen the amount of insulin you require.
Your pneumonia was treated with IV antibiotics. You were
transitioned to levofloxacin, an antibiotic which you can take
by mouth, which you should take tomorrow.
Your hospital stay was complicated by alcohol withdrawal. You
were treated for your withdrawal with valium. By the day of
discharge you were no longer showing signs of withdrawal and did
not require any valium.
You also complained of chronic back pain. You were given
tylenol and ibuprofen for your pain. You were also given a
lidocaine patch. You should take tylenol and ibuprofen together
for your pain, and you can use the lidocaine patch daily. If
your pain is too severe to respond, you can try oxycodone for
your pain.
Importantly, you should STOP drinking alcohol as you are
causing extreme harm to your health and are at danger as well
for dangerous withdrawal when you stop drinking suddenly.
Finally, it is absolutely imperative that you have a primary
care physician to closely follow your now chronic medical
problems such as atrial fibrillation, heart failure, diabetes,
alcohol dependence, and back pain. Please follow-up with a
primary care physician in the next 7 days for further management
of these problems. [**Name (NI) **] should also have your blood drawn for
lab work in 7 days which your primary care should follow-up.
....
The following changes were made to your medications:
You should START taking the following medications: metoprolol
tartrate, insulin (both lantus (glargine) and humalog),
metformin, lidocaine patch, tylenol and oxycodone as needed, a
multivitamin, levofloxacin (one dose on day after discharge),
lisinopril, baby aspirin.
.
You should STOP taking: digoxin, diltiazem.
.
You should CONTINUE all other prescribed medications.
.
You should talk to your primary care doctor about starting on a
Statin and titrating the doses of your metoprolol, lisinopril,
metformin, insulin, and diuretics (lasix and zaroxolyn
(metolazone)). You should talk to your primary care doctor
about long-term management of your chronic back pain.
.
It was a pleasure taking care of you.
Followup Instructions:
Please follow up with a primary care physician in the next 7
days!
|
[
"250.22",
"428.0",
"244.9",
"327.23",
"427.31",
"V43.64",
"291.81",
"V58.61",
"724.5",
"276.1",
"428.22",
"272.4",
"V43.65",
"716.90",
"274.9",
"303.91",
"305.1",
"349.82",
"486",
"493.90",
"518.81",
"V43.61",
"338.29",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
12716, 12764
|
6387, 10291
|
322, 367
|
13134, 13134
|
2525, 6364
|
15881, 15951
|
1916, 1925
|
10534, 12693
|
12785, 12900
|
10317, 10511
|
13285, 15858
|
1940, 2506
|
12922, 13113
|
279, 284
|
395, 1608
|
13149, 13261
|
1630, 1876
|
1892, 1900
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,722
| 132,900
|
10616
|
Discharge summary
|
report
|
Admission Date: [**2180-8-6**] Discharge Date: [**2180-9-1**]
Date of Birth: [**2114-5-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides) / Levaquin / Erythromycin
Base / Ivp Dye, Iodine Containing
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
hemodialysis
History of Present Illness:
Mrs. [**Known lastname 34891**] is a 66 year-old female with h/o hepatic
encephalopathy transferred from an OSH with mental status
changes and hypoxia. On day of admit, she was noted to have
mental status changes, unable to speak, and lethergic more than
usual. She had a FS glucose in the 50s with improvement in
mental status with [**Location (un) 2452**] juice. She also was noted to be
acutely hypoxic and cyanotic during this episode. She was
transferred to [**Hospital 8**] Hospital but requested to be
transferred here.
.
Of note, she had a recent admission to [**Hospital1 18**] for mental status
changes and RLL cellulitis. Her mental status changes were
thought to be secondary to hepatic dysfunction, seizure, or low
tolerance of hypoglycemia. She was admitted to rehab for
management of the necrotic wound on her RLL, discharged, and
treated with vanc/cefepime and VAC dressing.
.
In the ED, CXR showed infiltrate vs atelectasis and she was
started on azithromycin and ceftriaxone. EKG showed non-specific
ST changes, trop 0.04, ammonia 25. She was also noted to have
elevated coags with INR 1.5, PTT 44.9, and total bili 1.8. BNP
was markedly elevated at [**Numeric Identifier 34892**]. A V/Q scan was performed to rule
out PE (renal failure CI CT PE protocol) which was
indeterminate. Head CT was negative. She was admitted to
medicine in stable condition for further assessment.
.
Past Medical History:
1. Type I Diabetes Mellitus
2. Coronary Artery Disease
3. Congestive Heart Failure
4. CKD stage III
5. Hyperlipidemia
6. Gastritis
7. Venous Stasis
8. Allergic Rhinitis
9. Osteomylitis
10. RLE wound
.
ALLERGIES: Penicillins / Sulfa (Sulfonamides) / Levaquin /
Erythromycin Base / Ivp Dye, Iodine Containing
.
Social History:
Lives with husband, needs help with ADLs. Quit smoking in [**2154**].
Alcohol as per HPI.
Family History:
non-contributory
Physical Exam:
T: 95.8 BP: 120/67 HR: 94 RR: 19 95%ra
Gen: encephalopathic
HEENT: no conjunctival pallor, no scleral icterus appreciated,
MMM, no posterior pharyngeal erythema appreciated.
NECK: no posterior/anterior LAD, no JVD appreciated but thick
neck.
CV: RRR, S1+S2+, no murmurs or rubs appreciated, but distant.
LUNGS: CTAB, poor effort so cannot accurately assess, mild
crackles appreciated L>R, no wheezes appreciated
ABD: NABS, soft, non-tender, obese. No organomegaly appreciated.
EXT: tense, red lower extremity edema appreciated bilaterally.
1+ palpable pulses bilaterally dorsalis pedis, posterior tibial,
radial, ulnar, all 2+. +asterixis bilateral. +pronator drift.
Tender lower extremities.
SKIN: significant UE and LE findings. UE and shoulder/back
blanchable red, morbilliform-like rash, with interspersed
non-blanchable, purplish macules with irregular borders, with
some apparent excoriations. Tense edema LE with papular skin
findings on anterior lower legs bil.
NEURO: unable to assess given encephalopathy.
.
Pertinent Results:
.
LABS on admission: d-dimer 1662, hct stable at 37, no
leukocytosis - 5% eos, inr 1.5, ptt 44.9, pt 16, proBNP [**Numeric Identifier 34892**],
alb 3.0, tb 1.8, alt 14, ast 30, [**Doctor First Name **] 39, lip 23, tox screen
negative, lactate 2.2, cr 5.5, hco3 19, bun 85, ammonia 25
.
Platelets trend: 182 (admission)--> 44 (nadir) --> 67 (on
discharge)
.
HIT Ab: negative/indeterminate; Serum screening Ab: negative
Anti-platelet Ab: negative
.
EKG - poor R wave progression, subtle t wave changes anterior,
axis change lateral leads, no acute ST changes, low voltage.
.
STUDIES:
[**8-6**] - Lung Perfusion Scan - Indeterminate VQ scan.
[**8-6**] - CXR - L retrocardiac opacity likely atelectasis, although
pneumonia cannot be excluded and as such adjacent pleural
effusion may represent parapneumonic effusion.
[**8-6**] - CT head - Somewhat limited study due to motion. No acute
intracranial pathology identified.
[**8-7**] - CT abdomen/pelvis - Limited study. b/l moderate small
pleural
effusions. Small amount of perihepatic ascites and anasarca.
Small fat-containing right inguinal hernia. Nodular liver
suggestive of cirrhosis.
[**8-7**] - Renal US - Very limited study terminated prior to
completion but shows an unremarkable appearing right kidney.
[**8-7**] - Bilateral LE US - No evidence of DVT
[**8-8**] - CT head (s/p unwitnessed fall on the floor) - No evidence
of acute intracranial hemorrhage or fracture.
[**8-9**] - EEG - consistent with non-convulsive status epilepticus.
The accompanying video did not demonstrate any clear change in
state with
the discharges. The left-sided predominance suggests a potential
area of
cortical irritability and epileptogenesis in the left posterior
quadrant.
[**8-9**] - Echo - mildly dilated LA. normal LV wall thickness.
mildly dilated LV cavity. Overall LV systolic function is
severely depressed (LVEF= 30 %). no VSD. RV free wall is
hypertrophied. RV cavity is dilated with depressed systolic
funtion. number of AV [**Month/Year (2) 11719**] cannot be determined. AV [**Month/Year (2) 11719**]
are mildly thickened. no AV stenosis. no AR. mildly thickened MV
[**Month/Year (2) 11719**]. no MVP. Mild (1+) MR. [**First Name (Titles) **] [**Last Name (Titles) 11719**] are mildly
thickened. Moderate [2+] TR. Moderate PA systolic hypertension.
no pericardial effusion.
[**8-10**] - EEG - Compared to the prior day's recording, discharges
were less pronounced and were more often isolated and not
organized into prolonged electrographic seizures.
[**8-15**] - EEG - This is an abnormal routine EEG due to rare left
temporal
sharp wave discharges as well as rare isolated generalized
blunted sharp
and slow wave discharges, indicative of continued cortical
irritability
and potentional for epileptogensis. No repetive or sustained
discharges
were seen and no electrographic seizures were noted. In
addition, there
were frequent bursts of generalized delta frequency slowing in
the
setting of a slow and disorganized background, indicative of a
moderate
encephalopathy. This suggests deep midline or bilateral
subcortical
dysfunction
[**8-15**] - Abdominal US - Limited. Trace ascites, and none that can
be drained.
[**8-17**] Oropharyngeal Videofluoroscopy: Mild oral and pharyngeal
dysphagia with consistent penetration and occasional aspiration
with thin liquids.
Brief Hospital Course:
Below is a brief summary of her hospital course by problem:
.
# MS changes - The etiology of her mental status change remained
unclear, though was felt to be most likely secondary to hepatic
encephalopathy +/- acute renal failure. On her recent admission,
she had episodes of decreased responsiveness and waxing/[**Doctor Last Name 688**]
mental status thought likely secondary to metabolic derangements
associated with polypharmacy, hepatic dysfunction, seizures, or
very low tolerance to hypoglycemia. Neurologic work-up including
TSH, B12, folate, MRI/MRA head were unremarkable. She was
started on Keppra during that admission for question of possible
clinical seizures. She was followed by neurology again on this
admission, who felt the etiology was most likely due to
metabolic abnormalities. Tox screen was negative. EEG showed
epileptiform activity and it was thought that her mental status
changes could also be confusion associated with seizure activity
or post-ictal confusion. It was thought most likely secondary to
hepatic encephalopathy. She was treated with lactulose and
rifamixin and improvement, though gradual, was noted. Her mental
status waxed and waned over the course of her admission with
overall gradual improvement. She was maintained on keppra and
started on dilantin for seizures. It was later decided that she
did not require two anti-epileptic meds and dilantin was weaned
(to receive last dose on [**9-6**]). On day of discharge, she
continues to have waxing and [**Doctor Last Name 688**] mental status (most
somnolent after HD) but is felt to be at her baseline.
.
#) Renal failure - The patient was found to have
acute-on-chronic. Her chronic renal failure is likely [**1-21**] her
long history of type I DM, however the etiology of her acute
renal failure remained unclear. The most likely etiology was
thought to be ATN vs AIN (possible drug reaction to vancomycin).
Renal ultrasound w/ unremarkable right kidney, limited study of
left kidney, no hydronephrosis. She was initiated on HD during
this admission, initially via a femoral line until a R
subclavian tunneled HD catheter was placed on [**2180-8-11**]. She
tolerated HD well. She became anuric, however towards the end of
her admission, her creatinine trended downward and urine output
picked up to approximately 350cc per day. It was felt that she
may be slowly regaining some of her renal function. During her
last week of admission she also underwent ultrafiltration with
~2L removed daily. On her last day, ultrafiltration was stopped
early after 1.4L due to low BP with SBP 80s. It was thought that
she had reached the limit of ultrafiltration that she could
tolerate at this time. She was followed by the renal consult
service.
.
#) Thrombocytopenia - During this admission, the patient
developed thrombocytopenia of unclear etiology. Her platelets
dropped from 182 to a nadir of 44 during this admission. In the
setting of having received SC heparin, there was concern for
HIT. Heme/onc followed her during this admission. All heparin
products were held, however her platelets remained low (mainly
40s-50s) and HIT w/u was negative-- HIT Ab equivocal/negative,
serotonin screening Ab negative. Haptoglobin was normal, direct
Coomb's test negative. Retic elevated at 5.1. Her peripheral
smear was notable for abnormal form and nucleated RBCs but did
not provide further information as to the cause of her
thrombocytopenia. Once the HIT work-up was negative, heparin
products were no longer witheld. She was exposed to heparin at
HD without any significant effect on her platelet count. A bone
marrow aspirate was performed (bone marrow bx was attempted but
unsuccessful) and the results were still pending on discharge.
Anti-platelet antibody was negative. Etiology remeained unclear
and was thought to be possibly due to a drug reaction. On
discharge, her platelet count was 67 and stable, well above risk
for spontaneous bleeding. She will follow up with hematology as
an outpatient.
.
# Cirrhosis - The patient has cirrhosis most likely [**1-21**] NASH.
She underwent extensive work-up during her recent prior
admission that was negative so far. She has had cholestatic lab
abnormalities in our system since [**Month (only) 205**] with elevated alk phos
and t bili. Ammonia was normal. AST/ALT 'normal' but clinical
history and scan evidence of cirrhosis, also abnormality in
synthetic function, all suggesting long-term cirrhosis
hepatocyte depletion. +asterixis on physical exam suggestive of
alcoholic disease. But low MCV. CT scan showed cirrhosis and
ascites. Antimitochondrial, smooth muscle abs negative, hep
serologies negative. Initiated on lactulose last admit. +alcohol
as per all previous notes. Normal ferritin so unlikely
hemochromatosis. Abdominal ultrasound [**8-15**] with only minimal
ascites.
Etiology of elevated cholestatic enzymes likely [**1-21**] to diastolic
dysf with long standing diabetes since age of 6 requiring
insulin pump. Given past scan and serologies, cholangitis,
primary biliary cirrhosis and hepatitis not likely. Given
increased BMI, pt could have NASH. Primary biliary cirrhosis
possible with pruritis, but again, serologies do not support.
She was treated with lactulose and rifamixin. She also received
ursodiol until her t bili normalized. She also required attarax
for pruritis. She was followed by the liver service while
in-house and is scheduled for follow-up as an outpatient.
.
#) RLE wound: She initially suffered trauma to her right shin on
[**2180-6-9**] and it was treated at an OSH with primary closure, no
antibiotics. On her previous admission on [**2180-7-14**] she complained
of worsening RLE erythema and pain. She was started on
vanco/cefepime at that time. External swab of the wound grew
enterococcus (VSE, amp [**Last Name (un) 36**]) and pseudomonas (pan-[**Last Name (un) 36**]). No
osteomyelitis by CT. She was discharged on vanco/cefepime. On
re-admission, her RLE was again noted to be erythematous. She
was followed by vascular surgery here, who placed a VAC dressing
and felt that the wound was not infected and did not require
antibiotics. Antibiotics were discontinued on [**8-10**]. Vascular
continued to follow with periodic VAC dressing changes. The
wound was very slowly healing with minimal granulation tissue
present. On [**8-24**] it was noted that there was again increasing
erythema around the VAC site with possible purulent drainage.
She was started on vanco/cefepime. The wound was evaluated by
vascular surgery who felt it was not infected-- likely reaction
to dressing or possible fungal infection at the periphery of the
wound. The VAC dressing was removed on [**2180-8-25**] and replaced by
[**Hospital1 **] wet-to-dry dressings. ID was consulted and also felt that
the wound was unlikely infected. Vancomycin and cefepime were
discontinued.
.
#) Type I DM: She has had type I DM since age 6. She was on
insulin pump for years, then switched to lantus plus novolog
sliding scale in [**4-24**] for unclear reason. Has had recent
hypoglycemic episodes prior to admission requiring decreased
dose of sliding scale. As altered mental status persisted after
her hypoglycemia was corrected, it was felt that hypoglycemia
was not a significant contributor overall to her altered mental
status. The patient had labile glycemic control during this
admission. She was transferred to the MICU ([**Date range (1) 34893**]) out of
nursing concern for control of her blood glucose. She was
followed by the [**Last Name (un) **] diabetes service. She was maintained on
lantus and humalog insulin sliding scale.
.
#) CHF: Repeat ECHO with 35% EF, unchanged from prior. She was
treated with carvedilol. Would also benefit from and ACEI, which
was not started while in house out of concern to protect her
kidneys.
.
#) CAD: She was continued on ASA and beta blocker.
.
# Skin: Pt has multiple skin tears on her upper extremities and
also her back. Likely secondary to her multiple medical
problems, significant edema, and decreased albumin leading to
poor healing. She was followed by the wound care nurse and
treated supportively per their recommendations.
.
#) Aspiration risk: She was evaluated by speech and swallow and
found to be at risk for aspiration. She needs to be fed while
sitting up at 90 degrees and only when awake and alert.
.
#) Mrs. [**Known lastname 34891**] was DNR/DNI for this admission.
.
Medications on Admission:
1. Aspirin 81
2. Fluticasone 50 2 sprays [**Hospital1 **]
3. Docusate Sodium 50 [**Hospital1 **]
4. Lansoprazole 30 mg qd
5. Camphor-Menthol lotion
6. Ursodiol 300 mg [**Hospital1 **]
7. Levetiracetam 500 mg [**Hospital1 **]
8. Lactulose 10 g/15 [**Hospital1 **]
9. CefePIME 2 gm IV Q24H
10. Vancomycin 1000 mg IV Q 24H
11. ISS
.
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. Lactulose 10 g/15 mL Syrup Sig: Forty Five (45) ML PO TID (3
times a day).
3. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily) as needed for itching.
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Travoprost 0.004 % Drops Sig: One (1) Ophthalmic 3x/week ().
7. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS
(3 TIMES A DAY WITH MEALS).
11. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
12. Fluocinonide 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
13. Petrolatum Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day): to venous stasis areas on both legs, apply
liberally.
14. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical TID (3
times a day): to R leg wound and open areas.
15. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO at bedtime: weaning to off, please discontinue after
last dose on [**9-6**].
16. Keppra 250 mg Tablet Sig: 1.5 Tablets PO post-HD: pls give
post dialysis [this dose only to be given post HD in addition to
baseline keppra] .
17. Insulin Lispro 100 unit/mL Cartridge Sig: One (1)
Subcutaneous four times a day: as per sliding scale.
18. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
19. Insulin Glargine 100 unit/mL Cartridge Sig: Six (6) units
Subcutaneous at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
1) Hepatic encephalopathy
2) Acute on chronic renal failure
3) Right lower leg wound
Secondary:
1) Cirrhosis
2) Congestive heart failure
3) Coronary artery disease
Discharge Condition:
Vital signs within normal limits. Waxing and [**Doctor Last Name 688**] mental
status (note patient is often somnolent and slow to wake after
dialysis)-- appears to be at her baseline, at best she is A+O x3
and able to hold a coherent conversation. Urine output ~350cc
per day.
Discharge Instructions:
You were admitted to the hospital with mental status changes
from liver and kidney failure. You were treated with lactulose
and rifamixin for the liver failure. The cause of your kidney
failure was unclear, but thought to be due to a drug reaction to
the vancomycin which you had been on for your right leg wound.
You were started on hemodialysis which you will continue as an
outpatient. You will be followed by the nephrologists (kidney
specialists) at [**Hospital1 **]. On discharge, your mental status is
still waxing and [**Doctor Last Name 688**] but much improved from when you first
came into the hospital.
.
During your hospitalization, you also had a decrease in your
platelet count. This was extensively worked up and no clear
cause was determined. On discharge your platelet count is still
low but stable. You will follow-up with Hematology for this as
an outpatient.
.
You were also treated for your right leg wound which had some
surrounding irriation thought secondary to dermatitis or a
possible drug reaction. It was not thought to be infected.
Dermatology, vascular surgery, and the wound care nurse all gave
recommendations for the appropriate treatment.
.
You will be discharged to [**Hospital **] rehab today.
.
If you develop concerning mental status changes, if you think
that your right leg wound has become infected, or if you develop
fever (>101.5), shortness of breath, or chest pain, please go
the emergency room.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] of vascular surgery on
[**9-7**] at 9:30am, [**Last Name (NamePattern1) **] [**Location (un) 442**] room 5B ([**Telephone/Fax (1) 1237**]).
.
Please follow-up with Dr. [**Last Name (STitle) 2148**] of hematology on [**9-13**] at 10am.
Office is located [**Last Name (NamePattern1) **] in the basement, Suite G.
.
Please follow-up with Dr. [**Last Name (STitle) 623**] (epilepsy) as previously
scheduled on [**2180-9-13**] at 2:15pm.
.
Please follow-up with Dr. [**Last Name (STitle) 34894**] of gastroenterology on [**2180-12-20**]
at 1:10pm. His office is located at [**Last Name (NamePattern1) **], [**Location (un) **].
Telephone number is ([**Telephone/Fax (1) 1582**].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
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68,919
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Discharge summary
|
report
|
Admission Date: [**2152-8-3**] Discharge Date: [**2152-8-21**]
Date of Birth: [**2110-11-10**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
motor cycle collision/polytrauma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
41yo man with unknown medical history s/p motorcycle crash. Per
EMS report the patient was not helmeted, was thrown vs. fell
15-20 feet from vehicle. On the scene GCS was 3, attempted
intubation was unsuccessful. He was taken to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Hospital where again per report the patient's GCS was 14 however
he was combative with changing mental status and was thus
intubated. He received 2L NS and 1gm Ancef at the OSH. He was
transferred to [**Hospital1 18**] for management given concern for worsening
mental status and potential intracranial injury.
On arrival to the ED patient was moving all extremities and
agitated. On exam, a head laceration was noted as well as L
shoulder and hand abrasion; also a small amount of blood at the
left external auditory canal was noted. On imaging,
non-displaced posterior rib fractures, small L frontoparietal
subgaleal hematoma and soft tissue swelling were noted. Labs
were significant for acidemia (pH 7.28), lactate 2.4. Per
patient's family, alcohol abuse has been a long-standing issue,
as well as opiate abuse. He was on suboxone for detox but was
unable to afford the medication and abruptly stopped. He
attempted to supplement with alcohol to avoid withdrawal,
drinking a bottle of vodka and several beers daily. His last
drink was the morning prior to the accident.
Past Medical History:
PMH: HTN, Hyperlipidemia, EtOH/opiate abuse
PSH: shoulder surgery
MEDS: suboxone - (self d/c'd [**7-30**])
Social History:
EtOH: abuse; Recreational Drugs: Hx IVDU; Tobacco: [**Last Name (un) 5487**]
14yo daughter
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAMINATION upon admission: [**2152-8-3**]
HR: 77 BP: 146/83 Resp: 16 O(2)Sat: 100 Normal
Constitutional: intubated
HEENT: Pupils equal, round and reactive to light abrasion
forehead and swelling over nose, no deviation
c collar
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Nontender, Nondistended, Soft
Extr/Back: MAE + 2 DP b/l
Skin: Warm and dry significant abrasion left shoulder
Neuro: MAE +Purposeful movement
Pertinent Results:
[**2152-8-20**] 05:25PM BLOOD WBC-7.6 RBC-3.45* Hgb-11.3* Hct-32.4*
MCV-94 MCH-32.8* MCHC-35.0 RDW-12.8 Plt Ct-476*
[**2152-8-19**] 08:35AM BLOOD WBC-11.1* RBC-4.02* Hgb-13.1* Hct-37.5*
MCV-93 MCH-32.6* MCHC-34.9 RDW-13.0 Plt Ct-561*
[**2152-8-18**] 05:18AM BLOOD WBC-8.9 RBC-3.60* Hgb-11.8* Hct-32.7*
MCV-91 MCH-32.8* MCHC-36.1* RDW-13.1 Plt Ct-572*
[**2152-8-14**] 12:31AM BLOOD WBC-21.6* RBC-3.16* Hgb-10.3* Hct-30.3*
MCV-96 MCH-32.6* MCHC-34.0 RDW-12.8 Plt Ct-544*
[**2152-8-13**] 01:00AM BLOOD WBC-24.7* RBC-3.10* Hgb-10.2* Hct-30.1*
MCV-97 MCH-33.0* MCHC-34.0 RDW-12.8 Plt Ct-494*
[**2152-8-3**] 02:45PM BLOOD WBC-15.7* RBC-4.21* Hgb-14.0 Hct-39.7*
MCV-94 MCH-33.2* MCHC-35.2* RDW-13.3 Plt Ct-222
[**2152-8-20**] 05:25PM BLOOD Neuts-76.0* Lymphs-16.1* Monos-5.8
Eos-1.2 Baso-0.9
[**2152-8-7**] 12:28AM BLOOD Neuts-82.5* Lymphs-12.3* Monos-3.4
Eos-1.6 Baso-0.2
[**2152-8-20**] 05:25PM BLOOD Plt Ct-476*
[**2152-8-19**] 08:35AM BLOOD Plt Ct-561*
[**2152-8-18**] 05:18AM BLOOD Plt Ct-572*
[**2152-8-3**] 02:45PM BLOOD PT-11.6 PTT-25.1 INR(PT)-1.0
[**2152-8-3**] 02:45PM BLOOD Fibrino-259
[**2152-8-19**] 08:35AM BLOOD Glucose-115* UreaN-27* Creat-1.5* Na-131*
K-4.8 Cl-91* HCO3-23 AnGap-22*
[**2152-8-18**] 05:18AM BLOOD Glucose-104* UreaN-24* Creat-0.8 Na-137
K-4.7 Cl-101 HCO3-25 AnGap-16
[**2152-8-17**] 01:07AM BLOOD Glucose-115* UreaN-21* Creat-0.7 Na-135
K-4.4 Cl-99 HCO3-23 AnGap-17
[**2152-8-16**] 01:13AM BLOOD Glucose-131* UreaN-31* Creat-0.6 Na-139
K-4.2 Cl-103 HCO3-25 AnGap-15
[**2152-8-19**] 08:35AM BLOOD ALT-71* AST-39 AlkPhos-138* TotBili-0.3
[**2152-8-18**] 05:18AM BLOOD ALT-72* AST-37 LD(LDH)-236 AlkPhos-140*
TotBili-0.2
[**2152-8-17**] 01:07AM BLOOD ALT-73* AST-38 AlkPhos-146* Amylase-110*
TotBili-0.2
[**2152-8-18**] 05:18AM BLOOD Calcium-9.6 Phos-5.2* Mg-2.6
[**2152-8-16**] 01:13AM BLOOD Albumin-3.3* Calcium-9.3 Phos-4.5 Mg-2.5
[**2152-8-17**] 07:08AM BLOOD Vanco-15.9
[**2152-8-16**] 07:11AM BLOOD Vanco-13.4
[**2152-8-3**] 02:45PM BLOOD ASA-NEG Ethanol-298* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2152-8-14**] 06:44PM BLOOD Glucose-102 Lactate-1.1 Na-138 K-4.1
[**2152-8-14**] 11:22AM BLOOD Lactate-1.1
[**2152-8-16**] 01:26AM BLOOD freeCa-1.13
[**2152-8-15**] 01:40AM BLOOD freeCa-1.23
[**2152-8-3**]: cheat x-ray:
FINDINGS: Underlying trauma board partially obscures the view.
Single supine AP portable view of the chest was obtained.
Endotracheal tube is seen, terminating approximately 2.8 cm
above the carina. Nasogastric tube side port is at the level of
the proximal gastric fundus/GE junction, distal aspect not
included on the image, suggest advancing so that the side port
is well within the stomach. The left costophrenic angle is not
included on the images.
Given this, known bilateral dependent opacities likely
representing
aspiration, better evaluated on CT. No definite focal
consolidation, pleural effusion, or evidence of pneumothorax is
seen. No displaced fracture
[**2152-8-3**]: head cat scan:
IMPRESSION:
Left frontoparietal soft tissue swelling with no evidence of
acute
intracranial process
[**2152-8-3**]: cat scan of sinus and mandible:
IMPRESSION:
1. No evidence of acute facial fracture.
2. Mucosal thickening in the ethmoidal air cells is likely
related to
intubation. Mucus retention cysts are visualized in bilateral
maxillary
sinuses
[**2152-8-3**]: cat scan of the c-spine:
FINDINGS: There is no evidence of prevertebral soft tissue
swelling or acute cervical spine fracturs. Multiple small
well-corticated osseous fragments are visualized
anterior/adjacent to C5, C6, and C7 vertebral bodies and are
likely not from acute trauma (602B:36). Normal cervical lordosis
is maintained.
Visualized soft tissue structures are within normal limits.
Proximal aspect of endotracheal and nasogastric tube seen. The
included lung apices are clear
[**2152-8-3**]: cat scan of abdomen and pelvis:
IMPRESSION:
1. Small amount of fluid of possible intermediate density in the
right
superior mediastinum which is of nonspecific etiology but may be
secondary to venous injury. Aorta and other great vessels are
normal in caliber and
contour. Followup is recommended. No acute abdominal or pelvic
injury.
2. Nondisplaced posterior left fourth and fifth rib fractures.
Nondisplaced left scapula fracture.
3. Bibasilar opacities, likely related to aspiration, underlying
contusion
can not be entirely excluded.
4. NG tube terminates at the gastroesophageal junction/proximal
fundus.
Further advancement is recommended so that it is well within the
stomach.
Additionally, there is fluid in the distal esophagus which
raises risk for
aspiration.
5. Bladder wall appears diffusely thickened, which is
nonspecific in the
setting of underdistension. Correlate with urinalysis to exclude
infection.
Trauma is unlikely. No pelvic free fluid or pelvic fracture
seen.
6. Fatty liver.
[**2152-8-3**]: x-ray of left humerus:
IMPRESSION: Fracture of the infraglenoid ridge of the left
scapula.
[**2152-8-20**]: chest x-ray:
IMPRESSION: Multifocal atelectasis, but coexisting pneumonia in
the lower
lobes is possible.
[**2152-8-4**]: BAL:
/[**1-14**] 10:20 am BRONCHOALVEOLAR LAVAGE BAL.
**FINAL REPORT [**2152-8-6**]**
GRAM STAIN (Final [**2152-8-4**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2152-8-6**]):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
GRAM NEGATIVE ROD #2. ~[**2140**]/ML. FURTHER WORKUP ON
REQUEST ONLY.
Isolates are considered potential pathogens in amounts
>=10,000
cfu/ml.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 I
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2152-8-8**]: sputum culture:
[**2152-8-8**] 4:39 am SPUTUM Source: Catheter.
**FINAL REPORT [**2152-8-10**]**
GRAM STAIN (Final [**2152-8-8**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2152-8-10**]):
Commensal Respiratory Flora Absent.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
GRAM NEGATIVE ROD #3. RARE GROWTH.
[**2152-8-12**]: blood culture:
[**2152-8-12**] 5:11 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2152-8-18**]**
Blood Culture, Routine (Final [**2152-8-18**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final [**2152-8-14**]):
Reported to and read back by DR. [**Last Name (STitle) **] [**Name (STitle) **] PAGER#
[**Serial Number **] @ 0627
ON [**2152-8-14**].
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
[**2152-8-12**] 4:25 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2152-8-14**]**
GRAM STAIN (Final [**2152-8-12**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2152-8-14**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
SPARSE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S).
MODERATE GROWTH OF TWO COLONIAL MORPHOLOGIES.
GRAM NEGATIVE ROD(S). SPARSE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
[**2152-8-13**] 8:34 pm Mini-BAL
**FINAL REPORT [**2152-8-17**]**
GRAM STAIN (Final [**2152-8-14**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2152-8-17**]):
Commensal Respiratory Flora Absent.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA.
10,000-100,000 ORGANISMS/ML..
GRAM NEGATIVE ROD(S). ~3000/ML. FURTHER WORKUP ON
REQUEST ONLY.
Isolates are considered potential pathogens in amounts
>=10,000
cfu/ml.
GRAM NEGATIVE ROD(S). ~[**2140**]/ML. FURTHER WORKUP ON
REQUEST ONLY.
Isolates are considered potential pathogens in amounts
>=10,000
cfu/ml.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STENOTROPHOMONAS (XANTHOMONAS)
MALTOPHILIA
|
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
Admitted to the acute care surgery service on [**8-3**] following xfer
from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital s/p MCC. Patient was pan scanned as
per above and admitted to TSICU for further management.
Neuro: Patient arrived to TSICU intubated/sedated. Per family,
patient had been experiencing opiate withdrawal prior to admit
and was self-medicating with EtOH. On HD2 pt manifested
tachycardia/agitation c/w EtOH withdraw. CIWA scale titrated up
accordingly. Extubated [**8-6**] and noted to demonstrate withdrawal
from opiates. Suboxone resumed per home regimen that had been
discontinued by patient prior to admission related to inability
to afford medication. Following reintubation [**8-6**] sedation
regimen was optimized with combination
propofol/fentanyl/midzolam/precedex at various intervals
titrated to ventilator tolerance. Methadone was initiated when
extubated and following extubation, precedex was weaned off.
Patient was transferred to floor on methadone maintenance and
sublingual zyprexa.
CV: Patient admitted hemodynamically stable. Did not require
pressors during this admission. Manifested tachycardia/HTN
related to EtOH withdraw beginning on hospital day 2 and this
was effectively managed with CIWA scale and improved sedation.
Beyond withdraw period patient remained hemodynamically stable.
vital
signs were routinely monitored.
Pulmonary: Arrived to TSICU intubated w high likelihood of
aspiration related to initial trauma. Bronched for desats and
RML/RLL consolidations on CXR. Started on VAP coverage (see
ID). Extubated [**8-6**]. Re-intubated in setting desats/increasing
agitation. CXR at this time concernving for ARDS. Bronched and
esophageal balloon placed to optimize ventilatory management.
Triadine bed utilized to assist in pulmonary toilet while
intubated. Required high PEEP (~20) to maintain adequate
saturations. Ventilatory support weaned as tolerated and
patient successfully extubated [**8-16**]. Once extubated, pulmonary
toilet including incentive spirometry and early ambulation were
encouraged. Vital signs were routinely monitored.
GI/GU: On admission patient was made NPO and hydrated w IVF.
Tube feeds were initiated and advanced to goal. Patient
tolerated TFs well and they were continued while intubated.
Evaluated by speech and swallow and started on regular diet per
their recommendations on [**8-16**]. Bowel regimen was implemented
with initiation of TFs and diet was tolerated well.
Foley was placed in setting of trauma evaluation and removed
[**8-18**]. Patient required intermittent diuresis related to early
fluid resuscitation. This was implemented with lasix
intermittent vs drip with good effect. Intake and output were
closely monitored.
ID: CT Chest at time of admit showed B/L opacities c/w likely
aspiration. Pt spiked fever [**8-4**] and pan cultures were obtained.
Vanc/zosyn/cipro were started for VAP. BAL done in this
setting showed >100k E. coli. Cont to spike temps and
demonstrate high production respiratory secretions. Repeat
bronch w BAL [**8-5**] showed E.coli, S. pneumo. Acinetobacter was
seen on BAL [**8-7**]. Vanc and cipro were d/c'd [**1-5**] sensitivities
BAL specimens. BCx [**8-8**] showed GPCs and vanc resumed. ID c/s
obtained. All antibiotics discontinued and bactrim started [**8-11**].
Empiric C. diff coverage initiated 9/10 per ID given high stool
output, rising WBC and cont fevers. Initially w iv flagyl then
changed to po vanc [**8-13**]. Vancomycin was d/c'd [**8-17**] and patient
completed Bactrim course [**8-20**]. Patient's 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.
His cervical collar was cleared by clinical examination and
discontinued on [**8-21**]. He was evaluated by physical and
occupational therapy and recommendations for out-patient
occupational therapy. He was cleared to discharge home if
superivison can be provided. He was given a sling for comfort
for his left scapula fracture.
At the time of discharge on HD # 19, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance. His pain was controlled.
He was conversant and understood discharge instructions and the
need to continue discharge medications as prescribed. He was
discharged to his companion's home.
OF NOTE: Weaning of zyprexa was started on discharge [**8-21**]:
zyprexa decreased to 5 mg [**Hospital1 **], methadone decreased to 10 mg tid.
Please continue to wean as tolerated
Patient encouraged to follow-up with Dr. [**Last Name (STitle) 90461**], who patient
reports as his primary care provider. [**Name10 (NameIs) **] has follow-up
appointments which he has been encouraged to make with the acute
care service, ortho, and cognitive neurology.
Rpeat lab creat, na pending:
Lab results [**8-22**]: na=128, creat 0.9
Medications on Admission:
MEDS: suboxone - (self d/c'd [**7-30**])
Discharge Medications:
1. methadone 10 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*42 Tablet(s)* Refills:*0*
2. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) patch
Transdermal once a day.
Disp:*14 patch* Refills:*0*
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for diarrhea.
5. ibuprofen 800 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours: as needed for pain.
6. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dryness.
7. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours: as needed for pain.
8. Outpatient Occupational Therapy
cognitive assessment
9. olanzapine 5 mg Tablet Sig: One (1) Tablet PO twice a day for
14 days days.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Trauma: motor-cycle crash
Injuries:
Non-disp, post L [**3-7**] rib fractures
Multiple abrasions
L Subgaleal hematoma
L scapular fx
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 after you were involved in a
motor-cycle crash. You sustained rib fractures, a scapular
fracture, a small bleed in your head and multiple abrasions.
You had a breathing tube in place and you were monitored in the
intensive care unit. During this time, you developed a pneumonia
and you were treated with antibiotics. You had the breathing
tube removed but needed it replaced because you had difficulty
breathing. As your pneumonia resolved, your breathing improved
and you had the breathing tube removed. During your hospital
course you had problems with agitation related to withdrawal of
alcohol. You received medication to help you through this
diffcult period. Once your vital signs stabilzed and your
pulmonary status improved, you were transported to the surgical
floor. You have been evaluated by physical and occupational
therapy and recommendations made for your discharge with the
following instructions:
Your injury caused left [**3-7**] rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal antiinflammatory drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus
You also sustained a fracture to your left clavicle for which
you do not need surgery. Wear the sling for comfort when
ambulating. You may do simple exercises to your wrist and elbow
to keep them from getting stiff.
You did sustain a small bleed in your head. Please report:
*increased headache
*visual changes, ie. seeing double, loss of vision
*difficulty speaking
*weakness on one side of your body
*numbness on one side of your body
*facial drooping
Followup Instructions:
Please follow up with the acute care service in 2 weeks. Please
call for your appointment 24 hours after you are discharged.
The telephone number is # [**Telephone/Fax (1) 600**]. Please let them know
that you will need a chest x-ray prior to your visit.
Please follow up with the cognitive neurologist, Dr. [**First Name (STitle) **],
in 1 week. You can scheudule this appointment by calling #
[**Telephone/Fax (1) 6335**]
You will also need to follow-up with the Orthopedic Nurse
Practitioner, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], for your clavicle fracture.
You can schedule this appointment in 2 weeks. The telephone
number is #[**Telephone/Fax (1) 1228**]
Please folow up with your primary provider [**Last Name (NamePattern4) **] 1 week,
Dr.[**Last Name (STitle) 90461**]
Completed by:[**2152-8-22**]
|
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icd9cm
|
[
[
[]
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[
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18272, 18278
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12274, 17308
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336, 342
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18455, 18455
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2553, 12251
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2069, 2534
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18470, 18582
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1765, 1874
|
1890, 1982
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,929
| 133,686
|
4971
|
Discharge summary
|
report
|
Admission Date: [**2141-1-6**] Discharge Date: [**2141-1-14**]
Date of Birth: [**2083-10-25**] Sex: M
Service: MEDICINE
CHIEF COMPLAINT: Vomiting.
HISTORY OF PRESENT ILLNESS: This is a 57-year-old male with
history of insulin dependent diabetes, status post renal
transplant in [**2130**], recent admits for fever of unknown
origin, who now presents with a three day history of nausea,
vomiting, diarrhea, and fever of up to 101.8. As already
noted, the patient was recently admitted in late [**Month (only) 359**] for
workup of fever of unknown origin including a VATS procedure,
and readmitted in mid [**2140-12-9**] with similar
complaints without significant elucidation of his fever of
unknown origin. The patient was afebrile for five days prior
to discharge.
After discharge, the patient had been in his usual state of
health until a few nights prior to admission when he noted
progressive nausea and vomiting, and inability to tolerate
oral intake. He states that he has not been able to keep
anything down, and has noted almost projectile vomiting
approximately two hours after ingesting food. He states that
the emesis is compromised of undigested food. He has been
able to drink water and had red jello without any problem.
In the Emergency Department, he had laboratories consistent
with diabetic ketoacidosis. He was given 3 liters of
intravenous fluids, Phenergan, Zofran, and insulin. He was
transferred to the MICU for management of his diabetic
ketoacidosis.
PAST MEDICAL HISTORY:
1. Insulin dependent diabetes.
2. End-stage renal disease, status post kidney transplant in
[**2130**], baseline creatinine is 4-4.5.
3. Status post VATS in [**2140-11-8**].
4. Recent admissions for FUO with negative workup.
5. History of empyema/septic emboli.
6. Congestive heart failure.
7. Coronary artery disease, status post myocardial
infarction, status post left anterior descending artery PTCA
and stent in [**2139-10-10**].
8. History of Clostridium difficile colitis.
9. Osteoarthritis.
10. History of aspiration pneumonia.
11. MGUS.
12. History of methicillin-resistant Staphylococcus aureus,
Vancomycin resistant Staph, cleared.
13. History of gallstones.
14. History of right eye blindness.
MEDICATIONS:
1. Midodrine 10 mg po tid.
2. Prednisone 5 mg po q day.
3. Neurontin 300 mg po bid.
4. Lopressor 75 mg [**Hospital1 **].
5. Pravachol 40 mg po q day.
6. Humalog sliding scale.
7. Sodium bicarbonate 1300 mg po bid.
8. Glargine 38 units subQ q hs.
9. Procrit 10,000 units subQ 3x a week.
10. Protonix 40 mg po q day.
11. Aspirin 325 mg po q day.
12. [**Hospital1 **] sulfate 325 mg po q day.
13. Lasix 20 mg po q day.
14. Norvasc 5 mg po q day.
15. Colace 100 mg po bid.
ALLERGIES: Dicloxacillin which leads to dry heaves,
Compazine leads to hallucinations.
SOCIAL HISTORY: No tobacco in the last 18 years, very rare
EtOH, no IV drug use, lives with wife and daughter.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: Positive for fevers up to 101.8, negative
chills or rigors, negative upper respiratory infection
symptoms, negative headache, negative shortness of breath,
positive chest pain localized to his right chest at the site
of the recent VATS procedure, extending to the anterior chest
wall, treated with Tylenol #3 without success. Review of
systems is also positive for nausea, vomiting, abdominal
cramps, loose nonwatery stools x2 days, but negative for
bright red blood per rectum, melena, urinary symptoms, lower
extremity edema.
LABORATORIES: White count 11.8 with 84% neutrophils, 11%
lymphocytes, hematocrit 33.9, platelets 247. Sodium 143,
potassium 4.5, chloride 113, bicarb 16, BUN 86, creatinine
5.3, glucose 104, PT 13.5, PTT 27.1, INR 1.2. ALT 12, AST
19, alkaline phosphatase 125, total bilirubin 0.5, lipase 7.
CK 31, troponin is less than 0.3.
Urinalysis: Slightly hazy, trace blood, greater than 300
protein, 250 glucose, small bilirubin, negative leukocyte
esterase or nitrate, 3 red blood cells, 2 white blood cells,
few bacteria, 2 epi's. Urine sodium 54, urine creatinine
104, urine urea 516. Arterial blood gas: PH 7.13, CO2 28,
O2 93.
ELECTROCARDIOGRAM: Normal sinus rhythm at 79 beats per
minute, normal axis with PVCs, pseudonormalization of T waves
in I, V5 and V6, new T-wave inversion in V1.
CHEST X-RAY: Patchy density in the left middle lung zone,
questionable development of pneumonia, stable density in the
right lung base, 7th rib abnormality posteriorly which could
represent fracture.
HOSPITAL COURSE: In short, this is a 57-year-old male with a
history of insulin dependent diabetes, end-stage renal
disease status post renal transplant in [**2130**] with chronic
renal insufficiency with baseline creatinine of 4.0 to 4.5,
who presents with three days of nausea and vomiting,
decreased po intake, and fever up to 101.8, found to be in
diabetic ketoacidosis, transferred to the unit for further
management.
1. Endocrine: As already noted, the patient was found to be
in diabetic ketoacidosis on admission. His initial anion gap
was calculated to be 23. Etiologies behind the diabetic
ketoacidosis were thought to be infection given the fever
versus ischemia given the new electrocardiogram changes.
Patient received 8 units of insulin IV push, and then 8 units
per hour insulin drip. He also received 3 liters of normal
saline in the Emergency Department, in addition to another
liter in the MICU. Patient's gap quickly closed. He was
converted to sliding scale insulin, and his fluids were
continued at maintenance of D5 normal saline.
2. Infectious Disease: While in house, the patient started
spiking with fevers up to 105 degrees F. Patient's combined
blood cultures from [**1-6**] and [**2141-1-7**] grew 12/12 bottles of
Staphylococcus aureus, sensitive to oxacillin with a MIC of
0.25. Given the positive blood cultures, patient's fever was
not thought to be related to his recent FUO. The most likely
sources of the bacteremia were thought to be the site of the
VATS procedure, especially given that a small amount of pus
was noted coming from the site. In addition, a cardiac
source could not be ruled out.
Patient had a chest CT scan on [**2141-1-9**]. This showed
increased patchy ground-glass infiltrate in the right upper
lobe and left lower lobes, and a new 7th rib fracture.
Patient also had a staple right sided effusion. Recent chest
CT scan imaging for evaluation of empyema was negative.
Patient also had a transthoracic echocardiogram on [**2141-1-10**].
This showed a mild AR and MR, but no vegetations.
On [**2141-1-11**], the patient received a right sided
thoracentesis. This showed an essentially clear fluid, with
1,000 white blood cells, and 5,000 red blood cells. Also
total protein is 3.2, glucose 272, LDH 164, and pH of 7.44.
No organisms were seen, and culture was negative. Pleural to
serum total protein and LDH ratios were consistent with
slightly exudative fluid.
Patient last spiked on [**2141-1-9**]. Patient was kept on
oxacillin 2 grams IV q4h. He received a PICC line on his
left. The plan was to keep the patient on intravenous
oxacillin for at least one month's time given his bacteremia.
Subsequent surveillance cultures were negative.
3. Given the patient's new onset diabetic ketoacidosis and
electrocardiogram changes, he was ruled out by cardiac
enzymes. The patient ruled out successfully. He is
continued on aspirin, Lopressor, and the Pravachol.
4. Renal: The patient has a history of chronic renal
failure. The patient presented with acute and chronic
failure. His [**Doctor Last Name **] was not useful because the patient is on
chronic Lasix. His fractional excretion of urea was 31,
consistent with prerenal state as the value is less than 35.
The patient responded to IV fluids, and his creatinine
returned to a baseline of [**5-12**].5.
5. Right sided chest pain: The patient was admitted with
pleuritic right sided chest pain, correlating with the site
of his recent VATS and likely secondary to his newly found
fractured 7th rib. Given the patient's history of monoclonal
gammopathy of unknown significance, there is concern that the
patient may be converting to multiple myeloma. He may need a
bone marrow [**Date Range **] in the near future. Patient was
successfully treated with Percocet for the pain.
CONDITION ON DISCHARGE: Good.
DISCHARGE MEDICATIONS:
1. Midodrine 10 mg po tid.
2. Prednisone 5 mg po q day.
3. Oxacillin 2 grams IV q4h x1 month.
4. Neurontin 300 mg po bid.
5. Lopressor 75 mg po bid.
6. Pravachol 40 mg po q day.
7. Humalog sliding scale.
8. Bicarb 1300 mg po bid.
9. Glargine 38 units subQ q hs.
10. Procrit 10,000 units subQ 3x a week.
11. Protonix 40 mg po q day.
12. Aspirin 325 mg po q day.
13. [**Date Range **] sulfate 325 mg po q day.
14. Lasix 20 mg po q day.
15. Norvasc 5 mg po q day.
16. Colace 100 mg po bid.
DISCHARGE INSTRUCTIONS: The patient is to followup with Dr.
[**First Name (STitle) 805**] in [**2-10**] weeks. Patient will need to followup sooner
if he redevelops a fever, nausea, vomiting, decreased po
intake. He will also need to followup with Infectious
Disease.
DISCHARGE DIAGNOSES:
1. Staphylococcus aureus bacteremia, now cleared.
2. Insulin dependent diabetes.
3. End-stage renal disease, status post kidney transplant in
[**2130**].
4. Recent fever of unknown origin with negative workup.
5. Coronary artery disease, status post myocardial
infarction.
[**Name6 (MD) 251**] [**Last Name (NamePattern4) 11865**], M.D. [**MD Number(1) 11866**]
Dictated By:[**Name8 (MD) 4990**]
MEDQUIST36
D: [**2141-3-1**] 16:52
T: [**2141-3-2**] 07:23
JOB#: [**Job Number **]
|
[
"584.9",
"790.7",
"250.11",
"V42.0",
"428.0",
"276.0",
"998.59",
"511.9",
"585"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.62",
"38.93",
"34.91",
"88.72",
"86.04"
] |
icd9pcs
|
[
[
[]
]
] |
2936, 2954
|
9159, 9677
|
8378, 8866
|
4521, 8323
|
8891, 9138
|
2974, 4503
|
155, 166
|
195, 1506
|
1528, 2806
|
2823, 2919
|
8348, 8355
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,094
| 100,799
|
45437
|
Discharge summary
|
report
|
Admission Date: [**2114-11-27**] Discharge Date: [**2114-12-8**]
Date of Birth: [**2039-8-6**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Hydralazine / Ace Inhibitors / Diovan / Heparin Agents
Attending:[**First Name3 (LF) 6994**]
Chief Complaint:
CC:[**CC Contact Info **]
Major Surgical or Invasive Procedure:
CT Guided Thoracentesis
Bronchoscopy
Central line placement
History of Present Illness:
75 yo F w/PMH R pleural effusion, CAD, CHF (EF 55), DM, ESRD on
HD recent admission from [**Date range (1) 96973**] w/MRSA sepsis on
vancomycin(??osteomyelitis) now admitted for fever, shortness of
breath and cough.
.
At the NH, her fever was found to be 102.8. On presentation to
ED, her VS were T98.3 P68 BP106/41 R 14 and 96% on 2L. She
received 2L of NS and zosyn in ED.
.
Patient went for bronchoscopy today for RLL collapse which
showed severe tracheobronchomalacia on tidal respiration.
Pigtail was unable to be done. She then went to dialysis which
removed 1.5L of fluid. Dialysis was stopped early because she
was shivering and feeling cold. Upon return to the floor, she
required increased oxygen support, 92% on 6L(95% on 2L the same
AM), tachypneic to 40s and also hypertensive to 170s. Her ABG
showed 7.32/63/60 on 6L. She was given nebs x1 with no
improvement.
.
The patient reports increased cough, occassionally productive of
clear phlegm/sputum over the past several days. She also notes
increasing shortness of breath. She denies chest pain, PND,
orthopnea, abdominal pain, nausea, vomiting, diarrhea, urinary
symptoms(she does have minimal urine output), headahce,
dizziness.
Past Medical History:
- chronic R pleural effusion w/ RML, RLL collapse, tapped in
[**7-29**] transudative (attempted tap x 3 without success, on fourth
attempt were able to remove 200cc only) - on 2L oxygen at NH
- CAD: cath [**11-26**] with 3VD, s/p cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 to RCA.
- CHF: echo [**10-29**] show hyperdynamic EF, mild LVH
- Atrial Fibrillation
- Pulmonary HTN
- Hypertension
- Hyperlipidemia
- DM2
- ESRD from contrast nephropathy post cardiac catheterization
[**11-26**] on HD since [**12-28**] (baseline creatinine ([**2-24**])
- Severe lumbar spondylosis and spinal stenosis s/p laminectomy
in [**2110**]
- Basal Cell Carcinoma
- Osteomyelitis T5-T6 on suppressive vancomycin for 3 months
([**2113-4-13**] was day 1)
- MRSA bacteremia from HD line infection
- Admission [**Date range (1) 96974**] for MRSA sepsis. At that time, the
patient had back pain and their was concern for osteomyelitis.
She refused an MRI so was discharged on 6 weeks of abx.
Social History:
Lives at [**Hospital **] [**Hospital **] Nursing Home since [**2111**] and has been
bedridden since that time [**1-25**] spinal stenosis. Past tobacco
(quit [**2111**] 10py). Has three children - daughter nad son both in
[**Name (NI) 86**] area and split her HCP. Widowed in [**2108**]. Retired -
worked in retail clothing.
Family History:
Father died of CVA at 64yo. Mother died of MI at 86yo. Brother
had CAD. Grandmother had T2DM
Physical [**Year (4 digits) **]:
T101.4 BP173/86 P104 R40s 88-98% on 6L
Gen- lethergic, in respiratory distress
HEENT- anicteric, PERRLA, dry mucus membrane, neck supple, JVD
hard to appreciate
CV- tachycardic, no r/m/g
RESP- course inspiratory and expiratory stridor, accessory
muscle use, speak in few-word sentence, no cyanosis
ABDOMEN- soft, obese, nontender, nondistended, no bowel sounds
EXT- no peripheral edema, DP pulses not palpable, extremities
cold
NEURO- alert and oriented x3, oeby commands, CNII-XII intact,
neuro [**Year (4 digits) **] deferred due to respiratory distress
SKIN- no jaunduce
Pertinent Results:
[**2114-11-27**] 08:30PM PT-13.4* PTT-26.9 INR(PT)-1.2*
[**2114-11-27**] 08:30PM PLT COUNT-119*
[**2114-11-27**] 08:30PM PLT COUNT-119*
[**2114-11-27**] 08:30PM NEUTS-77.4* LYMPHS-14.3* MONOS-4.9 EOS-2.7
BASOS-0.6
[**2114-11-27**] 08:30PM WBC-5.7 RBC-3.33* HGB-10.8* HCT-32.3* MCV-97
MCH-32.6* MCHC-33.5 RDW-15.2
.
CTA Chest: IMPRESSION:
1. Almost complete atelectasis of the right lung due to
secretion in right main bronchi.
2. Longstanding loculated right pleural effusion with
homogeneous pleural thickening, unchanged.
3. Steadily increasing mediastinal lymph nodes, and pleural
thickening might have a benign explanation due to longstanding
pleural effusion. An indolent malignancy such as lymphoma cannot
be excluded, justifying thoracentesis and cytologic cell-block
examination.
.
CXR [**2114-12-7**]:
Portable AP chest radiograph compared to [**2114-12-3**].
Left PICC line tip terminates at the junction of the
brachiocephalic vein and SVC. The left lung is unremarkable. The
right pleural effusion again demonstrated with adjacent lung
atelectasis, slightly increased comparing to the previous film.
No evidence of pneumothorax is present.
.
Cytology: Negative for malignant cells
Brief Hospital Course:
75yo F with ESRD on HD, CAD, CHF, HTN, chronic right sided
effusion and R lung collapse, s/p bronch showing
tracheobronchomalacia, transferred to MICU for acute
exacerbation of hypoxia.
.
MICU COURSE:
# Acute exacerbation of hypoxia - correctable w/ O2(baseline
home O2 2L: initial DDX on admission included acute mucus plug,
worsening pneumonia/pulmonary edema, worsening collapse,
fever/high metabolic rate, PE. CXR show persistent RML and RLL
collapse, no PTX; bronch [**11-28**] show severe TBM. Patient was
given aggressive pulmonary toillette. There was some
improvement in her hypoxia however she continued to require
oxygen. She underwent a CT guided thoracentesis with pigtail
placement which revealed a transudate. There was a concern for
trapped lung and not much improvement in her oxygenation. She
was also treated with vanc/zosyn for 7 days for possible PNA.
.
# Longstanding loculated right pleural effusion with homogeneous
pleural thickening w/ enlarging mediastinal [**Doctor First Name **] - As above pig
tail placed under CT guidance but no relief. Likely trapped
lung.
.
# ESRD on HD QMWF: last HD [**11-28**]. Renal followed patient while
she was admitted. Continued epogen, calcitriol, folic acid.
# CAD: continue on plavix
# DM- continue on insulin sc
# thrombocytopenia: DIC lab negative, patient has history of
HIT.
# Anxiety:continued on citalopram, clonazepam
# spinal stenosis: on morphine at baseline
# PPX-PPI, pneumoboots
# code- DNR/DNI.
-----
During the day [**12-4**] patient went into A. fib with RVR upto 160s
and dropped her systolic bp to 60s. Given patients prior wishes
and after discussion with the family and PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], the
decision was made to change her goals of care to comfort
measures. All her regular medications were discontinued and she
was started on a morphine drip with titration to comfort. The
patient was transferred to the medical floor where this care
goal was continued. This was confirmed with family. On HOD #11,
patient expired.
Medications on Admission:
MEDICATION AT HOME
Metoprolol Tartrate 12.5 mg TID
Calcitriol 0.25 mcg QOD
Lidocaine 5 %(700 mg/patch) Q8AM-8PM
Folic Acid 1 mg daily
Vancomycin in Dextrose 1 g QHD Continue until [**2114-12-26**].
Ascorbic Acid 500 mg [**Hospital1 **]
Omeprazole 20 mg daily
Clopidogrel 75 mg daily
Citalopram 20 mg daily
MSSR 30 mg PO QMOWEFR
Morphine 15 mg q4h prn
Klonopin 0.5 mg twice a day.
Albuterol Sulfate neb prn
Ipratropium Bromide neb prn
Lactulose 30 ml PRN
Docusate Sodium 100 mg po bid
Miconazole Nitrate 2 % Powder [**Hospital1 **]
Senna 8.6 mg [**Hospital1 **]
Epoetin Alfa 4000 QHD
Insulin Lispro (Human): sliding scale 151-200 give 2u, 201-250
give 4u, 251-300 give 6u, 301-350 give 8u, 351-400 give 10u,.
.
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
NA
Discharge Condition:
Deceased
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2114-12-17**]
|
[
"724.02",
"511.9",
"486",
"428.0",
"E934.2",
"518.0",
"416.8",
"250.00",
"585.6",
"287.4",
"403.91",
"799.02",
"519.19",
"272.4",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.93",
"34.91",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
7809, 7818
|
4964, 7020
|
350, 411
|
7864, 7874
|
3734, 4941
|
7925, 7959
|
3013, 3715
|
7782, 7786
|
7839, 7843
|
7046, 7759
|
7898, 7902
|
286, 312
|
439, 1636
|
1658, 2652
|
2668, 2997
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,548
| 182,189
|
47013
|
Discharge summary
|
report
|
Admission Date: [**2195-1-18**] Discharge Date: [**2195-1-18**]
Service: MEDICINE
Allergies:
Bacitracin / Macrobid / Pyridium / Bactrim / Sulfa
(Sulfonamides) / Alphagan P
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
s/p cardiac arrest
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a [**Age over 90 **] yo F w h/o pulmonary fibrosis on home oxygen,
hypertension, and CRI who presents after cardiac arrest
witnessed by her son, who began CPR at home until the Fire
department arrived.
EMS arrived and found patient unresponsive. Cardiac monitor
advised no shock (PEA arrest). CPR performed and IV dopamine
gtt was started. She was intubated in the field. Her pulse and
blood pressure spontaneously returned. She arrived to ER in
NSR.
In the ER arrival vitals were 34.8 rectal P 96 BP 140/58 RR
23 SpO2 96% on mechanical ventilation. She received atropine 1
mg IV x2, ceftriaxone, levoflox 750 IV, and flagyl 500 IV.
Bedside echo was performed and showed no effusion. They put her
on a cooling protocol post-arrest.
Prior to her event, she had been c/o dyspnea and her sons had
increased her home oxygen to 4-5L. Of note, she was recently
seen in the ED for complaint of constipation; she was
disimpacted and given a bowel regimen as well as augmentin for a
UTI. Her son does report that she has c/o chest pain at home.
Her son, [**Name (NI) 401**], is HCP and states that the patient is DNR/DNI. He
would have stopped the code and intubation, but was unable to
provide paperwork to EMS.
Past Medical History:
1. Interstial Lung Disease w/ pulmonary fibrosis (O2 dependent)
2. Incontinence
3. Recurrent UTI's
4. Hypothyroidism
5. Hypertension
6. Pneumonia
7. Chronic Kidney Disease, Stage III
8. Chronic diastolic heart failure - echo [**7-23**]
Allergies:
Bacitracin / Macrobid / Pyridium / Bactrim / Sulfa /
(Sulfonamides) / Alphagan P
Social History:
No smoking, alcohol or drug use. Lives with her two sons,
performs all [**Name (NI) 5669**]. Good family support.
Family History:
Mother: breast cancer, deceased
Father: prostate cancer, deceased
Physical Exam:
Gen: patient currently hypothermic; lying still, eyes open and
not blinking
HEENT: Pupils dilated and fixed, no doll's eyes.
CVS: S1, S2, regular, distant heart sounds
Lungs: Breath sounds b/l
Abd: soft NT/ND.
Ext: no edema, can appreciate carotid pulse but not pulses in
extremities, fingers and feet blue and cold
Skin: mottled
Neuro: difficult to assess secondary to hypothermia; does not
withdraw from pain.
Pertinent Results:
Labs:
[**2195-1-18**] 11:32AM BLOOD WBC-17.9* RBC-4.76 Hgb-13.9 Hct-45.5
MCV-96 MCH-29.2 MCHC-30.5* RDW-15.9* Plt Ct-87*
[**2195-1-18**] 11:32AM BLOOD PT-19.5* PTT-51.1* INR(PT)-1.8*
[**2195-1-18**] 11:32AM BLOOD Fibrino-218
[**2195-1-18**] 11:32AM BLOOD UreaN-71* Creat-2.5*
[**2195-1-18**] 11:32AM BLOOD ASA-NEGATIVE Ethanol-NEG Acetmnp-NEGATIVE
Bnzodzp-NEGATIVE Barbitr-NEGATIVE Tricycl-NEGATIVE
[**2195-1-18**] 11:40AM BLOOD Glucose-237* Lactate-13.6* Na-141 K-6.0*
Cl-96* calHCO3-24
EKG: NSR. LAD. normal intervals. TWI in V1-V5.
CXR [**1-18**]:
1. Bilateral interstitial opacity likely representing edema.
2. Tip of ET tube is at the origin of the right main stem
bronchus.
Recommend withdrawing 3 cm for optimal position.
Brief Hospital Course:
[**Age over 90 **]yo woman s/p PEA arrest.
# PEA arrest:
Spoke with both sons, including HCP [**Name (NI) 401**]. They confirmed
patient's DNR/DNI status. Upon admission to the ICU, it was
difficult to assess neurologic status because she was still
hypothermic. While she was being warmed to reassess her status,
her BP dropped and she became increasingly bradycardic. Both
sons, including [**Name (NI) 401**] (the patient's HCP), were present and agreed
not to code the patient. She died at 4:23pm on [**2195-1-18**].
The attending was present and the patient's PCP was informed.
The family declined autopsy.
Medications on Admission:
-Augmentin
-Levoxyl 100 mcg qday
-Tylenol 500 mg prn headache
-Atenolol 25 mg qday
-Benzonatate 100 mg PO TID
-Lipitor 10 mg qday
-Folic acid 400 mg qday
-Multivitamin QDay
-Amlodipine 5 mg qhs
-Lisinopril 40 mg qhs
-ASA 81 mg qday
-Colace 100 mg [**Hospital1 **]
-Desipirimine 10 mg qhs
-Protonix 40 mg qday
Tylenol PM
-Xalatan 0.005% drop in right eye
Systane drop prn left eye
Fluticasone-Salmeterol 100-50 mcg/Dose [**Hospital1 **]
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Dx: Cardiac Arrest
Secondary Dx: Pulmonary fibrosis
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2195-1-18**]
|
[
"244.9",
"515",
"428.32",
"427.5",
"428.0",
"585.3",
"403.90",
"496",
"518.81",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
4460, 4469
|
3356, 3974
|
312, 318
|
4573, 4583
|
2595, 3333
|
4640, 4815
|
2078, 2145
|
4490, 4552
|
4000, 4437
|
4607, 4617
|
2160, 2576
|
254, 274
|
346, 1577
|
1599, 1929
|
1945, 2062
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,561
| 154,509
|
20920
|
Discharge summary
|
report
|
Admission Date: [**2200-6-9**] Discharge Date: [**2200-6-10**]
Date of Birth: [**2160-12-30**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
39M found walking in and out of traffic on the street by EMS,
with periods of combativeness and lethargy on scene, who was
brought to the ED.
.
In ED VS= 98.4 146/95 56 17 100%RA. He was found to have a
graduation certificate from [**Doctor First Name **] street treatment resources
step down services in his backpack. He was intermittently
combative and lethargic. He had bottles of his own clonidine,
neurontin, and xanax with him, and by report, a slip saying he
was on methadone 85mg qdaily.
.
Labs were essentially unremarkable (INR 1.3, UA with few
bacteria). ECG revealed sinus bradycardia. Head CT was
attempted, but cancelled as pt would not sit still.
.
He presentation was concerning for clonidine toxicity given
bradycardia, hypertension. He was given narcan 0.5 mg without
response, but improved after receiving a second 0.5mg dose. He
became lethargic again, and received another 0.5mg of narcan and
was started on narcan gtt at 1.25mg/hr.
.
Upon arrival to the MICU the patient is lethargic, and minimally
responsive to sternal rub. He withdraws to pain, PERRL. He is
minimally responsive to ABG, but does withdraw to the pain. ABG
7.45/80/45 on 3L. There is no improvement with narca 0.5mg x 2.
.
Review of systems: unable to obtain [**2-3**] lethargy.
Past Medical History:
- hep C positive
- bilateral sciatica
- anxiety disorder vs. personality disorder
- h/o heroin dependence and cocaine abuse
Previous psychiatric history:
- h/o panic attacks tx'd by an outpatient psychiatrist Dr. [**Last Name (STitle) 24051**]
- h/o multiple psychiatric and detox admissions
- h/o several suicide attempts including with heroin OD >2 y ago
Per his ICM at MBHP [**First Name8 (NamePattern2) 55644**] [**Last Name (NamePattern1) 5448**] [**Telephone/Fax (1) 55645**] she reports
that:
- [**Hospital **] hospital [**Date range (1) 42060**]
- CAB detox [**Date range (1) 19139**]
- Brounweed [**4-21**], steped down to eATS [**4-25**]
- CAB [**5-1**] for detox for two days
- Bournwood [**Date range (1) 1261**]
- [**2117-5-18**] step down to EATS [**Doctor Last Name **] [**Date range (1) 55646**],
extended to [**6-9**]
Social History:
Pt reports a good family, finished HS, family is in law
enforcemtn; brother is a homicide investigator; pt reports
receving a $100,000 inheritance several years ago and using
cocaine and drugs until he ran through the money; estranged from
his family
Family History:
No family h/o of dx'd psychiatric disorders
Physical Exam:
Vitals: 60 140/90 29 99% on 3L
General: lethargic, withdraws to pain.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obsese, +striaea, soft, non-tender, non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: PERRL, occulocephalic reflex intact, toes downgoing.
withdraws to pain in all four extremities.
Pertinent Results:
On admission:
[**2200-6-9**] 07:15PM BLOOD WBC-6.3 RBC-4.78 Hgb-13.7* Hct-39.1*
MCV-82 MCH-28.7 MCHC-35.1* RDW-14.3 Plt Ct-221
[**2200-6-9**] 07:15PM BLOOD Glucose-116* UreaN-12 Creat-1.1 Na-139
K-4.2 Cl-101 HCO3-30 AnGap-12
[**2200-6-9**] 07:15PM BLOOD Calcium-9.6 Phos-3.7 Mg-2.0
[**2200-6-9**] 07:15PM BLOOD ALT-39 AST-37 LD(LDH)-195 AlkPhos-98
TotBili-0.7
[**2200-6-9**] 07:15PM BLOOD PT-14.4* PTT-31.5 INR(PT)-1.3*
.
[**2200-6-10**] 12:08AM BLOOD Type-ART Temp-36.5 O2 Flow-3 pO2-84*
pCO2-40 pH-7.45 calTCO2-29 Base XS-3 Intubat-NOT INTUBA
Comment-O2 DELIVER
[**2200-6-10**] 12:08AM BLOOD Lactate-0.8
[**2200-6-10**] 05:34AM BLOOD TSH-0.67
[**2200-6-9**] 07:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2200-6-9**] 08:13PM URINE bnzodzp-POS barbitr-POS opiates-NEG
cocaine-NEG amphetm-NEG mthdone-POS
.
[**2200-6-9**] 08:13PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2200-6-9**] 08:13PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-7.0 Leuks-NEG
[**2200-6-9**] 08:13PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
.
On discharge:
[**2200-6-10**] 05:34AM BLOOD WBC-9.4 RBC-4.74 Hgb-13.7* Hct-38.7*
MCV-82 MCH-28.9 MCHC-35.4* RDW-14.3 Plt Ct-237
[**2200-6-10**] 05:34AM BLOOD Glucose-129* UreaN-12 Creat-0.8 Na-137
K-4.3 Cl-104 HCO3-26 AnGap-11
[**2200-6-10**] 05:34AM BLOOD Calcium-9.5 Phos-4.1 Mg-2.0
Brief Hospital Course:
39M found wandering in traffic admitted with altered mental
status [**2-3**] substance abuse.
.
# Altered mental status: Discharged from detox program on day of
admission, presenting with altered mental status. Given
prescribed medications found with him, mostly likely [**2-3**] benzo
and clonidine abuse although also taking higher doses of
gabapentin than prescribed. Denied suicidal ideation but noted
to have very impulsive behavior on psych eval. Was to be
discharged on same medication regimen and f/u with outpatient
prescribing psychiatrist. However, later called mother
threatening suicide. Given this new information, made Section 12
with plan to discharge pt to dual diagnosis facility. Pt
continued on home clonidine and gabapentin; recommended ativan
2mg tid prn agitation and zyprexa 5mg tid prn agitation by
Psych.
.
# Sinus bradycardia: [**Month (only) 116**] be [**2-3**] to medication intoxication
although pt also reports bradycardia at baseline. No evidence of
infarct on ECG.
.
# Code: Presumed full
.
# Communication: With patient and mother, [**Name (NI) **] [**Name (NI) 55647**]
([**Telephone/Fax (1) 55648**]).
Medications on Admission:
Medications: (filled at CVS [**Telephone/Fax (1) 55649**], Rx by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24051**])
- neurontin 800mg po tid
- clonidine 0.1 mg po tid
- cvs stool softener 100mg po bid
- alprazolam 4mg po qdaily
Per [**Doctor Last Name **]:
- clonidine 0.1 mg tid
- colace 100mg [**Hospital1 **]
- abilify 5 mg at hs
- vistaril 50 mg tid
- methadone 85 mg a day
Discharge Medications:
1. Methadone 5 mg Tablet Sig: Seventeen (17) Tablet PO DAILY
(Daily).
2. Neurontin 800 mg Tablet Sig: One (1) Tablet PO three times a
day.
3. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO three times a
day.
4. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO three times a
day as needed for agitation.
5. Zyprexa 5 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for agitation.
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1680**] Hospital - [**Location (un) 538**]
Discharge Diagnosis:
Clonidine overdose
Intoxication
Discharge Condition:
Medical issues stable for transfer to dual diagnosis facility
Discharge Instructions:
You were evaluated for your unusual behavior which was felt
related to your overuse of drugs such as xanax, clonidine,
methadone, and neurontin. You were evaluated by Psychiatry here
and are being discharged to a dual diagnosis facility.
No changes were made to your medications, and you should take
all medications as prescribed. Many of your medications can
cause drowsiness or impaired judgment. Taking more than
prescribed can be harmful to your health and to those around
you. Please review your medication regimen further with a
physician.
Seek immediate medical attention if you develop chest pain,
difficulty breathing, confusion, thoughts about hurting yourself
or others, or any other concerning symptoms.
Followup Instructions:
Please follow up with your outpatient psychiatrist after your
discharge from your dual diagnosis facility.
Completed by:[**2200-6-11**]
|
[
"724.3",
"972.6",
"427.89",
"V45.81",
"E858.3",
"301.9",
"070.54",
"304.01",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6955, 7036
|
4891, 4997
|
318, 325
|
7112, 7176
|
3448, 3448
|
7942, 8080
|
2769, 2814
|
6480, 6932
|
7057, 7091
|
6056, 6457
|
7200, 7919
|
2829, 3429
|
4595, 4868
|
1586, 1625
|
257, 280
|
353, 1567
|
3462, 4581
|
5012, 6030
|
1647, 2484
|
2500, 2753
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,504
| 145,988
|
28795
|
Discharge summary
|
report
|
Admission Date: [**2199-8-26**] Discharge Date: [**2199-8-29**]
Date of Birth: [**2161-12-22**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p fall from attic (10 feet)
Major Surgical or Invasive Procedure:
none
History of Present Illness:
37 transgender male (prev female) fell 10 feet from attic, with
reported loss of motor and sensation below T10. Patient was
transferred from [**Hospital **] hospital boarded and c-collared, c/o HA
and back pain.
Past Medical History:
s/p hysterectomy (part of gender reassignment)
Social History:
in the process of gender reassigment (born a female, but
considers self male now)
Family History:
married, with 2 adopted kids
Physical Exam:
PE: 99.0, 78, 118/61, 18, 97% RA
GCS 15, A&Ox3
pupils 3-->2 bilaterally, c-collar in place
RRR
CTAB
Soft/NT, FAST negative
Pelvis stable
rectal tone: normal, guaic negative
Back: tenderness to palpation along lower thoracic spine
Ext: DP 2+ bilaterally
Neuro: sensory level at 10, decreased LE movement bilaterally
(flicker of foot dorsiflexion), toes downgoing bilaterally
Patient's neuro exam improved while in the hospital; he had full
motor function of lower extremities (with reported absence of
sensation over thighs) on discharge.
Pertinent Results:
[**2199-8-26**] 12:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2199-8-27**] 04:10AM BLOOD Glucose-217* UreaN-11 Creat-1.0 Na-138
K-3.4 Cl-102 HCO3-25 AnGap-14
[**2199-8-26**] 12:50PM BLOOD Fibrino-471*
[**2199-8-26**] 12:50PM BLOOD PT-12.2 PTT-23.8 INR(PT)-1.0
[**2199-8-26**] 12:50PM BLOOD WBC-4.1 RBC-4.26* Hgb-13.0* Hct-39.3*
MCV-92 MCH-30.5 MCHC-33.1 RDW-13.2 Plt Ct-206
[**2199-8-26**] 12:50PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-4* pH-6.5 Leuks-NEG
CT head: neg.
CT C-spine: osseous defect anterior aspect R. foramen
transversarium at C7 level.
CT Torso w/ recons: neg.
MR [**Name13 (STitle) **]: no extrinsic cord compression seen at any level
MR [**Name13 (STitle) 2853**]: neg.
MR [**Name13 (STitle) **]: Annular bulge of the disc at L5-S1 level.
CXR: no traumatic injury
Brief Hospital Course:
Neuro: Patient was admitted with apparent loss of sensory and
motor function below level of T10. During hospitalization he
regained ability to walk without help, but still c/o some lower
extremity sensory loss. Imaging of the C,T,L and S spine was
normal. MRI of the spinal cord did not reveal any lesions. CT
of the head was normal.
GU: Patient was re-started on flagyl for a sexually transmitted
illness (presumed bacterial vaginosis); he was started on
bactrim for UTI.
Heme: Pt received sq heparin while in hospital for DVT
prophylaxis.
Pschy: given some discrepancies on motor exam, psychiatry was
consulted regarding the potential for a conversion disorder. A
conclusive diagnosis could not be made, however reassurance was
provided to the patient regarding expectations for a full
recovery, in accordance with psychiatry service's
recommendations.
Medications on Admission:
Flagyl
Discharge Medications:
1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain/fever.
Discharge Disposition:
Home
Discharge Diagnosis:
1) s/p fall trauma
2) UTI
Discharge Condition:
stable, able to walk and with normal sensation
Discharge Instructions:
You were admitted to [**Hospital1 18**] on [**2199-8-26**] after a fall.
Initially, you had limited sensation and motor function of your
lower extremities. Over the course of your hospitalization,
your strength and sensation in your lower extremities returned
to normal levels. Imaging of the bones of your neck and back,
your spinal cord, your brain and your abdomen were normal.
headache, vision changes, back pain, decreased mutor function of
your lower extremities, difficulty breathing, chest pain,
nausea/vomiting, fever/chills, or any other symptoms that are
concerning to you.
You should take all medications as prescribed; you should not
drink alcoholic beverages while taking Flagyl (metronidazole)
because of a reaction that causes severe nausea and vomiting.
Followup Instructions:
You should contact your primary care physician and inform
him/her of your hospitalization.
Completed by:[**2199-8-29**]
|
[
"724.2",
"E881.0",
"300.11",
"302.50",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3574, 3580
|
2272, 3133
|
345, 352
|
3650, 3699
|
1383, 1922
|
4521, 4643
|
779, 809
|
3190, 3551
|
3601, 3629
|
3159, 3167
|
3723, 4498
|
824, 1364
|
276, 307
|
380, 594
|
1931, 2249
|
616, 664
|
680, 763
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,287
| 120,681
|
36084
|
Discharge summary
|
report
|
Admission Date: [**2195-12-24**] Discharge Date: [**2195-12-30**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
hypoxia, SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **] y/o F with PMHx of COPD on home O2 (baseline 90% on 2LNC),
Afib and Diastolic CHF who was noted to at nursing home resident
who was found today at NH SOB and desat 84% on 4LNC. She was
transferred to [**Hospital1 18**].
.
In the ED, initial vs were: T 100.5 P 98 BP 137/78 R28 80%RA,
92% NRB. Patient was given Ceftriaxone, Azithro, Solumedrol 125
IV X1, and nebs in ED. She was started on nasal bipap with sats
in 95%
.
On arrival to ICUs she is c/o mild non-productive cough, but
denies pain, fever, chills, chest discomfort, palpitatiosn,
muscle aches.
Past Medical History:
Diastolic Heart Failure
Atrial Fibrillation on coumadin
Remote h/o TIAs
COPD on home O2 (2L at baseline)
Scoliosis
Osteoarthritis
L hip/R pelvis fx managed nonoperatively
Recent LLE cellulitis
Social History:
Was coming from [**Hospital 100**] Rehab MACU. Normally ambulates with
walker. A&OX3 and functional at baseline. On oxygen 2L. Past
smoker, quit >30years ago. No etoh or illicits. Son/daughter are
nearby and involved. DNR/DNI.
Family History:
+HTN, DM. overall non contributory to currently illness and
given her age.
Physical Exam:
PE on admission:
Vitals: T: 98.7 BP: 147/84 P: 89 R: 95%bipap O2:
General: Alert, oriented to person, tremulous, tolerating nasal
mask
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: ronchi throughout with some scarce wheeses L>R, no
crackles
CV: irregular, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2195-12-24**] 11:30AM BLOOD WBC-6.4 RBC-3.79* Hgb-12.2 Hct-37.2
MCV-98 MCH-32.1* MCHC-32.8 RDW-14.4 Plt Ct-230
[**2195-12-25**] 05:20PM BLOOD WBC-2.7* RBC-3.33* Hgb-10.5* Hct-31.9*
MCV-96 MCH-31.5 MCHC-32.9 RDW-14.6 Plt Ct-190
[**2195-12-28**] 03:30AM BLOOD WBC-4.8 RBC-3.33* Hgb-10.3* Hct-32.1*
MCV-96 MCH-30.9 MCHC-32.1 RDW-14.2 Plt Ct-194
[**2195-12-30**] 04:12AM BLOOD WBC-7.0# RBC-3.63* Hgb-11.6* Hct-33.6*
MCV-93 MCH-31.8 MCHC-34.4 RDW-14.3 Plt Ct-189
[**2195-12-24**] 11:30AM BLOOD Glucose-112* UreaN-24* Creat-1.2* Na-143
K-3.7 Cl-99 HCO3-33* AnGap-15
[**2195-12-26**] 04:00AM BLOOD Glucose-149* UreaN-37* Creat-1.2* Na-145
K-4.6 Cl-105 HCO3-33* AnGap-12
[**2195-12-27**] 03:57PM BLOOD Glucose-173* UreaN-49* Creat-1.4* Na-146*
K-4.6 Cl-101 HCO3-42* AnGap-8
[**2195-12-29**] 04:29PM BLOOD Glucose-245* UreaN-30* Creat-1.0 Na-136
K-3.8 Cl-82* HCO3-44* AnGap-14
[**2195-12-30**] 06:12AM BLOOD K-3.7
[**2195-12-25**] 06:33AM BLOOD proBNP-5511*
[**2195-12-25**] 03:25AM BLOOD Calcium-8.4 Phos-4.6* Mg-2.0
[**2195-12-27**] 03:57PM BLOOD Calcium-9.2 Phos-3.2 Mg-2.2
[**2195-12-30**] 04:12AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.2
[**2195-12-24**] 11:30AM BLOOD Digoxin-0.3*
[**2195-12-24**] 07:12PM BLOOD Type-ART pO2-139* pCO2-70* pH-7.21*
calTCO2-30 Base XS--1
[**2195-12-25**] 11:01AM BLOOD Type-ART pO2-60* pCO2-65* pH-7.29*
calTCO2-33* Base XS-2
[**2195-12-26**] 01:33PM BLOOD Type-[**Last Name (un) **] pO2-163* pCO2-86* pH-7.23*
calTCO2-38* Base XS-5 Comment-GREEN TOP
[**2195-12-28**] 03:42AM BLOOD Type-[**Last Name (un) **] Temp-36.5 Rates-/28 FiO2-40
pO2-52* pCO2-83* pH-7.32* calTCO2-45* Base XS-12 Intubat-NOT
INTUBA Vent-SPONTANEOU
[**2195-12-27**] 07:40PM BLOOD Lactate-2.6*
[**2195-12-28**] 03:42AM BLOOD Lactate-1.8
Imaging:
FINDINGS: A small right pleural effusion is seen which has
decreased in size since the prior study. Patchy opacities at the
right lung base are likely atelectasis, although infection
cannot be excluded. Linear density near the left lung base is
likely atelectasis. No other areas of focal consolidation are
noted. There is no pulmonary edema. The cardiomediastinal
silhouette is difficult to assess due to severe scoliosis;
however, cardiomegaly is stable and the mediastinal silhouette
is unchanged. There is calcification of the aorta. Visualized
osseous structures appear intact.
IMPRESSION: Decrease in size of small right pleural effusion.
Most likely
atelectasis in the right lower lobe, although infection cannot
be excluded. Stable cardiomegaly.
Brief Hospital Course:
[**Age over 90 **] y/o F with PMHx of COPD on home O2, Diastolic CHF who
presents with sob and hypoxia likely due to copd exacerbation
unable to wean from bipap.
The big picture is that she has multifactorial severe resp
failure including:
- Severe COPD
- Chronic diastolic heart failure, PH from that as well as cor
pulmonale, afib
- Restrictive ventilatory defect from severe kyphoscoliosis,
large hiatal hernia, pleural effusions, which also contributes
to atelectasis
She has not had a robust response to medical therapy. I am
concerned that though she is critically ill with high oxygen
requirement, this is probably her baseline and she may not
improve to the point of requiring less supplemental O2.
.
# Hypoxia: likely secondary to COPD exaccerbation with or
without an underlying pneumonia. Treated for COPD exaccerbation
with steroids and azithromycin. Also started on ceftriaxone for
? CAP and vanco for ? HAP considering she was a nursing home
resident. The first two days of her hospitalization she
required intermittent bipap treatment to maintain O2 sats with
goal btw 88-92. Then she started to maintain good O2
saturations in the above mentioned goal on 60% face mask, which
is the amount of oxygen she was wearing in rehab before
readmission. She was mentating well and not complaining of SOB
with this mask. She was switched to levofloxacin after the
first doses of antibiotics mentioned above, and treated with a
course of this which was stopped on [**12-29**]. She completed a course
of azithromycin. Initially for steroids she was on IV 125 mg
solumedrol, then switched to 40 mg IV bid dosing and then
transitioned to PO 40 steroids. And we recommend 3 more days of
prednisone 40 mg daily, then 2 days of 20 mg daily, then 2 days
of 10 mg daily, then 2 days of 5 mg daily, then stopping.
.
# Diastolic Heart Failure: continued toprol at home dose
initially. Diuresed over the course of her hospitalization and
then started to appear clinically dry and develop a contraction
alkalosis. We are continuing to hold her lasix and
acetazolamide. It should be restarted based on her clinical
fluid status and resolution of her alkalosis.
.
# Atrial Fibrillation: was rate controlled and anticoagulated
with coumadin. Went into afib with RVR during hospitalization
on [**12-27**]. Control with PO and IV metoprolol failed and Dilt gtt
was started. She was weaned off the diltiazem gtt on [**12-29**] and
transitioned to PO diltiazem of 30 mg qid. Her dose was
increased to 60 mg qid with good control and rates in the
80s-90s. We did not restart her metoprolol. It could be
restarted as needed for rate control.
.
# ARF: had increase in her creatinine to 1.4, likey due to
dehydration from over diuresis. With holding of her diuretics,
it returned to her baseline around 1.0 or 0.9. She made
appropriate urine throughout her hospitalization.
.
# FEN: repleted electrolytes prn
.
# Prophylaxis: Subcutaneous heparin
.
# Access: PIVs
.
# Code: DNR/DNI
.
# Communication: Patient
daughter: [**Name (NI) **] [**Numeric Identifier 81859**]; [**Last Name (un) **]
[**Telephone/Fax (5) 81860**]
Medications on Admission:
Albuterol Sulfate q4hrs
Ascorbic Acid 500 mg [**Hospital1 **]
Buspirone 10 mg qdinner
Multivitamin daily
Docusate Sodium 100 mg prn
Omeprazole 20 mg daily
Lorazepam 0.5 mg qam
Citalopram 40 mg daily
Ipratropium Bromide q4hr
Furosemide 120 mg [**Hospital1 **]
CALCIUM 500+D 500 [**Hospital1 **]
Digoxin 125 mcg Tablet [**11-27**] tablet per day
Warfarin 2 mg daily
Metoprolol Succinate 50 mg daily
acetazolamide 250 mg [**Hospital1 **]
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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Buspirone 10 mg Tablet Sig: One (1) Tablet PO DINNER
(Dinner).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
8. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment
Inhalation Q6H (every 6 hours).
12. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
13. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
14. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 3 days: The complete taper with prednisone 20 mg for 2 days,
then 10 mg for 2 days, then 5 mg for 2 days, then stop.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnosis:
1. COPD exaccerbation
2. Atrial fibrillation with rapid ventricular response
3. Diastolic heart failure
Secondary Diagnosis:
1. Hx of TIAs
2. Scoliosis
Discharge Condition:
frail, afebrile, on 60% face mask high flow O2
Discharge Instructions:
You were admitted to the hospital for having low oxygen levels
at your [**Hospital1 **] center. You came to the ICU and we
treated you with antibiotics, steroids and extra oxygen. The
reason for your SOB and low oxygen level was likely an
exaccerbation of your COPD.
You will return to [**Hospital1 **] where they will continue to
use high flow oxygen to help you breath. You will also be able
to do more physical therapy while there.
If you start feeling more SOB, the rehab staff starts noticing
fevers, chills, confusion or any other concerns, you should
return to the hospital.
Followup Instructions:
Please continue care with the doctors [**First Name (Titles) **] [**Last Name (Titles) **]
[**Name5 (PTitle) **].
Follow up with your PCP as needed after rehab.
Completed by:[**2195-12-30**]
|
[
"V46.2",
"428.0",
"276.3",
"427.31",
"V58.61",
"518.81",
"584.9",
"428.40",
"491.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
9433, 9512
|
4527, 7660
|
284, 291
|
9733, 9782
|
2004, 4504
|
10417, 10611
|
1377, 1453
|
8146, 9410
|
9533, 9533
|
7686, 8123
|
9806, 10394
|
1468, 1471
|
232, 246
|
319, 898
|
9681, 9712
|
9552, 9660
|
1485, 1985
|
920, 1115
|
1131, 1361
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,333
| 134,061
|
8230
|
Discharge summary
|
report
|
Admission Date: [**2144-5-6**] Discharge Date: [**2144-5-12**]
Date of Birth: [**2096-7-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Zyban
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Stage IIIB (T4) carcinoma of the
right lung.
Major Surgical or Invasive Procedure:
s/p median sternotomy for mediastinal mass w/ gortex to SVC.
History of Present Illness:
Mr. [**Known lastname 8878**] is a 48-year-old gentleman with
biopsy-proven T4 carcinoma of the right upper lobe presenting
a superior vena caval syndrome. He received induction
chemoradiotherapy with an excellent response and no evidence
for distant disease. He had adequate functional reserve, and
given his youth and good performance status, an
aggressive approach to resect the disease and reconstruct his
central veins was planned for this admission.
Past Medical History:
-Stage IIIB (T4) NSCLCA
-s/p RUL lobectomy en bloc w/ SVC and brachiocephalic veins
resection and [**Doctor Last Name 4726**]-tex reconstruction of SVC and brachiocephalic
veins [**2144-5-6**]
-s/p radiation and chemotherapy
Social History:
History of 1ppd tobacco use. Patient lives with his partner in
[**Location (un) 538**]. He works for a company that sells scientific
research equipment.
Family History:
Notable for extensive CAD in multiple relatives in their 50's,
including his father, who had an MI at age 52.
Physical Exam:
General: well appearing anxious man in NAD
HEENT: notable for facial swelling consistant w/ SVC syndrome.
Chest: CTA bilat
COR: RRR S1,S2. Slightly distant heart sounds.
Abd: soft, round, NT, ND, +BS
Extrem: no LE C/C/E
neuro: intact
Pertinent Results:
[**2144-5-10**] CXR
A single AP view of the chest is obtained [**2144-5-10**] at
approximately 13:15 hours following the removal of a right sided
pleural tube. The right sided hydropneumothorax is not
significantly changed since the prior examination. Minimal left
costophrenic angle blunting may represent fibrosis or a small
left pleural effusion. Evidence of surgery in the right upper
lobe.
IMPRESSION:
Stable appearances of the chest following chest tube removal.
[**2144-5-8**] Chest CT: IMPRESSION:
1. No large fluid collection to explain hematocrit drop
identified. Expected area of dense atelectasis and probable
hematoma noted within the surgical bed.
2. Pneumomediastinum and right-sided hydropneumothorax with
small air component. Chest tube/drains appear appropriately
positioned.
3. Surgical chain sutures and vascular grafts/stents from recent
right upper segmental resection and SVC reconstruction.
4. Consolidation noted within the medial right lower lobe may
represent atelectasis or early aspiration pneumonitis. This may
be followed up on subsequent imaging.
5. Stable left back sebaceous cyst.
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2144-5-11**] 07:30AM 7.3 3.05* 9.0* 27.3* 89 29.6 33.2 14.7
231
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2144-5-11**] 07:30AM 231
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2144-5-11**] 07:30AM 103 9 0.7 136 4.2 101 26 13
Brief Hospital Course:
Pt was admitted and taken to the OR for Bronchoscopy, Median
sternotomy, Right upper lobectomy en bloc with superior vena
cava and right and left brachiocephalic veins. Mediastinal
lymphadenectomy. [**Doctor Last Name 4726**]-Tex reconstruction of superior vena cava
in both brachiocephalic veins. Pt's post op course was
unremarkable. A right apical and basilar chest tube were placed
in the OR and were removed on POD 2 and 3 respectively. He
progressed well post operatively-pain was well controlled on PCA
then transitioned to po pain med. reg diet, and was ambulating
indep on roomair. He was d/c'd to home on POD#6.
Medications on Admission:
none
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*75 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
s/p median sternotomy for mediastinal mass w/ gortex to SVC.
Discharge Condition:
good
Discharge Instructions:
call Dr.[**Name (NI) **] office [**Telephone/Fax (1) 170**] if you develop fever,
chills, chest pain, shortness of breath, redness or drainage
from your incision site.
Followup Instructions:
Call Dr.[**Doctor Last Name 4738**] [**Telephone/Fax (1) 170**] office for a follow up
appointment
Completed by:[**2144-5-20**]
|
[
"198.89",
"196.1",
"197.2",
"162.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.3",
"33.22",
"38.45",
"99.04",
"32.4"
] |
icd9pcs
|
[
[
[]
]
] |
4198, 4255
|
3154, 3778
|
316, 379
|
4360, 4367
|
1679, 3131
|
4583, 4713
|
1299, 1410
|
3833, 4175
|
4276, 4339
|
3804, 3810
|
4391, 4560
|
1425, 1660
|
231, 278
|
407, 864
|
886, 1112
|
1128, 1283
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,996
| 114,140
|
8529
|
Discharge summary
|
report
|
Admission Date: [**2159-9-13**] Discharge Date: [**2159-9-22**]
Date of Birth: [**2096-1-23**] Sex: M
Service: MEDICINE
Allergies:
Vicodin / Oxycodone
Attending:[**First Name3 (LF) 6378**]
Chief Complaint:
MSSA bacteremia
Major Surgical or Invasive Procedure:
Transesophageal echocardiogram
IV antibiotics
History of Present Illness:
63 y/oM with PMH of eczema p/w fevers, back pain and MSSA
bacteremia.
.
Symptoms started on Sunday with low back pain and subjectives
fevers/ chills after lifting heavy furniture. Pain
progressively worsened throughout the night, prompting the
patient to go to OSH ED the following day. Evaluated there with
baseline labs, CT abdoman/ pelvis, CXR, urinalysis and blood cx
which showed hematuria and mild leukocytosis to 13. The patient
was diagnosed with lumbar strain and d/ced home with ibuprofen
and vicodin for pain control.
.
The following day, the OSH called patient with blood cx growing
BPC in clusters. Evaluated later that day by PCP who drew
repeat blood work prior to starting antibiotics. On Wednesday
evening, patient noted an erythematous itching rash that spared
his palms and soles. he called the doctor on call who though
that this could be an allergic reaction to the vicodin and
recommended discontinuation. The patient also noted that the
back pain had moved to his shoulders and neck. This morning,
PCP called patient and referred him to the ED as repeat blood cx
grew GPC in clusters.
.
On presentation to [**Hospital1 18**], initial VS:99.1 94 114/70 18 99.
Blood pressure fluctated slightly through ED course, dropping as
low as 80/50 but rising appropriately with IVF (in total
received 3L NS). Initial labs notable for WBC count of 6.4 with
30% bandemia and ARF with creatinine of 2.0 from baseline of
0.9. Blood cultures, urinalysis and CXR taken prior to giving
dose of vancomycin and zosyn. There was some concern that pt
maybe developping anaphylaxis due to rash and relative
hypotension, also given dose of benadryl and solumedrol. Given
concern for epidural abscess, ortho spine was consulted and
recommended MRI spine despite reassuring neurologic exam. Given
concern for possible development of severe sepsis, patient was
admitted to the MIU for fluid resuscitation and IV Abx prior to
further diagnostic evaluation.
.
ROS:
pertinent (+): per HPI
pertinent (-): denies weight change, shortness of breath/ cough,
abdominal discomfort, change in bowel movements, peripheral
edema or any other complaints
Past Medical History:
- eczema
- cellulitis x 2
- severe scoliosis
Social History:
Works at a law firm, currently undergoing a divorce. Denies any
tobacco use, social ETOH use.
Family History:
Father with MI at age 50 s/p PCI. HTN, hyperlipidemia in family,
no CA.
Mother: deceased from rare retro-ocular cancer
Physical Exam:
Physical Exam:
VS: Temp: 100.6 BP:129/81 HR: 88 RR: 23 O2sat 98% RA
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions
NECK: JVP @ 15cm with hepatojugular reflex, no palpable LAD.
Stiff neck with limited ROM due to pain, Negative kernig/
negative burdinski
RESP: crackles left base
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, mild RUQ tenderness to palpation
EXT: no c/c/e, warm/ well-perfused. No spinal tenderness to
palpation
SKIN: erythematous blanching plaques over forearm, trunck and LE
sparing palms and soles
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps
RECTAL: per ED exam + rectal tone
.
Physical Exam on day of discharge:
Vitals: tc 98.4, tm 99.4 119/73 (110-119/60-73) 63 (63-778) 18
97% RA
GEN: a/ox3, NAD much more comfortable appearing, working on
laptop in bed
HEENT: oropharynx clear, PERRL, EOMI. collar off
Lung: CTAB no w/c/r
RRR: RRR but no m/r/g
Abd: soft NT +BS
Ext: no c/c/e no LE edema
Skin: rash same no extention, seems to be improved form
admission less red
Neuro: non-focal, pt alert and oriented able to answer all
questions appropirately and relay history; upper ext strength
intact
Pertinent Results:
Admission labs:
[**2159-9-12**] 12:05PM BLOOD WBC-8.9# RBC-4.42* Hgb-13.6* Hct-41.7
MCV-94 MCH-30.9 MCHC-32.7 RDW-13.0 Plt Ct-146*
[**2159-9-12**] 12:05PM BLOOD Neuts-87* Bands-6* Lymphs-0 Monos-7 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2159-9-13**] 06:50PM BLOOD PT-13.0 PTT-26.5 INR(PT)-1.1
[**2159-9-12**] 12:05PM BLOOD ESR-37*
[**2159-9-13**] 06:50PM BLOOD Glucose-122* UreaN-22* Creat-2.0*# Na-133
K-3.7 Cl-97 HCO3-25 AnGap-15
[**2159-9-13**] 06:50PM BLOOD ALT-42* AST-45* CK(CPK)-97 AlkPhos-68
[**2159-9-13**] 06:50PM BLOOD Calcium-8.7 Phos-2.8 Mg-2.0
[**2159-9-12**] 12:05PM BLOOD %HbA1c-5.4 eAG-108
[**2159-9-12**] 12:05PM BLOOD Triglyc-82 HDL-64 CHOL/HD-2.5 LDLcalc-79
[**2159-9-12**] 12:05PM BLOOD PSA-2.6
[**2159-9-13**] 08:40PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2159-9-13**] 08:40PM URINE Blood-MOD Nitrite-NEG Protein-75
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2159-9-13**] 08:40PM URINE RBC-[**1-19**]* WBC-0-2 Bacteri-RARE Yeast-NONE
Epi-0-2
[**2159-9-14**] 02:42AM URINE Hours-RANDOM Creat-28 Na-22 K-16 Cl-34
MICRO:
[**9-12**] UCx: negative
[**2159-9-12**] 12:05 pm BLOOD CULTURE
**FINAL REPORT [**2159-9-15**]**
Blood Culture, Routine (Final [**2159-9-15**]):
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
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.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Anaerobic Bottle Gram Stain (Final [**2159-9-13**]):
REPORTED BY PHONE TO DR. [**Last Name (STitle) **] @ 0815A, [**2159-9-13**].
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Aerobic Bottle Gram Stain (Final [**2159-9-13**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
.
Blood cultures remained positive through [**2159-9-17**]. Blood
cultures after [**2159-9-17**] show no growth to date.
.
STUDIES:
[**9-13**] CXR: Right base atelectasis with no definite pneumonia
identified.
Severe scoliosis as above.
[**9-14**] TTE: no vegetations seen
[**9-14**] MRI C/T/L spine: 1. Abnormal signal in the retropharyngeal
space, concerning for edema or phlegmon. No drainable fluid
collection identified.
2. Multilevel degenerative changes, most severe at C5-C6 with
severe canal narrowing and probable abnormal cord signal
identified due to chronic compression.
.
Portable TTE (Complete) Done [**2159-9-14**] at 12:46:57 PM
FINAL
Conclusions
The left atrium is elongated. The estimated right atrial
pressure is 10-20mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
65%). Right ventricular chamber size and free wall motion are
normal. The aortic root is mildly dilated at the sinus level.
The aortic arch is mildly dilated. 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 appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
No mass or vegetation is seen on the mitral valve. There is
moderate pulmonary artery systolic hypertension. No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
IMPRESSION: no vegetations seen
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
.
TEE (Complete) Done [**2159-9-18**] at 3:34:50 PM FINAL
Conclusions
No atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. No masses or vegetations are seen on the
aortic valve. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. No mass or vegetation is seen on the mitral
valve. No mitral regurgitation is seen. There is no pericardial
effusion.
IMPRESSION: No vegetations found.
.
MR of SPINE W &W/O CONTRAST Study Date of [**2159-9-14**] 11:01 AM
FINDINGS:
CERVICAL SPINE: There is T2 hyperintensity in the
retropharyngeal space
anterior to C3-C6 (5, 10), which is T1 hypointense and
demonstrates
enhancement on post-contrast imaging. These findings are
concerning for
either retropharyngeal edema or phlegmon. No drainable fluid
collection is
identified.
Multilevel degenerative changes of the cervical spine are noted
and most
severe at C3 through C6.
At C3-C4, there is uncovertebral hypertrophy, posterior disc
osteophyte
complex and moderate canal narrowing with probable bilateral
neural foraminal narrowing.
At C4-C5, there is a posterior disc osteophyte complex,
uncovertebral
hypertrophy and severe canal narrowing.
At C5-C6, there is posterior disc osteophyte complex,
uncovertebral
hypertrophy with severe canal narrowing and decrease in the CSF
signal. There is question of abnormal cord signal, posterior
C5-C6, seen on STIR imaging which could represent chronic
myelomalacia(11, 9).
THORACIC SPINE: There is marked kyphoscoliosis with chronic
compression
deformities of multiple thoracic vertebral bodies. Incidental
note is made of a probable hemangioma at T10. There is no
evidence of abnormal enhancement or STIR signal suggestive of
infection in the thoracic spine.
LUMBAR SPINE: Multilevel degenerative changes in the lumbar
spine including multilevel disc bulging, facet arthropathy and
ligamentum flavum hypertrophy.
IMPRESSION:
1. Abnormal signal in the retropharyngeal space, concerning for
edema or
phlegmon. No drainable fluid collection identified.
2. Multilevel degenerative changes, most severe at C5-C6 with
severe canal
narrowing and probable abnormal cord signal identified due to
chronic
compression.
.
CT PELVIS W/CONTRAST Study Date of [**2159-9-19**] 6:29 PM
CT OF THE TORSO WITH IV CONTRAST TECHNIQUE: Multidetector
scanning is
performed from the thoracic inlet through the symphysis during
dynamic
injection of 130 cc of Optiray.
CT OF THE CHEST WITH IV CONTRAST: There is no axillary,
mediastinal or hilar lymphadenopathy. There are moderate
bilateral pleural effusions. There is an area of ground-glass
opacity in the right upper lobe measuring 2.8 x 1.3 cm. There is
atelectasis in the lower lobes bilaterally.
CT OF THE ABDOMEN WITH IV CONTRAST: A subcentimeter hypodense
lesion is seen in the dome of the liver as well as in segment
VIII. A third lesion is seen in segment VI and segment IVb.
These are too small to characterize but likely represent cysts
or hemangiomas. The gallbladder is unremarkable. In the spleen,
there is a punctate calcification. The pancreas, adrenal glands
and both kidneys are unremarkable. There is no retroperitoneal
lymphadenopathy.
CT OF THE PELVIS WITH IV CONTRAST: The small and large bowel are
normal.
There is no free fluid in the pelvis. No pelvic lymphadenopathy
is
identified.
On bone windows, there are no concerning osteolytic or
osteosclerotic lesions.
IMPRESSION:
1. Ground-glass opacity in the right upper lobe is concerning
for infection.
Followup to resolution is recommended to exclude underlying
malignancy.
2. Moderate bilateral pleural effusions and bilateral
atelectasis.
3. Subcentimeter hypodense lesions in the liver are too small to
characterize but likely represent cysts or hemangiomas.
.
MRI SOFT TISSUE NECK, W/O & W/CONTRAST Study Date of [**2159-9-19**]
8:29 PM
FINDINGS:
The study is limited with inadequate fat suppression.
There is enhancement in the end plate and anterior aspect of
intervertebral disc at C5-6 with further abnormal enhacement in
the prevertebral and epidural space extending to one vertebral
level below C6.
There is a slither of prevertebral fluid in the retropharyngeal
space, as seen on the recent MRI, less than 2 mm in depth
spanning from C3 to C5 vertebral levels. There is no abnormal
enhancement to suggest collection or mass. Small volume
posterior cervical nodes are demonstrated. There is no soft
tissue asymmetry in the neck. Maxillary mucous retention cyst is
seen on the right.
Bilateral large pleural effusions, larger on the right, is
demonstrated.
IMPRESSION:
Study is limited by motion. Subtle end plate and epidural
enhancement
suspicious for diskitis. No evidence of drainable collection in
the neck. A slither of prevertebral fluid as seen on the
previous MRI.
Bilateral pleural effusions larger on the right
.
BILAT UP EXT VEINS US Study Date of [**2159-9-21**] 9:53 AM
BILATERAL UPPER EXTREMITY ULTRASOUND: [**Doctor Last Name **] scale, color, and
Doppler
ultrasound was used to evaluate the bilateral internal jugular,
subclavian, axillary, brachial, basilic and cephalic veins.
There is normal compressibility (where applicable), flow and
augmentation throughout.
IMPRESSION: No DVT of either upper extremity
.
Brief Hospital Course:
63 y/oM with PMH of eczema p/w fevers, back pain and MSSA
bacteremia.
.
1. MSSA bacteremia: pt p/w fevers, bandemia and hypotension
responsive to fluids. No obvious etiology on exam and CXR, U/A
was unrevealing. Although complaints of back pain were
concerning for possible epidural abscess, the patient was
neurologically intact. MRI showed retropharyngeal edema/question
of a phlegmon, other than degenerative changes. Neurosurgery
recommended wearing cervical collar at all times until the
patient can follow up in their clinic in eight weeks. Blood
cultures grew out MSSA, for which the patient had already been
started on nafcillin. TTE was negative for vegetations. TEE was
performed which was also negativel for vegitation. However, pt
continued to have positive blood cultures and fever so decision
was made to repeat the neck MRI and CT scan the pt's torso to
determine if there was an alternative site of infection or if
there had been coalescing of the possible phlegmon in the
retropharyngeal space; these studies were negative. The pt also
had repeated episodes of phebitis so US of upper extremety was
performed which was negative. Blood cultures remained positive
through [**9-17**]; blood cultures taken after [**9-17**] have shown no
growth to date. As no other source could be identified and the
pt was clinically improved in terms of pain and fever, the pt
was discharged home on IV nafcillin to complete a 6 week course
ending on [**2159-10-26**]. Close follow-up was planned with the pt's
PCP, [**Name10 (NameIs) **] and Neurosurgery.
.
2. ARF: creatinine was elevated to 2.0 from baseline of 0.9,
most likely from dehydration in setting infection, possibly
exacerbated by ibuprofen use for pain. The creatinine trended
downwards with IV fluid administration and ARF resolved.
.
3. Rash: present with erythematous itching rash presumed to be
secondary to allergic reaction to vicodin s/p methylprednisolone
in the ED. If secondary to hives should have resolved and did
not seem to fit with drug eruption. Although an infectious rash
is possible with staph aureus, not typical of toxic shock
syndrome. The patient was given sarna lotion PRN. The rash
gradually showed improvement.
.
4. Back pain: the patient required regular doses of narcotic
analgesics and lidocaine patches to control his back pain. There
was concern for possible osteomyelitis or discitis but MRI
findings were described as above (also see report in results
section). Because of the possible allergic reaction to vicodin
and question of a similar reaction to oxycodone, pt was given PO
morphine. Pt was switched to long act MS contin w/morphine IR
for breakthrough pain.
.
5. Hypoxia: Patient was satting in low 90s on [**12-20**] liters by
nasal cannula. He had no respiratory complaints. He was given an
incentive spirometer for lung expansion, given findings of
atelectasis on CXR and his O2 sats improved.
.
Pt has ID, PCP and Neurosurgery [**Name9 (PRE) 702**] planned.
Code: Full
Medications on Admission:
CALTRATE PLUS - Tablet - ONE EVERY DAY
DEXAMETHASONE SODIUM PHOSPHATE - 4 mg/mL Solution - for
iontophoresis as needed
SILDENAFIL [VIAGRA] - 100 mg Tablet - [**11-18**] to 1 Tablet(s) by
mouth
as needed
(had been on ibuprofen and vicodin from OSH but had allergic
reaction)
Discharge Medications:
1. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1)
Intravenous Q4H (every 4 hours) for 6 weeks: Start date of
[**9-13**]; end date of [**10-26**] for a total course of 6 weeks.
Disp:*252 * Refills:*0*
2. Caltrate Plus 600-400 mg-unit Tablet Sig: One (1) Tablet PO
once a day.
3. dexamethasone sodium phosphate 4 mg/mL Solution Sig: One (1)
Injection prn as needed for for iontophoresis as needed .
4. sildenafil 100 mg Tablet Sig: 0.5-1 Tablet PO prn as needed
for erectile dysfunction.
5. ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): do not
wear for longer than 12 hrs at a time with 12hrs of patch free
time between each application.
Disp:*10 Adhesive Patch, Medicated(s)* Refills:*2*
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
9. morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
10. morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours) for 7 days.
Disp:*14 Tablet Sustained Release(s)* Refills:*0*
11. Outpatient Lab Work
Please have weekly CBC w/diff, LFTs and chem 7.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Therapies
Discharge Diagnosis:
Primary:
MSSA bacterimia
retropharyngeal edema or phelgmon
.
Secondary:
C5-C6 cervical stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital because you had severe back
and neck pain, fevers, and were found to have bacteria growing
in your blood. In addition, it appeared that you may have had an
allergic reaction to vicodin (you should avoid taking this in
the future as it may cause serious health consequences). You
were admitted to the ICU because your blood pressure was
unstable as a result of the infection as well as the allergic
reaction. You symptoms improved with supportive IV fluids and IV
antibiotics. Several studies were performed to try to identify
the source of your infection. One of these studies was an MRI of
your spine which showed an area of inflamation and possible
infection in your neck. We also performed several
echocardiograms, one placing the probe on your chest and one
placing the probe in your esophagus. The one performed by
placing the ultrasound probe on your chest appeared normals but
because you continued to have fevers for several days despite
antibiotics we also obtained the echocardiogram placing the
probe in your esophagus. This showed no evidence of
endocarditis. Initially, your blood cultures continued to remain
positive despite appropriate antibiotics which prompted us to
repeat several other imaging studies to look for other possible
sources. These studies did not show any new evidence of
infection. After several more days of antibiotics, your fevers
resolved with antibiotics and your blood cultures consistently
showed no growth.
.
We also managed your pain and your symptoms gradually improved.
You were discharged from the hospital to complete a six week
course of antibiotics. It will be very important for you to take
your antibiotics as prescribed. In addition, it will be very
important for you to keep all of your follow-up appointments
with your doctors to ensure full resolution of your infection.
.
The following changes were made to your medications:
- Please complete the full course of nafcillin 2gm IV every 4
hours for a total of 6 (six) weeks duration to be completed on
[**2159-10-26**].
- To help manage your pain, please continue taking Ibuprofen
400-600 mg PO every 6hrs for pain/inflamation as needed for
pain.
- To help manage your pain, please continue lidocaine 1 patch
daily (can keep on for up to 12hrs but must have a patch free
time of 12hrs between patches) as needed for pain.
- To help manage your pain, we've also prescribed long acting
Morphine SR (MS Contin) 30 mg PO every 12 hrs.
- If your pain is not controlled after taking iburprofen and MS
Contin, we have also provided you with Morphine Sulfate IR 15 mg
PO/NG Q4H as needed for SEVERE breakthrough pain not otherwise
controlled for with the above regimen. If your pain is not
controlled on this regimen and you are having frequent episodes
of uncontrolled pain, please go to your doctor immediately. We
have only provided you with sufficient pain medication until
your next primary care doctor appointment as your pain will need
to be reassessed and new prescriptions written to provide
appropriate pain managament.
- While you are taking morphine be sure to also take colace and
senna to prevent constipation.
- Please continue to take all of your other home medications as
prescribed.
Please be sure to take all medication as prescribed.
.
Please be sure to keep all follow-up appointments with your
Primary Care Doctor as well as Neurosurgery and Infectious
Disease.
.
You will need to have weekly labs to monitor your white blood
cell count as well as liver and kidney function while on
antibiotics. We have written prescriptions for these for you.
.
It was a pleasure taking care of you and we wish you a speedy
recovery.
Followup Instructions:
Please be sure to keep all follow-up appointments with your
Primary Care Doctor as well as Neurosurgery and Infectious
Disease
.
Department: INTERNAL MEDICINE
When: MONDAY [**2159-9-24**] at 1:30 PM
With: [**Last Name (NamePattern5) 6666**], MD, MPH [**Telephone/Fax (1) 4775**]
Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: MRI
When: TUESDAY [**2159-10-30**] at 12:10 PM
With: MRI [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Hospital 1422**]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: TUESDAY [**2159-10-30**] at 1:45 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
.
Department: INFECTIOUS DISEASE
When: THURSDAY [**2159-9-27**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10000**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: INFECTIOUS DISEASE
When: THURSDAY [**2159-10-25**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10000**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6384**] MD, [**MD Number(3) 6385**]
Completed by:[**2159-9-22**]
|
[
"038.11",
"995.91",
"518.0",
"799.02",
"458.9",
"693.0",
"478.24",
"692.9",
"723.0",
"276.51",
"737.30",
"584.9",
"E935.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.97",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
18543, 18612
|
13744, 16730
|
296, 344
|
18752, 18752
|
4161, 4161
|
22598, 24374
|
2720, 2840
|
17055, 18520
|
18633, 18731
|
16756, 17032
|
18903, 22575
|
2870, 4142
|
241, 258
|
372, 2524
|
4177, 13721
|
18767, 18879
|
2546, 2592
|
2608, 2704
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,373
| 149,123
|
35352
|
Discharge summary
|
report
|
Admission Date: [**2115-12-26**] Discharge Date: [**2115-12-31**]
Date of Birth: [**2051-6-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Peptostreptococcus bacteremia/Endocarditis/Aortic root
dilitation/abscess//CHB with Transvenous pacing wire in
place/ARF/fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 80594**] is a 64 year old man s/p a bioprosthetic aortic
valve replacement in [**12-29**] who presented to [**Hospital3 16025**] with fevers. He was observed and sent home. Upon growth
of gram positive cocci from his blood cultures, he was called
back to the hospital. Upon assessment he was found to be
hypotensive, bradycardic with a junctional rhythm, in ARF and
mottled. He was intubated, requiring pressors and Transvenous
pacing wire for hemodynamic augmentation.TEE showed vegetation
on TV, left atrial thrombus and aortic dilitation. After a
hospital course at Bay State to optimize Mr.[**Known lastname 80595**] status,
Mr.[**Known lastname 80594**] was transferred to [**Hospital3 **] Medical Center for
evaluation for surgical intervention for his aortic and
tricuspid valve endocarditis.
Past Medical History:
Aortic valve replacement [**12-29**] (AS)
Atrial Fibrillation
EtOH abuse with DTs
Cirrhosis- Childs B
Gastrointestinal bleed
Gastroesophageal reflux disease
Congenstive heart failure
Coronary artery disease
MSSA sputum [**11-28**]
Cerebral vascular accident
Social History:
Mr. [**Known lastname 80594**] [**Last Name (Titles) 80596**] 1 pint of vodka daily. He has a 20 pack
year smoking history.
Family History:
noncontributory
Physical Exam:
At the time of admission, Mr. [**Known lastname 80594**] was sedated and
intubated. His skin exam revealed a diffuse macular rash
covering his back, chest, arms, and legs with evidence of skin
sloughing on groin and arms. Stage II pressure ulcers are noted
on his coccyx, buttucks, and upper thighs including several
blisters. His upper back revealed several skin tears. An
x-Left subclavian line site was noted to be red and macerated
with serous drainage. His right toes were noted to be dusky and
include several areas of maceration and necrosis. Ausculatation
of his lungs revealed bilateral rhonchi which was coarse and
diffuse. His heart was of regular rate and rhythm with a III/VI
systolic ejection murmur. His bowels were distended but soft
with positive bowel sounds. His extremities were warm with 3+
edema. No varicosities were noted.
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 1955**] [**Hospital1 18**] [**Numeric Identifier 80597**]Portable TEE
(Complete) Done [**2115-12-27**] at 3:28:30 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2051-6-17**]
Age (years): 64 M Hgt (in): 71
BP (mm Hg): 108/62 Wgt (lb): 235
HR (bpm): 70 BSA (m2): 2.26 m2
Indication: Endocarditis. Bioprosthetic aortic valve disease.
Endocarditis. Left ventricular function. Mitral valve disease.
Prosthetic valve function.
ICD-9 Codes: 424.90, 428.0, 440.0, V43.3, 424.1, 424.0
Test Information
Date/Time: [**2115-12-27**] at 15:28 Interpret MD: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**],
MD
Test Type: Portable TEE (Complete) Son[**Name (NI) 930**]:
Doppler: Full Doppler and color Doppler Test Location: West
SICU/CTIC/VICU
Contrast: None Tech Quality: Adequate
Tape #: 2009W004-2:15 Machine: Vivid i-4
Sedation: Fentanyl: 75 mcg
(See comments below for other sedation.)
Patient was monitored by a nurse throughout the procedure
Echocardiographic Measurements
Results Measurements Normal Range
Findings
Patient was sedated with Propafol iv per CVICU intensivist.
Moderate size left pleural effusion was noted. Due to recent
diagnosis of antral mass and gastric bleed, the GE junction was
not crossed.
LEFT ATRIUM: Mild LA enlargement. Mild spontaneous echo contrast
in the body of the LA. Thrombus in the body of the LA. Definite
thrombus in the LAA. All four pulmonary veins not identified.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Depressed RAA ejection
velocity (<0.2m/s). No ASD by 2D or color Doppler.
LEFT VENTRICLE: Severely depressed LVEF.
AORTA: Complex (>4mm) atheroma in the descending thoracic aorta.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR).
Thickened AVR leaflets. Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Probable
vegetation on mitral valve. Mild to moderate ([**11-22**]+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Moderate vegetation on tricuspid valve. Moderate to severe [3+]
TR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. Local anesthesia was provided by
benzocaine topical spray. The patient was sedated for the TEE.
Medications and dosages are listed above (see Test Information
for the patient.
Conclusions
The left atrium is mildly dilated. There is mild spontaneous
echo contrast in the body of the left atrium. The LAA is
completely filled with thrombus that extends into the body of
the left with measuring 1.5x2.5 cm anteriorly and 2.1x2.0 cm
posteriorly. The right atrial appendage ejection velocity is
depressed (<0.2m/s) with a 1.2x1.3 cm non-mobile echodensity
consistent with a possible appendage thrombus (clip [**Clip Number (Radiology) **]). No
atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is severely depressed
[LVEF<30%]. There are complex (>4mm) non-mobile atheroma in the
descending thoracic aorta. A well-seated bioprosthetic aortic
valve is present with diffusely thickened leaflets, but without
discrete vegetation. The aortic wall appears thickened
(?abscess) with the "thickening" extending into the interatrial
septum. Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. A minimally mobile 0.5x0.8cm
echodensity is seen extending from the aortic prosthesis into
the left atrium (clip [**Clip Number (Radiology) **]) c/w possible vegetation. Mild to
moderate ([**11-22**]+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. A highly mobile, 1.1x1.6cm
echodensity is seen attached at the base of the septal leaflet
of the tricuspid valve c/w a vegetation. Moderate to severe
[[**12-24**]+] tricuspid regurgitation is seen.
IMPRESSION: Large thrombus in the left atrial appendage and
extending into the body of the left atrium. Possible right
atrial appendage thrombus. Moderate sized tricuspid valve
vegetation and possible mitral annular vegetation. Thickened
mitral leaflets with mild-moderate mitral regurgitation. Well
seated bioprosthetic aortic valve with thickened leaflets and
extensive thickening of the aortic root extending into the
interatrial septum c/w infection/abscess. Mild aortic
regurgitation. Complex non-mobile atheroma in the descending
aorta.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2115-12-27**] 20:08
[**2115-12-30**] 02:28AM BLOOD WBC-7.1 RBC-3.05* Hgb-9.6* Hct-28.5*
MCV-93 MCH-31.4 MCHC-33.6 RDW-16.9* Plt Ct-172
[**2115-12-30**] 02:28AM BLOOD Glucose-154* UreaN-28* Creat-1.1 Na-132*
K-4.1 Cl-102 HCO3-23 AnGap-11
[**2115-12-30**] 02:28AM BLOOD ALT-34 AST-68* LD(LDH)-409* AlkPhos-226*
TotBili-1.0
Brief Hospital Course:
Mr. [**Known lastname 80594**] is a 64 year old man who was transferred to [**Hospital1 18**]
for evaluation for surgical intervention of his aortic and
tricuspid valve endocarditis. Dur to the multiple complexities
of Mr.[**Known lastname 80595**] medical problems, multiple medical services
were consulted for evaluation and recommendations. He was seen
in consultation by the hepatology service given his significant
history of alcohol use and it was felt that he has Childs class
B hepatic cirrhosis. Electophysiology consulted regarding his
transvenous pacing wire with a screw-in pacing lead. EP
recommmended maintaining the current lead and treating him
medically.Dermatology and the wound care service made various
recommendations regarding his necrotic lower extremity digits,
erythematous rash, and multiple skin injuriesh. Zosyn was the
suspected culprit behind the rash and was subsequently
discontinued. Please see treatments and frequency for details of
skin recommendations. The dentist saw him, noted that he had
recent extractions which are healing, and felt he had no active
infections. A carotid ultrasound was completed and he was found
to have no significant stenosis.The infectious disease service
evaluated him and recommended placing him [**Last Name (un) 7245**] on Vancomycin.
Given the bleeding risk of cardiac surgery in a patient with
Childs class B cirrhosis along with Mr. [**Known lastname 80595**] multiple
complex medical issues, his family was approached with the
recommendation not to proceed with this very high risk surgery.
On hospital day #2 Mr.[**Known lastname 80594**] had a run of non-sustained VTach
with unstable hemodynamics. Inotropic drips were weaned to
minimum support. Electrolytes repletion was vigilently
maintained thereafter with resolution of ectopy.No further
intervention was required.HD# 4 Mr.[**Known lastname 80594**] was successfully
extubated. Due to altered mental status, his diet is slowly
being advanced. On hospital day #5 his family was in agreement
and discussed with Dr.[**Last Name (STitle) 914**] their desire to transfer
Mr.[**Known lastname 80594**] back to [**Hospital6 16029**] for medical
treatment.
Medications on Admission:
Vancomycin 1gm daily
Heparin 5000 units SQ TID
Ativan 2 mg Q8hrs
MVI
Quetiapine 25mg daily
Nexium
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID
(3 times a day).
5. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
7. Dobutamine in D5W 1,000 mcg/mL Parenteral Solution Sig: One
(1) Intravenous INFUSION (continuous infusion). Currently at
4mcg/kg/min
8. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
9. Pantoprazole 40 mg IV Q12H
10. Lorazepam 1 mg IV Q8H:PRN
and notify MD
11. Magnesium Sulfate 2 gm IV PRN mg < 2
12. Calcium Gluconate 2 gm / 100 ml D5W IV PRN ICA < 1.12
13. Potassium Chloride 20 mEq / 50 ml SW IV PRN K < 4.0
14. Vancomycin 1000 mg IV Q 12H ***Please see ID recommendations
check trough prior to 4th dose
15. Thiamine 100 mg IV DAILY
16. FoLIC Acid 1 mg IV Q24H
17. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: One (1) Intravenous ASDIR (AS DIRECTED).
Currently 950 units/hour, PTT goal 50-70
18. AcetaZOLamide 250 mg IV Q12H
Discharge Disposition:
Extended Care
Discharge Diagnosis:
aortic valve, tricuspid valve endocarditis
Discharge Condition:
critical but stable
Discharge Instructions:
**Transfer back to Bay state Hospital
Followup Instructions:
continue medical treatment for endocarditis
Completed by:[**2115-12-31**]
|
[
"707.05",
"518.81",
"707.09",
"707.03",
"571.5",
"996.61",
"707.22",
"427.1",
"038.9",
"V42.2",
"530.81",
"E930.0",
"415.12",
"303.91",
"421.0",
"427.31",
"693.0",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11714, 11729
|
8028, 10214
|
406, 413
|
11816, 11837
|
2616, 8005
|
11924, 12000
|
1708, 1725
|
10363, 11691
|
11750, 11795
|
10240, 10340
|
11861, 11901
|
1740, 2597
|
240, 368
|
441, 1268
|
1290, 1549
|
1565, 1692
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,201
| 112,315
|
31043
|
Discharge summary
|
report
|
Admission Date: [**2153-5-28**] Discharge Date: [**2153-6-2**]
Date of Birth: [**2073-5-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Asymptomatic
Major Surgical or Invasive Procedure:
[**2153-5-29**] Aortic Valve Replacement utilizing a 21mm Mosaic Porcine
Bioprosthesis
History of Present Illness:
This is a very healthy 79 year old female who was noted to have
a heart murmur on routine examination. Serial echocardiograms
have shown significant progression of her aortic valve stenosis,
most recently [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.7cm2, with a peak gradient of 74 mmHg.
Subsequent cardiac catheterization showed normal coronary
arteries. Based on the above results, she was referred for
cardiac surgical intervention. She is asymptomatic and remains
very active.
Past Medical History:
Aortic Valve Stenosis
s/p Vein Stripping
s/p Benign Breast Mass Removal
Social History:
Denies history of tobacco. Rare ETOH. She lives alone and still
works part-time at an office.
Family History:
Denies premature coronary disease
Physical Exam:
Vitals: T afebrile, BP 142/80, HR 88, RR 20
General: pleasant elderly female in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, grade 4/6 systolic ejection
murmur which radiates to carotids
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2153-6-2**] 07:05AM BLOOD WBC-9.2 RBC-3.18* Hgb-10.0* Hct-28.8*
MCV-91 MCH-31.4 MCHC-34.7 RDW-14.2 Plt Ct-313#
[**2153-5-30**] 02:10AM BLOOD PT-11.6 PTT-27.8 INR(PT)-1.0
[**2153-6-2**] 07:05AM BLOOD Glucose-98 UreaN-10 Creat-0.6 Na-140
K-4.0 Cl-102 HCO3-31 AnGap-11
RADIOLOGY Preliminary Report
CHEST (PA & LAT) [**2153-6-1**] 4:38 PM
CHEST (PA & LAT)
Reason: evaluate for pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
80 year old woman s/p AVR
REASON FOR THIS EXAMINATION:
evaluate for pleural effusions
HISTORY: Evaluate pleural effusions in 80-year-old female status
post AVR.
Comparison is made to prior radiographs dated [**2153-5-30**].
PA AND LATERAL CHEST RADIOGRAPHS:
FINDINGS:
There has been interval increase in bilateral pleural effusions
(right greater than left), both small in size with fluid noted
tracking within the major fissure on the left. There is no
evidence of new parenchymal consolidation with persistent
retrocardiac opacity likely representing atelectasis. No
pneumothorax or pulmonary edema. Symmetric biapical pleural
thickening is stable.
IMPRESSION:
Interval increase in small bilateral pleural effusions, right
greater than left.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) 3347**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5034**]
Cardiology Report ECHO Study Date of [**2153-5-29**]
PATIENT/TEST INFORMATION:
Indication: Intra-op TEE for AVR
Height: (in) 64
Weight (lb): 122
BSA (m2): 1.59 m2
Status: Inpatient
Date/Time: [**2153-5-29**] at 09:07
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW06-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
MEASUREMENTS:
Left Ventricle - Septal Wall Thickness: 0.9 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 3.9 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.4 cm
Left Ventricle - Fractional Shortening: *0.13 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 55% (nl >=55%)
Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.0 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: *4.8 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 90 mm Hg
Aortic Valve - Mean Gradient: 60 mm Hg
Aortic Valve - LVOT Peak Vel: 1.00 m/sec
Aortic Valve - LVOT Diam: 1.9 cm
Aortic Valve - Valve Area: *0.6 cm2 (nl >= 3.0 cm2)
INTERPRETATION:
Findings:
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No
ASD by 2D or
color Doppler.
LEFT VENTRICLE: Normal LV wall thicknesses and cavity size.
Overall normal
LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in
aortic root. Normal ascending aorta diameter. No atheroma in
ascending aorta.
Normal aortic arch diameter. Simple atheroma in aortic arch.
Normal descending
aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic
valve leaflets. Severe AS (AoVA <0.8cm2). Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. No MS. Trivial MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure. The patient appears to be in sinus rhythm. Results
were personally
post-bypass
data
Conclusions:
PRE-BYPASS: No atrial septal defect is seen by 2D or color
Doppler. Left
ventricular wall thicknesses and cavity size are normal. Overall
left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber
size and free wall motion are normal. There are simple atheroma
in the aortic
arch. There are simple atheroma in the descending thoracic
aorta. There are
three aortic valve leaflets. The aortic valve leaflets are
severely
thickened/deformed. There is severe aortic valve stenosis (area
<0.8cm2).
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly
thickened. Trivial mitral regurgitation is seen.
POST-BYPASS: Well-seated valve. Normal biventricular systolic
function.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD on [**2153-6-4**] 09:55.
Brief Hospital Course:
Mrs. [**Known lastname 73317**] was admitted and underwent an aortic valve
replacement by Dr. [**Last Name (STitle) 68853**]. For surgical details, please see
seperate dictated operative note. Following the operation, she
was brought to the CSRU for invasive monitoring. Within several
hours, she awoke neurologically intact and was extubated without
difficulty. Initially tachycardic with frequent premature atrial
contractions, she was started on low dose beta blockade and
Amiodarone to prevent atrial fibrillation. She otherwise
maintained stable hemodynamics and transferred to the SDU on
postoperative day two. Over several days, she continued to make
clinical improvements with diuresis. She remained in a normal
sinus rhythm as beta blockade was advanced as tolerated. She
continued to progress and was discharged to home on POD#4 in
stable condition.
Medications on Admission:
Aspirin 81 qd, Vitamin, Calcium
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
4. Lopressor 50 mg PO BID.
5. Amiodorone 400 mg PO daily for 7 days, then decrease dose to
200 mg PO daily.
6. Ultram 50 mg PO q 4 hours PRN
7. Lasix 20 mg PO BID x 7 days.
8. Potassium Chloride 20 mg PO BID x 7 days.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Aortic Valve Stenosis - s/p AVR
s/p Vein Stripping
s/p Benign Breast Mass Removal
Discharge Condition:
Good
Discharge Instructions:
Patient should shower daily, no baths. No creams, lotions or
ointments to incisions. No driving for at least one month. No
lifting more than 10 lbs for at least 10 weeks from the date of
surgery. Monitor wounds for signs of infection. Please call
cardiac surgeon if start to experience fevers, sternal drainage
and/or wound erythema.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) 1290**] in [**4-19**] weeks - call for appt.
Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**2-17**] weeks - call for appt.
Local cardiologist, [**Last Name (un) 32255**] in [**2-17**] weeks - call for appt.
Completed by:[**2153-6-4**]
|
[
"424.1",
"E878.1",
"997.3",
"518.0",
"785.0",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61",
"89.64",
"39.64",
"38.91",
"89.68",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
7844, 7893
|
6280, 7141
|
333, 422
|
8019, 8026
|
1636, 2037
|
8408, 8717
|
1174, 1209
|
7223, 7821
|
2074, 2100
|
7914, 7998
|
7167, 7200
|
8050, 8385
|
3088, 6257
|
1224, 1617
|
281, 295
|
2129, 3062
|
450, 951
|
973, 1047
|
1063, 1158
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,720
| 198,412
|
39772
|
Discharge summary
|
report
|
Admission Date: [**2128-8-3**] Discharge Date: [**2128-8-28**]
Date of Birth: [**2063-2-24**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Pancreatic head mass
Major Surgical or Invasive Procedure:
Whipple procedure, [**2128-8-3**]
History of Present Illness:
Mrs. [**Known lastname 87581**] was a 65 year old woman with no significant past
medical history who was well until approximately one month prior
to admission when she presented with jaundice and weight loss to
an OSH. She initially underwent ERCP at [**Hospital **] hospital with a
plastic stent placed on a stricture but without biopsy due to
her ASA 81mg adily. She had a CT with visualization of the
stricture as well as with dilation of both the pancreatic and
common bile ducts.
She was subsequently referred to [**Hospital1 18**] for EUS with FNA of the
CBD and pancreas however given her increased jaundice and
pruritis it was thought that her current plastic stent in the
CBD may not be providing adequate biliary drainage. This was
removed, brushings were taken, and a self expanding metal stent
was placed in the CBD. Patient was discharged on [**7-10**] with
cholestyramine and augmentin.
Since her discharge she continued to have persistent pruritis.
Her urine was reportedly "gold" colored and she is was urinating
about every hour, with frequent burning. Repeat lab tests
showed increased bilirubin (from 25 to 30). She had insomnia
secondary to the pruritis and urinary frequency. She also had
frequent loose stools, up to [**9-8**] BMs per day.
She was readmitted to [**Hospital1 18**] for another ERCP on [**2128-7-16**] and
scheduled for surgery on [**2128-8-3**].
She returned on [**2128-8-3**] for a Whipple operation.
Past Medical History:
1. Hypertension
2. Ectopic pregnancy
3. Anemia, megalobastic
Social History:
Lives at home with her husband. Smokes 14 cigarettes per day
for many years; occasional alcohol. No current drug use or in
past. Retired from work in human resources. Has 2 children and 5
grand children
Family History:
Son with diabetes, type II.
Brief Hospital Course:
Mrs. [**Known lastname 87581**] was taken to the operating room for a Whipple
procedure and cholecystectomy on [**2128-8-3**]. The operation
proceeded without complication. Please refer to the operative
report for additional details. Mrs. [**Known lastname 87581**] was sent to the
surgical floor after a brief stay in the PACU.
On the morning of POD 1, Mrs. [**Known lastname 87581**] was afebrile, vitals
stable, alert but minimally oriented, confused and agitated.
Her narcotics were removed from her epidural and overall pain
regimen. Lab results showed significantly elevated LFTs --
ALT/AST 2229/2919 up from 231/336 the day prior. Bilirubin was
17.8 up from 13.7. A serum ammonia level was tested and
returned at 24. A UTI was suspected based on UA dipstick and
ciprofloxacin was started but stopped the next day after the
urine cx returned no growth and no clinical signs of infection.
Her INR was 1.8 (from 1.9 the day prior) and her potassium was
2.9 (from 3.5 and 4.0 previously).
Over the course of the next few days, the patient was less
agitated but her delirium was persistent with continued
confusion, nonsensical speech and behavior and lack of
orientation. Her liver function tests, however, were
consistently trending downwards with ALT/AST/TBili from
1590/1450/18.2 (POD 2) to 561/157/14.3 (POD 4) to 117/42/10.8
(POD 9). Her INR went down to 1.1 on POD 2 and remained at 1.1
on POD 3. From a electrolyte perspective, she was hypokalemic
post operatively which gradually resolved by POD 8. Her
potassium levels remained persistently in the low 3s with
interspersed values of 2.6 and 2.8. Her phosphorous was 2.2 and
1.8 on POD 1 and 2 respectively prior to normalizing to 3.8 and
eventually 3.1 on POD 9. From a nutritional perspective, she
was transitioned from NPO to sips on POD 4, to clears on POD 5,
to fulls on POD 7 and to a regular diet with pureed consistency
on POD 8. She tolerated all advances with no emesis, no
apparent nausea or abdominal bloating. She was taking in low
volumes but more than 400 cc of intake with her dietary
advances.
On the evening of POD 7, the patient was intermittently alert
and oriented with markedly less confusion and able to hold a
sensible conversation with family members as well as members of
the healthcare team. This waxed and waned into POD 9 where she
was clear most of the day, alert and oriented to person, time
and place though continued to have intermittent nonsensical
thought and speech. She had several loose bowel movements,
sample sent for c.diff and started on empiric flaygl therapy.
On POD 10, Mrs.[**Known lastname 87583**] confusion returned intermittently,
improved from prior but but she appearing more tired, especially
after getting out of bed with physical therapy and after a 2.5
mg dose of oxycodone. Oxycodone was thereafter removed from her
medication list and replaced solely with tylenol.She had fewer
loose bowel movements.
On the morning of POD 11, Mrs. [**Known lastname 87581**] was mentating, alert but
not entirely oriented but interspersed with nonsensical speech.
Her physical exam was unchanged: the incision was clean, dry and
intact, her abdomen soft, non-tender and with minimal
distention, unchanged from prior exams. In the early afternoon,
after lunch, Mrs. [**Known lastname 87581**] had a loose bowel movement and was
being cleaned by the nursing staff. After the conclusion of
this process, her husband who re-entered the room noticed that
the patient was not breathing and was unresponsive. He alerted
the nursing staff who called a code. Mrs. [**Known lastname 87581**] was found to
be in PEA arrest, then ventricular fibrillation. She was
actively coded for 10 minutes prior to regaining a pulse with
chest compressions performed throughout, receiving three shocks,
epinephrine, bicarbonate and vasopressin. She ultimately
regained a pulse and was transferred to the SICU.
During this process, labs indicated that Mrs.[**Known lastname 87583**]
hematocrit was 11.9 (last checked value was POD 9 at 30.3 and
had remained stable at approximately 30 during her entire
post-op course) and had an INR of >21. Overall, starting from
the code and overnight, Mrs. [**Known lastname 87581**] received 8 units of blood,
6 units of FFP, and 1 unit of cryoprecipitate. CT scan done
that night showed a large intraperitoneal bleed, mostly clotted,
with no active extravasation of contrast. It was decided to
manage her non-operatively with close monitoring with serial
hematocrits, with fluid resuscitation and a low dose neo drip.
She was hemodynamically stable, responding appropriately to the
blood transfusions, with her hematocrit going from
11.9-->13.7-->28.8 overnight. Initially her bladder pressures
were monitored frequently to monitor for abdominal compartment
syndrome due to an on-going bleed. Her hematocrit remained
stable in the mid 20s. Her bladder pressures were normal and
measurements were stopped [**8-18**].
Mrs.[**Known lastname 87583**] time in the SICU was dominated by neurological
and cardiovascular/renal/fluid management issues. They are
described in detail over her 2 week course in the ICU.
CARDIOVASCULAR/RENAL:
On [**2128-8-15**] she remained hemodynamically stable but her UOP
decreased after finishing transfusions of blood. The pressors
were titrated accordingly to maintain increased renal perfusion
and urine output. She was transfused 2units on [**2128-8-16**] to a
post-tx hct of 28.9, her remained stable at INR 1.1, her
pressors were weaned and her Cr was 1.6. Her pressors were
turned off entirely on [**2128-8-17**] and she remained hemodynamically
stable for the next few days and her renal function improved
gradually(1.2 on [**8-17**] to 0.6 on [**8-22**]).
From [**Date range (1) 87584**], Mrs.[**Known lastname 87583**] hemodynamic status started to
worsen again. She had some low blood pressure issues (SBPs in
the 80s) and low urine output (20 cc/hr, Cr bumped suddenly to
1.7 from 0.6) for which she received a IVF boluses including
both crystalloid and albumin, eventually had pressors restarted
for a short period of time then dc'd after her toes were found
to be blue then restarted after her toe ischemia resolved and
pressures dropped again, this time with limited change in color
of the toes. Her fluid overload status continued to worsen by
both clinical (edema, decreased pO2 on ABG) and radiologic
measures (worsening CXR). A lasix drip was started on [**2128-8-26**]
and diuresis was successful (she was negative almost 800 ml as
opposed to daily positive in I's/O's since ICU admission) but
her blood pressure did not tolerate it and it was dc'd shortly
thereafter. She received a total of 3 units of blood between
[**8-26**] and into [**8-27**]. Her Cr remained elevated at 1.8 on [**8-27**].
NEUROLOGICAL
--------------
Mrs. [**Known lastname 87581**] remained largely unreactive to external stimuli
after the code. Initially, she retracted her extremities in
response to pain but this disappeared over the first day in the
ICU. She was thought to have had some seizure-like activity the
morning of the 26th ( morning after the PEA arrest) which
resolved when treated with midazolam. She failed to regain any
meaningful neurologic function two days post the PEA event, even
with sedation weaned and turned off.
Neurology was consulted and suggested a head CT to rule out a
brain hemmorrhage which could have been an additional etiology
leading to the PEA arrest. They also noted that while some of
the decreased alertness and activity may be the result of the
poor liver function and its inability to clear sedatives, the
lack of return to function two days post was a poor prognostic
indicator. They additionally recommended a monitoring EEG to
rule out seizure activity.
The EEG revealed nonconvulsive status epilepticus, and she was
treated with keppra and ativan starting [**2128-8-17**]. The NCSE
continued on EEG for the next several days, ultimately ceasing
in NCSE activity by [**2128-8-20**] and showing slight improvement on
exam but with no wakefulness and continued guarded prognosis.
[**8-22**] repeat CT Head showed no interval changes and no evidence
of hemorrhage or hypoxia. EEG monitoring, however, showed a
burst suppression pattern which was thought to be an indicator
of poor prognosis. EEG monitoring was stopped on [**8-23**]. She
continued to be minimally reactive even with sedation off
throughout her final days and did not improve. Neurology noted
slim chances at improvement and suggested that her poor
neurologic function could not be accounted for by metabolic or
on-going multi-organ failure issues, possibly the result of
ischemic insult to the brain.
A family meeting was convened on [**2128-8-19**] with Dr. [**Last Name (STitle) 468**]
(Surgery), Dr. [**Last Name (STitle) 5856**] (ICU) and Dr. [**Last Name (STitle) 7594**] (Neurology) present to
discuss goals of care. The team recommended continued support
and the family concurred with wishes to continue all efforts.
After deteriorating clinical status over the next week and
increasingly grim chances of neurological recovery, a second
family meeting was held, led by Dr. [**Last Name (STitle) 468**] on [**8-27**]. Her poor
prognosis was explained and the family agreed to a plan of DNR
but continued life-sustaining medications until further
discussions with the rest of the family for
comfort-measures-only and withdrawal-of-care. Mr. [**First Name (Titles) **] [**Known lastname 87585**], the patient's husband, indicated the family's desire to
withdraw life-sustaining measures and switch to
comfort-measures-only on [**8-28**].
Mrs.[**Known lastname 87583**] medications were discontinued. She was extubated
at approximately 4:35 PM on Saturday, [**2128-8-28**] with morphine
administration for comfort. She was pronounced at 4:42 PM.
Of note, on an ID front, Mrs. [**Known lastname 87581**] was started on flagyl on
[**8-14**] for empiric therapy of loose stools thought to be C. Diff.
It was dc'd on [**8-16**] after 3 negative samples. A BAL done on
[**2128-8-15**] grew coag + staph and Moraxella. Initially broad based
antibiotic therapy was started (vanc/cipro/flagyl) and was
further refined (nafcillin/cipro) when sensitivites showed MSSA
on [**8-23**]. Her WBC count was 13.7 immediately post-operatively
and remained in the 11-18 range before gradually increasing to
the mid-to-high 20s range in the ICU.`
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Pancreatic head carcinoma
2. Post operative delirium
3. Liver failure
4. Renal insufficiency
5. Abdominal hemmorrhage
Discharge Condition:
Deceased
Completed by:[**2128-8-29**]
|
[
"157.0",
"E878.8",
"E935.2",
"276.69",
"584.5",
"482.41",
"427.31",
"507.0",
"292.81",
"482.83",
"575.12",
"787.91",
"285.1",
"707.00",
"427.5",
"570",
"V70.7",
"518.5",
"401.9",
"998.11",
"276.8",
"196.2",
"345.3",
"348.31",
"707.20",
"780.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"99.15",
"51.22",
"99.60",
"33.23",
"38.93",
"96.6",
"52.7",
"96.04",
"38.91",
"33.24",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
12695, 12704
|
2220, 12672
|
333, 368
|
12869, 12908
|
2168, 2197
|
12725, 12848
|
273, 295
|
396, 1845
|
1867, 1929
|
1945, 2152
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,317
| 183,600
|
50904
|
Discharge summary
|
report
|
Admission Date: [**2130-6-4**] Discharge Date: [**2130-6-14**]
Date of Birth: [**2075-11-18**] Sex: F
Service: MEDICINE
Allergies:
Compazine
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Hypotension, BRBPR
.
Major Surgical or Invasive Procedure:
Flexible sigmoidoscopy
.
History of Present Illness:
54 yo F with HIV, HCV cirrhois/ESLD, myopathy, adrenal
insufficienty, lives at [**Location **] ([**Last Name (un) **]) who presents with diffuse
abdominal pain and bleeding per vagina/rectum. Patient noted to
be more lethargic and complaining of diffuse abdominal pain. Per
NH records she also has had vaginal and rectal bleeding as well
as pressure ulcers perirectally and perivaginally. Her blood
pressure was in the 90's systolic. She was afebrile. She was
given 1L NS and sent to the [**Hospital1 18**] ED. Of note, she was recently
admitted from [**2045-5-14**] with BRBPR thought to be [**2-4**] to an anal
fissure. She did not have a colonoscopy at that time. She was
not noted to be bleeding vaginally at that time. She admitted
prior to that in early [**5-11**] with delta MS, UTI and hypercalcemia
thought to be [**2-4**] to po supplementation.
.
In the ED, VS: 97.7 89 83/62 24 99% RA. She received 3L NS.
SBP stabilized in 100s x 3 hrs in ED. Patient received empiric
Ceftriaxone for SBP. RUQ showing no ascites however, no
cholecystitis. Diffuse abd tenderness on exam, CT abd/pelvis
performed showing no acute intraabdominal process. U/A negative
for infection, +blood/+yeast. ECG unchanged. CXR clear. Liver/GI
aware, bleeding thought to be [**2-4**] to anal fissues. R femoral CVL
placed due to poor access.
.
Upon arrival to the floor patient somnolent but arousable and
complaining of periumbilical abd pain.
.
Past Medical History:
# Hepatitis C Cirrhosis - Viral load 406,000 IU/mL ([**4-11**])
# HIV: followed at [**Hospital1 **] by Dr. [**Last Name (STitle) 724**]
- Diagnosed [**10/2118**]. Nadir CD4 314 [**10/2118**]
- Started on combivir/Kaletra [**2124**], now on truvada and Kaletra
# SLE - followed at [**Hospital1 2177**], has chronic arthralgias
# Syphilis h/o +RPR, s/p PCN [**2119**], titer 1:8 [**Hospital1 2177**]
# Adrenal insufficiency, orthostatic hypotension, on
corticosteroids since [**10-10**]
# Depression
# HPV s/p LEEP [**2125**]
# DJD right hip
# Anemia
# Fibrocystic breast disease
# s/p tubal ligation
# Severe muscle wasting
# Anal hemorrhoids, h/o LGIB, anal fissure
# bowel/bladder incontinence
# perianal/perivaginal decubitus ulcers stage III
.
Social History:
Currently lives at [**Hospital3 537**]. Not working, former medical
assistant. No alcohol, tobacco or illicit drugs. Uses cane to
ambulate.
.
Family History:
Non-contributory.
.
Physical Exam:
VS: 97.5 92 116/57 25 100% RA
GEN: chronically ill appearing, NAD
HEENT: OP very dry, eyes dry, PERRL, poor dentition
NECK: supple
CV: nl S1 S2, RRR
CHEST: CTA b/l with good air movement
ABD: distended, soft, tender in epigastrium, periumbilica and
RLQ, no rebound or guarding, BS+, no HSM appreciated, no
ascities
EXT: [**2-5**]+ dowy pitting edema to above the knee, severely wasted
distal musculature, cool extremities
RECTAL: tender to palpation, stage III decubiti perirectal,
brown blood per rectum, no mass/fissues/hemorrhoids palpated
VAGINAL: small perivaginal excoriations; brown blood per vagina,
no mass palpated, non tender
NEURO: drowsy but arousable, CN grossly intact including PERRL,
not following commands, oriented to person and place, no
asterixis or clonus, strength: just able to resist gravity of
LE, upper extremities 4+, toes down going b/l, sensation
symmetric and intact
.
Pertinent Results:
PERTINENT LABS:
[**2130-6-4**] WBC-12.5* Hgb-10.3* Hct-31.6* MCV-101* Plt Ct-154#
[**2130-6-4**] Neuts-80.1* Lymphs-13.1* Monos-6.6 Eos-0 Baso-0.2
[**2130-6-4**] PT-14.7* PTT-39.2* INR(PT)-1.3*
[**2130-6-4**] Glucose-220* UreaN-31* Creat-0.7 Na-132* K-4.9 Cl-106
HCO3-21*
[**2130-6-4**] ALT-54* AST-47* AlkPhos-161* TotBili-4.1*
[**2130-6-4**] Lipase-95*
[**2130-6-4**] Albumin-1.9* Calcium-10.0 Phos-2.6* Mg-2.0
[**2130-6-4**] 12:47PM Lactate-2.1*
[**2130-6-5**] 05:41AM Lactate-3.1*
[**2130-6-5**] 01:28PM BLOOD Type-MIX pO2-35* pCO2-32* pH-7.43
calTCO2-22
.
[**2130-6-4**] URINALYSIS: Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.026
Blood-TR Nitrite-NEG Protein-NEG Glucose-1000 Ketone-NEG
Bilirub-NEG Urobiln-4* pH-6.5 Leuks-NEG RBC-[**11-23**]* WBC-[**3-8**]
Bacteri-0 Yeast-MANY Epi-0
.
MICRO DATA:
BLOOD CX [**6-4**]:
URINE CX [**6-4**]:
.
STUDIES:
CT ABD/PELVIS W/CONTRAST [**6-4**]: 1. No acute intra-abdominal
process.
2. Small left renal hypodensities, too small to characterize,
likely reflect renal cysts.
3. Stable compression deformities of the T12 and T9 vertebral
bodies.
4. Interval resolution of right lower lobe pneumonia.
.
RUQ ULTRASOUND [**6-4**]: Targeted grayscale views of the right upper,
left upper, right lower, and left lower quadrants of the abdomen
were obtained. There is no evidence of ascites. Limited views of
the liver demonstrate a coarsened echotexture, consistent with
known history of cirrhosis.
.
CXR [**6-4**]: Limited exam without acute cardiopulmonary
abnormalities.
.
TRANSVAGINAL ULTRASOUND [**6-5**]: Unremarkable uterus and adnexa with
simple nabothian cyst in the cervix.
.
Brief Hospital Course:
54 year-old female with HIV, HCV cirrhosis/ESLD, myopathy, bed
bound/NH presents with vaginal/rectal bleeding.
.
# Bleeding: Unclear source based on exam as there was
reportedly both old blood per vagina and per rectum. Does have
h/o anal hemorrhoids and fissure, however no clear fissure or
hemorrhoids palpated on presentation exam. Hct appears to
fluctuate, but also appears to have been drifting down over the
past several admissions. Hct, however was stable at 31 on
presentation (compared with hct on recent d/c) with only mild
drop to 28 and stable x3 in the [**Hospital Unit Name 153**] after having received
several liters of IVFs. No c-scope in our system and has been
deferred on last admissions given stability in hct and
hemodynamics. Although there was also old blood in vagina
(menstruating), transvaginal U/S was without evidence of uterine
wall thickening/abdnormalities. She does have h/o LEEP in past
and no paps in our system so ? bleeding from cervical source.
Further into her admission, she had a precipitous hct drop from
29 -> 23 yesterday with melena and red clots per rectum. She was
transferred back to the MICU. NG lavage negative at time of
arrival to MICU. Sigmoidoscopy performed which showed possible
recto-vaginal fistula. Hct stable after 3 units pRBCs. Rectal
ulcer and hemorrhoids also noted which may be source of
bleeding.
.
# Hypotension: SBPs in the 80s on presentation to the ED and
have since remained stable 90s-low 100s. Early infection of
concern given leukocytosis, however afebrile and without clear
source. Received Ceftriaxone x 1 in ED reportedly out of
concern for SBP however imaging is negative for ascites. U/A
was negative on presentation and no infiltrates were appreciated
on CXR/CT. Despite abdominal pain, no clear pathology was found
on CT abd/pelvis. All culture data was negative. WBC trended
upwards during the admission, 10--> 16, and so she was started
on empiric broad spectrum antibiotics with vanco and zosyn.
.
# Hepatic encephalopathy: Became progressively more somnolent
during the hospital course. On admission, she was somnolent, but
arousable easily and able to answer questions for history,
oriented to place, person, but not to date. Likely hepatic
encephalopathy. Hypercalcemia may also have been contributing
as her calcium levels were higher this admission as it has been
previously. Lactulose dose was titrated up however she became
progressively somnolent over the course of her admission to the
point that she was unresponsive. No clear source of infection
(although does have yeast in urine, however in setting of foley)
to suggest precipitant. Did have BRBPR on presentation however
no profound bleed to suggest as major precipitant. Was getting
tramadol prn for pain, but otherwise without sedating
medications. ABG performed in ICU revealed a resp. alkalosis so
hypercarbia not contributing.
.
# Abdominal pain: Etiology unclear and was present during her
last admission as well (she reports chronic x several months).
As above, no ascites on abdominal imaging to suggest underlying
SBP. ? in the setting of hypercalcemia. CT abd/pelvis without
other clear pathology to suggest cause. Although does have h/o
recurrent UTIs, UA negative with exception of many yeast; this
in the setting of foley catheter. Gyn pathology also possible
given blood per vagina, however transvaginal U/S negative for
definitive pathology.
.
# Hypercalcemia: In review of labs, has had elevated calcium
previously and of note, has also had hypophosphatemia
previously; PTH checked recently in [**2130-5-4**] and was normal.
PO supplements certainly contributing however calcium not
markedly changed in the setting of holding PO supplementation
and IVFs.
.
# Hyponatremia: Likely hypervolemic hyponatremia in the setting
of ESLD. Adrenal insufficiency may also be contributing. BS
also elevated to 200s, however pseudohyponatremia seems to be
only minimal contributor. In review of labs, Na fluctuates mid
120s to low 130s and thus is within this range at 132.
.
# Anemia: Longstanding with fluctuating baseline hct mainly
between mid 20s and low 30s. Hct does appear to have drifted
down sone since her [**Month (only) 116**] admissions at which time it was 33-34
range. Elevated MCV likely in setting of liver disease as b12
and folate normal 5/[**2130**].
.
# Leukocytosis: Unclear etiology. Initially was 12.5 with mild
left shift. CX data unremarkable. CT with colitis and CXR neg.
Mild ascites so SBP possible. Afebrile. Initial UA had yeast,
foley was changed and repeat UA unremarkable. C diff neg x1.
She was covered empirically with vanco and zosyn, though no
clear source of infection was found.
.
# HCV cirrhosis/ESLD: MELD was 23. Continued lactulose and
rifaximin.
.
# HIV: VL <50 copies [**2130-4-25**]. Continued HIV outpatient regimen.
.
# Adrenal Insufficiency: Continued dexamethasone.
.
# Hyperglycemia: Glucose in 200s, likely [**2-4**] to steroids. HbA1c
5.1 [**4-11**]. In review of labs, however, has intermittently been
elevated in past but not for sustained durations. She was
covered with an insulin sliding scale.
.
# Myopathy: Severe wasting on examination, patient now not
ambulating. During last admission, patient was seen by neurology
service while inpatient. She underwent EMG which found no
chronic polyneuropathic component to her weakness but no clear
etiology for myopathy. MR cervical spine was found to have
moderate stenosis that was chronic, but it was felt that her
diffuse weakness was not
consistent with the stenotic location. Thoracic MRI was at that
time was unrevealing. The thought on discharge was that myopathy
was due to cachexia, poor nutritional status with muscle wasting
due to her HAART and HIV and that neuropathy that complicates
her ability to use her muscles. Given chronic steroids, ?
whether they too may be contributing. Continued nutrition with
TFs initially, until she was made CMO.
.
# SLE: Continued hydroxychloroquine.
.
# Depression: Continued SSRI.
.
# Code: Over the course of several family meetings, decision was
made to make pt DNR/DNI and then CMO, given the progression of
her ESLD. She died on [**2130-6-14**].
.
Medications on Admission:
MEDICATIONS: per NH records
1. Rifaximin 200 mg TID
2. Emtricitabine 200 mg po daily
3. Tenofovir Disoproxil Fumarate 300 mg po daily
4. Lopinavir-Ritonavir 200-50 mg po BID
5. Hydroxychloroquine 200 mg po daily
6. Calcium Carbonate 500 mg Tablet TID W/MEALS
7. Ipratropium-Albuterol q 6 hrs prn
8. MVI po daily
9. Tramadol 50 mg po TID prn
10. Darbepoeitin 100 mcg SC friday
11. Dexamethasone 0.75 TID
12. Nystatin 100,000 unit/mL Suspension 5 ML PO TID
13. Famotidine 20 mg daily
14. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Appl Rectal QID
PRN rectal pain.
15. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Powder PO DAILY
16. Lactulose 30 ML PO TID
17. Insulin Regular SS
18. Colace 100 mg po bid prn
19. Senna 8.6 mg po BID prn
20. Dulcolax 10 mg prn
21. Econazole 1 % Cream Topical [**Hospital1 **]
22. Citalopram 20 mg po daily
23. Nystatin S&S
24. Saliva substitute tid
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: Recto-vaginal bleed, Hepatic encephalopathy
.
Secondary:
Hepatitis C cirrhosis
HIV
Lupus
Adrenal insufficiency
Depression
Anemia
Severe muscle wasting
.
Discharge Condition:
Expired
.
Discharge Instructions:
.
Followup Instructions:
.
|
[
"285.9",
"572.2",
"623.8",
"275.42",
"569.3",
"799.4",
"V08",
"584.9",
"707.09",
"255.41",
"276.1",
"710.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.24",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12480, 12489
|
5338, 11530
|
291, 317
|
12694, 12705
|
3680, 3680
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12755, 12759
|
2723, 2744
|
12510, 12673
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11556, 12457
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12729, 12732
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2759, 3661
|
230, 253
|
345, 1776
|
3697, 5315
|
1798, 2547
|
2563, 2707
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,514
| 173,409
|
39611
|
Discharge summary
|
report
|
Admission Date: [**2148-7-3**] Discharge Date: [**2148-7-5**]
Date of Birth: [**2078-12-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Anemia and upper GI bleed
Major Surgical or Invasive Procedure:
EGD [**2148-7-4**]. Result: Stricture with nodular, ulcerated and very
friable overlying mucosa - differential diagnosis includes
changes following recent upper endoscopy, post-radiation or
recurrence of esophageal cancer. Clotted blood was seen in the
cardia and part of the fundus The cardia mucosa was edematous
and friable. Multiple bands that were disclodged from the
mucosa were noted
No lesions amenable to endoscopic treatment were noted.
Otherwise normal EGD to third part of the duodenum.
History of Present Illness:
The patient is a 69 year old male with a history of COPD (FEV1
of 1.9 requiring 3L NC at home), pulmonary hypertention, CAD/CHF
(unknown EF), Barrett's esophagus and esophageal adenocarcinoma,
signet ring cell type, diagnosed in Feruary [**2146**] who presents
from [**Hospital6 19155**] with a chronic upper
gastrointestinal bleed. He was treated with chemotherapy
(FLOFOX) and radiation completed in [**2147-5-15**]. In [**Month (only) 205**] of
[**2146**], he was noted to be anemic and required monthly blood
transfusions. In addition, he was started on iron infusions in
[**2147-9-14**]. In [**2147-12-15**], he had an EGD that showed
some "irritation in the stomach" but no direct source of
bleeding. In [**2148-5-14**], a colonoscopy revealed extensive
diverticulosis and he had three polypectomies that were positive
for signet ring carcinoma identical to his esophageal
adenocarcinoma. This failed to resolve his anemia and an
elective EGD done today [**2148-7-3**] showed a large clot in the
proximal stomach with ongoing oozing from the gastric cardia
contained within a small hiatal hernia. This area was
cauterized and several attempts were made to band this. The
patient was given two units of blood while at the outside
hospital. His Hct went from 21.5 to 25.6. The patient
continued to have a low level of chronic oozing and was admitted
to [**Location (un) **] and then transferred to [**Hospital1 18**] for futher management
and argon plasma coagulation.
For 3-4 weeks, the patient has felt weak. He is lightheaded
when he stands. He has not fallen. He denies nausea, vomitting,
fevers, chills, and changes in weight. He denies changes in
vision. He denies BRBPR and says that his stools are "dark
chocolate". He has some numbness and tingling in his lower
extremities that has been chronic due to diabetic nephropathy.
Past Medical History:
1. COPD FEV1 of 1.9, 3LNC at home
2. pulmonary hypertension
3. Barrett's esophagus/ GERD
4. Esophageal adenocarcinoma, signet ring cell type, metastatic
to the colon
5. GI bleeding
6. Anemia
7. Radiation gastritis of gastric cardia with GI bleed
8. chronic arthritis
9. diabetes
10. gout
11. hypercholesterolemia
12. hypertension
13. congestive heart failure
14. chronic renal insufficiency
Social History:
Social History: Worked as heavy machine operator.
- Tobacco: 80 pack years, quit in [**2129**]
- etOH: one drink per month
- Illicits: denies
Family History:
Mother had breast cancer in her 60s. Negative for GI
malignancies
Physical Exam:
VS: T 100.1, 130/50, HR 96, RR 18, 98% 3LNC
GEN: NAD, Barrel Chest
HEENT: MMM, no OP lesions, JVP 8cm, neck is supple, no cervical,
supraclavicular, or axillary LAD
CV: RR, Nl S1S2 no S3S4 MRG
PULM: CTAB
ABD: Slightly distended but soft, BS+, non-tender, no masses or
hepatosplenomegaly
LIMBS: No LE edema no clubbing no cyanosis
SKIN: Lower extremity pre tibial lesions bilaterally, non
ulcerated, non erythematous
NEURO: CNII-XII nonfocal, strength 5/5 of the upper and lower
extremities, sensation is decreased in plantar aspects of both
feet.
Pertinent Results:
[**2148-7-3**] 08:32PM GLUCOSE-114* UREA N-18 CREAT-0.9 SODIUM-141
POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-26 ANION GAP-14
[**2148-7-3**] 08:32PM estGFR-Using this
[**2148-7-3**] 08:32PM CALCIUM-9.1 PHOSPHATE-2.4* MAGNESIUM-1.8
[**2148-7-3**] 08:32PM WBC-9.0 RBC-2.79* HGB-10.0* HCT-30.3*
MCV-109* MCH-35.9* MCHC-33.1 RDW-21.7*
[**2148-7-3**] 08:32PM NEUTS-89.4* BANDS-0 LYMPHS-4.4* MONOS-4.3
EOS-1.8 BASOS-0.2
[**2148-7-3**] 08:32PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-2+ MICROCYT-OCCASIONAL POLYCHROM-1+
SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL
[**2148-7-3**] 08:32PM PLT SMR-NORMAL PLT COUNT-171
[**2148-7-3**] 08:32PM PT-12.6 PTT-23.9 INR(PT)-1.1
EGD [**2148-7-4**]: Please see invasive procedures section for results.
Brief Hospital Course:
The patient is a 69 year old male with a history of COPD (FEV1
of 1.9 requiring 3L NC at home), pulmonary hypertention,
Barrett's esophagus, CAD/CHF (EF unknown) and esophageal
adenocarcinoma, signet ring cell type, diagnosed in Feruary [**2146**]
who presents from [**Hospital6 19155**] with a chronic upper
gastrointestinal bleed.
#Upper GI Bleed: Patient has a history of metastatic esophageal
adenocarcinoma s/p chemo-radiation with radiation gastritis and
oozing from a clot in the gastric cardia. Hematocrit was found
to be 21 at the outside hospital, he was given 4 units of packed
red blood cells at that time, and his Hct was 30.3 upon arrival
to [**Hospital1 18**]. A gastroenterology consult was obtained. The patient
was kept NPO and was started on pantoprazole 40mg iv q12hrs. An
EGD was performed on [**2148-7-4**], which showed a stricture at the
gastroesophageal junction which was attributed to either
post-radiation changes, a recurrence of his esophageal
adenocarcinoma or changes related to a recent endoscopy. A clot
was seen in the gastric cardia. There was no active bleeding.
No biopsies were taking due to the high risk for bleeding. The
patient's Hct was 24.1 on [**2148-7-6**] and he was transfused one unit
of packed red cells before discharge from the hospital with
close followup.
#COPD: Requires 3LNC at home. Continued home regimen below.
-proair HFA 2 puffs INH QID
-fluticasone salmeterol 250/50 one puff [**Hospital1 **]
-Oxygen 3LNC
.
#marcocytic hyperchromic Anemia: blood draw taken after 2 units
of blood. The patient was supplemented as outlined below.
-ferrous sulfate
-supplement iron and vitamin C
-supplement B12 and folate
.
#Diabetes Mellitus II: Complicated by diabetic neuropathy. The
patient's insulin regimen was cut by 75% while he was NPO. He
was sent home on his usual regimen.
-Continue home insulin 80 units 75/25 AM and PM
-Add HISS
-neurontin for diabetic neuropathy
.
#h/o Gout: well controlled
-con't allopurinol 100mg daily
.
#h/op hypercholesterolemia. Will f/u as an outpatient.
-not on any home medication
.
#hypertension: Atenolol and aldactone were held for the first
two days of hospitalization. The patient was HD stable and these
medications were restarted prior to discharge.
-atenolol 12.5mg Daily
-aldactone 25mg Daily
.
#h/o congestive heart failure
-con't digoxin 0.25mg daily
.
#Depression: No suicidal ideation.
-con't fluoxetine 20mg daily
.
# FEN: Replete electrolytes on scales
# Prophylaxis:
- DVT ppx: heparin SQ
- GI ppx: no PPI
- Bowel regimen: standing colace and senna PRN
# Access: R sided port-a-cath and peripheral ivs
# Communication: with patient and daughters
# Emergency Contact: daughters
# Code: presumed full
# Disposition: pending ICU care outlined above.
Medications on Admission:
1. proair HFA 2 puffs INH QID
2. allopurinol 100mg daily
3. atenolol 12.5mg Dailuy
4. digoxin .25mg daily
5. colace 6 tabs daily
6. ferrous sulfate one teaspoon daily
7. fluoxetine 20mg daily
8. fluticasone salmeterol 250/50 one puff [**Hospital1 **]
9. flonase nasal spray once per day
10. gabapentin 300mg PO qhs
11. hydrocodone5/ APA 500 one tab po tid
12. insulin 75/25 80units subcutaneous AM and PM
13. If glucose>200, adds 10U of regular insulin
14. multivitamin
15. omeprazole
16. aldactone 25mg daily
17. Oxygen 3LNC
18. Oxycontin 40mg TID
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation Q6H (every 6 hours) as needed for
dyspnea.
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
[**12-16**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
6. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
8. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q8H (every 8 hours) as needed for pain.
9. Insulin Regular Hum U-500 Conc 500 unit/mL Solution Sig: One
(1) Injection twice a day: Please follow your home insulin
regimen. .
10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours) as needed
for pain.
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**12-16**] Inhalation Q6H (every 6 hours) as needed
for SOB, wheezing.
13. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: One (1)
PO DAILY (Daily).
14. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
16. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Upper gastrointestinal bleed
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Last Name (Titles) 87400**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were transferred here from [**Hospital3 12594**] because your red blood cell levels were low and you
were found to have a bleed in your stomach. While you were
here, we gave you blood transfusions and put you on an
intravenous medication (protonix) to decrease your stomach acid.
On [**2148-7-4**], you had an upper gastrointestinal endoscopy, which
showed a stricture at the junction between your esophagus and
your stomach. This stricture could represent a reccurence of
your esophageal cancer, post-radiation treatment changes, or
changes related to having recieved a previous endoscopy. There
was no bleeding visualized during the endoscopy and no
procedures could be performed to stop or prevent future bleeding
because there was a high risk of creating more bleeing. Your
red blood cell levels are more stable now than when you came
into the hospital, but we expect that you will continue to need
close followup as well as red blood cell transfusions. You will
recieve one unit of red cells before you leave the hospital.
Please make the following changes to your home medication
regimen:
1) Please take pantoprazole (protonix) 40mg tablets, one tablet
two times per day.
Followup Instructions:
Please make an appointment to see your oncologist within one
week from hospital discharge.
Please make an appointment to see your primary doctor within one
week from hospital discharge.
|
[
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"428.0",
"V10.03",
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icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
9848, 9854
|
4764, 7532
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340, 841
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9934, 9934
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3963, 4741
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3313, 3380
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3395, 3944
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275, 302
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869, 2720
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9949, 10061
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2742, 3134
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3167, 3297
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,518
| 177,172
|
46978
|
Discharge summary
|
report
|
Admission Date: [**2118-5-19**] Discharge Date: [**2118-5-25**]
Date of Birth: [**2043-6-6**] Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
S/p Total Hip Replacement
Major Surgical or Invasive Procedure:
total hip replacement
History of Present Illness:
This is a 74 year old male with PMH significant for HTN, CAD,
diastolic dysfunction, moderate pulmonary hypertension with an
estimated PASP of 41 mm Hg on last ECHO in [**4-4**], OA,
hyperlipidemia, DM2, who was admitted to the MICU for
post-operative monitoring following a L THA revision. Of note,
the patient was recently admitted to [**Hospital1 18**] from [**4-13**] - [**4-18**],
during which time he underwent left total hip arthroplasty on
[**4-13**]. Post-operative course was complicated by development of
AMS, left-sided facial droop, and left sensory neglect. Pt was
seen by the neurology service at that time and was diagnosed
with CVA. Per report he had good functional recovery with just
minimal left sided weakness. He was started on Lovenox and
[**Month/Year (2) **] following that admission in addition to aspirin 325mg
which he was taking previously.
.
The patient did well after discharge until [**2118-5-13**] when he
presented to orthopedic clinic following a fall at home. X-rays
at that time showed a periprosthetic fracture with the Accolade
femoral stem rotated and a displaced fracture of the left
greater trochanter. He was made non-weight bearing and was
scheduled for surgical revision on [**2118-5-19**]. It is unclear what
blood thinners the patient was on prior to surgery, although it
seems that the Lovenox had been discontinued a few days prior.
It is unclear if and when his aspirin and [**Name (NI) **] were
discontinued prior to surgery. Unfortunately, the surgery was
complicated by a large amount of blood loss and hemodynamic
instability requiring Levophed 0.1 mcg/kg/min and phenylephrine.
Anesthesia was attempting to wean the phenylephrine prior to
transfer to the ICU. Orthopedics consulted trauma surgery to
assist in the OR given the amount of bleeding. Per OMR, he
required 12 units of pRBCs, 14 units of FFP, and a 6 pack of
platelets intraoperatively. He was kept sedated with propofol
and small bolus doses of ketamine and fentanyl during the
procedure. He remained intubated at time of transfer to the
ICU. He did not have a central line, but has good peripheral
access and an A-line.
.
On arrival to the MICU, initial vs were: T=96.4, P=49,
BP=103/61, R=10, O2 sat=100% on vent. Patient was intubated, off
of sedation, and minimally responsive. Phenylephrine was weaned
off due to bradycardia to the 30s.
Past Medical History:
hypertension, coronary artery disease, osteoarthritis, elevated
cholesterol, diabetes, and occasional anxiety; tonsillectomy
Social History:
Retired, lives with wife. [**Name (NI) 4084**] smoked and does not drink
alcohol
Family History:
Brother died at age 59 unexpectedly, cause unknown. Grandmother
with diabetes.
Physical Exam:
General: a/o x 3.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
rhonchi
CV: Bradycardic, 2/6 SEM radiating to the left axilla
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding. LBM [**2118-5-25**].
GU: Condom cath to drainage bag [**1-26**] scrotal edema
Neuro: Intact with no focal deficits
LLE:
* Incision healing well with staples
* Thigh full but soft
* No calf tenderness
* 5/5 strength
* SILT, NVI distally
* Toes warm
Pertinent Results:
[**2118-5-20**]:
CT head w/contrast:
1. No acute intracranial hemorrhage. If there is concern for
acute
infarction, an MRI with DWI can be obtained for further
evaluation.
2. Multiple paranasal sinus disease, likely relates to the
endotracheal
intubation.
[**2118-5-25**] 07:00AM BLOOD WBC-6.2 RBC-3.20* Hgb-9.6* Hct-28.8*
MCV-90 MCH-30.1 MCHC-33.4 RDW-15.1 Plt Ct-201
[**2118-5-24**] 04:34AM BLOOD WBC-7.2 RBC-3.28* Hgb-9.9* Hct-29.1*
MCV-89 MCH-30.2 MCHC-34.1 RDW-15.8* Plt Ct-155
[**2118-5-23**] 05:14AM BLOOD WBC-7.4 RBC-2.97* Hgb-8.9* Hct-26.9*
MCV-91 MCH-30.0 MCHC-33.2 RDW-15.5 Plt Ct-145*
[**2118-5-22**] 05:52PM BLOOD WBC-9.7 RBC-3.28* Hgb-9.9* Hct-28.9*
MCV-88 MCH-30.2 MCHC-34.2 RDW-15.8* Plt Ct-139*
[**2118-5-22**] 11:33AM BLOOD WBC-9.7 RBC-3.07* Hgb-9.3* Hct-27.3*
MCV-89 MCH-30.2 MCHC-34.0 RDW-15.7* Plt Ct-120*
[**2118-5-22**] 04:23AM BLOOD WBC-9.0 RBC-3.16* Hgb-9.6* Hct-28.2*
MCV-89 MCH-30.3 MCHC-33.9 RDW-15.6* Plt Ct-103*
[**2118-5-21**] 10:58PM BLOOD WBC-9.4 RBC-3.16* Hgb-9.4* Hct-27.9*
MCV-89 MCH-29.9 MCHC-33.8 RDW-15.5 Plt Ct-100*
[**2118-5-21**] 05:37PM BLOOD WBC-10.0 RBC-3.45* Hgb-10.5* Hct-29.8*
MCV-86 MCH-30.3 MCHC-35.1* RDW-15.7* Plt Ct-105*
[**2118-5-21**] 12:48PM BLOOD WBC-10.4 RBC-3.54* Hgb-10.7* Hct-30.8*
MCV-87 MCH-30.2 MCHC-34.8 RDW-15.7* Plt Ct-97*
[**2118-5-21**] 03:11AM BLOOD WBC-10.0 RBC-3.41* Hgb-10.6* Hct-30.5*
MCV-89 MCH-30.9 MCHC-34.6 RDW-15.6* Plt Ct-92*
[**2118-5-20**] 05:19PM BLOOD WBC-11.8* RBC-3.64* Hgb-11.1* Hct-31.5*
MCV-86 MCH-30.4 MCHC-35.2* RDW-15.4 Plt Ct-103*
[**2118-5-20**] 04:01AM BLOOD WBC-9.9 RBC-2.93* Hgb-8.9* Hct-25.5*
MCV-87 MCH-30.5 MCHC-35.0 RDW-16.3* Plt Ct-124*
[**2118-5-19**] 03:51PM BLOOD WBC-10.0# RBC-3.74* Hgb-11.2* Hct-31.5*
MCV-84 MCH-29.9 MCHC-35.5* RDW-15.9* Plt Ct-82*#
[**2118-5-19**] 10:40AM BLOOD WBC-5.1 RBC-3.28* Hgb-9.6* Hct-28.2*
MCV-86 MCH-29.2 MCHC-34.0 RDW-16.3* Plt Ct-169
[**2118-5-19**] 09:15AM BLOOD WBC-3.7*# RBC-2.69* Hgb-7.9* Hct-23.8*
MCV-88 MCH-29.4 MCHC-33.3 RDW-16.3* Plt Ct-233
[**2118-5-25**] 07:00AM BLOOD PT-18.1* PTT-30.7 INR(PT)-1.6*
[**2118-5-24**] 04:34AM BLOOD PT-16.1* PTT-30.1 INR(PT)-1.4*
[**2118-5-23**] 05:14AM BLOOD PT-17.2* PTT-32.8 INR(PT)-1.5*
[**2118-5-22**] 05:52PM BLOOD PT-16.5* PTT-31.2 INR(PT)-1.5*
[**2118-5-22**] 04:23AM BLOOD PT-14.7* PTT-30.5 INR(PT)-1.3*
[**2118-5-25**] 07:00AM BLOOD Glucose-109* UreaN-14 Creat-0.8 Na-140
K-3.4 Cl-103 HCO3-30 AnGap-10
[**2118-5-24**] 04:34AM BLOOD Glucose-116* UreaN-17 Creat-0.8 Na-142
K-3.5 Cl-107 HCO3-29 AnGap-10
[**2118-5-23**] 05:14AM BLOOD Glucose-138* UreaN-23* Creat-0.9 Na-144
K-3.7 Cl-111* HCO3-28 AnGap-9
[**2118-5-22**] 05:52PM BLOOD Glucose-145* UreaN-21* Creat-1.0 Na-144
K-3.9 Cl-113* HCO3-27 AnGap-8
[**2118-5-20**] 04:01AM BLOOD ALT-6 AST-28 LD(LDH)-242 AlkPhos-51
TotBili-0.4
[**2118-5-25**] 07:00AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.6
[**2118-5-24**] 04:34AM BLOOD Calcium-8.5 Phos-2.5* Mg-1.5*
Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Postoperative course was remarkable for the following:
1. This is a 74 year old male with PMH significant for HTN, CAD,
diastolic dysfunction, moderate pulmonary hypertension with an
estimated PASP of 41 mm Hg on last ECHO in [**4-4**], OA,
hyperlipidemia, DM2, who was admitted to the MICU
post-operatively while still intubated and sedated for
hemodynamic monitoring following a left THA revision complicated
by a large amount of blood loss and hemodynamic instability
requiring two pressors.
2. [**Hospital Unit Name 153**] course: The patient had extensive blood loss requiring
12 units of pRBCs, 14 units of FFP, and a 6 pack of platelets.
He was also on Levophed and phenylephrine to maintain his blood
pressures. There was concern for CVA or neurogenic shock as his
blood pressures have varied widely from 80s-180s systolic, he is
bradycardic, however CTA head was negative. Central line was
placed and levophed continued for low pressures. He received
another 1 unit of PRBC and 1 unit of platelets. He was also
noted to have ST elevations on EKG likely in setting of demand
ischemia related to hypotension and blood loss in setting of
CAD.
Patient was extubated POD2. Aspirin and [**Hospital Unit Name 4532**] held, coumadin
was started on POD 3 for DVT ppx. Ancef was continued until
removal of JP drains on POD3.
3. POD 4 - Hct 26.9 -> Transfused 1 unit PRBCs
Otherwise, pain was initially controlled with a PCA followed by
a transition to oral pain medications on POD#1. The patient
received lovenox for DVT prophylaxis starting on the morning of
POD#1. The foley was removed on POD#2 and the patient was
voiding independently thereafter. The surgical dressing was
changed on POD#2 and the surgical incision was found to be clean
and intact without erythema or abnormal drainage. The patient
was seen daily by physical therapy. Labs were checked throughout
the hospital course and repleted accordingly. At the time of
discharge the patient was tolerating a regular diet and feeling
well. The patient was afebrile with stable vital signs. The
patient's hematocrit was acceptable and pain was adequately
controlled on an oral regimen. The operative extremity was
neurovascularly intact and the wound was benign.
The patient's weight-bearing status is PARTIAL (50%) weight
bearing on the operative extremity at all times with
posterior/trochanter off precautions.
Mr. [**Known lastname 634**] is discharged to rehab in stable condition.
Code: Full
Contact: [**Name (NI) **] [**Name (NI) 634**] (wife) [**Telephone/Fax (1) 99629**](h), [**Telephone/Fax (1) 99630**] (c);
[**First Name4 (NamePattern1) **] [**Known lastname 634**] (daughter) [**Telephone/Fax (1) 99631**]; [**First Name4 (NamePattern1) 553**] [**Known lastname **]
(daughter) [**Telephone/Fax (1) 99632**]
Medications on Admission:
1. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily). (recently discontinued)
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): hold for loose stools.
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for Pain.
5. aspirin, buffered 325 mg Tablet Sig: One (1) Tablet PO twice
a day for 3 weeks: AFTER completing all lovenox syringes, please
take as directed with food. you may resume your preoperative
dose after completing this regimen.
6. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
10. lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. metformin 500 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO DAILY (Daily).
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
15. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): was held on [**4-17**] and [**4-18**].
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. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
7. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM for 6 weeks: Goal INR 2-2.5
Dr. [**Last Name (STitle) **].
Disp:*30 Tablet(s)* Refills:*1*
8. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
9. furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
12. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily).
13. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
14. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
L hip greater trochanteric periprosthetic fracture with stem
rotation
Hypotension
Hypovolemia
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:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon or your primary physician.
6. Please keep your wounds clean. You may shower starting five
(5) days after surgery, but no tub baths or swimming for at
least four (4) weeks. No dressing is needed if wound continues
to be non-draining. Any stitches or staples that need to be
removed will be taken out by the visiting nurse (VNA) or rehab
facility three
weeks after your surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment in four (4) weeks.
8. Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
9. ANTICOAGULATION: Please continue your coumadin for six (6)
weeks to help prevent deep vein thrombosis (blood clots). Goal
INR 2-2.5. [**Male First Name (un) **] STOCKINGS x 6 WEEKS. To be followed by PCP [**Last Name (NamePattern4) **].
[**Last Name (STitle) **] after discharge from rehab (Phone: [**Telephone/Fax (1) 6699**], Fax:
[**Telephone/Fax (1) 66415**]).
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four (4)
week checkup. Please place a dry sterile dressing on the wound
each day if there is drainage, otherwise leave it open to air.
Check wound regularly for signs of infection such as redness or
thick yellow drainage. Staples will be removed by the visiting
nurse or rehab facility in three (3) weeks.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound checks, and staple removal at three weeks
after surgery.
12. ACTIVITY: PARTIAL (50%) weight bearing on operative
extremity. Posterior and trochanter off precautions. No
strenuous exercise or heavy lifting until follow up appointment.
Physical Therapy:
LLE PWB (50%) at all times
2 crutches or walker at all time
Posterior/trochanter off precautions
Mobilize
HIGH fall risk
Treatments Frequency:
Dry sterile dressing daily as needed for drainage
Wound checks
Ice as tolerated
Staple removal POD 21 ([**2118-6-9**]) - replace with steristrips
TEDs x 6 weeks
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2118-6-17**] 11:00
Completed by:[**2118-5-25**]
|
[
"820.09",
"600.00",
"V12.54",
"E888.9",
"276.2",
"564.00",
"412",
"411.89",
"272.4",
"428.30",
"996.42",
"250.00",
"401.9",
"V58.61",
"293.0",
"V45.82",
"998.0",
"998.11",
"285.1",
"E878.1",
"428.0",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.35",
"00.72"
] |
icd9pcs
|
[
[
[]
]
] |
12553, 12650
|
6620, 9731
|
331, 354
|
12788, 12788
|
3707, 6597
|
16401, 16633
|
3016, 3097
|
11218, 12530
|
12671, 12767
|
9757, 11195
|
12971, 15266
|
3112, 3688
|
16072, 16194
|
16216, 16378
|
266, 293
|
15278, 16054
|
382, 2752
|
12803, 12947
|
2774, 2901
|
2917, 3000
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,150
| 167,216
|
52178
|
Discharge summary
|
report
|
Admission Date: [**2172-5-4**] Discharge Date: [**2172-5-6**]
Date of Birth: [**2092-2-13**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins / Carbapenem / A.C.E Inhibitors /
Angiotensin Receptor Antagonist
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
80 y.o. male with past medical history of CAD, DM, CHF, HTN
took finger sugar this afternoon at noted to be 400,
asymptomatic so took glucose tablet, realizing this was the
incorrect management for his elevated blood sugar, proceeded to
take 50U regular insulin x4.
In the ED, was noted to have initial FSBS 142 at 17:55, then
drifted to 74, at 18:30, and started on D10 drip at 100/hr,
since then sugars have been 83-143-11 every 40 minutes.
Past Medical History:
- CAD, s/p MI in [**2166**] (intraoperative MI during nephrectomy),
s/p LAD stent in [**11/2167**] and OM1 stent in [**12/2167**] (c/b in-stent
restenosis of OM1 s/p balloon angio in 1/[**2169**]).
- Type II DM - c/b peripheral neuropathy and nephropathy
- Chronic Kidney Disease - baseline creatinine 2-2.5; s/p
partial R nephrectomy for RCC in [**2166**]
- Systolic CHF - prior LVEF ([**6-/2170**]) of 35%; Most recent ECHO in
[**6-27**] at [**Hospital1 18**] shows EF of 45-50%
- Hypertension
- Hypercholesterolemia
- H/o Renal cell carcinoma, s/p partial R nephrectomy [**2-/2166**]
- H/o prostate CA, s/p XRT
- Type 1 RTA
- Hypoaldosteronism
- H/o hyperkalemia
- Anemia - baseline hematocrit 30
- Fulminant C. diff colitis ([**2167**]), s/p total colectomy w/
ileostomy
- H/o multiple falls, s/p mid-shaft and surgical neck humerus
fracture ([**7-/2169**])
- BiPap at home for ?OSA
- Major depression
Social History:
Retired attorney (once argued before the supreme court). Lives
alone. H/o tobacco, quit 55 years ago. Denies EtOH. Uses a
scooter to get around, but can walk with a walker.
Family History:
Father -- CVA, fatal, 49 yo
Mother -- MI, fatal, 80s
Sister -- breast cancer, 81 yo
Physical Exam:
Afebrile, VSS, on room air
Gen -- elderly, pleasant male in NAD
HEENT -- sclera anicteric, op clear
Heart -- regular
Lungs -- clear
Abd -- soft, benign, +BS
Ext -- no edema, lesion or rash, wears right brace while
ambulating (with walker)
Psych -- full affect
Pertinent Results:
Admission:
[**2172-5-4**] 06:10PM BLOOD WBC-8.1 RBC-3.99* Hgb-11.1* Hct-33.4*
MCV-84 MCH-27.8 MCHC-33.1 RDW-15.0 Plt Ct-348
[**2172-5-4**] 06:10PM BLOOD Neuts-62.0 Lymphs-28.4 Monos-7.3 Eos-1.7
Baso-0.6
[**2172-5-4**] 06:10PM BLOOD Glucose-120* UreaN-50* Creat-3.3* Na-140
K-3.6 Cl-100 HCO3-26 AnGap-18
[**2172-5-5**] 04:45AM BLOOD Calcium-9.7 Phos-4.1 Mg-2.3
[**2172-5-4**] 07:40PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2172-5-4**] 07:40PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2172-5-4**] 07:40PM URINE RBC-0 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0
================================
Discharge:
[**2172-5-6**] 07:20AM BLOOD WBC-8.8 RBC-3.86* Hgb-11.0* Hct-33.3*
MCV-86 MCH-28.5 MCHC-33.0 RDW-15.0 Plt Ct-343
[**2172-5-6**] 07:20AM BLOOD Glucose-351* UreaN-50* Creat-3.0* Na-139
K-4.1 Cl-102 HCO3-25 AnGap-16
================================
CHEST (PORTABLE AP) [**2172-5-4**] 6:38 PM
FINDINGS: Single bedside AP examination labeled "upright at
18:50" is compared with study dated [**2172-1-31**]; the overall
appearance is not much changed. There are bilateral pleural
effusions with chronic pleural abnormality involving the left
hemithorax, and associated atelectasis. Allowing for this, no
focal consolidation is seen. There is cardiomegaly with LV
enlargement, but no pulmonary vascular congestion or overt
edema. There are atherosclerotic changes involving the thoracic
aorta.
IMPRESSION: Chronic changes, with no definite acute airspace
process.
Brief Hospital Course:
80 year old male with DM2 admitted after accidental insulin
overdose.
Mr. [**Known lastname **] was initially admitted to the [**Hospital Unit Name 153**] for managment of
insulin overdose and monitoring for hypoglycemia. He was on a
dextrose drip for the initial portion of his stay, until humalog
felt to be adequately cleared. He was subsequently transferred
to the general medicine floor, where he had hyperglycemia,
likely related to decreased Lantus dose and rebound effect from
hypoglycemia. [**Last Name (un) **] was consulted for evaluation, and they
recommended discharge on previous home regimen. Diabetic
teaching and close follow up were arranged with primary
providers at [**Last Name (un) **] as outpatient.
Otherwise, his multiple chronic medical problems were stable
throughout his admission and no medications were changed.
Medications on Admission:
Amlodipine 10 mg Tablet [**Hospital1 **]
Calcitriol 0.25 mcg Capsule Daily
Gabapentin 300 mg Capsule TID
Insulin Glargine 46U QHS
Insulin Lispro Sliding Scale
Paroxetine HCl 30 mg Daily
Simvastatin 60 mg Daily
Torsemide 20 mg Tablet Daily
Aspirin 81mg Daily
Epogen [**Numeric Identifier 389**] U/ml 10,000u every other week
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
4. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Simvastatin 40 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
8. Lantus 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime.
9. Humalog
Please resume previous sliding scale as directed by your [**Last Name (un) **]
physician.
Discharge Disposition:
Home With Service
Facility:
Greater [**Location (un) 1468**] VNA
Discharge Diagnosis:
1. hypoglycemia secondary to insulin
Discharge Condition:
stable, mildly hyperglycemic
Discharge Instructions:
You were admitted after an overdose of insulin. You were managed
with infusion of intravenous glucose to prevent life threatening
hypoglycemia.
It is imperative that you take only the amount of insulin as
prescribed according to your sliding scale. If you are having
high blood sugars not responsive to insulin, call your primary
endocrinologist, Dr. [**Last Name (STitle) 978**], prior to administering more
insulin.
Please take all medications as prescribed. Please follow up
with your primary care physician.
[**Name10 (NameIs) **] your doctor or return to the emergency room if you
experience refractory elevated blood sugars, blood sugars less
than 60, symptoms of lightheadedness, loss of consiousness,
palpitations, sweats, chills, nausea, vomiting or abdominal pain
or for any other concerning symptoms
Followup Instructions:
Please call your primary endocrinologist for an appointment
within 7-10 days of discharge:
[**Last Name (LF) 978**], [**First Name7 (NamePattern1) 7208**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Please follow up with your psychiatrist and primary care
physician [**Name Initial (PRE) 176**] 2 weeks of discharge. [**Last Name (LF) **],[**First Name3 (LF) **] S.
[**Telephone/Fax (1) 14148**]
You also have the following appointments scheduled
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20430**], MD Date/Time:[**2172-6-4**] 2:00
Provider: [**Name10 (NameIs) 1248**],CHAIR ONE [**Name10 (NameIs) 1248**] ROOMS Date/Time:[**2172-5-14**]
3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20430**], MD Date/Time:[**2172-5-14**] 2:00
|
[
"327.23",
"E858.0",
"428.22",
"272.0",
"428.0",
"414.01",
"250.80",
"403.90",
"962.3",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5912, 5979
|
3941, 4790
|
366, 373
|
6060, 6091
|
2366, 3918
|
6953, 7772
|
1986, 2071
|
5165, 5889
|
6000, 6039
|
4816, 5142
|
6115, 6930
|
2086, 2347
|
313, 328
|
402, 847
|
869, 1776
|
1792, 1970
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,375
| 182,984
|
30981
|
Discharge summary
|
report
|
Admission Date: [**2153-5-18**] Discharge Date: [**2153-6-12**]
Date of Birth: [**2072-2-11**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
FALLS
Major Surgical or Invasive Procedure:
Right sided burr holes x 2
Right craniotomy x 2
History of Present Illness:
HPI:
The patient is an 81y old man with background of HTN and
neuropathy and unexplained coma. He is transferred today from an
OSH with large R SDH after unwitnessed fall at home 2 days ago.
He was seen with his daughter providing additional background
history.
Mr [**Known lastname 73222**] had a fall at home 4 days ago. His daughter saw him
that day and he seemed well aside from a single episode each of
vomiting and urinary incontinence. He seemed fine on day 2 after
the event. But on day three he said he was not feeling himself
and on the phone seemed to be having trouble finding words, and
was less active than usual. His daughter did observe he was
holding the R eye shut more than usual and this persisted to
today. Today he also had decreased oral intake. She found him
this morning weak and unable to get off the toilet. Says he had
not been there very long. He complains now of double vision. No
H/A, neck or back pain, dizzyness/weakness or paraesthesias.
Past Medical History:
PMH:
Coma ?cause in [**2151**] on the day of his wife's wake
HTN
Thyroid disorder (mild, not on relpacement)
Neuropathy ?Critical care or other
Cataracts with previous OR
Hearing impairment: wears hearing aid usually
Social History:
SH: Lives alone. Has 2 children and 4 step children. Retired.
25y
pack history. Nil in 30y. Nil EtOH in 10y. No drugs.
Family History:
NON CONTRIB
Physical Exam:
ON ADMISSION
Exam:
T-97.9 BP-155/76 HR-73 RR-20 O2Sat96% RA
Gen: Lying in bed, obese
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Some inconsistency between elements of his history and
that of daughter. Eg. he responded in the affirmative regarding
question of PMH of DM, unknown to daughter and no approp
medications for diabetes. Oriented to person, not place or date
([**5-23**]). In attentive, unable to say DOW backwards. Speaks
in short phrases; naming intact for high but not low frequency
objects. No dysarthria. [**Location (un) **] intact. Registers [**2-17**], recalls
0/3 in 5 minutes. No right left confusion. No evidence of
apraxia or neglect.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual fields are full to confrontation. R ptosis
at
rest but able to elevate lid well on command. Extraocular
movements intact bilaterally, few beats horizontal end gaze
nystagmus with diplopia. Sensation intact V1-V3. Facial
movement
symmetric. Hearing impaired for normal voice. Palate elevation
symmetrical. Sternocleidomastoid and trapezius normal
bilaterally. Tongue midline, movements intact.
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
No pronator drift
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: Stocking distribution of decr sensation to light
touch, cold. Unable to sense vibration even at iliac crest. Decr
proprioception.
Reflexes:
+2 and symmetric throughout UE, 1+ bilat patella and 0 at
ankles.
Toes downgoing bilaterally
Coordination: finger-nose-finger normal.
Gait: deferred
Pertinent Results:
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2153-5-19**] 1:17 AM
CT HEAD W/O CONTRAST
Reason: S/P BURR HOLES
[**Hospital 93**] MEDICAL CONDITION:
81 year old man with large R SDH s/p burr holes
REASON FOR THIS EXAMINATION:
?decr in R SDH
CONTRAINDICATIONS for IV CONTRAST: Not needed
INDICATION: 81-year-old male with large right subdural
hemorrhage, status post burr hole placement. Please evaluate for
decrease in size of right subdural hemorrhage.
COMPARISON: [**2153-5-18**].
TECHNIQUE: Non-contrast head CT.
FINDINGS: There has been interval placement of right-sided burr
hole, and interval decrease in size of large right subdural
fluid collection, which remains moderate in size, with layering
foci of high attenuation and new pneumocephalus. Degree of mass
effect upon subjacent cortex has lessened, and degree of
subfalcine herniation has also lessened, with approximately 10
mm of leftward shift of midline structures, compared to 15 mm
seen on previous scan. There is no longer effacement of the
suprasellar cistern.
Note is now made of apparent small left-sided extra-axial fluid
collection, which appears to represent small chronic left
subdural hemorrhage, not well appreciated on prior scan.
IMPRESSION:
1. Status post right frontal burr hole, with interval decrease
in size of right subdural fluid collection. Decreased mass
effect and subfalcine herniation, evidenced by decrease in
leftward shift of normally midline structures. Decreased
effacement of the suprasellar cistern.
2. Small left convexity extra-axial fluid collection likely
represents small chronic left subdural hematoma.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5718**]
DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**]
Approved: SAT [**2153-5-19**] 9:34 AM
RADIOLOGY Preliminary Report !! Wet Read !!
CTA HEAD W&W/O C & RECONS [**2153-5-18**] 6:55 PM
CTA HEAD W&W/O C & RECONS
Reason: KNOWN SDH
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
81 year old man s/p fall 3 days ago with mental status change
and known SDH and SAH
REASON FOR THIS EXAMINATION:
r/o aneurysm
CONTRAINDICATIONS for IV CONTRAST: None.
COMPLEX SUBDURAL COLLECTION OVER THE RIGHT CEREBRAL CONVEXITY
WITH MIXED LOW AND HIGH ATTENUATION REPRESENTING EITHER
HYPERACUTE UPON ACUTE SUBDURAL VS ACUTE ON CHRONIC SUBDURAL.
THIS COLLECTION EXERTS SUBSTANTIAL MASS EFFECT ON THE SUBJACENT
CORTEX WITH 1.5CM LEFTWARD MIDLINE SHIFT OF THE FALX CEREBRI.
THERE IS RIGHT SUBFALCINE HERNIATION AS WELL AS IPSILATERAL
UNCAL HERNIATION WITH EARLY TRANSTENTORIAL HERNIATION DENOTED BY
EFFACENMENT OF THE MESENCEPHALIC CISTERN.
A HYPOATTENUATION COLLECTION ALONG THE LEFT CEREBRAL CONVEXITY
[**Month (only) **] REPRESENT AN OLD CHRONIC SUBDURAL HEMATOMA. THERE IS A
SLIGHT HYPERATTENUATING FOCUS ALONG THE LEFT CEREBRAL CONVEXITY
2:19 WHICH [**Month (only) **] REPRESENT A FOCUS OF ACUTE BLOOD.
NO ANEURISMS IDENTIFIED. FULL REPORT WILL BE ISSUED WHEN 3D
REFORMATTED IMAGES AVAILABLE. [**Doctor Last Name 4391**]
DR. [**First Name (STitle) **] [**Doctor Last Name 4391**]
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2153-5-29**] 1:19 PM
CT HEAD W/O CONTRAST
Reason: please evaluate for interval change
[**Hospital 93**] MEDICAL CONDITION:
81 year old man decreased mental status, s/p SDH evacuations
REASON FOR THIS EXAMINATION:
please evaluate for interval change
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Decreased mental status, status post subdural
hematoma evacuation.
TECHNIQUE: Non-contrast head CT.
FINDINGS: As noted on the prior examination of [**2153-5-28**],
there is an unchanged mixed density subdural hematoma. The
amount of gas in the subdural space has improved since prior
examination. The degree of uncal and subfalcine herniation is
unchanged. There are no new areas of intracranial hemorrhage. No
significant left subdural collection is noted. There is a right
frontal craniotomy.
IMPRESSION: Compared to [**2153-5-28**], there has been no change
in the right cerebral convexity subdural hematoma. There is
unchanged uncal and subfalcine herniation.
DR. [**First Name (STitle) 61688**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Approved: TUE [**2153-5-29**] 4:36 PM
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2153-5-29**] 11:04 AM
CHEST (PORTABLE AP)
Reason: recurrent SDH, dopoff just placed, eval for location
[**Hospital 93**] MEDICAL CONDITION:
81 year old man with SHD and appears SOB
REASON FOR THIS EXAMINATION:
recurrent SDH, dopoff just placed, eval for location
INDICATION: Dobhoff placement.
CHEST, ONE VIEW: Comparison with [**2153-5-21**]. Dobhoff tube is
not seen; it may be looped in the oropharynx. Streaky densities
seen at the left lung base, may represent atelectasis or early
consolidation. Minor atelectasis is seen at the right lung base.
No pneumothorax. Cardiac, mediastinal, and hilar contours are
unchanged.
IMPRESSION: Dobhoff not well seen and may be looped in
oropharynx.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4392**]
Approved: TUE [**2153-5-29**] 10:07 PM
Brief Hospital Course:
Pt was admitted through the emergency department after multiple
falls at home. He was brought to the OR on the day of admission
[**2153-5-18**] for evacuation of a large right SDH. He underwent the
procedure and awoke from anesthesia without complication. His
post-op CT showed decreased mass affect. On [**5-21**] he had mental
status changes and his repeat CT showed worsening of the right
SDH. The patient went back to the OR for re-evacuation via the
previous burr hole on [**2153-5-22**].
He was transferred to step-down unit after meeting pacu criteria
and post op CT was improved. His mental status improved
significantly. His diet and activity were advanced and he was
evaluated by PT and OT. ASA will not be restarted per Dr.
[**Last Name (STitle) **]. He was placed on dilantin and boluses were given
periodically to maintian appropriate levels. On [**2153-5-24**] PT deemed
that he was safe to go with with home PT and did not require
rehab.
The patient fell on [**2153-5-25**] and his repeat head CT showed
increased midline shift and
acute on chronic SDH. The patient's mental status decreased
throughout the day and he had word-finding difficulty and was
only oriented to himself. On [**2153-5-26**] he went back to the OR for a
craniotomy to evacuate the SDH. His post-op CT showed a moderate
decrease in size of the SDH and a decrease in the midline shift.
On [**2153-5-27**] the patient had decreased mental status again as well
as N/V and he had another CT scan which was worse than the
previous one. Once again, there was an increase in size of the
SDH and an increase in the amount of shift. He was taken back to
the OR for re-evacuation. Post-operatively he was oriented x 1
with dysarthria. He was also found to have a thrombus in the
left basilic vein.
On [**2153-5-28**] the patient continued to have confusion and
dysarthria. His CT scan showed an increasing degree of
subfalcine herniation. The decision was made to monitor the pts
progress without repeat operative intervention at this time.
The patient was monitored in the ICU and contiued to remain
encephlopathic appearing on [**5-31**] we did a toxic metabolic work
up: NL liver enzymes; alb 2.7; stopped dilantin started keppra
Bcx neg [**5-28**]; toxicology/inf w/u all normal; EEG encpehlopathic
On [**6-1**] we decide to re-evacuate and place a subdural drain.
Initial post op CT showed good drainage of subdural a follow up
CT on [**6-4**] showed continued chronic subdural with less shift as
post op we decided to keep the drain and irrigate the drain and
initially had increase output. The drain was kept in place
until [**6-6**] and a repeat CT showed Slight decrease in size of
right subdural hematoma with residual 5 mm of leftward midline
shift. The small left collection is unchanged.
His speech improved but it continues to remain his only true
deficit. He passed his speech and swallow on [**6-8**] and his tube
feeding were stopped and diet advanced to soft with nectar thick
liquids. His staples will be removed prior to discharge.
Medically he remained stable he had one +VRE swab.
Medications on Admission:
MEDS:
Flomax 0.4mg qhs
Citalopram 20mg po qd
Aspirin EC 325mg po qd
Protonix 40mg po qd
Metoprolol 50mg po bid
B6 60mg po qd
Acetaminophen prn
Aleve prn (naproxen)
Docusate prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital
Discharge Diagnosis:
SUBDURAL HEMATOMA
Left basilic vein thrombus
Discharge Condition:
NEUROLOGICALLY STABLE
Discharge Instructions:
??????Have a 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,
excessive bending
??????You may wash your hair only after sutures and/or staples have
been
removed
??????You may shower before this time with assistance and use of a
shower
cap
??????Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
??????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 101.4?????? F
Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) 1669**] TO SCHEDULE AN APPOINTMENT WITH
DR.[**Last Name (STitle) **] TO BE SEEN IN 4 WEEKS WITH A HEAD CT.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITH OR WITHOUT CONTRAST
PLEASE FOLLOW UP WITH YOUR CARDIOLOGIST WITHIN ONE WEEK OF YOUR
DISCHARGE.
Completed by:[**2153-6-12**]
|
[
"427.89",
"E888.9",
"496",
"348.4",
"852.21",
"355.8",
"348.39",
"453.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"02.12",
"01.39",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
13328, 13399
|
9258, 12356
|
327, 377
|
13488, 13512
|
3852, 3970
|
14741, 15051
|
1778, 1791
|
12584, 13305
|
8398, 8439
|
13420, 13467
|
12382, 12561
|
13536, 14718
|
1806, 2134
|
280, 289
|
8468, 9235
|
405, 1382
|
2778, 3833
|
2173, 2762
|
2158, 2158
|
1405, 1624
|
1641, 1762
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,086
| 149,787
|
53876
|
Discharge summary
|
report
|
Admission Date: [**2168-4-12**] Discharge Date: [**2168-4-23**]
Date of Birth: [**2083-12-9**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 110521**] is an 84 y.o. female with Alzheimer's dementia who
is s/p unwitnessed fall over a chair. Has Alzheimer's at
baseline, usually uses a cane, was carrying tea and tripped over
chair with + head strike.
While waiting in triage, had R facial twitching, became stiff
and
unresponsive lasting 20-30 seconds. Patient was loaded with
fosphenytoin. Head CT showed multiple intraparenchymal
contusions. Neurosurgery was consulted for further management.
While, in the ED patients blood pressure continued to climb from
180 systolic to 201 mmHg systolic when patient was evaluated.
She is nonverbal and had no complaints. Moreover, patient had
another episode of seizures requiring Ativan and a load of 1gm
of
dilantin.
Past Medical History:
Alzheimers, HTN, osteoporosis
Social History:
unknown
Family History:
unknown
Physical Exam:
O: T: 98.6 BP: 201/110 HR: 92 R 16 100% O2Sats
Gen: frail, elderly woman, with eyes closed appears postictal
HEENT:no racoon or battle sign; eyes: clear, no papilledema,
nose
patent
Neuro:
GCS 10 E4V1M5, postictal and nonverbal, eyes open spontaneously,
localizes to pain in all extremities, not following commands, no
clonus, toes upgoing bilaterally
CT Head - shows multiple intraparenchymal contusions/hemorrhages
between the [**Doctor Last Name 352**] white matter areas. There is blood in the left
occipital and temporal horns. There is a calcified posterior
parietal mass without mass effect.
On the day of discharge [**2168-4-18**]:
deceased
Pertinent Results:
CT HEAD W/O CONTRAST [**2168-4-12**]
1. Multiple areas of intraparenchymal hemorrhage at the
[**Doctor Last Name 352**]-white matter
junction, concerning for hemorrhagic metastatic lesions. Please
correlate
with any known history of malignancy and an MRI can be obtained
for further evaluation.
2. Intraventricular hemorrhage within the left lateral
ventricle.
3. Sclerotic lesion within the right temporal bone, which may
represent a
metastasis in the setting of multiple brain lesions
CT torso [**2168-4-13**]
1. No evidence for acute intrathoracic, intra-abdominal, or
pelvic process on this non-contrast-enhanced CT.
2. Distended bladder in the presence of a Foley catheter.
Clinical
correlation for catheter function is recommended.
3. Scattered subcentimeter pulmonary nodules. Differential
diagnosis
includes metastases in a patient with concern for malignancy.
4. 8 cm right renal cyst containing a smoothly calcified
septation.
Non-urgent ultrasound could be performed for further evaluation
if clinically warranted and if not done recently.
5. 4 mm left thyroid nodule. Non-urgent ultrasound could be
performed for
further evaluation if clinically warranted and if not done
recently.
6. Thick-walled cyst in the left inguinal region, possibly a
seroma, but of indeterminate etiology.
7. Aortobifemoral stent graft, incompletely evaluated in the
absence of
intravenous contrast.
8. Coronary artery and aortic valve calcifications, of
indeterminate
hemodynamic significance.
9. Lumbar vertebral body compression deformities, likely chronic
given the
presence of vertebroplasty material, but chronicity cannot be
determined on this study.
MR HEAD W & W/O CONTRAST Study Date of [**2168-4-13**] 9:04 PM
IMPRESSION:
1. Interval progression of multiple supratentorial
intraparenchymal
hemorrhages which are associated with enhancing nodules
suggesting metastatic
bleeds. Stable intraventricular extension without evidence of
obstructive
hydrocephalus.
2. Innumerable foci of microhemorrhages scattered throughout the
cerebrum
which are compatible with hemorrhage in the setting of amyloid
disease.
Brief Hospital Course:
84 y/o F s/p fall presents with multiple hemorrhagic brain
lesions. In ED, she had a general seizure and was intubated for
airway protection. She was admitted to neurosurgery for further
evaluation. She was transferred to the ICU for Q1H neuro check.
She was bolused with dilantin and 24hr EEG was placed for
monitoring for seizures. MRI head was ordered to further
evaluate lesions. CT torso was done which showed pulmonary
nodules.
Her exam on [**4-13**] was no EO, localize LUE, RUE weak flex, BLE w/d.
She was in new a-fib and placed on a dilt gtt. She was also
febrile overnight and cultures are pending. EEG did not show any
seizure activity since she was placed on dilantin.
On [**4-14**]: A MRI was performed which was consistent with Interval
progression of multiple supratentorial intraparenchymal
hemorrhages which are associated with enhancing nodules
suggesting metastatic bleeds. Stable intraventricular extension
without evidence of obstructive hydrocephalus. Innumerable foci
of microhemorrhages scattered throughout the cerebrum which are
compatible with hemorrhage in the setting of amyloid disease. Dr
[**Last Name (STitle) 724**] of neuro oncology was consulted and given MRI results that
patient has poor prognosis. On exam, the patient was intubated.
She was able to localize left upper extremity. The right upper
extremity the patient exhibited weak flexion. The patient
withdrew to noxious stimulous in the bilateral lower
extremities. There was no eye opening to noxious.
On [**4-15**], A family meeting was held and the patient was made DNR
with plan to await family member arrival for progression to Care
and comfort measures and extubation.
On [**4-16**], The family was at the bedside and there was no change in
the patient status.
on [**4-17**]: The remanding daughter arrived and the MRI images were
reviewed again with the family and the patient was made CMO and
extubated.
On [**4-18**], The patient was surrounded by family and she was
tachycardic at 1150-120. The patients o2 saturation was 72%,
however she then recovered her O2 sat to the low 90's and was
able to be transferred to the floor to remain CMO.
On [**4-19**] and [**4-20**], the pt appeared comfortable with a RR of 18-20.
She was on morphine gtt. As she was unlikely to pass away in
the next 2-3 days, we consulted palliative care for possible
hospice recs. The family expressed their wishes to keep her
here and not transport her at this time.
She passed with family at her side on [**2168-4-23**]
Medications on Admission:
aspirin 81 mg Daily
Calcium 500 + D 500 mg (1,250 mg)-400 unit Tab Daily
folic acid 1 mg daily
Multivitamin Tab Daily
metoprolol succinate ER 25 mg 24 hr Tab Daily
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
multiple brain metastatic hemorrhagic lesions
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2168-4-28**]
|
[
"780.39",
"733.00",
"198.4",
"199.1",
"401.9",
"E885.9",
"277.39",
"V66.7",
"198.3",
"348.5",
"431",
"V49.86",
"427.31",
"331.0",
"294.10",
"437.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
6803, 6812
|
4038, 6556
|
316, 323
|
6902, 6911
|
1908, 4015
|
6967, 7005
|
1197, 1207
|
6771, 6780
|
6833, 6881
|
6582, 6748
|
6935, 6944
|
1222, 1889
|
267, 278
|
351, 1101
|
1123, 1155
|
1171, 1181
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,697
| 115,438
|
31510
|
Discharge summary
|
report
|
Admission Date: [**2164-10-18**] Discharge Date: [**2164-10-25**]
Date of Birth: [**2120-9-9**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
HA/ confusion
Major Surgical or Invasive Procedure:
[**10-18**]:Right craniotomy with tumor resection
History of Present Illness:
44 yo W with PMH of metastatic melanoma s/p radiation and IL-2
tx presented to OSH with HA and confusion. Pts spouse reporting
pt would forget turns in directions while driving, forgets doing
the grocery shopping, short term memory loss and personality
changes over the past week. HA is frontal, worse in the evening,
responds to ibuprofen. No nausea or vomiting. No visual changes.
No focal deficits.
.
In the ED, VS: T 99.1 HR 76 BP 105/49 RR 18 98RA. Head CT showed
mass lesion in the brain with midline shift and associated
edema. Patient received 10mg load dexamethasone and cerebyx
1000mg and was transferred to [**Hospital1 18**] for further management. She
was evaluated by neurosurgery who recommended steroids. She also
received IV morphine for pain control. She was then transferred
to the [**Hospital Unit Name 153**] for further observation.
Past Medical History:
Metastatic melanoma
s/p resection of a right shoulder lesion notable for melanoma in
[**2159-1-24**]. METS to right frontal bone, ascending colon and
right tibia. S/p cyber-knife radiation to the skull on
[**2163-10-11**] and began HD IL-2 therapy on [**2163-11-14**]. S/p XRT to the
right tibia completed on [**2164-3-15**]. Plan for orthopedic surgery
in [**Month (only) 359**] of tibial lesion.
Social History:
She lives with her husband and two children. She lives on the
[**Location (un) **]. She is a teacher. No tobacco. She rarely drinks
alcohol.
Family History:
Mother had pancreatic cancer and diabetes at 63. Her
grandmother's brother died of melanoma and her great grandmother
died of colon cancer.
Physical Exam:
Temp 97.5 HR 72 BP 107/51 RR 12 SpO2 98%
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL, Pupils dilated
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : , No(t) Crackles : , No(t) Wheezes : )
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended
Extremities: Right: Absent, Left: Absent
Skin: Warm, No(t) Rash:
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): Person, place, time, Movement:
Purposeful, Sedated, Tone: Normal
On Discharge:
AOx3, full strength and power throughout upper and lower
extremties.
Pertinent Results:
[**2164-10-18**] 12:15AM WBC-9.3 RBC-3.82* HGB-11.2* HCT-34.4* MCV-90
MCH-29.4 MCHC-32.7 RDW-12.4
[**2164-10-18**] 12:15AM NEUTS-92.4* LYMPHS-6.6* MONOS-0.7* EOS-0.2
BASOS-0.1
[**2164-10-18**] 12:15AM PLT COUNT-377
[**2164-10-18**] 12:15AM GLUCOSE-164* UREA N-19 CREAT-0.7 SODIUM-139
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-26 ANION GAP-11
[**2164-10-18**] 12:40AM PT-13.2 PTT-27.7 INR(PT)-1.1
[**2164-10-18**] 09:01AM PLT COUNT-400
[**2164-10-18**] 09:01AM WBC-6.7 RBC-4.21 HGB-12.6 HCT-37.2 MCV-89
MCH-29.9 MCHC-33.8 RDW-12.2
[**2164-10-18**] 09:01AM OSMOLAL-295
[**2164-10-18**] 09:01AM CALCIUM-9.4 PHOSPHATE-3.4 MAGNESIUM-1.9
[**2164-10-18**] 09:01AM GLUCOSE-127* UREA N-13 CREAT-0.7 SODIUM-138
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-27 ANION GAP-14
[**2164-10-18**] 12:30PM OSMOLAL-293
Labs on Discharge:
[**2164-10-25**] 06:00AM BLOOD WBC-9.6 RBC-3.43* Hgb-10.2* Hct-30.5*
MCV-89 MCH-29.9 MCHC-33.6 RDW-12.3 Plt Ct-512*
[**2164-10-25**] 06:00AM BLOOD Plt Ct-512*
[**2164-10-25**] 06:00AM BLOOD Glucose-108* UreaN-18 Creat-0.7 Na-135
K-4.5 Cl-98 HCO3-31 AnGap-11
[**2164-10-25**] 06:00AM BLOOD Calcium-9.5 Phos-3.7 Mg-2.1
[**2164-10-25**] 06:00AM BLOOD Phenyto-11.5
Imaging:
Head CT [**10-18**]:IMPRESSION:
1. New 4.7 x 5.2 cm mass lesion of the right frontal lobe with
surrounding
the vasogenic edema and subfalcine herniation considering the
rapid
development of the mass lesion, the metastatic disease is most
likely
possibility.
2. Stable 19 mm irregular lytic lesion of the right frontal
bone, stable
since [**2163**] but might still represent a metastatic focus.
Head CT ([**10-18**]):
IMPRESSION:
1. Status post resection of the right frontal mass with blood
and
pneumocephalus formation at the resection site. The vasogenic
edema and
subfalcine herniation are relatively unchanged.
2. Right frontotemporal subdural pneumocephalus, which is an
expected
finding after the recent surgery.
Head CT [**10-22**]:
IMPRESSION: Slight improvement in mass effect. Otherwise, no
significant
change.
Brief Hospital Course:
44 yo female with history of melanoma and now with concerning
findings of CNS metastasis and significant mass effect. She has
had stability of neuro exam over the time in the ICU.
1)Metastatic CNS Lesion--significant mass effect is noted and Rx
is started. Neurosurgery evaluation is underway.
-Transfer to the West if surgical intervention is planned
-Mannitol 50mg q 6 hrs--Serum OSMS to be checked q 6 with goal
of >310 until revised with neuro-surgery or neurology
-Dilantin
-Dexamethasone 4mg q 6 hours
-Neurology to evaluate patient for aid in management and Rx
2)Metastatic Melanoma-
-Will consult oncology (Dr. [**Last Name (STitle) 1729**]
-Will have to defer treatment planning for additional metastatic
sites.
Patient was transferred to the [**Hospital Ward Name **] under the care of Dr.
[**Last Name (STitle) **] to undergo surgical resection of her right sided mass.
Post operatively, she did well and was found to be appropriate
for home discharge. She was continued on steroids, and given
follow up instructions for cyberknife and BTC appointment.
Medications on Admission:
Klonopin
Discharge Medications:
1. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for headache, pain.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*60 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic Melanoma
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been prescribed an anti-seizure medicine, take it as
prescribed and follow up with laboratory blood drawing drawing
in 7 days and fax results to [**Telephone/Fax (1) 87**].
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**11-6**] days for removal of your
sutures and a wound check.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
??????You will not need an MRI of the brain.
You have also had cyberknife schedule to occur on [**2164-11-12**] @
11:15am with [**First Name11 (Name Pattern1) 4224**] [**Last Name (NamePattern4) 4225**], MD Phone:[**Telephone/Fax (1) 1228**]. At this
time, a brain tumor clinic appointment will be scheduled
Completed by:[**2164-10-25**]
|
[
"V10.82",
"198.5",
"V16.0",
"780.09",
"348.5",
"198.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"38.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6955, 6961
|
4924, 5993
|
291, 343
|
7025, 7049
|
2877, 3686
|
8614, 9284
|
1827, 1969
|
6052, 6932
|
6982, 7004
|
6019, 6029
|
7073, 8591
|
1984, 2773
|
2787, 2858
|
238, 253
|
3705, 4901
|
371, 1228
|
1250, 1649
|
1665, 1811
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
890
| 195,962
|
29545
|
Discharge summary
|
report
|
Admission Date: [**2180-12-6**] Discharge Date: [**2180-12-22**]
Date of Birth: [**2113-11-30**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal pain, hypotension, fever.
Major Surgical or Invasive Procedure:
[**2180-12-7**]: ICP monitor placement
[**2180-12-7**]: Successful placement of an 8 French percutaneous right
transhepatic internal-external biliary drain (PCT).
[**2180-12-21**]: Removal of temporary HD cathteter and placement of
Tunneled IJ HD cathterer in Interventional Radiology.
History of Present Illness:
Mr [**Known lastname 70851**] is a 67 year old male who is s/p Whipple surgery in
[**2140**] for biliary versus pancreatic cancer, who presented to OSH
with dyspnea and fevers. Had an episode of RUQ abdominal pain
earlier in day that resolved. No nausea or vomiting. No
diarrhea. Originally thought to be in CHF at OSH and treated
with Lasix 40mg IV, and was also thought to have an infiltrate
on CXR concerning for PNA. However, labs at OSH showed elevated
LFTs and bilirubin 2.6. An abdominal US and MRCP were done,
which showed mildly dilated intra-hepatic ducts that could be
consistent with prior Whipple. He then became febrile and
hypotensive with SBPs in the 60s requiring a dopamine drip.
Transferred to [**Hospital1 18**] for evaluation of possible cholagitis.
Past Medical History:
PMHx:
1. CAD s/p CABG [**2177-12-23**] with SVG to PL of Cx, SVG to OM
branch, LIMA to LAD. There were no bypassable targets in RCA
territory.
2. CKD (baseline Cr 1.4-1.8 in [**2177**])
3. chronic atrial fibrillation ? of s/p MAZE or PVI on coumadin
at home
4. Pancreatic CA vs biliary CA s/p Whipple in [**2140**]'s
5. DM
6. Hyperlipidemia
7. Cardiac Risk Factors include coronary artery disease,
diabetes, and dyslipidemia.
8. Pancreatitis
.
PSHx: Bile duct tumor removal, Cholecystectomy
Social History:
50 pack year smoking history but quit 20 yrs ago, no ETOH X 20
yrs, retired, used to work for GE, lives independently with his
wife.
Family History:
Mother died of an unknown cancer. Father died of an MI at 65.
Brother had an MI at 66. Another brother had a CABG at 55. He
has 2 healthy children.
Physical Exam:
On Admission:
VS: 98.7 130 76/39 20 95
Gen: Ill-appearing man, answering questions
HEENT: MMM, scleral icterus
CV: irregular, tachycardic
Lungs: course BS
Abd: softly distended, non-tender with deep palpation
ext: no c/c/e
Pertinent Results:
On Admission:
[**2180-12-6**] 09:34PM TYPE-ART PO2-104 PCO2-23* PH-7.38 TOTAL
CO2-14* BASE XS--9 INTUBATED-NOT INTUBA
[**2180-12-6**] 09:34PM LACTATE-8.2*
[**2180-12-6**] 09:12PM LACTATE-7.7*
[**2180-12-6**] 09:00PM GLUCOSE-265* UREA N-51* CREAT-3.3*#
SODIUM-137 POTASSIUM-3.3 CHLORIDE-100 TOTAL CO2-16* ANION GAP-24
[**2180-12-6**] 09:00PM ALT(SGPT)-776* AST(SGOT)-1722* ALK PHOS-252*
TOT BILI-3.4* DIR BILI-2.2* INDIR BIL-1.2
[**2180-12-6**] 09:00PM LIPASE-38
[**2180-12-6**] 09:00PM cTropnT-0.08*
[**2180-12-6**] 09:00PM CK-MB-17*
[**2180-12-6**] 09:00PM ALBUMIN-3.2* CALCIUM-7.3* PHOSPHATE-2.7
MAGNESIUM-0.9*
[**2180-12-6**] 09:00PM URINE HOURS-RANDOM
[**2180-12-6**] 09:00PM URINE GR HOLD-HOLD
[**2180-12-6**] 09:00PM WBC-18.8*# RBC-3.43* HGB-9.8* HCT-30.5*
MCV-89 MCH-28.6 MCHC-32.2 RDW-14.4
[**2180-12-6**] 09:00PM NEUTS-89* BANDS-0 LYMPHS-1* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-9* MYELOS-0
[**2180-12-6**] 09:00PM HYPOCHROM-OCCASIONAL ANISOCYT-OCCASIONAL
POIKILOCY-1+ MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL
POLYCHROM-1+ STIPPLED-1+ BITE-OCCASIONAL ELLIPTOCY-1+
[**2180-12-6**] 09:00PM PLT SMR-LOW PLT COUNT-112*#
[**2180-12-6**] 09:00PM PT-29.6* PTT-37.5* INR(PT)-2.9*
[**2180-12-6**] 09:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2180-12-6**] 09:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
.
IMAGING:
[**2180-12-6**] ABD/PELVIC CT W/CONTRAST:
1. Probable 1.4-cm distal CBD stone/debris.
2. Two ovoid foci of high-attenuation in the pancreatic neck
raising possibility of hemorrhagic lesions vs partially
calcified lesion. No pancreatic ductal dilatation. Differential
considerations include hemorrhagic metastases versus hemorrhagic
pseudocyst vs amorphous calcification/debris in pancreatic duct,
although no ductal dilatation. Further evaluation with MRCP is
advised.
3. Mediastinal and retroperiteonal lymphadenopathy, raising the
possibility of an underlying hematological/lymphomatous
malignancy vs. metastases, although not typical presentation for
pancreatic metastases. Close interval followup and further
clinical evaluation is recommended.
.
[**2180-12-7**] Echocardiogram:
The left atrium is markedly dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function.
Compared with the prior study (images reviewed) of [**2180-12-7**],
biventricular systolic function is improved.
.
[**2180-12-10**] HEAD CT:
There are a number of small foci of diminished density within
the white matter of both cerebral hemispheres, most evident in
the left frontal periventricular white matter and more
distinctly within the left lentiform nucleus, and to a lesser
extent, the right lentiform nucleus. There is a probable
punctate focus of diminished density within the right cerebellar
hemisphere. While nonspecific in etiology, given patient age,
chronic small vessel infarction would appear the most likely
diagnosis. There is no hydrocephalus or shift of normally
midline structures. There is mild peripheral cerebral atrophy.
There is heavy atherosclerotic calcification of the cavernous
internal carotid arteries, and to a moderate extent, the distal
vertebral arteries at the level of the foramen magnum. The
surrounding osseous and extracranial soft tissues reveal mild
air-fluid levels within the sphenoid sinus, as well as mild
bilateral ethmoid sinus mucosal thickening, likely representing
effects of intubation. Multiple metal staples are seen in the
right frontal scalp, at the site of the former bolt insertion.
CONCLUSION: No intracranial hemorrhage. Probable chronic
small-vessel infarction.
.
[**2180-12-12**] BILAT LOWER EXT VEINS:
No deep venous thrombosis involving the right or left lower
extremity.
.
[**2180-12-14**] Tube Cholangiogram/CHALNAGIOGRAPHY:
Cholangiogram performed through the existing biliary catheter
showed the catheter to be in a satisfactory position and
draining well. There was no evidence of any bile duct
obstruction seen. A minor adjustment was made to the catheter
position by pushing it in by about a centimeter.
Brief Hospital Course:
The patient was transferred from an OSH and was admitted to the
General Surgical Service in the SICU on [**2180-12-6**] for spetic
shock and cholangitis. In the Emergency Department, he was made
NPO and intubated, intensive fluid rescusitation was initiated,
a foley catheter was placed, initially started on Levophed and
Neomycin in ED changed to Neo and Vassopressin for pressure
support, lines placed, and started on empiric IV Vancomycin and
Zosyn. Abdominal CT revealed high density material in the CBD
and projecting over the pancreatic neck and body, question of
stones, calcification. Mild biliary dilation, without other
acute abnormalities to explain patients clinical condition.
Cardiology consulted; felt that EKG changes and troponin leak
indicative of likely demand ischemia due to septic picture.
Recommended ECHO, diuresis, hold off on cardioversion. Patient
takes coumadin at home for history of atrial fibrillation,
arriving with INR 2.9. Recieved a total of 8 units of FFP in
preparation for percutaneous transhepatic biliary drain (PTBD)
placement in Interventional Radiology. On [**2180-12-7**], the patient
underwent Percutaneous transhepatic cholangiogram, placement of
an 8 French internal-external locking right percutaneous biliary
drain, and post-tube placement cholangiogram. PTBD was placed to
gravity drainage. Transfer to inpatient unit occurred on
[**2180-12-16**].
.
NEURO: Upon return from OR for PTC placement, he was noted to
have fixed and dilated right pupil. He was intubated, sedated
and still hemodynamically very unstable so a Head CT was unable
to be obtained at this point. Neurology and, subsequently,
Neurosurgery were consulted for evluation of pupilary findings.
An ICP monitor bolt placed with an opening ICP of 20mm. When
re-examined the next morning, pupils were small and reactive. On
[**2180-12-10**], the [**Last Name (un) 8745**] bolt was removed, and a Head CT performed,
which showed no intracranial hemorrhage, but probable chronic
small-vessel infarction. He remined neurologically intact.
The patient received Fentanyl PRN in the SICU with good effect.
When transferred to the inpatient floor, he was nolonger
experiencing any pain, and did not require pain medications
other than acetaminophen PRN.
.
CV: Upon admission, the patient required three pressors to
maintain hemodynamic stablitiy. Cardiology was consulted for
uncontrolled atrial fibrillatio, and the patient was started on
a Diltiazen drip. Weaned off pressors on [**2180-12-10**]. Diltiazem was
transitioned to Metorpolol with the patient ultimately stable on
125mg PO BID. Warfarin was restarted on [**2180-12-15**], but discontinued
on [**2180-12-18**]. Held for [**2180-12-21**] Tunneled HD catheter placement.
Coumadin restarted at 2mg in the evening. PT/INR should be
checked daily at Rehab facility until therapeutic; INR goal 2.5
with a therapeutic range of [**1-17**]. Once on the floor, the
patient's other anti-hypertensive and diuretic medications were
restarted. He remained cardiovascularly stable.
.
Pulmonary: Upon admission, the patient was intubated and placed
on mechanical ventilation for need of aggressive fluid
rescusitation and hemodynamic instability. He became fluid
overloaded, which responded well to CVVH diuresis, with
resultant improvement in respiratory status. He was extubated on
[**2180-12-16**] without problem. Thereafter, the patient remained
stable from a pulmonary standpoint; vital signs were routinely
monitored. Good pulmonary toilet, early ambulation and incentive
spirrometry were encouraged throughout hospitalization.
.
GI/GU/FEN: Upon admission, the patient was made NPO with IV
fluids. ON [**2180-12-8**], he was started on CVVH after placement of a
temporary HD catheter. On [**2180-12-9**], he was negative 1300mL via
CVVH diuersis. He was doing very well with CVVH with up to 20kg
of fluid removed, close to dry weight. Began recovering some
renal function with excellent urine output, albeit with lasix.
Overall, he tolerating Continuous renal replacement therapy
(CRRT) well. He had experienced respiratory alkalosis on
[**2180-12-12**], which compensated with metabolic acidosis CRRT fluid
changed to BB32.
A dobhoff was placed, and tubefeeds started on [**2180-12-11**], which
were continued until [**2180-12-16**], when discontinued and the dobhoff
removed. The patient underwent a swallow evaluation, and was
started on a renal diet on [**12-18**]/201, which he tolerated.
Patient's intake and output were closely monitored, and IV fluid
was adjusted when necessary. Electrolytes were routinely
followed, and repleted when necessary.
Renal felt that the patient was experiencing acute renal failure
in the context of a history of mild chronic renal insufficiency
and acute spetic shock. It is expected that hemodialysis will be
a temporary intervention, and that recovery to baseline can be
expected. Final Renal recomemendations were enclosed with the
patient's discharge inforamtion.
The PTBD was capped on [**2180-12-20**], which was well tolerated
without abdominal pain, nausea, vomiting or fever. He will be
discharged with the capped PTBD. In 1 month, the patient will
have a repeat PTBD cholangiogram with possible diliation as an
outpatient. Potential discontinuation of the PTBD will be
determined at future follow-up with Dr. [**Last Name (STitle) **].
.
ID: Admitted with septic shock, with Blood culture at OSH with
strep bovis/clostridium clostriforme, blood cultures here were
negative. Was started on meropenem/vancomcyin. Infectious
Disease Service consulted. Bile cultures with polymicrobial
organisms. Changed to ceftriaxone and flagyl. Then changed to
Unasyn alone to treat the S. bovis, clostridium, and the
bacteroides in the bile culture. The patient's white blood count
and fever curves were closely watched for signs of infection.
Staples on scalp from previous bolt removed prior to discharge.
.
Endocrine: Given his acute renal failure, home Metformin was
stopped, and the patient was placed on an insulin regimen. The
[**Last Name (un) **] Diabetes Service was consulted. The patient's blood sugar
was monitored throughout his stay; insulin dosing was adjusted
accordingly. At the time of discharge, the patient was receiving
Lantus 20units QHS plus sliding scale insulin with good glycemic
control.
.
Hematology: While hospitalized, the patient received 10 units of
FFP, most of which were given initially upon admission to
correct his INR before emergent PTBD placement. Other units were
given prior to invasive procedures, such as tunneled HD catheter
placement. He received 1 unit PRBCs on [**2180-12-18**] for a HCT
23.0/HGB 7.4 during CVVH. He was started on erythropoietin as
part of his dialysis regimen. Pre-discharge HCT 23.9 /HGB 8.1 on
[**2180-12-22**] for which one unit was transfussed during dialysis
prior to discharge.
.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating his renal
diet, ambulating, voiding without assistance, and was not
experiencing any significant pain. He was discharged to an
extended care facility with inhouse HD capabilities for
rehabilitation. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Asa 81 mg daily
Lisinopril 5mg daily
Metformin 1000 mg [**Hospital1 **]
Creon
Protonix 40 mg daily
Simvastatin 40 mg daily
Amlodipine 10 mg daily
Coumadin 2mg daily
Lopressor 100 mg [**Hospital1 **]
bumetanidine 2 mg daily
Discharge Medications:
1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-16**]
Drops Ophthalmic PRN (as needed) as needed for eye irritation.
2. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Amylase-Lipase-Protease 60,000-12,000- 38,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
4. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO BID (2
times a day).
5. Bumetanide 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Acyclovir 5 % Ointment Sig: One (1) Appl Topical ASDIR (AS
DIRECTED).
8. Lantus 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
9. Insulin Lispro 100 unit/mL Solution Sig: 2-16 units
Subcutaneous As directed per Humalog Insulin Sliding Scale.
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
11. Coumadin 2 mg Tablet Sig: One (1) Tablet PO QEVENING.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
1. Cholangitis
2. Septic shock secondary to strep bovis and clostridium
clostridiiforme bacteremia
3. Demand ischemia - resolved
4. Anisocoria with elevated intra-cranial pressure - resolved
5. Acute renal failure in the context of mild chronic renal
insufficiency and septic shock. Expect resolution with temporary
hemodialysis.
.
Secondary:
1. Type II DM
2. Atrial fibrillation
3. CAD
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-23**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
PTBD 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).
*The drain is capped. Call the doctor, nurse practitioner or
nurse if you expereince fever, abdominal pain, nausea, vomiting.
*Wash the area gently with warm, soapy water or 1/2 strength
hydrogen peroxide with a sailine rinse, pat dry, and place a
drain sponge.
*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.
Monitor the hemodialysis catheter site for redness, swelling,
increased pain, or drainage from the insertion site. Follow care
instructions as advised by your Dialysis Nurse.
Followup Instructions:
Please call ([**2181**] to arrange a follow-up appointment
with Dr. [**Last Name (STitle) 39375**] (PCP) in [**1-17**] weeks.
.
Please call ([**Telephone/Fax (1) 2828**] to schedule a follow-up appointment
with Dr. [**Last Name (STitle) **] (Surgery) in 3 weeks.
Completed by:[**2180-12-22**]
|
[
"250.00",
"V58.61",
"576.2",
"272.4",
"379.41",
"785.52",
"V10.09",
"414.00",
"995.92",
"518.81",
"038.0",
"276.3",
"276.6",
"585.2",
"584.5",
"V45.81",
"576.1",
"427.31",
"276.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"87.54",
"87.51",
"96.72",
"96.04",
"96.6",
"01.10",
"38.93",
"38.95",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
16317, 16396
|
7533, 15000
|
351, 639
|
16836, 16836
|
2537, 2537
|
18404, 18699
|
2126, 2278
|
15273, 16294
|
16417, 16815
|
15026, 15250
|
16981, 18381
|
2293, 2293
|
276, 313
|
667, 1444
|
5869, 7510
|
2552, 5860
|
16850, 16957
|
1466, 1959
|
1975, 2110
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,676
| 135,916
|
1479
|
Discharge summary
|
report
|
Admission Date: [**2184-3-6**] Discharge Date: [**2184-4-2**]
Date of Birth: [**2109-9-28**] Sex: M
Service: MEDICINE
Allergies:
Zocor
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Central venous line placement
Endotracheal Intubation
Arterial Line placement
History of Present Illness:
-- per admitting hospitalist --
74 year-old man presents with fatigue, chills, and poor PO
intake over one month. Patient reports that two months ago, he
was able to walk 30 minutes/day with weights, but over the few
weeks prior to admission, he has felt fatigued and is more
easily fatigued. He has daytime somnolence and night insomnia.
He denies any localizing symptoms. He denies nausea, vomiting,
anorexia, abdominal pain, melena, BRBPR, new lymphadenopathy,
meningismus. Patient denies weight loss, but on review of the
records, patient has lost 10 pounds over one month. He reports
lightheadedness and dizziness with standing for several weeks.
Of note, he presented to his PCP [**Last Name (NamePattern4) **] [**2184-2-12**] with fatigue and
weakness. He was found to have a low normal TSH (0.46) and low
free T4 (0.9). He was referred to endocrinology for evaluation
of central hypothyroidism. He was also found to be anemia to Hct
of 30 with his last checked Hct 41.6 six years prior with anemia
labs consistent with anemia of chronic disease.
In [**Hospital1 18**] ED, his vitals were T 103.5, HR 125, BP 96/ 52, RR 18,
98% on RA. He was found to be markedly dehydrated. A right groin
line was placed and he was given 7L of IVF. He remained
hypotensive at 81/46, so he was started on Levophed 0.2. He was
given Vancomycin, Ceftriaxone, and Decadron as he was initially
alert and oriented x3 but tangential in thought for concern for
meningitis. His mental status improved with hydration therefore
LP was not pursued.
Past Medical History:
Coronary artery disease s/p cardiac cath in [**2175**]
Hypertension
Chronic renal insufficiency
Hyperlipidemia
Benign prostatic hyperplasia
Insomnia
Social History:
Patient is a former smoker, quit at age 42. Used to drink beer
or wine twice daily but has not drank for a month due to
fatigue.
Family History:
Mother died at 95 secondary to CAD. Father died at 85 secondary
to pancreatic cancer and had known colon cancer. He is married
with three children.
Physical Exam:
VS: T: 97.9, BP 122/84, RR 15, 98% on 2LNC
GEN: No acute distress
HEENT: EOMI, Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
CHEST: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
SKIN: No rash
EXT: Warm, well perfused, 2+ pulses, trace pedal edema
NEURO: Alert and oriented x3, CN 2-12 intact, strength 5/5
BUE/BLE, sensory intact, fluent speech
PSYCH: Calm, appropriate
Pertinent Results:
[**2184-3-6**]
WBC-4.3 RBC-2.69* Hgb-7.9* Hct-24.7* MCV-92# Plt Ct-184
Neuts-66 Bands-2 Lymphs-14* Monos-13* Eos-0 Baso-0 Atyps-5*
Metas-0 Myelos-0
PT-15.4* PTT-32.4 INR(PT)-1.3*
Glucose-159* UreaN-46* Creat-2.4* Na-133 K-4.6 Cl-100 HCO3-21*
AnGap-17
ALT-21 AST-36 CK(CPK)-12* AlkPhos-139* TotBili-0.9 ALB 2.2
TotProt-6.3* Calcium-8.5 Phos-4.6* Mg-1.8
Lactate-2.6* K-4.5
Lipase 21
ABG 7.49 / 67 / 35
Serial troponins negative
RHEUM:
[**Doctor First Name **] 1:40
CRP-110.4* ESR-142*
ENDO:
T4-3.3* Free T4-0.87*
07:45AM BLOOD Cortisol-11.0
02:00PM BLOOD Cortisol-24.2*
HEME:
Iron 15, TIBC 146, HAPTO 263, FERRITIN 1532, TRF 112, RETIC 1.9
VIT B12 767, FOLATE 14.7, Methylmalonic acid 280
SPEP Elevated IgG
ID:
BLOOD CULTURES all no growth to date
URINE CULTURES negative
SPUTUM CULTURE negative
HIV negative
Monospot negative
Lyme serology negative
MRSA screen negative
RPR Non-reactive
FUNGAL CULTURE [**2184-3-20**] PENDING
EBV IgM Ab PENDING
CMV IgG IgM PENDING
HBsAg PENDING
HBsAb PENDING
HBcAb PENDING
HCV Ab PENDING
CXR [**2184-3-6**] IMPRESSION: No definite pneumonia, but PA/lateral
recommended when clinically feasible given tenting along right
hemidiaphragm.
CT ABD/PEL [**2184-3-9**]:
1. Faint pulmonary ground-glass opacities may represent atypical
infection or small airways inflammation.
2. Splenomegaly.
3. Bilateral adrenal nodules.
4. Severe atherosclerotic disease, with likely high-grade
stenosis of the
left renal artery origin.
5. Small fusiform dilatation of infrarenal aorta.
6. Small hypoattenuating renal lesions, too small to
characterize by CT
criteria.
VQ LUNG SCAN [**2184-3-11**]:
IMPRESSION: Intermediate-level suspicion (30-40%) for PE.
CTA CHEST [**2184-3-12**]:
1. No pulmonary embolism or acute aortic pathology.
2. Mild subpleural inter- and intra-septal thickening with lower
lobe
predominance but without honeycombing, raising suspicion for
interstitial lung disease such as NSIP or early UIP. Recommend
followup in six months with HRCT in prone position.
3. AP-elongation of upper trachea and lunate-shaped lower
trachea,
incompletely assess but suspicious for tracheobronchomalacia.
Recommend
followup with dedicated CT trachea if clinically indicated.
4. Marked coronary artery calcification.
5. Right adrenal nodule, grossly unchanged.
BONE MARROW BX [**2184-3-13**]:
1. MARKEDLY HYPERCELLULAR (80-90% CELLULAR) MYELOID DOMINANT
BONE MARROW WITH DYSERYTHROPOIESIS AND DYSMEGAKARYOPOIESIS, SEE
NOTE 1.
2. INCREASED IRON STORES WITH DECREASED SIDEROBLAST SUGGESTIVE
OF ANEMIA OF INFLAMMATORY BLOCK.
3. MILD PLASMACYTOSIS, SEE NOTE 2.
NOTE 1: In a patient with cytopenias, the marrow findings of
hypercellularity and dyspoiesis raise the possibility of
involvement by a myelodysplastic process. Please correlate with
clinical findings to exclude other secondary causes of marrow
insults which may lead to dyspoietic changes; suggest follow-up
and repeat biopsy, if cytopenia persists in the absence of
identifiable secondary causes. Please correlate with cytogenetic
findings.
NOTE 2. Plasma cells are 3% of aspirate differential and 10-15%
of marrow core biopsy cellularity by CD138 staining. However, by
immunoglobulin light chain staining, plasma cells appear
polytypic with a slight lambda predominance, and morphologic
findings diagnostic of a plasma cell myeloma are not seen in
material evaluated. Please correlate with clinical, other
laboratory (e.g. SPEP, UPEP etc) and radiologic findings.
CT HEAD [**2184-3-13**] IMPRESSION: No hemorrhage, edema, or evidence of
acute process.
ECHOCARDIOGRAM [**2184-3-15**]: The left atrium is normal in size. The
estimated right atrial pressure is 0-10mmHg. Left ventricular
wall thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No masses or
vegetations are seen on the aortic valve, but cannot be fully
excluded due to suboptimal image quality. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No masses or
vegetations are seen on the mitral valve, but cannot be fully
excluded due to suboptimal image quality. Trivial mitral
regurgitation is seen. No masses or vegetations are seen on the
tricuspid valve, but cannot be fully excluded due to suboptimal
image quality. The pulmonary artery systolic pressure could not
be determined. There is an anterior space which most likely
represents a promient fat pad.
Compared with the report of the prior study (images unavailable
for review) of [**2176-3-18**], posterior wall hypokinesis cannot be
definitively identified. No vegetations identified, but the
images are suboptimal. If clinically indicated, a
transesophageal echocardiographic examination is recommended.
RIGHT TEMPORAL ARTERY BIOPSY [**2184-3-18**]: Temporal artery with
intimal hyperplasia. No arteritis seen.
MRI Brain and Pituitary [**2184-3-21**] IMPRESSION:
- Multiple punctate bifrontal and left parietal acute embolic
infarcts, without significant mass effect or associated shift of
midline structures.
- No abnormality of the pituitary gland is seen.
- Left mastoid opacification.
Brief Hospital Course:
74 year old man who presented with one month of fatigue and FUO.
Initially admitted to ICU with hypotension, treated with
pressors and IVF, which then were successfully weaned off.
Patient was called out to floor. Patient underwent an extensive
fever workup for hematologic, infectious, rheumatologic, and
endocrine sources, none of which revealed a definitive
diagnosis.
The patient developed altered mental status during the
admission; imaging of the head demonstrated multiple acute
embolic infarcts. A TTE/TEE showed no evidence of vegetations.
No other cause for thromboembolic phenomena was identified. The
patient's neurological status continued to decline on the floor,
and he became tachypneic / dyspneic but remained stable on
oxygen.
During one night of admission on the floor, the patient became
acutely unresponsive and was found to be asystolic. A code blue
was called and the patient underwent CPR for PEA/asystole for
approximately 20 minutes, after which the patient was brought
back into NSR with a palpable pulse.
He was re-admitted to the ICU and underwent the Arctic Sun
cooling protocol. Following rewarming, the patient remained
unresponsive and with a persistent vasopressor requirement.
Additional infectious workup continued to be negative. Repeat
MRI brain was suggestive of watershed infarcts possibly
sustained during cardiac arrest.
After extensive discussion with the patient's family, including
his wife, it was decided that comfort measures only would be
pursued. Vasopressors were withdrawn, the patient was extubated
and expired quietly thereafter at 3:05 PM on [**2184-4-2**].
Medications on Admission:
Atorvastatin 20 mg daily
Nitroglycerin 0.3 SL prn chest pain
Toprol 25 mg XL daily
Zestril 10 mg daily
Zolpidem 10 mg qhs
Aspirin 325 mg daily
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
N/A
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2184-4-2**]
|
[
"585.3",
"427.5",
"486",
"785.51",
"434.91",
"780.79",
"600.00",
"E879.8",
"996.62",
"414.01",
"403.90",
"790.7",
"244.9",
"780.60",
"287.5",
"584.9",
"285.21",
"518.81",
"276.4",
"276.1",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.21",
"03.31",
"88.72",
"38.91",
"96.72",
"38.93",
"41.31",
"96.04",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10279, 10288
|
8432, 10058
|
270, 349
|
10335, 10340
|
3028, 8409
|
10392, 10551
|
2243, 2392
|
10251, 10256
|
10309, 10314
|
10084, 10228
|
10364, 10369
|
2407, 3009
|
225, 232
|
377, 1909
|
1931, 2081
|
2097, 2227
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,951
| 177,458
|
10210
|
Discharge summary
|
report
|
Admission Date: [**2155-10-10**] Discharge Date: [**2155-10-15**]
Date of Birth: [**2083-8-7**] Sex: M
Service: Medicine Oncology
HISTORY OF PRESENT ILLNESS: This is a 72-year-old male with
a history of non-small cell lung cancer, diagnosed in [**2155-5-13**] who initially presented with dyspnea on exertion and
discovered to have a right sided malignant effusion that was
subsequently treated with talc pleurodesis. He has had an
indwelling pleural catheter, which was used to drain his
pleural space q3 days and has previously had a negative work
up for metastasis, who then underwent six cycles of
carboplatin and Taxol, which was completed one week ago. He
felt well until the day prior to admission when he developed
mild dyspnea, malaise and a productive cough with green
sputum. He had a routine visit in the oncology clinic on the
day prior to admission for blood work and administration of
Aranesp. His ANC was found to be 180, it was previously 3850
on the 22nd. Later that evening the patient checked his
temperature and it was 101, so he went to the ER and was
found to have a temperature of 102.5. He was hypotensive, as
low as 80/48. The patient was pancultured, received 4 to 5
liters of IV normal saline and 2 grams of cefepime. The
blood pressure remained low, so he was started on peripheral
dopamine which caused increased tachycardia, so the dopamine
was discontinued. A right IJ triple lumen catheter was
placed and he was started on Levophed and admitted to the
intensive care unit. The patient denied chest pain, dysuria,
anorexia, melena, bright red blood per rectum, pain at the
chest tube site. He does have numbness and paresthesias of
his hands and feet, which started at the time of initiating
chemotherapy.
PAST MEDICAL HISTORY:
1. Nonsmall cell lung cancer diagnosed in [**2155-5-13**] by
right malignant effusion, talc pleurodesis with Pleurovac in
[**2155-5-13**], status post six cycle of carboplatin and Taxol
therapy, completed one week ago.
2. Dupuytren's contractures correction in the right hand.
3. Hard of hearing.
4. Right hip arthroplasty at [**Hospital6 2910**] in
[**2154**].
5. Seasonal allergies.
ALLERGIES: Bone scan tracer causes a rash, Percocet leads to
nausea and vomiting.
MEDICATIONS: He is on GCSF, it was left given on [**10-5**],
he is on Aranesp last given [**6-10**] and has completed his
course, multi-vitamin.
SOCIAL HISTORY: He had asbestos exposure while in the
military; he worked in the engine room of a ship for 4 years,
which was lined with asbestos. He is a former tobacco
smoker; he smoked one pack a day and pipe smoking for 4
years, he quit in [**2155-4-12**]. Alcohol - he drinks 12 to
24 beers a week. He has no history of drug use. He lives
with his wife, he is a retired mechanic and is DNR and DNI.
FAMILY HISTORY: Father had a history of blood clots. His
mother died of an intracerebral bleed, no history of lung
cancer or any malignancies.
PHYSICAL EXAMINATION: Vital signs in the ER, temperature of
102.0, heart rate 116, blood pressure 131/68, oxygen
saturation 94% on room air. He is an elderly white male in
no apparent distress. HEENT - PERRL, EOMI, anicteric, mucous
membranes are moist. Neck - right IJ catheter in place, no
lymphadenopathy. Lungs - decreased breath sounds on the
right, an indwelling chest tube catheter, generally clear,
but with mild expiratory wheezes throughout. Cardiovascular
is tachycardia, normal S1 and S2, regular rhythm, no murmurs,
rubs or gallops. Abdomen is mildly distended, hypoactive
bowel sounds, no masses, nontender. Extremities - no
clubbing, cyanosis or edema, he has 2+ DP pulses bilaterally.
Skin - there are no rashes. Neurologic - decreased sensation
to light touch on his feet, strength 5/5 on the lower
extremities, globally decreased strength to [**5-17**] on his right
lower extremity, hip, knee and ankle and the patient
attributes this to his hip replacement and sciatica.
LABS ON ADMISSION: White count was 1.7, differential - 4
neutrophils, 4 bands, 50% lymphocytes, 18% monos, 8 meta and
12 myelocytes. His ANC was 320, hematocrit 28, platelets
100. PT 14, PTT 60.4. His INR 1.3. His chem-7 was normal
with the exception of potassium of 3.4. His urinalysis was
negative. Blood cultures and urine cultures were sent from
the emergency room. A chest x-ray showed persistent right
hydrothorax. The left lung was clear. A repeat chest x-ray
showed the right IJ catheter tip in the distal superior vena
cava.
The patient was admitted to the intensive care unit for
febrile neutropenia and hypotension and requiring pressor
therapy.
HOSPITAL COURSE BY SYSTEMS:
1. Febrile neutropenia: He was started on cefepime 2 grams
IV q8 hours for empiric coverage. Blood cultures and urine
cultures were followed. Although the chest x-ray did not
show signs of an infiltrate the right sided effusion could
have been obscuring a pneumonia on the right. The pleural
space was drained and cultured. On the first day the patient
was hemodynamically stable and was transferred to the general
floor on 3 liters of oxygen nasal cannula. Throughout his
hospital course he was started on Levaquin for suspected
pneumonia. At the time of discharge his blood cultures were
negative to date. His pleural cultures had grown greater
than 3 colony types with first growth coag negative organisms
and his sputum had been consistent with oropharyngeal flora.
2. Pulmonary: The patient had pneumonia as stated above.
He also had an increasing effusion in his right lung.
Interventional pulmonary was contact[**Name (NI) **] regarding further
recommendations with how to manage his malignant effusion.
CT surgery was also contact[**Name (NI) **] regarding his candidacy for a
VATS procedure, however, CT surgery decided that given his
overall picture he was not a candidate for the VATS
procedure, so they recommended leaving the drain to gravity,
however, the patient received interventional pulmonary, the
fluid would be drained on [**10-14**] and they would continue
to follow fluid cultures. The initial pleural fluid studies
were not consistent with empyema. At the time of discharge
he went home continuing his regular catheter care.
3. Anemia: Over the hospital course he was transfused 2
units. His hematocrit remained stable, in the low 3-0 silk
for the rest of his hospital course.
4. Heme: The patient was noted to have an elevated PT and
PTT, his fibrinogen level was elevated, so it was felt that
this was likely secondary to a vitamin K deficiency. The
patient was given one dose of p.o. vitamin K on [**10-12**].
5. Neutropenia: The patient's neutropenia resolved without
the use of GCSF. No further precautions were taken at the
time.
6. The patient was seen by physical therapy during this
hospital course and it was felt that he would need follow up
about 3 to 5 times a week for gait training and endurance
training.
The patient was discharged home on [**2155-10-15**] with the
following discharge instructions of an antibiotic.
FINAL DIAGNOSES:
1. Small cell lung cancer with malignant right pleural
effusion.
2. Febrile neutropenia.
3. Pneumonia.
FOLLOW UP: Follow up with oncologist, Dr. [**Last Name (STitle) **].
INVASIVE PROCEDURES: He had his effusion drained.
DISCHARGE MEDICATIONS: He was discharged home on home oxygen
by nasal cannula and titrate the oxygen so that his
saturation remained above 93% with ambulation and activity.
He was also discharged home on multi-vitamin one capsule p.o.
q.day as well as the admission medications and Levaquin for 3
more days 500 mg p.o. and Albuterol with ipratropium bromide
inhalers to use p.r.n..
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 11-160
Dictated By:[**Name8 (MD) 8736**]
MEDQUIST36
D: [**2155-10-30**] 16:41
T: [**2155-11-3**] 09:32
JOB#: [**Job Number 34059**]
|
[
"162.9",
"V55.8",
"288.0",
"486",
"458.9",
"197.2",
"285.22",
"286.7",
"V43.64"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2839, 2968
|
7322, 7905
|
4664, 7051
|
7068, 7175
|
7187, 7298
|
2991, 3973
|
176, 1768
|
3988, 4636
|
1790, 2412
|
2429, 2822
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,346
| 198,826
|
3712+3713+3714
|
Discharge summary
|
report+report+report
|
Admission Date: [**2128-7-11**] Transfer Date: [**2128-7-13**]
Date of Birth: [**2090-7-13**] Sex: F
Service: MEDICAL ICU/GREEN TEAM
HISTORY OF PRESENT ILLNESS: The patient is a 37-year-old
woman with a history of Susac syndrome which is an
inflammatory/vasospastic disease of small blood vessels that
leads to multiple microinfarctions in the brain, and history
of depression. The patient was transferred from an outside
hospital after an unwitnessed ingestion of Prozac (60 pills x
20 mg/pill) and verapamil SR ([**5-9**] pills x 180 mg/pill) at
about 10:30 pm on the day prior to admission in an attempted
suicide.
The patient was found by husband the morning of admission
facedown on the floor but conscious and vomiting. The
patient was brought to an outside hospital where, on arrival,
she had vomiting, suicidal ideation. Vital signs were 84/45,
heart rate 80, respiratory rate 16, O2 sat 97% on room air.
ECG at the outside hospital showed normal sinus rhythm with
prolonged QT interval. Pacer pads were placed but not used.
Blood pressure decreased to the 70s/40s, heart rate decreased
to the 50s, and ECG changed to a questionable complete
heart block. The patient was given calcium gluconate,
potassium chloride, Zofran, insulin, D5 drip, magnesium,
atropine, charcoal, and an NG tube was placed. The patient
was also given about 2 liters of normal saline. The patient
was started on dopamine for her low blood pressure, and then
later Levophed also for her low blood pressure. A left
subclavian central line was also placed at the outside
hospital, and urine toxicology and serum toxicology screens
were negative. The patient was transferred to [**Hospital1 18**] for
further management.
In the ambulance, on the way here, the patient's mental
status worsened, and she became lethargic and was intubated
for airway protection. Upon transfer here, the patient was
admitted directly to the Medical ICU where she was responsive
but unable to answer questions, as she was sedated.
In speaking to the patient's family, the patient has recently
had increasing bizarre behavior and had been seen in clinic,
and a full note is on the [**Hospital 16730**] medical record. The
patient's family denied that she has had suicidal ideation,
or a suicide attempt in the past. The patient was most
recently hospitalized in [**2128-4-1**] for ocular findings that
were consistent with recurrence of her Susac syndrome.
PAST MEDICAL HISTORY:
1. Susac syndrome.
2. Depression.
MEDICATIONS AT HOME:
1. Prozac 20 mg [**Hospital1 **].
2. Verapamil SR 180 mg [**Hospital1 **].
SOCIAL HISTORY: Lives in [**Location 3786**] with her son and husband,
disabled, previously a postal worker. Denies tobacco,
alcohol or drug use.
FAMILY HISTORY: Father with MI at 68 years old complicated
by an arrhythmia. Mother with breast cancer. One aunt with
diabetes mellitus type 2.
PHYSICAL EXAM UPON PRESENTATION TO MICU: Temperature 98.6,
heart rate 118, blood pressure 105/44, mean arterial pressure
64, respiratory rate 18, O2 sat 100% on assist control
ventilation with 60% O2, 800 cc tidal volume, pressure
support 18, PEEP 5.
GENERAL: Intubated female, alert and oriented x 3, nodding
yes or no to questions.
HEENT: Extraocular muscles intact, moist mucous membranes,
black from charcoal. Pupils 5 mm, symmetric and reactive.
NECK: No JVD, bruits, or lymphadenopathy.
HEART: Tachycardic but regular, S1, S2, no murmurs, rubs or
gallops.
LUNGS: Clear to auscultation anteriorly.
ABDOMEN: Decreased but present bowel sounds, nontender,
nondistended.
EXTREMITIES: No clubbing, cyanosis or edema.
NEURO: No focal deficits, intact strength and sensation
throughout.
LABS/DIAGNOSTICS AT ADMISSION: White blood count 26.9,
hematocrit 36.1, platelets 224, PT 13.9, INR 1.3, PTT 22.5.
ELECTROLYTES: Sodium 142, potassium 3.3, chloride 107,
bicarb 20, BUN 22, creatinine 1.6, glucose 202.
LFTs: ALT 24, AST 19, LD 201, CK 67, alk phos 62, total bili
0.5.
Amylase 61, lipase 26.
Calcium 9.1, phosphate 1.1, magnesium 2.1.
Albumin 3.9.
ABG AT PRESENTATION: 7.47 pH, 26 PCO2, 196 PO2, lactate 4.8.
ECG: Tachycardia at 116, normal axis, QT 0.45. Again,
patient in accelerated junctional rhythm.
CHEST X-RAY: Appropriate placement of endotracheal tube and
NG tube, no acute process.
CONCISE SUMMARY OF HOSPITAL COURSE - 1) CV, HYPOTENSION,
TACHYCARDIA: SSRIs known to cause tachycardia, as well as
hypo and hypertension. Calcium channel blocker overdose
known to cause negative inotropy, dromotropy and chronotropy.
The patient was weaned on her Levophed and dopamine drips.
The patient was started on Neo given her increased ectopy,
but continued low blood pressure. The patient was given
fluid boluses of normal saline, as well. Overnight, the
patient's need for pressors decreased, and she was DC'd on
all pressors and required no further fluid boluses by the
morning after admission. The patient's showed no signs of
fluid overload, and she was monitored closely with an
arterial line for blood pressure and telemetry for rhythm and
heart rate. Cardiology was consulted and recommended just
close monitoring without further intervention. Cardiology
has now signed-off and believed that the patient's
cardiovascular status is stable and should remain that way,
given that verapamil SR was ingested over two days ago. The
patient's ECG returned to [**Location 213**] sinus rhythm the morning
after admission from her previous accelerated junctional
rhythm. The patient currently has blood pressure in the
90s-100s/50s-70s, stable off pressors. The patient's heart
rate is in the 80s-100s.
2) TOXICOLOGY: Toxicology consult was brought in, given the
patient's overdose of Prozac and verapamil. They have left
articles about these medications and their overdose affect in
the patient's chart. They currently recommend no further
intervention. They agreed with insulin and D5 drip, which
the patient was maintained on overnight after admission.
This insulin and D5 drip are recommended in the literature
for calcium channel blocker overdose for cardiac
stabilization, as well as because calcium channel blockers
can decrease pancreatic insulin secretion. Toxicology
consult has signed-off and believe that the patient should be
stable now, given that the overdoses were ingested greater
than 48 hours ago.
3) RESPIRATORY: The patient intubated for lethargy and
mental status change in the ambulance. The patient did very
well on ventilator support throughout the night. The patient
was extubated the morning after admission and did very well
on room air.
4) GI: Calcium channel blockers can increase the risk of
bowel infarction. The patient with slightly decreased bowel
sounds on admission. The patient, since admission, has had
bowel movements with no abdominal pain, or signs or symptoms
of bowel infarction. Recommend continuing to monitor. The
patient was maintained on proton pump inhibitors. The
patient's NG tube was taken out the morning after admission,
and the patient has tolerated clear liquid diet very well.
The patient was also given colace and bisacodyl prn.
5) NEUROLOGICAL: The patient was stable at admission and
continues to be stable. The patient with a history of Susac
syndrome, but without current complaint, signs, or symptoms
of active disease. SSRI overdose can cause restlessness,
mental status change, tremor, rigidity, increased deep tendon
reflexes, clonus, ataxia, mydriasis, neuromalignant syndrome
risk. Calcium channel blocker overdose can decrease blood
pressure and can lead to seizures, or change in mental
status. The patient exhibited no abnormal neurological
findings throughout her hospital stay. B12 and folate were
both within normal limits. RPR is pending. These lab values
were sent due to her possibly decreased mental status at
admission. Recommend following up on the RPR.
6) ENDOCRINE: Calcium channel blocker overdose can increase
glucose by blocking insulin secretion at the pancreas. The
patient was placed on insulin drip and then started on D5W
drip to keep her blood sugar glucose between 80 and 100. As
per toxicology, would also help in cardiac stabilization.
The insulin drip and glucose were DC'd the morning after
admission, since the patient's glucoses continued to be
stable and less than 120. Recommend continuing qid
fingersticks. Patient's TSH was also checked at admission
due to her changed mental status and was found to be normal.
7) RENAL: Patient with increased creatinine at admission.
[**Month (only) 116**] have been due to hypovolemia due to her vomiting at
presentation to the outside hospital. The patient was
hydrated, and her creatinine has normalized to within normal
limits. The patient's most recent ABG was also within normal
limits.
8) INCREASED WHITE BLOOD COUNT AT ADMISSION: Patient with no
evidence of infection. The patient did spike a fever the
first night of admission, but this was likely hyperthermia
due to her SSRI use. The patient has been now afebrile for
greater than 24 hours, and cultures have all been negative to
date. Recommend following up on final blood culture and
urine culture reads. White blood count has decreased from 30
yesterday to 15 today. Increased white blood count at
admission likely related to stress response.
9) PSYCH: The patient with suicide attempt, history of
depression. The patient began having visual hallucinations
during her second night of admission. The patient also with
very flat affect and bizarre behavior, at times difficult to
control by nursing staff. The patient has received low-dose
Haldol prn with good effect once or twice during this
hospital stay. The patient has been continued with a 1:1
sitter and use restraints as needed, given her suicide
attempt. Psychiatry has been consulted and recommends
transfer to their floor after medically stable.
10) PROPHYLAXIS: Patient maintained on a GI prophylaxis, as
well as subcu heparin. The patient also put on 1:1 sitter
given her suicidal ideation.
CODE: Full.
ACCESS: Subclavian central line in the left was placed at
the outside hospital. Plan to remove this line prior to
transfer to the Psych [**Hospital1 **].
DISPO: Plan transfer to Psych [**Hospital1 **] as soon as a bed is
available, as the patient is medically stable.
CONDITION ON TRANSFER: Medically stable.
DISCHARGE DIAGNOSES:
1. Suicide attempt with overdose of Prozac and verapamil.
2. Hypotension.
3. Respiratory distress.
4. Mental status change.
5. Psychotic behavior and hallucinations.
6. Arrhythmia, now resolved, which has now normalized.
7. Decreased renal function, now resolved.
8. Electrolyte abnormalities which have been corrected.
DISCHARGE MEDICATIONS:
1. Bisacodyl prn.
2. Famotidine.
3. Subcu heparin which should be DC'd when the patient is
out-of-bed and mobile.
4. Tylenol prn.
5. Insulin sliding scale.
6. Colace [**Hospital1 **].
FOLLOW-UP PLANS: Plan transfer to Psych Floor for further
work-up and follow-up of psych issues.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Name8 (MD) 16731**]
MEDQUIST36
D: [**2128-7-13**] 10:18
T: [**2128-7-13**] 09:21
JOB#: [**Job Number 16732**]
Admission Date: [**2128-7-11**] Discharge Date: [**2128-8-1**]
Date of Birth: Sex:
Service:
ADDENDUM TO DISCHARGE SUMMARY [**2128-7-13**].
HOSPITAL COURSE:
Problem #1. Respiratory: The patient became agitated and
desaturated to 80% oxygen saturation on 100% nonrebreather
mask, also became tachypneic to the 40s on the evening of
[**7-13**]. ABGs were consisted with respiratory alkalosis
and increasing AA gradient. The patient was intubated the
evening of [**7-13**] and the CT angiogram revealed ground
glass opacities and large pleural effusions consistent with
multifocal pneumonia but with no evidence of a pulmonary
embolism. The patient was started on levofloxacin and Flagyl
for presumed aspiration pneumonia. From [**7-14**] when the
patient was reintubated until [**7-26**], the patient's
respiratory status remained poor. The patient was maintained
on a ventilator on assist control and pressure support when
tolerated.
When the patient's ventilatory settings were decreased and
the patient was allowed to breath more spontaneously, she
regularly became tachypneic to the 40s with decreased tidal
volumes and decreased oxygen saturation. During this time,
the patient's rapid, shallow breathing index was in the
150-300 range. An echocardiogram was performed on [**7-15**] to evaluate her cardiac status and possible congestive
heart failure. The echocardiogram was within normal limits
and did not suggest CHF. The patient was found to have
methicillin resistant Staphylococcus aureus in her sputum and
started on vancomycin for a vent associated pneumonia. The
patient was also continued on levofloxacin and Flagyl for a
total course of 14 days.
On [**7-18**] the patient underwent a bronchoscopy, which
revealed copious secretions that were somewhat purulent. The
secretions were greatest in the lowest lobes. At the point
when I switched services out of the medical ICU, the patient
continued to be intubated and was continued to be treated
with vancomycin and levofloxacin and Flagyl.
Problem #2. Fevers: The patient shortly after being
intubated, the patient began spiking fevers initially as high
as 105 degrees. The patient was given Tylenol, as well as
placed on a cooling blanket. The patient for the next 10
days or so between [**7-14**] and [**7-26**] continued to
spike fevers to the 102 to 103 degree range. The patient was
pancultured numerous times and one blood culture did grow out
gram positive cocci. Neurology was consulted regarding a
possible central process for the fevers but a central process
was thought to be unlikely. The patient's fevers defervesced
several times only to reappear again the following day.
On [**7-21**] a lumbar puncture was done, which was Grams
stain negative with no white blood cells. CT scan of the
head was also done, which found only a suggestion of
sinusitis with no other process. Infectious disease fellow
was consulted regarding the patient and after checking a
vancomycin trough, the dose of this antibiotic was deemed to
be insufficient. The vancomycin dose was therefore increased
and the vancomycin troughs were monitored for therapeutic
range. Following this, the patient's fevers slowly trended
down and eventually defervesced. During this time,
ultrasound of the abdomen revealed no pathology and liver
function tests were within normal limits.
Neurologic/Psychiatric: The patient was restarted on
verapamil, as well as aspirin for her see sick syndrome as
per her neurology attending, Dr. [**Last Name (STitle) 10442**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Dictator Info 16733**]
MEDQUIST36
D: [**2128-8-1**] 20:12
T: [**2128-8-1**] 20:37
JOB#: [**Job Number 16734**]
Admission Date: [**2128-7-11**] Discharge Date: [**2128-8-5**]
Date of Birth: [**2090-7-13**] Sex: F
Service: INPATIENT MEDICINE
ADDENDUM
The patient was transferred to the Medicine Team from the
MICU on [**2128-7-30**].
1. Respiratory: While in the MICU, the patient had
difficulty weaning from the ventilator. She would become
hypoxic and tachypneic when we would attempt to wean her.
Finally the patient received Decadron 4 mg on [**7-29**] for
vocal cord edema, and she was successfully extubated on
[**7-29**]. The patient did not have any signs or symptoms of
respiratory distress once she was extubated.
The patient was initially requiring 2 L oxygen to maintain
oxygen saturation above 95%. The patient's oxygen
requirements were weaned, and upon discharge, she had an
oxygen saturation of 96% on room air.
2. Fevers/infectious disease: The patient was continually
febrile after [**7-26**]. The patient had an abdominal CT on
[**7-28**] looking for any kind of intra-abdominal or
intrapelvic collection or abscess. The patient had no
abscesses found on that CT.
The patient defervesced on [**7-29**] and remained afebrile
until discharge. As stated previously, the patient was found
to have MRSA pneumonia. She completed a 14-day course of
Flagyl and a 14-day course of Vancomycin and a 21-day course
of Levofloxacin. The patient remained afebrile until
discharge.
3. Psychiatric: The patient was initially placed on a 1:1
sitter when she was transferred to the floor. The patient
was then further evaluated by Psychiatry and was found to be
no longer suicidal. It was determined that she would not
require a psychiatric hospitalization at this time.
She can go to a rehabilitation facility and follow-up as an
outpatient. The patient did not exhibit any agitation or
behavioral problems throughout the remainder of the
hospitalization and did not express any suicidal thoughts or
ideation.
4. Mental status changes: When the patient was transferred
to the floor, she initially exhibited some slight confusion
and was not oriented to time. This was probably likely
secondary to a metabolic syndrome from overdose. She had no
other deficits throughout the hospitalization.
The patient's mental status improved by discharge, and she
was alert and oriented times three.
5. Nutrition: The patient was initially placed on tube
feeds through a feeding tube. She was evaluated by Speech
and Swallow and was placed on a soft solid, thickened liquid
diet secondary to aspiration of thin liquids on [**8-5**].
The NG tube was discontinued once she was taking adequate
p.o. intake.
6. Physical therapy: The patient was seen and treated by
Physical Therapy once she was transferred to the floor. She
will require rehabilitation and physical therapy on a
long-term basis once discharged from the hospital in order to
help her return to her near baseline activity.
The patient was discharged in good condition to a
rehabilitation facility.,
DISCHARGE DIAGNOSIS:
1. Susac syndrome.
2. Overdose of Prozac and Verapamil.
DISCHARGE MEDICATIONS: Bisacodyl 10 mg per rectum at night
as needed for constipation, Docusate 100 mg p.o. b.i.d. as
needed for constipation, Verapamil 40 mg p.o. q.8 hours,
please hold for blood pressure less than 80, Aspirin 325 mg
p.o. q.d.
FOLLOW-UP: The patient is to follow-up with her primary care
physician within one month, her neurologist within one month,
and with Psychiatry for outpatient treatment within one
month.
DR.[**Last Name (STitle) 313**],[**First Name3 (LF) 312**] 12-766
Dictated By:[**Last Name (NamePattern1) 16735**]
MEDQUIST36
D: [**2128-8-5**] 13:22
T: [**2128-8-5**] 13:55
JOB#: [**Job Number 16736**]
|
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26,318
| 137,872
|
8860
|
Discharge summary
|
report
|
Admission Date: [**2134-11-19**] Discharge Date: [**2134-12-1**]
Date of Birth: [**2064-1-10**] Sex: M
Service: CT [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is a 69 year old,
Spanish speaking gentleman with a known history of coronary
artery disease, peripheral vascular disease and diabetes
mellitus type 2, who presented with approximately five to six
weeks of dizziness and multiple falls, the last one about a
week prior to admission. He also reported episodes of facial
numbness and tingling and slurred speech at that time. He
did have some blurry vision and diplopia several weeks ago.
His dizziness did not appear to be vertiginous, but was
postural. He had stable, chronic, paroxysmal nocturnal
dyspnea and orthopnea without any chest pain with his falls
and dizziness, but he did have some chronic angina. He used
three to four nitro sublingually per day. He was admitted to
the cardiology medical service on [**11-19**].
PAST MEDICAL HISTORY: CAD with three vessel disease.
Peripheral vascular disease status post axillo-bifemoral
bypass graft and left below knee amputation. Noninsulin
dependent diabetes mellitus. History of MRSA. CHF. Chronic
renal insufficiency. Pulmonary hypertension.
LABORATORY DATA: The patient was worked up for the
cardiology service. Labs on admission were as follows.
White count 7.6, hematocrit 35.5, platelet count 264,000. PT
12.3, PTT 23.0, INR 1.0. Admission CK 92, MB fraction 95,
troponin 0.04. Sodium 138, K 5.6, chloride 107, bicarb 22,
BUN 58, creatinine 2.7, blood sugar 123. Anion gap 9.
Second CK was 90 with second troponin 0.03. Chest x-ray
showed old granuloma with no effusion, no infiltrate, no
edema. EKG showed sinus brady with T wave inversions in
leads 1 and L, no ST depressions, also showed the presence of
an old inferior myocardial infarction.
HOSPITAL COURSE: The patient was assessed also for
bradycardia at that time. He was admitted to the C-Med
service. Meds on admission were amitriptyline, aspirin,
Avandia, captopril, glyburide, Imdur, Lasix, Lipitor,
Lopressor, triamcinolone, Nitrostat p.r.n. He had a 40 pack
year history of tobacco, quit 20 years ago. No history of
alcohol. He was followed on the cardiology service. His
dizziness was worked up. He was seen by the neurology
service for workup of dizziness. They noted and assessed his
multiple risk factors for stroke. He had presented with
postural dizziness and unsteadiness. They recommended
getting scans and giving him gentle hydration and to get
physical therapy involved for gait evaluation.
The patient was also seen by case management. He was
followed every day by cardiology. He did start to have some
episodes of what could be described as chest pain. His
electrolytes were corrected as he was followed every day.
Lopressor was adjusted several times and then stopped when
the patient had bradycardia on the morning of the 4th. He
was also followed by his medical attending with plans to
consult cardiology again. On the 4th he also had more
shortness of breath with jaw pain in the morning. EKG was
done and then repeated after sublingual nitroglycerin, which
relieved his chest pain. He was still complaining of
dizziness at that time whenever he sat up or was out of bed
and felt like he was going to pass out or lose consciousness
"as if a black shade came down." When he didn't move, he was
okay. His blood pressure also rose into the 170s. Nitrates
were increased.
The patient had a cardiology consult on the 5th. Given his
history, his symptoms, his bradycardia and his EKG evidence
of an old inferior MI, they recommended getting cardiac
catheterization done, but the issue was his creatinine at
that time which was still 2.5 and 2.6. On [**11-23**] again he
had another episode of chest pain. They were going to
perform a Persantine MIBI on the 6th in the afternoon, but it
was not performed, given the fact that he had ST segment
depressions in inferior leads and in V4 to V6, so the plan
was to then just proceed with cardiac cath. His pain was
relieved with nitroglycerin.
The patient's neuro followup exam on the 6th said that the
MRI showed right cerebellar encephalomalacia in the PICA
distribution. Please read their final report dictated by
cardiology and radiology. He was seen again by cardiology on
the 7th. His creatinine had risen slightly to 2.8 with white
count still normal at 9. His EKG from the 6th did show ST
depressions in V6 through V6 and 1 and aVL as well as some
LVH. Decision was to start a nitroglycerin drip, give him
Mucomyst and the appropriate meds for premedication, to use a
special dye to help protect his kidneys during cardiac
catheterization. On the 7th he underwent cardiac
catheterization that showed LVEDP of 19, normal left main, 80
percent LAD lesion of diagonal one bifurcation, ostial 80
percent circumflex lesion with a taper to a 90 percent lesion
at the bifurcation with OM1 and OM2 and inferior lesions
distally in OM2. The right was the dominant vessel which was
occluded ostially and supplied by collaterals.
The patient was referred to cardiac surgery. He was seen by
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] who noted the history of left and right
femoral bypass grafts prior to left BKA. Meds at that time
were as follows: amitriptyline 25 mg p.o. q.d., aspirin 325
mg p.o. q.d., Avandia 4 mg p.o. q.d., captopril 50 mg p.o.
t.i.d, glyburide 5 mg p.o. q.d., Imdur 60 mg p.o. q.d., Lasix
80 mg p.o. q.d., Lipitor 20 mg p.o. q.d., Lopressor 100 mg
p.o. b.i.d. Triamcinolone and Nitrostat were also given,
doses are not listed. The patient had no known allergies.
Echo on [**11-22**] showed LV ejection fraction of 35 percent
with 1 to 2+ MR. [**Name13 (STitle) 227**] his severe three vessel disease and
his depressed LV function, he was referred for cardiac
surgery. Prior to operations his labs were white count 8.7,
hematocrit 29.4, platelet count 275,000. INR 2.0, PT 17.3,
PTT greater than 150 on heparin. Prior to heparin, previous
INR was 1.0 to 1.2. Sodium 136, K 5.0, chloride 110, CO2 19,
BUN 37, creatinine 2.5, blood sugar 138. Amylase 137. LFTs
were normal. UA was negative. Chest x-ray showed no acute
cardiopulmonary disease.
Neurology evaluation, in summary, said there was no acute
stroke and it was likely vascular in origin. On exam lungs
were clear bilaterally. Heart was regular rate and rhythm,
no murmur was noted. Abdomen was softly distended, but
nontender with positive bowel sounds. Extremities were warm
with no edema, noting, of course, the left BKA. On the 8th
he had carotid ultrasound done which showed no stenosis on
the left internal carotid, but 40 to 60 percent right
internal carotid stenosis. MRA of the neck prior to
operation showed mild atherosclerotic disease at the right
proximal ICA without high grade stenosis. Bilateral
vertebral arteries and left ICA demonstrated normal flow.
MRA of the head showed left vertebral artery ended in the
PICA. He was seen by the stroke team for evaluation, but it
was clear the patient was going to have to have bypass
surgery at that time, given his severe coronary artery
disease and his recurrent symptoms, necessitating
nitroglycerin drip and heparin. The last creatinine prior to
surgery was 2.7. Coags were repeated.
On [**11-26**] the patient underwent coronary artery bypass
grafting times three with LIMA to the LAD, vein graft to the
OM and vein graft to the PDA. The patient was transferred to
the cardiothoracic ICU on a milrinone drip of 0.5 mcg per kg
per minute and a Levophed drip of 0.02 mcg per kg per minute.
In the first 12 hours the patient was unresponsive despite
the fact that propofol had been off for 12 hours with no
signs of waking. On exam his pupils were very sluggish on
the evening prior and nonresponsive in the evening. The
physicians caring for the patient were aware. There was no
response to painful stimuli, turning, suctioning, etc.
Please refer to the nursing exam notes. On postoperative day
one the patient remained on a Levophed drip at 0.04 and a
milrinone drip at 0.25 and a neo drip at 1.25 as well as an
insulin drip at 8 units per hour. Pulse was 132 in sinus
tachycardia with blood pressure 121/50 with PA pressure of
33/21 and index of 2.1 and mixed venous of 65 percent. His
blood gas was 7.30/40/79/20/-5. He was sating 96 percent
with an FIO2 of 50 percent on SIMV.
The patient was seen by the neurology resident the following
morning. Postoperatively white count rose slightly to 13.2,
hematocrit 34.2. BUN 29, creatinine 2.5. He received two
units of FFP, five units of packed red blood cells, one unit
of platelets. Following the neurology resident's exam, the
patient was intubated off sedation approximately 16 hours at
the time of exam with no response to verbal or physical
stimuli, no spontaneous movements. Pupils were 1 mm and not
clearly reactive. He showed no gag, cough reflexes, etc., on
exam, no withdrawal or posturing and he was flaccid in all
four extremities, noting, of course, the left BKA. He had
received approximately one dose of morphine 2 mg and
developed a low grade fever with some hypotension requiring
Levophed and Neo-Synephrine pressor support. Given his
issues, the CT surgery team was concerned the patient was not
stable enough to go for CT or MRI scanning at that time and,
hopefully, would be able to obtain a head CT when the patient
was stable enough for transport.
On postoperative day two EEG showed low voltage, no seizures.
The patient received Lasix and concentrated his drips. He
was hemodynamically unstable, requiring bolusing and two
units of packed red blood cells on milrinone at 0.25, neo
2.25. He had also been given aspirin and Plavix and multiple
doses of Lasix at that time. Chest x-ray showed an
infiltrate in the left upper lobe and interstitial edema. He
remained on SIMV ventilator support. Creatinine rose to 3.5
from 2.5. White count rose to 15.9. On postoperative day
three his drips were weaned down to neo 0.5. He was started
on Levaquin 250 q.48 for his pulmonary infiltrate,
maintaining a mixed venous of 66 percent and remaining on
SIMV ventilator support. Renal consult was obtained. Renal
evaluated him and recommended holding on diuresis for now if
he started making urine. No indication for dialysis at this
time with the diagnosis of likely acute renal failure on top
of chronic renal failure with ATN probably related to
hypotension.
On [**11-29**] the patient was still unresponsive. CT scan
had been reviewed. The scan showed a total PCA stroke
causing lesions in the occipital cortices, thalamic,
hypothalamic and brain stem and cerebellum. The patient's
medulla probably was not affected as much or more as
posterior circulation territories. The diagnosis by the
neurology resident at that time was that the lesions were
incompatible with life and they offered their services to
talk to the family at that time. The patient remained
completely neurologically unresponsive and the prognosis was
grave. On the 13th this was discussed again by the stroke
team with the cardiothoracic surgery team and the family
wanted to withdraw care, but were awaiting family members
from [**Name (NI) 531**]. The plan was agreed to by the neurology
stroke team. The patient had another visit from the renal
Fellow on postoperative day five. Note of the grave
prognosis and catastrophic stroke was discussed as the family
waited to gather all members.
On postoperative day five white count was 14.3, hematocrit
25.8 with creatinine 3.9. The plan was again agreed to
withdraw support at that time with no compressions or
defibrillations. The Swan-Ganz catheter was pulled. At 2:30
in the afternoon discussion was held with the complete
family, wife and children and Dr. [**Last Name (STitle) 1537**] and it was decided
that ventilatory support should be discontinued. The
patient's wife stated that due to grave prognosis from
stroke, the patient had stated that he would not want to live
with no meaningful quality of life nor prolonged ventilatory
support. The patient was extubated by the team at 14:34 with
family at bedside. No spontaneous respirations were noted.
The patient was asystolic at 14:41. The patient was
pronounced at 14:41. The family was at the bedside during
pronouncement of death by the cardiothoracic surgery team and
Dr. [**Last Name (STitle) 30874**], the cardiothoracic surgery resident.
Again, the patient expired at 14:41 on [**2134-12-1**].
FINAL DIAGNOSES:
1. Status post coronary artery bypass grafting times three.
2. Status post axillo-bifemoral bypass grafting.
3. Noninsulin dependent diabetes mellitus.
4. Coronary artery disease.
5. Hypertension.
6. Hypercholesterolemia.
7. History of prior smoking.
8. Chronic renal insufficiency.
9. Peripheral vascular disease with additional left femoral
bypass and left BKA and right bypass grafting.
10. History of MRSA.
11. Congestive heart failure.
Again, the patient expired in the cardiothoracic ICU on
[**2134-12-1**].
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2135-3-28**] 09:32
T: [**2135-3-28**] 09:38
JOB#: [**Job Number 30875**]
|
[
"443.9",
"584.5",
"414.01",
"E878.2",
"428.0",
"250.00",
"411.1",
"997.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.55",
"99.04",
"37.22",
"36.16",
"99.07",
"39.61",
"88.52",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
1892, 12570
|
12587, 13394
|
187, 980
|
1003, 1874
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,344
| 164,617
|
26740
|
Discharge summary
|
report
|
Admission Date: [**2121-3-17**] Discharge Date: [**2121-3-27**]
Service: MEDICINE
Allergies:
Strawberry / Egg
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Productive Cough, hypoxia, MS changes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo F w/ h/o HTN, CVA, hyperlipidemia was brought via
Ambulance from [**Hospital1 **] to [**Hospital1 18**] for worsening productive cough,
found to be hypoxic per VNA at 80% while lying down and 85%
sitting up, as well as noticed to be confused with MS changes.
Pt lives independently in [**Hospital3 **], however, in setting
of recent discharge 4 days ago from the hospital for [**Name (NI) 25730**] PNA, pt
had VNA services to monitor post discharge status. Pt was
recently admitted for 2 weeks with [**Name (NI) 25730**] PNA and MS changes which
were attributed to PNA. She was treated with Azithromycin for 2
weeks and was not sent home on any antiobiotics. Prior to this
recent hospitalization at an OSH, she completed 2 courses of
Levaquin for a R sided ear infection. At that time she also c/o
R sided temporal pain, R sided jaw pain and ear pain. She has
had several problems w/her ears in the past for which she sees
and Ear doctor on occasions. After her stroke ~5 years ago she's
had hearing difficulties b/l, R ear> deficit than L, and is
blind in R eye.
.
Pt was feeling well at home, however, son noticed that 2 days
after discharge was starting to c/o R ear pain, increasing
productive cough, and once again MS changes. Her VNA found pt
hypoxic as noted above and called her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] whom
recommended pt be brought into [**Hospital1 18**] ED for further care. In [**Name (NI) **]
pt was afebrile, noted to have EKG changes (ST dep V5-V6, AF,
L-axis deviation), BNP elevated at [**Numeric Identifier 65873**], and a WBC of 19.4 with
lactate 2.4. She received ASA 325, blood cultures drawn,
Ceftriaxone 1gm IV X1, and Azithromycin 500mg PO x1.
.
On further ROS: Pt denied any F/C/Sweats. PT denies any
CP/Palpitations/SOB. Pt also denies myalgias, and arthralgias.
Productive cough as noted above, N/V x1, no abdominal pain, no
change in bowel habits and no BRBPR or blood in stools. Pt with
urinary incontinence x years on ditropan, denies any dysuria. Pt
also denies HA/Lightheadedness/Dizziness.
Past Medical History:
-HTN
-Hypercholesterolemia
-CVA ~4-5 years ago
-Bladder incontinence
-Blind R eye s/p laser surgery
-Colon CA s/p surgical removal of cancerous polyp 15 years ago
Social History:
-Pt lives independently in [**Hospital3 400**] w/VNA services. Has
11 siblings and sons check in on Pt often.
-Pt smoked 1ppweek x 1-2year(s), quit ~>60 years ago.
-Drinks 1 glass of wine occasionally with dinner
-Denies any other drug use, OTC meds
Family History:
-Parents and several siblings with DM c/b limb amputations, h/o
HTN, Colon CA-brother
Physical Exam:
-V 97.4 HR 75 BP 112/52 RR32 100%2LNC
-GEN: NAD
-HEENT: Lpupil RRL, Rpupil fixed-surgical scar minimally RL,
anicteric sclera, OP Clear-no exudates, submandibular LAD-non
tender, no thyromegaly, L-Ear with extremely narrowed
canal-unable to visualize TM [**1-30**] cerumen, R-Ear also w/narrowed
canal and unable to visualize TM, Dry MM
-RESP: Rhonchi throughout, no crackles, no wheezing, no stridor
-CV: Irreg, Nml S1,S2, No M/R/G, JVP well below mandible
-ABD: Soft ND/NT +BS
-EXT: minimal non-pitting edema at ankles, warm, 1+DP pulses b/l
-NEURO: A&OX2(self, place)
Pertinent Results:
[**2121-3-17**] CXR:
IMPRESSION:
1. Findings remain concerning for early pneumonia in the right
upper lobe and possibly in the periphery of the left lower lobe.
Followup radiographs are suggested to document resolution
following appropriate therapy.
2. Small bilateral pleural effusions.
.
Brief Hospital Course:
AP: [**Age over 90 **] yo F w/h/o recent hospitalization for [**Age over 90 25730**] PNA p/w new RUL
PNA, ear pain, jaw pain and MS changes.
.
On arrival to the floor, pt appear cool and pale, sats in the
80's. Placed on NRB. BP 178/ , HR 120's. Exam concerning for
flash pulmonary edema. 10 mg lopressor, 2 mg morphine, nitro
gtt, lasix 40 mg IV given. ABG 7.21/70/61. Transferred to MICU
for further monitoring. In MICU, given NIPPV, nitro drip. With
control of rate and HTN, patient's BP, HR, O2 sat improved and
patient was called out to floor.
.
#. PNA: Pt was recently discharged from an OSH w/[**Age over 90 25730**] PNA
completing a course of Azithromycin for 2 weeks. Pt represents
with worsening productive cough, and new infiltrate on CXR,
elevated WBC. She was started on Ceftriaxone and Vanco added
while in MICU for worsening respiratory distress. In setting of
worsening consolidations b/l on CXR, increased WBC and fevers
her ABX were switched to Vanco and Zosyn. Her Ulegionella was
negative and blood cultures were NGTD. She required daily Chest
PT multiple times/day, Atrovent/Albuterol nebs standing, nasal
suction daily as she was very rhonchorous with excessive amounts
on pulmonary consolidation/junk. Sputum w/GPC in pairs. She was
maintained on supplemental O2 sating at 92-94% 2LNC.
.
.
#. Elevated CK/Tn-T: Pt noted to have elevated CE and ST segment
depression in precordial lateral leads. Pt denies any
CP/palpitations or SOB but may be demand ischemia in setting of
multilobar PNA and new onset AF and may not necessarily be
NSTEMI.
*CAD: Pt has no known h/o MI or CAD, however new onset AF. Her
CE were elevated in setting of HTN, multilobar PNA, EKG changes
c/w demand ischemia. While pt in MICU, per team and family
wishes decided to medically manage and optimize BP control as pt
would not undergo invasive interventions (ie cath). Her CE were
not continued to follow in setting of medical management and
optimized BP, rate control. She was continued on BB, ASA,
Statin. However on [**2121-3-21**] she started to have melena and her
ASA was d/c'd. She remained CP free throughout her course.
.
*PUMP: Pt w/no known h/o CHF but has occasional LE edema, and
elevated BNP
--ECHO showed hyperdynamic EF 70%, no wall motion abnormalities
but showed mild-mod AR. She required 40IV Lasix daily since
[**2121-3-17**] for crackles and pulm edema on CXR.
.
*RHYTHM: Pt w/new onset AF, no h/o being on coumadin in past. In
setting of increased risk vs. benefit, she was not
anticoagulated. She also started to have melena which made
anticoagulating contraindicated.
.
.
# HTN: Pt w/known HTN on Atenolol and HTCZ at home. On
presentation to ED, BP stable, however BP elevated to 220 SBP
while on floor. She was started on Nitro gtt but weaned off
quickly and controlled with BB. Pt also noted to be in RAF and
dilt was added which also helped w/BP control. While on floor
her BP was well controlled on both Dilt and BB. However, she
started to have melena on [**3-21**] and her BB was not titrated up
for BP controlled.
.
#. Melena: Pt started to have melena on [**2121-3-20**]. Pt denied any
abdominal pain, no hematemasis or hematochezia. Pt's hct
remained stable at 28-30. Per pt's family who was very involved
in her care, did not want invasive interventions for the pt.
Options of EGD/[**Last Name (un) **] were brought up but family had not made
decision whether they wanted further invasive procedures for the
pt. She was followed clinically with serial HCT checks.
.
.
# R sided Ear pain/Temporal/Jaw pain: Pt w/ possible Temporal
arteritis, however no tenderness to palpation over R temporal
area or Jaw area on exam. Difficult to visualize TMs w/poor
anatomy. ESR sent and level at 36 not concerning for TA.
Continued standing dose of tylenol for analgesia. Head CT also
noted for Possible partial opacification of the right mastoid
air cells.
.
#. MS changes: Pt with MS changes during recent hospitalization
in setting of PNA as well as some MS changes on current
presentation. Pt was put on Remeron at OSH for delirium with
poor effect. Pt with multiple RF for delirium, ICU delirium, in
different hosp rooms during admission, [**Age over 90 **] years of age, and
multilobar PNA. Per [**Female First Name (un) 1634**] consult and concern for MS changes,
Heat CT obtained without evidence of acute process, bleed, or
stroke. Family very supported, encouraged to orient pt daily.
Haldol low dose given prn o/n for agitation.
.
# Hypercholesterolemia
--Continued home meds
.
#. Urinary Incontinence: Pt has had incontinence for years, not
an acute episode.
--check UA and verify not UTI in setting of elevated WBC,
lactate. Pt did not have UTI throughout her course.
.
.
#. CODE: DNR/DNI
.
[**Hospital Unit Name 153**] course:
.
# Respiratory distress: This was felt to be most likely
secondary to worsening pna as well as diastolic CHF. We felt
that PNA was the primary process, and worsening multi-focal
infiltrates were seen on CXR. Cx data was negative throughout
her time in the [**Hospital Unit Name 153**], but felt that she was recurrently
aspirating. She in fact failed a speech and swallow video study,
with aspiration of all consistencies of food. Therefore she was
kept NPO. No evidence of new pulmonary edema, but volume
overload initially was contributing. She was continued on
vancomycin and zosyn for her PNA. She had a reported reaction to
penicillin, so we contact[**Name (NI) **] her PCP yesterday [**Name Initial (PRE) **] she had diarrhea
once with amoxicillin, never any allergic reaction. This was
changed in POE. She was also treated with albuterol and
ipratroprium nebulizers and supplemental oxygen. She never
required NIPPV or intubaiton, but was not able to wean off her
oxygen requirement. On her final day in the MICU she had
worsening dyspnea with increased respiratory rate. No response
to lasix. She was started on prn morphine, and a fmily meeting
regarding goals of care was held. The decision was made to make
her [**Name Initial (PRE) 3225**] given her clearly stated wishes to her family prior to
this illness, and their comfort with upholding those wishes.
.
# depression: Pt reported "I just want to shoot myself", and
said many times that she did not want to go on. Per her son, she
has also seemed depressed, and expressed similar thoughts to
him. Psychiatry was consulted, and found that she did not have
capacity to make decisions secondary to delerium> She was placed
on a 1:1 sitter for safety, and her HCP, her son [**Name (NI) **], made care
decisions with his family. As discussed above, she was made [**Name (NI) 3225**]
following a family meeting [**2121-3-26**]. SW and palliative care were
also consulted and saw the patient and gave recommendations.
.
# Diastolic CHF: This was a new onset this hospitalization; with
BNP 13,316. ECHO showed hyperdynamic EF 70-80%, mild LVH. She
was diuresed prn for clinical signs of overload, and treated
with IV metoprolol (refusing NGT and po meds).
.
# AF: She had new onset AFib this hospitalization, with no
history of being on coumadin in past. Her TSH was WNL. She did
not receive any anticoagulation given recent melena and goals of
care. She was rate controlled with IV lopressor as she refused
NGT and po meds.
.
# Elevated CK/Tn-T: She had a mild trop elevation to peak 0.14,
CK peak 301. This was felt to be likely [**1-30**] to demand in setting
of CHF. No known h/o MI or CAD, ruled out by enzymes. She was
contiued on lopressor. Her ASA was initially held due to her
recent GI bleed, but then restarted after her hematocrit was
stable for > 1 week. Her statin was held secondary to no po
meds, and refusing NGT.
.
# HTN: Pt w/known HTN on Atenolol and HTCZ at home. She was
treated with IV lopressor.
.
# Melena: Her hematocrit was stable in the [**Hospital Unit Name 153**], but melena
first noted [**2121-3-20**]. Per family are not sure whether they would
want pt to undergo any invasive procedures including
EGD/Colonoscopy. her hematocrit was followed daily, stable > 1
week. Finally goals of care were changed to [**Last Name (LF) 3225**], [**First Name3 (LF) **] no further
labs or treatment.
.
# R sided Ear pain/Temporal/Jaw pain: temporal arteritis has
been considered by previous physicians; asymptomatic in [**Hospital Unit Name 153**].
.
#. Delerium: Pt with MS changes during recent hospitalization in
setting of PNA as well as some MS changes on current
presentation. Pt was put on Remeron at OSH for delirium with
poor effect. Pt with less responsiveness on [**2121-3-20**], head CT
negative for acute process. Geriatrics following along and
ecouraging family support, hand holding, reorientation, minimize
meds. We avoided any benzos, and treated her PNA.
.
# Hypercholesterolemia: She had been initially continued on her
statin, but this was then held secondary to no po meds.
.
#. Urinary Incontinence: Pt has had incontinence for years, not
an acute episode. No evidence UTI on UA & Cx.
.
#. FEN: Repleted lytes PRN; failed speech and swallow exam; NPO
until family meeting when pt was made [**Date Range 3225**], and then she was able
to have pos as desired. She did not want any tubes including a
PEG, and her HCP and family concurred.
.
#. PPX: PPI, Hep SC, Bowel Regimen
.
#. CODE: DNR/DNI; Following a family meeting with Dr. [**Last Name (STitle) **] on
[**2121-3-26**], patient was made comfort measures only. She was
transferred to the floor on [**3-26**] with a scopolamine patch for
secretions. She was initially given morphine IV boluses PRN, but
was changed to a drip titrated to comfort. She expired on
[**2121-3-27**] with family at bedside.
.
#. HCP [**First Name8 (NamePattern2) 65874**] [**Name (NI) 9048**] [**Telephone/Fax (1) 65875**]
Son [**Name (NI) **]/Daughter in [**Name2 (NI) **]-[**Doctor Last Name 4320**]: [**Telephone/Fax (1) 65876**] H/[**Telephone/Fax (2) 65877**]Cell
PCP is Dr [**Last Name (STitle) **]
Medications on Admission:
-Atenolol 50mg daily
-Detrol 4mg daily
-HCTZ 25mg daily
-Lipitor 10mg daily
-NTG SL prn
Discharge Disposition:
Expired
Discharge Diagnosis:
Recurrent Aspiration Pneumonias
Discharge Condition:
Expired
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2121-3-28**]
|
[
"507.0",
"428.30",
"401.9",
"380.4",
"794.31",
"438.89",
"424.1",
"780.09",
"518.0",
"578.1",
"427.31",
"428.0",
"272.4",
"V10.05",
"518.82",
"788.30",
"V66.7",
"V18.0",
"388.70",
"369.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
13901, 13910
|
3861, 13763
|
261, 267
|
13985, 14144
|
3547, 3838
|
2852, 2939
|
13931, 13964
|
13789, 13878
|
2954, 3528
|
184, 223
|
295, 2383
|
2405, 2569
|
2585, 2836
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,298
| 150,972
|
45215
|
Discharge summary
|
report
|
Admission Date: [**2178-8-22**] Discharge Date: [**2178-8-26**]
Date of Birth: [**2132-4-15**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
GI bleeding
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy, Colonoscopy, Capsule Study
History of Present Illness:
46M with history of GI bleed, crohn's disease s/p ileocolonic
anastomosis, and GERD presents with bright red blood per rectum
since [**8-22**] at 9am. Had small amount of blood in BM this a.m.,
then 2 more BM (about 1 cup) that had more bright red blood
before coming to the ED. In the ED, his vitals were: 2 97.7 110
115/84 18 99%RA. He syncopized while on the toilet passing large
bloody bowel movements. His NG lavage was negative. T+S was sent
and two peripheral IVs were placed. He received 2L NS, 4mg
zofran, 40mg pantoprazole. VS on transfer were 37.6, 90, 115/67,
16, 100RA.
Currently, patient is resting in bed and endorses
lightheadedness and mild epigastric/periumbilical abd pain.
Patient reports last GI bleed similar to this was [**2160**]. Says
last GI bleed was from a duodenal ulcer. Patient is followed by
a GI here, supposed to have endoscopy on [**8-24**]. Denies chest pain
or shortness of breath. Denied recent illness. Crohns has been
silent. He had a glass of wine at dinner the night before and
also took one aspirin for back [**Last Name (un) **] (he otherwise does not use
aspirin given h/o ulcers/GI bleed).
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, dysuria, hematuria.
Past Medical History:
Crohn's disease ([**Doctor Last Name 1940**])
s/p TI, Cecum resection
h/o GI bleeds (with NSAIDs)
GERD
HTN
CRI (creatinine = 1.3-1.4)
Depression / ADD ([**Doctor Last Name **])
allergic rhinitis ([**Doctor Last Name **])
Seborrhea
h/o left TM perforation (Nadol MEEI)
s/p right knee arthroscopy '[**67**] (Zarins)
s/p right knee ACL repair
Social History:
He is married, does not smoke cigarettes. Occasional glass of
wine. Works in startup. 3 children.
Family History:
Positive for breast cancer (mother), [**Name (NI) 4522**] disease in (son),
No family history of colorectal cancer.
Physical Exam:
ADMISSION EXAM [**2178-8-22**]:
VS - Temp 99.1F, BP 122/80, HR 92, R 18, O2-sat 100% RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM
NECK - supple, no JVD
HEART - Regular rate, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh
ABDOMEN - Hypoactive BS. Slightly distended. soft. Mild
tenderness to palpation in epigastrum/periumbilical area. no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-4**] throughout, sensation grossly intact throughout
DISCHARGE EXAM:
Afebrile, vital signs stable. Normotensive.
GENERAL - NAD, comfortably lying in bed.
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, pale
conjunctiva, dry MM
NECK - supple, no JVD
HEART - Regular rate, nl S1-S2, no MRG
LUNGS - CTAB no rales, wheezes, rhonchi
ABDOMEN - BS +. Slightly distended. soft. teympanitic. mildly
tender to palpation R paraumbilical. no rebound/guarding
EXTREMITIES - no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
Pertinent Results:
ADMISSION LABS:
[**2178-8-22**] 08:03PM GLUCOSE-117* UREA N-29* CREAT-1.2 SODIUM-140
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15
[**2178-8-22**] 08:03PM CALCIUM-8.4 PHOSPHATE-2.3* MAGNESIUM-1.7
[**2178-8-22**] 08:00PM WBC-20.0* RBC-3.66* HGB-11.5* HCT-33.2*
MCV-91 MCH-31.4 MCHC-34.6 RDW-12.7
[**2178-8-22**] 08:00PM PLT COUNT-270
[**2178-8-22**] 08:00PM PT-11.5 PTT-24.2* INR(PT)-1.1
[**2178-8-22**] 06:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]->1.050*
[**2178-8-22**] 06:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-TR
[**2178-8-22**] 06:00PM URINE RBC-1 WBC-4 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2178-8-22**] 02:22PM LACTATE-1.9
[**2178-8-22**] 02:05PM GLUCOSE-106* UREA N-28* CREAT-1.4* SODIUM-138
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-26 ANION GAP-15
[**2178-8-22**] 02:05PM estGFR-Using this
[**2178-8-22**] 02:05PM CALCIUM-9.0 PHOSPHATE-2.4* MAGNESIUM-2.0
[**2178-8-22**] 02:05PM WBC-13.5*# RBC-4.52* HGB-13.9* HCT-40.3
MCV-89 MCH-30.8 MCHC-34.6 RDW-12.9
[**2178-8-22**] 02:05PM NEUTS-56.8 LYMPHS-35.6 MONOS-6.1 EOS-1.0
BASOS-0.5
[**2178-8-22**] 02:05PM PLT COUNT-291
DISCHARGE:
[**2178-8-25**] 07:50AM BLOOD WBC-11.6* RBC-3.36* Hgb-10.5* Hct-29.8*
MCV-89 MCH-31.2 MCHC-35.2* RDW-13.6 Plt Ct-177
[**2178-8-25**] 07:50AM BLOOD Glucose-106* UreaN-9 Creat-1.0 Na-139
K-3.8 Cl-104 HCO3-25 AnGap-14
[**2178-8-25**] 07:50AM BLOOD Calcium-8.9 Phos-2.6* Mg-2.1
IMAGING
CTA ABD/PELVIS [**8-22**]:
CTA ABD/PELVIS [**8-22**] Wet Read:
1. Linear hyperdensity within sigmoid colon on arterial phase
persists on delayed phase, which is not typical for active
extravasation. This may represent a hyperdense body in the stool
that has slightly changed in position since the non-contrast
phase. No large active extravasation of contrast and otherwise
no acute intraabdominal process.
2. S/p ileocecal anastomosis w/o complication.
3. Diffuse hepatic steatosis
EGD REPORT:
Findings: Esophagus:
Mucosa: A salmon colored mucosa suggestive of Barrett's
esophagus was found.
Stomach: Normal stomach.
Duodenum: Normal duodenum.
Other
findings: No evidence of active or recent bleeding.
Impression: Mucosa suggestive of Barrett's esophagus
No evidence of active or recent bleeding.
Otherwise normal EGD to third part of the duodenum
Recommendations: Continue home PO PPI 40mg daily
If continued evidence of bleeding would pursue CTA or tagged RBC
scan to identify lower source of bleed.
Further plans per inpatient GI team
Additional notes: The attending was present for the entire
procedure. The patient's home medication list is appended to
this report. FINAL DIAGNOSES are listed in the impression
section above. Estimated blood loss = zero. No specimens were
taken for pathology
COLONOSCOPY REPORT:
Findings:
Lumen: Evidence of a previous ileo-colonic anastomosis was
seen.
Mucosa: Localized erythema, granularity and ulcerations were
noted in the anastomosis.
Impression: Previous ileo-colonic anastomosis of the colon
Erythema, granularity and ulcerations in the anastomosis
Recommendations: In patient care. Capsule endoscopy. PPD to
begin Humira Rx.
Additional notes: The efficiency of colonoscopy in detecting
lesions was discussed with the patient and it was pointed out
that a small percentage of polyps and other lesions including
colon cancer can be missed with the test. The patient's home
medication list was reconciled FINAL DIAGNOSES are listed in the
impression section above. Estimated blood loss=zero. No
specimens were taken for pathology.
Brief Hospital Course:
REASON FOR ADMISSION: 46M with history of GI bleed, crohn's
disease s/p ileocolonic anastomosis, reflux esophagtitis
presents with bright red blood per rectum.
# GI Bleed: Patient admitted to MICU for close monitoring after
having two large bloody bowel movements in ED. Patient was
given two liters of IV fluids and two units of packed red blood
cells and started on IV PPI. CTA of pelvis and abdomen did not
show any source of the bleeding. Gastroenterology was consulted
for GI bleed. Upper GI bleed very unlikely given negative NG
lavage and EGD. Colonoscopy performed and showed ulceration at
ileo-colonic anastamosis site, which may account for bleeding.
To rule out other cause of bleeding a capsule endoscopy was
started and will be followed up as outpatient. Hemoglobin and
hematocrit stablized and there was not further bleeding.
# Chron's- Patient has history of Chron's requiring partial
colectomy with ileocolonic anastamosis. Colonoscopy showed
ulceration at the site of anastamosis, which may account for GI
bleed. Pentasa was initially held and then restarted following
colonoscopy. A PPD was negative in preparation for starting
Humira. Patient will follow up with GI as outpatient.
Chronic Issues:
# GERD- PPI as above.
# HTN: PT currently with low blood pressures. HCTZ was held and
restarted on discharge.
# CRI: Baseline creatinine 1.3-1.4. Pt received IV contrast
during CT scan. Patietn hydrated with IV fluids. Creatinine
trended down to 1.0 on discharge.
TRANSITIONAL ISSUES:
1) Hepatic statosis on CT to be followed up as outpatient
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**].
1. Desonide 0.05% Cream 1 Appl TP [**Hospital1 **]:PRN skin
to affected areas
2. Lorazepam 0.5-1 mg PO HS:PRN anxiety
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN congestion
4. Omeprazole 20 mg PO BID
5. Calcium Carbonate 500 mg PO QID:PRN stomach upset
6. Hydrochlorothiazide 25 mg PO DAILY
7. Fluoxetine 20 mg PO DAILY
8. FoLIC Acid 0.4 mg PO DAILY
9. Vitamin D 800 UNIT PO DAILY
10. Mesalamine 1000 mg PO BID
Discharge Medications:
1. Calcium Carbonate 500 mg PO QID:PRN stomach upset
2. Desonide 0.05% Cream 1 Appl TP [**Hospital1 **]:PRN skin
to affected areas
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN congestion
4. FoLIC Acid 0.4 mg PO DAILY
5. Lorazepam 0.5-1 mg PO HS:PRN anxiety
6. Mesalamine 1000 mg PO BID
7. Omeprazole 20 mg PO BID
8. Vitamin D 800 UNIT PO DAILY
9. Fluoxetine 20 mg PO DAILY
10. Hydrochlorothiazide 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Lower GI Bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 96624**],
It was a pleasure to care for you at [**Hospital1 827**]. You were admitted because you were having
gastrointestinal bleeding. The GI team performed an upper and a
lower endoscopy, and found some redness and ulcers near the site
of you prior surgical anastamosis. They also gave you a capsule
study to evaluate the rest of your bowels to ensure there were
not any other sites of bleeding. Your blood counts have
stabilized, so you can follow up the results as an outpatient.
You may resume your home medications as usually prescribed.
Followup Instructions:
Department: [**Hospital **] MEDICAL GROUP
When: MONDAY [**2178-8-31**] at 11:30 AM
With: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3879**] [**Telephone/Fax (1) 133**]
Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) 858**]
Campus: OFF CAMPUS Best Parking: On Street Parking
Please notify your insurance company of your new PCP
Department: GASTROENTEROLOGY
When: WEDNESDAY [**2178-9-2**] at 3:30 PM
With: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], M.D. [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital **] MEDICAL GROUP
When: MONDAY [**2179-1-11**] at 8:30 AM
With: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3879**] [**Telephone/Fax (1) 133**]
Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) 858**]
Campus: OFF CAMPUS Best Parking: On Street Parking
Completed by:[**2178-8-27**]
|
[
"585.3",
"780.2",
"403.90",
"530.11",
"V45.89",
"V16.3",
"571.8",
"E878.2",
"477.9",
"285.1",
"555.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.19",
"45.13",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
9677, 9683
|
7053, 8266
|
280, 337
|
9751, 9751
|
3455, 3455
|
10504, 11575
|
2213, 2331
|
9233, 9654
|
9704, 9730
|
8657, 9210
|
9902, 10481
|
2346, 2967
|
2983, 3436
|
8571, 8631
|
229, 242
|
365, 1713
|
3472, 7030
|
9766, 9878
|
8282, 8550
|
1735, 2081
|
2097, 2197
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,910
| 157,555
|
5025
|
Discharge summary
|
report
|
Admission Date: [**2185-11-21**] Discharge Date: [**2185-11-29**]
Service: Medicine
CHIEF COMPLAINT: Weakness and lethargy.
HISTORY OF PRESENT ILLNESS: This is an 80-year-old Caucasian
male with a past medical history significant for hypertension
and atrial fibrillation who was recently admitted from
[**2185-11-6**] to [**2185-11-9**] with syncope thought
to be secondary to dehydration.
He returned to the [**Hospital1 69**]
Emergency Department with the acute onset of weakness and an
inability to get out of bed.
The patient had been in his usual state of health until the
morning of presentation to the Emergency Department. He had
noted fecal incontinence associated with urination
(approximately six to seven times per day for the past five
to six days) and now two to three times per day for the past
two days. He awoke on the morning of presentation with
urinary and fecal incontinence during the night.
In the Emergency Department, his blood pressure was found to
be 89/54 initially responsive to intravenous fluids.
However, despite giving three liters of intravenous fluids
his blood pressure remained 85 to 115/50 to 60. He also
continued to be tachycardic in the low 100s. He was given
500 mg intravenously of Levaquin times one for a question of
urosepsis, given that the urinalysis showed positive
leukocyte esterase.
REVIEW OF SYSTEMS: On review of systems, the patient
complained of chills, but no fevers. He denied any rigors,
decrease in oral intake, chest pain, shortness of breath,
headache, nuchal rigidity, nausea, vomiting, abdominal pain,
lower extremity edema, urinary symptoms, bright red blood per
rectum, and melena.
PAST MEDICAL HISTORY:
1. Atrial fibrillation; status post VVI pacemaker.
2. Polymyalgia rheumatica.
3. Recent admission for syncope.
4. Anal fistula repair.
5. Benign prostatic hypertrophy.
6. Depression.
7. Hypertension (since [**2166**]).
8. Status post pneumonia in [**2181**] (hospitalized).
MEDICATIONS ON ADMISSION:
1. Atenolol 25 mg p.o. q.d.
2. Coumadin 5 mg p.o. q.h.s.
3. Hytrin 5 mg p.o. q.h.s.
4. Lanoxin 125 mcg p.o. q.d.
5. Prednisone 2.5 mg p.o. t.i.d.
6. Proscar 5 mg p.o. q.d.
ALLERGIES: QUINIDINE.
SOCIAL HISTORY: The patient is widowed. He lives alone. He
has one daughter. The patient has a 62-pack-year tobacco
history; but he quit many years ago. One drink per day. A
former marketing manager.
FAMILY HISTORY: Family history was noncontributory.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed vital signs with a temperature of 97, heart rate was
107 and irregular, blood pressure was 89/54, respiratory rate
was 21, and oxygen saturation was 99% on 3 liters. In
general, the patient was a very mildly obese Caucasian male
lying in bed. He appeared very weak. Mucous membranes were
dry. Poor skin turgor. Head, eyes, ears, nose, and throat
examination revealed pupils were equal, round, and reactive
to light and accommodation. Extraocular movements were
intact. The oropharynx was clear. No lymphadenopathy. No
jugular venous distention. Cardiovascular examination
revealed heart sounds poorly heard. Normal first heart sound
and second heart sound. A quiet systolic murmur. Lungs were
clear to auscultation bilaterally. The abdomen revealed
normal active bowel sounds. Soft, nontender, and
nondistended. No masses. Extremity examination revealed no
cyanosis, clubbing, or edema. Neurologic examination
revealed alert and oriented times four. No focal signs.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count was 13.8 (with 81% neutrophils, 13% lymphocytes,
and 5% monocytes), hematocrit was 37.4, platelets were 236,
and mean cell volume was 90. Sodium was 135, potassium was
4.8, chloride was 100, bicarbonate was 20, blood urea
nitrogen was 30, creatinine was 3, and blood glucose was 100.
Anion gap was 15. Urinalysis revealed large leukocyte
esterase.
RADIOLOGY/IMAGING: A chest x-ray revealed pacemaker in
place. No acute cardiopulmonary process.
Electrocardiogram revealed irregularly irregular, rate of
122, normal QRS, normal axis. T wave inversions in V2 to V3.
Biphasic T waves in V4 through V6. Question of
pseudonormalization.
HOSPITAL COURSE BY ISSUE/SYSTEM: In short, This is an
80-year-old Caucasian male with a past medical history
significant for atrial fibrillation, polymyalgia rheumatica,
hypertension, and recent admission for syncope secondary to
dehydration who presented with weakness, incontinence,
multiple bowel movements, and hypotension.
1. HEMODYNAMIC ISSUES: The patient was observed to be very
dry on admission. He had very dry mucous membranes, poor
skin turgor, hypotension, and tachycardia. He was thought to
be very volume depleted.
Because the patient did not respond to fluids initially, he
was sent to the Medical Intensive Care Unit. Eventually,
after receiving more than four to five liters of fluid, the
patient's blood pressure rebounded, and he was not nearly as
tachycardic.
2. CARDIOVASCULAR SYSTEM: (a) Pericardial effusion: Of
note, during the [**Hospital 228**] Medical Intensive Care Unit stay,
he received a transthoracic echocardiogram to evaluate his
cardiac function.
An echocardiogram from [**2185-11-22**] showed an ejection
fraction of 45%, mild global left ventricular dysfunction,
and a moderate-to-large circumferential pericardial effusion
with a circumference of 2.5 cm. The right ventricle was
noted to be unusually small, and "stranding" was seen
laterally; consistent with organization/chronicity of
effusion. The echocardiogram also showed 1+ aortic
regurgitation, 1+ mitral regurgitation, and 1 to 2+ tricuspid
regurgitation.
Because of the new effusion, the patient received a Swan-Ganz
catheter. The right atrial pressure was 22. The right
ventricular pressure was 41/22. The pulmonary artery
pressure was 45/30, and the pulmonary capillary wedge
pressure was 30. The relative equalization of diastolic
pressures was worrisome for tamponade physiology.
The patient next underwent a pericardiocentesis. 300 cc of
fresh bloody fluid with clots was retrieved. Analysis showed
greater than one million red blood cells and [**Pager number **] white blood
cells. There were no organisms visualized, and the culture
was negative. The patient's initial pericardial pressure was
measured at 15. This went down to 6 after the
pericardiocentesis. Because it did not go down to 1, it was
surmised that the patient's effusion was chronic in nature.
This was consistent with the stranding seen on
echocardiogram. Eventually, the patient's pericardial
pressure came down further, and his chamber pressures
normalized.
In terms of the etiology of the patient's pericardial
effusion, it was most likely secondary to his polymyalgia
rheumatica and chronic in nature. The patient had an
erythrocyte sedimentation rate of 70, and a borderline
rheumatoid factor.
Of note, the patient's INR was also noted to be as high as
5.9. This may have been the trigger in addition to minor
trauma. Otherwise, it was still possible that this effusion
was idiopathic in nature. It was very unlikely that the
patient's effusion was post myocardial infarction in nature,
as the patient ruled out.
In terms of infectious causes, the patient had a negative
purified protein derivative, and no organisms were seen in
the effusion. In terms of malignant causes, cytology
revealed no malignant cells. Of note, the patient is being
worked up for possible colon cancer given the recent finding
of colonic thickening on abdominal computed tomography.
Repeat transthoracic echocardiogram on [**2185-11-24**]
revealed only a small pericardial effusion. There were no
echocardiographic signs of tamponade. In comparison to the
transthoracic echocardiogram on [**2185-11-22**]; most of the
pericardial fluid has been removed.
(b) Pump: Because of the aggressive volume resuscitation at
the beginning of the patient's admission, the patient went
into mild congestive heart failure. After receiving low
doses of intravenous Lasix, the patient cleared his lungs of
any fluid.
2. INFECTIOUS DISEASE ISSUES: The patient initially had an
evaluated white blood cell count, but was afebrile.
Urinalysis was significant for large leukocyte esterase.
However, the patient had only 3 to 5 white blood cells in a
clean catch sample. He was given one dose of Levaquin in the
Emergency Department. No further antibiotics were
administered.
In terms of the patient's frequent stooling, the patient was
found to be Clostridium difficile negative. In addition, his
stool cultures and ova and parasite studies came back
negative. The patient's blood cultures remained negative
from admission.
3. GASTROINTESTINAL SYSTEM: Because the patient was in
house, there was a decision made to work up the colonic
thickening seen on a recent abdominal computed tomography.
The patient was prepped with GoLYTELY. He received a
colonoscopy on [**2185-11-29**].
The report was read as a normal colonoscopy to the level of
the cecum.
4. ENDOCRINE SYSTEM: The patient was normally on low-dose
prednisone for his polymyalgia rheumatica at 2.5 mg p.o.
t.i.d. The patient had a cortisol level on [**2186-11-22**]
at a level of 14.
There was a fear that he may be adrenally suppressed. A
cosyntropin stimulation test was performed. The patient's
pre-cosyntropin level was 2.8, and his post cosyntropin level
was 11. Because of this finding, the patient was placed on a
slightly increased dose of his prednisone at 10 mg p.o.
q.a.m. and 5 mg p.o. q.p.m. This was quickly tapered as the
patient was clinically doing well.
5. RENAL SYSTEM: The patient has a history of chronic renal
insufficiency. His creatinine on admission was 3. This was
felt likely to be secondary to volume depleted. With
intravenous fluids, the creatinine came down to the patient's
baseline of 1.5 to 1.7. The patient had good urine output
after receiving fluids.
CONDITION AT DISCHARGE: Condition on discharge was good.
MEDICATIONS ON DISCHARGE:
1. Atenolol 25 mg p.o. q.d.
2. Coumadin 5 mg p.o. q.h.s.
3. Hytrin 5 mg p.o. q.h.s.
4. Lanoxin 125 mcg p.o. q.d.
5. Prednisone 2.5 mg p.o. t.i.d.
6. Proscar 5 mg p.o. q.d.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow
up with his primary care physician (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **])
within one to two weeks.
DISCHARGE DIAGNOSES:
1. Severe dehydration.
2. Diarrhea.
3. Hemorrhagic pericardial effusion; status post
pericardiocentesis.
4. Polymyalgia rheumatica.
5. Atrial fibrillation.
6. Hypertension.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 16316**]
Dictated By:[**Name8 (MD) 4990**]
MEDQUIST36
D: [**2186-1-11**] 09:28
T: [**2186-1-11**] 09:46
JOB#: [**Job Number 20770**]
|
[
"725",
"584.9",
"401.9",
"998.12",
"427.31",
"276.5",
"423.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
2432, 4234
|
10470, 10943
|
10076, 10255
|
2004, 2207
|
10290, 10449
|
4269, 10001
|
10016, 10050
|
1377, 1673
|
112, 136
|
165, 1356
|
1695, 1978
|
2224, 2414
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,313
| 147,441
|
38865
|
Discharge summary
|
report
|
Admission Date: [**2130-6-18**] Discharge Date: [**2130-7-3**]
Date of Birth: [**2081-11-3**] Sex: M
Service: NEUROSURGERY
Allergies:
lorazepam
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
pain
Major Surgical or Invasive Procedure:
[**2130-6-19**] Spinal angiogram with embolization of T5 lesion
[**2130-6-20**] T3-6 Laminectomies, T1-T8 posterior fusion, T3-5
interbody fusion
[**2130-6-28**] PEG placement
History of Present Illness:
48 yo male with h/o stage IV squamous cell lung cancer with
known T4 metastasis who presents to the ED with two days of
difficulty walking and one day of parasthesias above the belly
button all the way down to his feet.
Patient was initially diagnosed with lung cancer in 10/[**2126**]. He
has failed surgery, chemotherapy, and external beam radiation.
Patient developed new difficulty with walking on [**6-16**]. Yesterday
([**6-17**]), he developed new numbness and paresthesias from his
waist down and significant increase in pain. Review of systems
is also positive for increased fatigue and worsening anorexia.
He denies loss of bowel or bladder control.
In the ED, a code cord was called. An MRI of the spine was
obtained that revealed destructive lesions in the upper thoracic
vertebral column and mechanical compression of the cord. The
neurosurgery spine service was consulted.
Past Medical History:
PAST MEDICAL HISTORY:
# Non-Small Cell Lung CA. LLL Mass. s/p thoracotomy at [**Hospital6 **] in [**2127-9-28**]. s/p chemotherapy and
radiation at [**Hospital3 328**], completed in [**2127-11-28**].
# Hyperlipidemia.
# Episodic headaches. These are bifrontal. Imaging has been
negative for metastatic disease.
# History of hepatitis in childhood. He thinks that this was
hepatitis B.
# Right Hand Cellulitis, secondary to foreign body.
PAST SURGICAL HISTORY:
#Thoracotomy at [**Hospital3 **] in [**2127-9-28**].
Social History:
Lives at home in [**Location (un) 3786**] with wife and two children. Works as
respiratory therapist at Mt Aubrun. Wife works as an
administrative assistant at [**Hospital1 18**]. 25+ pack-year h/o smoking,
quit with cancer diagnosis. Denies EtOH, drugs.
Family History:
No history of lung cancer in family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.2 P: 104 R: 24 BP: 99/63 SaO2: 98%
Gen: Cachectic in obvious pain.
HEENT: Pupils: 2 to 1 bilaterally EOMs intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT [**Last Name (un) 938**] G
Sensation: Decreased from 3 inches above umbilicus and below
Reflexes: Pa Ac
Right 2+ 1+
Left 2+ 1+
Toes downgoing bilaterally on Babinski.
No evidence of clonus
DISCHARGE PHYSICAL EXAM:
Vitals stable, afebrile
Cachectic appearing man, TLSO brace in place, able to transfer
to wheelchair
Awake and alert
cooperative with exam
Diminished sensation below umbilicus
diminished muscular effort bilat, but no focal muscular deficits
no focal cranial nerve deficits
Pertinent Results:
MRI C/T/L SPINE ([**2130-6-18**]): Interval worsening of metastatic
disease in the thoracic spine with near-complete compression of
the T4 vertebral body and progression of compression at T5.
There is severe cord compression at T3-T4. There is anterior
epidural disease at T5 and T6. There is a new kyphotic
angulation with the apex at T4.
CT T-SPINE ([**2130-6-18**]):
1. As seen on recent MR of the thoracic spine, severe
compression fractures of T4 and T5 vertebral bodies with 2.1 cm
lytic lesion in the T6 vertebral body. All findings are
consistent with metastatic disease from known lung carcinoma.
2. Diffuse involvement of the left hemithorax by lung carcinoma
as described on recent CT chest.
EKG [**2130-6-20**]
Sinus rhythm. Non-specific ST-T wave changes in the lateral
leads. Compared to the previous tracing of [**2130-5-25**] no diagnostic
change.
CXR [**2130-6-20**]
Known total left lung collapse with deviation of the trachea and
mediastinum to the left is noted. There are two nodular
opacities within the right upper lobe and one projecting over
the diaphragm in the right lower lobe that are consistent with
CT findings. Port-A-Cath is unchanged. The right lung is
otherwise clear. No pleural effusions and no pneumothorax.
SPINAL ANGIOGRAM [**2130-6-20**]
CLINICAL INFORMATION: Patient with lung cancer metastatic to
T4, presenting with cord compression. Preoperative tumor
embolization is requested.
PROCEDURE: Informed consent was obtained from the patient after
explaining the risks, indications, and alternative management.
Risks explained included stroke, loss of vision and speech,
temporary or permanent with possible treatment with stent or
coils if needed. The patient was brought to the interventional
neuroradiology suite and placed on the biplane table in supine
position. Both groins were prepped and draped in the usual
sterile fashion. access to the right common femoral artery was
obtained using a 19-gauge single wall needle under local
anesthesia using 1% lidocaine mixed with sodium bicarbonate and
with aseptic precautions. Through the needle, a 0.35 [**Last Name (un) 7648**]
wire was introduced and the needle taken out. Over the wire, a
5 French
vascular sheath was placed and connected to a saline infusion
(mixed with
heparin 500 units and 500 cc of saline) with a continuous drip.
Through the sheath, a 4 French Berenstein catheter was
introduced and connected to a continuous saline infusion (with
heparin mixture equalling 1000 units of
heparin and 1000 cc of saline).
The following vessels were selectively catheterized and
arteriograms were
performed from these locations.
1. Right common carotid artery.
2. Right subclavian artery.
3. Left subclavian artery.
4. Left vertebral artery.
5. Left common carotid artery.
6. Right T7 intercostal artery.
7. Left T6 intercostal artery.
8. Right T5 intercostal artery.
FINDINGS:
Right common carotid artery: No tumor blush or evidence of
blood supply to tumor is identified from the right common
carotid artery. The carotid
bifurcation is patent without evidence of stenosis.
Right subclavian artery: No evidence of tumor supply or blush
was seen from the right subclavian artery. The artery is patent
without evidence of stenosis or occlusion.
Left subclavian artery: Faint blush identified from the left
subclavian
superior to the level of the tumor, likely representing thyroid
supply. There is no pseudocyst or occlusion of the left
subclavian artery.
Left vertebral artery: There is no stenosis or occlusion of the
left
vertebral artery, which originates from the left subclavian
artery. No
evidence of tumor supply was seen from the left vertebral
artery.
Left common carotid artery: No evidence of tumor blood supply
was seen from the left common carotid artery. The carotid
bifurcation is patent without evidence of stenosis or occlusion.
Right T7 intercostal artery: No evidence of tumor supply was
seen from this vessel.
Left T6 intercostal artery: The left T6 and left T5 intercostal
artery share a conjoined origin. No evidence of tumor supply
was seen from injection at
this level.
Right T5 intercostal artery: Tumor blush was visualized from
this vessel
distally.
Interventional procedure was performed at this point, with five
2 x 3 mm Vortx pushable coils deployed distally into the
proximal right T5 intercostal artery.
Right common femoral artery angiogram was performed through the
sheath after procedure was performed, which demonstrated widely
patent right common femoral artery. The puncture site was
closed utilizing Angio-Seal device.
The patient was sent to the floor with orders. The procedure
was uneventful and the patient tolerated the procedure well
without complications.
IMPRESSION: Embolization of right T5 intercostal artery
utilizing 2 x 3 mm Vertx pushable coils for embolization of
metastatic disease to the vertebral body.
CXR [**2130-6-21**]
In comparison with the study of [**6-20**], thoracic fusion procedure
has
been performed with metallic devices in place and skin sutures
in position. The precise position of the endotracheal tube is
somewhat difficult to see, though it appears to be about 4 cm
above the carina. Complete opacification of the left hemithorax
and Port-A-Cath are again seen.
CT T-spine [**2130-6-22**]
1. Patient is status post corpectomy and laminectomy with metal
implants in the T1-T8 region. There is no evidence of large
hematoma at the surgical site.
2. The left T1 screw is in the median aspect of the pedicle,
but still could be contained within the bone. The remaining
screws are fully contained within the bone with no lucency
surrounding them.
[**2130-6-27**] Video Swallow
Gross aspiration with nectar-thickened and thin liquids. For
further information, please see the detailed note provided by
the speech and swallow division in OMR.
[**2130-6-27**]
1. Numerous right pulmonary nodules are increased in size since
the [**2130-5-25**] chest CT examination, concerning for
neoplastic progression. Neighboring ground-glass opacities
could be seen with an inflammatory reaction; although infection
is difficult to exclude, organizing pneumonia after chemotherapy
is fairly common.
2. New right adrenal metastasis.
3. New left iliac lytic mass, likely metastasis.
4. Post-corporectomy and laminectomy from T1 through T8, across
a destructive soft tissue mass centered about T3 through T5,
with likely abutment against the cord, better visualized on a
recent CT T-spine examination. Detailed paraspinal assessment is
limited due to streak artifacts.
5. Loss of the bordering fat plane between the distal esophagus
and the
thoracic soft tissue mass. Underlying local invasion cannot be
excluded.
6. Unchanged appearance of complete left lung collapse and
neighboring
moderate pleural effusion.
[**2130-6-28**]
No evidence of deep vein thrombosis in either right or left
lower
extremity.
[**7-1**] Abd Xray- IMPRESSION: Air is seen throughout the colon, but
no colonic distention is identified.
Brief Hospital Course:
48 yo M with h/o stage IV squamous cell lung carcinoma with
known mets to T4 who presents with two days of leg weakness and
paresthesias below the waist, found to have near-complete T4
vertebral body compression and severe cord compression at T3-T4.
He was admitted to the neurosurgical floor with a plan for
surgical resection of the lesion with surgical fixation.
On [**6-20**] the patient underwent embolization of the T4 tumor to
reduce blood loss during surgical fixation. Post embolization,
the groin site appeared normal and there was minimal s-s
drainage.
On [**6-21**] the patient was taken to the OR and underwent a T3-6
lami, T1-T8 post fusion; T3-5 interbody fusion with Dr.
[**Last Name (STitle) 739**] and Dr. [**Last Name (STitle) 1352**] of the orthopedics department. A
hemovac was left in place. He received a unit of blood intra-op.
He was left intubated and was taken to the ICU and received
another unit of PRBCs. He was moving all extremties when off
sedation. He was extubated on [**6-21**] and was respirating well.
Chronic pain service was consulted..SDU orders were written.
[**Date range (1) 9459**]: The patient was unable to tolerate a diet and a NG
was unable to be placed secondary to compression on esophagus.
Nutrition was consulted and TPN was commenced. The patient
continued to have postoperative pain and chronic pain management
was consulted. The patient was started on a dilaudid PCA and
then switched to morphine given concerns for hallucinations. The
patient was fitted for a post-surgical brace and made progress
with physical therapy.
On [**6-25**] the patient had a TPN order placed, tylenol was made
standing IV. On [**6-26**] the patient stated that the CTLSO brace was
very uncomfortable and as such we called NEOPS to come and
evalaute the brace for a better fit. Pain service recommeded
adding a basal rate for morphine overnight to improve overnight
pain control.
On [**6-27**] he had a CT torso that showed a new adrenal and ilaic
lesion and post-op changes. He failed speach and Swalloe eval
and was taken to the OR with Dr. [**Last Name (STitle) **] and had a endoscopic PEG
palcement under general anesthesia. He was tachycardic to 120's
inthe PACU. He intermittently complained of back pain and at
times some chest discomfort. EKG showed some ST depression in
the inferior leads. Troponin was 0.14. IVF boluses were given.
BP and sats were stable. Cardiology consult suggested starting
ASA, cycling enzymes. Screening LENS did not show any DVT. Pain
management increased his Fentanyl to his home dose of 100mcg.
They also chnaged his PCA to a routine dosage per the patient's
request.
On [**6-28**] the patient had a PEG placed. He was noted to be
tachycardic in the PACU and EKG showed some ST depressions in
the lateral leads, increased from baseline. His cardiac enzymes
were cycled and peaked at 0.14 then trended down. He denied
chest pain. His blood pressure remained stable and he was
afebrile. He was given aspirin and metoprolol and a cardiology
consult was placed. They agreed with the above management.
On [**6-29**] he was started on Tube feeds per nutrition's
recommendations. He had high residuals multiple times and they
had to be held though. For this reason he was continued on TPN.
The patient was seen by palliative care and after discussion
with the attending, the patient and his wife decided to change
the code status to DNR/DNI. The patient expressed his desire to
go home with hospice care. He was again seen on [**6-30**] by
palliative care and further changes were made to his plan of
care. He was started on PO pain medication and his fentanyl
patch was increased. He was still not tolerating his tube feeds
so he was started on reglan and TPN was again continued. He
changed to a higher concentration of tube feeds. He remained
neurologically stable and his staples were removed without
incident.
On [**7-1**] His pain was well controlled on the new PO regimen.
incision was stable. Family teaching was initiated. He was
initially thought to be tolerating his tube feeds at the new
goal, but in the afternoon he had high residuals (thick
consistency & fowl smelling). An abdominal xray was obtained
which revealed distention throughout but no clear ileus and he
was given a dose of methylnaltrexone.
On [**7-2**] the patient tolerated his TF's as they were raised to
goal. His pain was well controlled.
On [**7-3**] he was stable and all of his home care supplies were
ready and he was cleared for discharge home.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Fentanyl Patch 50 mcg/hr TP Q72H
2. FoLIC Acid 1 mg PO DAILY
3. Vitamin D [**2117**] UNIT PO DAILY
4. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
5. Calcium Carbonate 500 mg PO DAILY
6. ALPRAZolam 0.5 mg PO TID:PRN anxiety
7. Gabapentin 600 mg PO ASDIR
600 mg qam, 600 mg qpm, 1200 mg qhs
8. Lactulose 30 mL PO BID
Discharge Medications:
1. wheelchair
Needs wheelchair
Dx: metastatic cancer to spine
2. Home Services
standard hospital bed, adjustable
3. ALPRAZolam 0.5 mg PO TID anxiety
can be crushed and absorbed sublingual. Hold for sedation
RX *alprazolam 0.5 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
4. Calcium Carbonate 500 mg PO DAILY
5. Fentanyl Patch 100 mcg/hr TP Q72H
RX *fentanyl 100 mcg/hour 1 patch: place on skin q72hr Disp #*30
Each Refills:*0
6. Fentanyl Patch 25 mcg/hr TP Q72H
please give in addition to 100mcg/hr patch for a total of
125mcg/hr
RX *fentanyl 25 mcg/hour place 1 patch on skin q72hr Disp #*30
Each Refills:*0
7. Gabapentin 600 mg PO BID
600 mg qam, 600 mg qpm
RX *gabapentin 600 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
8. Gabapentin 1200 mg PO QHS
RX *gabapentin 600 mg 2 tablet(s) by mouth at bedtime Disp #*60
Tablet Refills:*0
9. Lactulose 45 mL PO TID
RX *lactulose 10 gram/15 mL 45 ml by mouth three times a day
Disp #*90 Packet Refills:*0
10. Acetaminophen IV 1000 mg IV Q 8H
standing
11. Aspirin 325 mg PO DAILY
12. Bisacodyl 10 mg PO BID:PRN constipation
Patient may refuse. Hold for loose stools.
13. Bisacodyl 10 mg PR DAILY
pt may refuse; hold for loose stools
14. Docusate Sodium (Liquid) 100 mg PO BID
15. Fleet Enema 1 Enema PR DAILY:PRN constipation
pt may refuse
RX *Disposable Enema 19 gram-7 gram/118 mL 1 Enema(s) rectally
daily Disp #*60 Packet Refills:*0
16. Heparin 5000 UNIT SC TID
RX *heparin (porcine) 5,000 unit/mL inject subQ three times a
day Disp #*90 Syringe Refills:*0
17. 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.
RX *Heparin Lock 10 unit/mL [**Last Name (un) **] IV line care q1hr Disp #*60
Packet Refills:*0
18. Heparin Flush (100 units/ml) 5 mL IV DAILY:PRN clotting
RX *Heparin Lock 100 unit/mL per IV line care daily Disp #*60
Packet Refills:*0
19. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, flush with 10 mL Normal Saline followed by
Heparin as above per lumen.
RX *Heparin Lock 100 unit/mL [**Last Name (un) **] PORT care daily Disp #*60
Packet Refills:*0
20. Methocarbamol 1000 mg PO QID
RX *methocarbamol 500 mg 2 tablet(s) by mouth four times a day
Disp #*90 Tablet Refills:*0
21. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 1 tablet by mouth QIDACHS Disp
#*120 Tablet Refills:*0
22. Metoprolol Tartrate 25 mg PO TID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
23. Milk of Magnesia 30 mL PO Q4H:PRN constipation
24. Morphine Sulfate (Concentrated Oral Soln) 15 mg PO Q4H
Hold for RR<10
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 15 mg by mouth
q4hr Disp #*90 Packet Refills:*0
25. Morphine Sulfate (Concentrated Oral Soln) 15 mg PO Q4H:PRN
pain
Hold for RR<10
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 15 mg by mouth
q4hr Disp #*120 Packet Refills:*0
26. Ondansetron 4 mg IV Q8H:PRN nausea/vomitting
RX *ondansetron HCl 2 mg/mL infuse 4mg q4hr Disp #*90 Packet
Refills:*0
27. Polyethylene Glycol 17 g PO DAILY
RX *Miralax 17 gram 1 packet by mouth daily Disp #*90 Packet
Refills:*0
28. Senna 1 TAB PO BID:PRN constipation
29. FoLIC Acid 1 mg PO DAILY
30. Vitamin D [**2117**] UNIT PO DAILY
31. Home Services
Standard Oral Suction
32. Tube Feeds
Tubefeeding: Two Cal HN Full strength;
Starting rate: 20 ml/hr; Advance rate by 10 ml q6h Goal rate: 45
ml/hr
Residual Check: q4h Hold feeding for residual >= :
250 Flush w/ 100 ml water q8h
Refills: 90 (3 month supply)
33. Home Services
Comode: standard hospital
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 3894**] Health VNA
Discharge Diagnosis:
T5 spinal tumor
Thoracic Cord Compression
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 should wear your brace when out of bed or when your head
of bed is above 30 degrees.
?????? You may put the brace on at the edge of your bed.
?????? You may use a shower chair to bath without the brace on.
?????? No tub baths or pool swimming for two weeks from your date of
surgery.
?????? Do not smoke.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Limit your use of stairs to 2-3 times per day.
?????? Have a friend or family member check your incision daily for
signs of infection.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort. Pain medication should
be used as needed when you have pain. You do not need to take it
if you do not have pain.
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. for two weeks.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
?????? 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:
?????? 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 101.5?????? F.
?????? Loss of control of bowel or bladder functioning
Followup Instructions:
Follow Up Instructions/Appointments
??????Please call ([**Telephone/Fax (1) 4676**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**] to be seen in 4 weeks. You will need AP and
Lateral thoracic Spine X-rays prior to your appointment.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2130-8-1**]
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icd9cm
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19100, 19100
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2879, 3154
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,331
| 162,098
|
48289
|
Discharge summary
|
report
|
Admission Date: [**2130-2-8**] Discharge Date: [**2130-2-13**]
Date of Birth: [**2070-4-5**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
nausea, fatigue, doing poorly at home
Major Surgical or Invasive Procedure:
None
History of Present Illness:
59 year-old female with Crohn's disease status post multiple
bowel resections with ileostomy, on chronic TPN, as well as
smoldering myeloma followed without treatment, with a history of
metastatic squamous cell esophageal cancer, presents with
worsening fatigue and draining enterocutaneous fistula. Patient
has not received any treatment for esophageal cancer given her
poor performance status. She reports that the fistula has opened
for about 3 weeks but cannot quantify the output. She reports
that her ileostomy output might be less than usual. Her energy
level has been dramatically less than before, with her too weak
to do anything at home but staying in bed. She continues to rely
on TPN. Recently she received metronidazole and experienced
nausea, which resolved after the antibiotic was stopped. She
continues to experience pain in her left shoulder and both legs.
She also has intermittent abdominal pain.
.
Review of Systems:
(+) Per HPI
(-) Review of Systems: GEN: No fever, chills, night sweats,
recent weight loss or gain. HEENT: No headache, sinus
tenderness, rhinorrhea or congestion. CV: No chest pain or
tightness, palpitations. PULM: No shortness of breath, or
wheezing. GUI: No dysuria or change in bladder habits. NEURO: No
numbness/tingling in extremities.
Past Medical History:
ONCOLOGIC HISTORY:
She initially noted new heartburn intermittently in fall [**2128**].
This became more severe in [**2129-11-9**] and on [**2129-12-5**] EGD was
performed by Dr. [**First Name (STitle) 452**], and this showed segmental continuous
granularity, friability, and erythema of the mucosa in the
distal
esophagus from 25-30 cm. Biopsy of distal esophagus revealed
markedly atypical squamous epithelium highly suspicious for
squamous cell carcinoma.
On [**2129-12-23**] endoscopic ultrasound showed an ulcerated,
infiltrative circumferential mass at 30 cm causing partial
obstruction, close to 2 cm in maximum depth. By EUS criteria
this
was T3N1 with evidence of invasion beyond the muscularis layer.
Two peri-tumoral nodes were noted which were not sampled as they
could not be sampled without traversing the primary esophageal
lesion first. Biopsy revealed invasive squamous cell carcinoma.
On [**2130-1-3**] PET/CT showed FDG-avid mass (SUV 15.4) involving the
distal [**12-12**] of the esophagus through the level of the GE
junction,
with adjacent FDG avid soft tissue possibly representing a nodal
mass. There was FDG avidity (SUV 5.6) in ill-defined
retrotracheal soft tissue, concerning for second site of
esophageal involvement or nodal conglomerate. There was a
posterolateral subpleural right upper lobe mass, 1.9 x 2.2 cm,
concerning for pleural metastasis (SUV 14.9). In the right
femur,
4 cm below the femoral neck was markedly increased FDG
avidity (SUV 9.4) in marrow without correlative lesion on CT.
On [**2130-1-12**] she had CT-guided biopsy of the right upper lobe mass
revealing squamous cell carcinoma, felt to be metastatic from
her
esophageal primary. She is also followed by Dr. [**Last Name (STitle) 12354**] who
has
recommended palliative radiation, possibly with concurrent
chemotherapy, for her dysphagia.
.
OTHER MEDICAL HISTORY:
# Crohn's disease with history of resections and short gut
syndrome, ileostomy, on chronic TPN since [**2124**]
# smoldering myeloma, followed by Dr. [**Last Name (STitle) **] since [**8-17**],
with stable paraprotein. Has not required therapy.
# arthritis
# osteoporosis and history of multiple thoracic compression
fractures
# history of MSSA disseminated infection s/p admission to the [**Hospital1 **]
in [**2124**] with septic pulmonary emboli, left iliopsoas abscess, T9
paraspinal abscess, and T7-9 vertebral osteomyelitis s/p
percutaneous pigtail drain, parascapular abscess
Social History:
She lives with her husband of 33 years as well as their 25
year-old son. She retired in [**2123**] and previously ran the
production line at [**Doctor Last Name **]. She smoked about 3 cigarettes/day for
20-25 years. She denies alcohol, illicit drug use.
Family History:
Her grandmother had myeloma. Her mother had thyroid cancer.
There
is no other family history of cancers.
Physical Exam:
VS: T 97.9, BP 118/70, HR 116, RR 16, 94%RA
GEN: cachetic woman looking much older than age, awake, alert,
NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. No cervical,
supraclavicular, or axillary LAD
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: soft, nontender, ileostomy bag in place with stool, midline
fistula with surrounding erythema and no active drainage
Extremities: wwp, no edema. DPs, PTs 2+.
Pertinent Results:
Admission:
[**2130-2-9**] 12:57AM BLOOD WBC-39.6*# RBC-4.12* Hgb-10.8* Hct-34.3*
MCV-83 MCH-26.2* MCHC-31.5 RDW-15.2 Plt Ct-174#
[**2130-2-9**] 12:57AM BLOOD Glucose-114* UreaN-28* Creat-0.7 Na-155*
K-2.1* Cl-109* HCO3-35* AnGap-13
[**2130-2-9**] 12:57AM BLOOD Calcium-10.7* Phos-2.7 Mg-2.1
Day of death:
[**2130-2-13**] 03:18AM BLOOD WBC-54.9* RBC-3.49* Hgb-9.4* Hct-29.0*
MCV-83 MCH-27.0 MCHC-32.5 RDW-19.1* Plt Ct-19*
[**2130-2-13**] 03:18AM BLOOD PT-23.4* PTT-75.7* INR(PT)-2.2*
[**2130-2-13**] 03:18AM BLOOD Glucose-103* UreaN-48* Creat-2.1*# Na-145
K-4.1 Cl-114* HCO3-17* AnGap-18
[**2130-2-13**] 03:18AM BLOOD ALT-26 AST-61* LD(LDH)-816* AlkPhos-136*
TotBili-3.1*
[**2130-2-13**] 03:18AM BLOOD Calcium-10.0 Phos-7.2*# Mg-3.0*
Imaging:
CT ABD & PELVIS WITH CONTRAST Study Date of [**2130-2-10**] 3:58 PM
IMPRESSION:
1. Multifocal large hypoenhancing areas in the kidneys and
spleen, compatible
with multifocal abscess from septic emboli.
2. New large heterogeneously enhancing lesion in the left
hepatic dome,
adjacent to and contagious from the known esophageal cancer at
the GE
junction, likely represents interval aggressive tumor
infiltrate. New large
cystic lesion anterior to the new hepatic mass, could represent
an abscess or a biloma. This cystic lesion is amenable to
image-guided drainage/aspiration.
3. Interval marked enlargement of bilateral adrenal lesions,
compatible with aggressive metastatic growth.
4. Oral contrast has reached the ileostomy, without small bowel
obstruction. No free air.
5. Interval marked enlargement of the right lower lobe squamous
cell
carcinoma site.
6. Marked interval interstitial thickening in the posterior
aspect of left
lower lobe, likely represents lymphangitic carcinomatosis.
However, if the
patient had interval radiation therapy, this could also
represent
post-radiation changes.
7. Ill-defined heterogeneous esophageal tumor at the GE
junction,
incompletely assessed.
Brief Hospital Course:
59 year-old female with Crohn's disease status post multiple
bowel resections with ileostomy, on chronic TPN, as well as
smoldering myeloma followed without treatment, with a history of
metastatic squamous cell esophageal cancer, presents with
worsening fatigue and draining enterocutaneous fistula.
Brief Hospital Course:
Prior to transfer to the [**Hospital Unit Name 153**] Ms [**Known lastname 19267**] [**Known lastname 13662**] presented with
failure to thrive at home. She was found to have profound
hyperkalemia and on CT abdomen/pelvis there were multiple
abscess as well as growing metastases noted. She had a ruptured
enterocutaneous fistula that had been draining for the past few
weeks. Her WBC elevated to 45. She triggered for AMS as she
became more confused, tachypneic, to 30s, tachycardic to 130s
and newly hypoxic to 86% on RA. [**Hospital Unit Name 153**] called to evaluate as she
was 97% on 2L. A/Ox2 and appearing delirious. She had crackles
on the left. She was tachycardic to 130s. Her blood pressure was
110/70s. She was given 20mg IV lasix on the floor and then her
BP dropped to 84/40 and she was given 500cc IV fluid and
transferred to the [**Hospital Unit Name 153**].
In the [**Hospital Unit Name 153**], she was covered for sepsis with broad spectrum
antibiotics and ID was consulted. Her cardiac enzymes were
positive, and cardiology was consulted. Her WBC continued to
climb. A discussion was held with her family, and her code
status was changed to DNR/DNI. Overnight [**Date range (1) 81346**], her BP
decreased. On evaluation she appeared to have a mixed picture of
distributive and cardiogenic shock. She was started on a
levophed drip to maintain blood pressures. Her oxygen
requirement began to increase, and at 4:30 in the morning, her
heart rate went in to the 170s-190s in what appeared to be an
SVT. Her husband was called and told that she was declining and
that he ought to come in. On the phone he had agreed with the
team to move toward comfort measures only. He arrived, and
shortly after that she passed away peacefully with her husband
at her side.
Medications on Admission:
CLONIDINE - 0.1 mg Tablet - 1 Tablet(s) by mouth twice a day
CYANOCOBALAMIN (VITAMIN B-12) - 1,000 mcg/mL Solution - 1 cc
injection QMo Please give 10 cc vial
FENTANYL - 12 mcg/hour Patch 72 hr - apply one patch every 72
hours
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth twice a day
OXYCODONE - 5 mg Tablet - 1 Tablet(s) by mouth every 6 hours as
needed for pain
SUCRALFATE - (Not Taking as Prescribed: pt states she doesn't
feel it really helps her) - 1 gram/10 mL Suspension - 2 tsp by
mouth four times a day
TRAMADOL-ACETAMINOPHEN [ULTRACET] - 37.5 mg-325 mg Tablet -
0.5-1
Tablet(s) by mouth every 6 as needed for pain
ZOLEDRONIC ACID-MANNITOL&WATER [RECLAST] - (Prescribed by Other
Provider) - 5 mg/100 mL Solution - once per year
Medications - OTC
CALCIUM-VITAMIN D3-VITAMIN K [VIACTIV] - (Prescribed by Other
Provider) - 500 mg-100 unit-[**Unit Number **] mcg Tablet, Chewable - 1
Tablet(s)
by mouth once a day
LOPERAMIDE - 2 mg Tablet - 4 Tablet(s) by mouth twice a day as
needed
PSYLLIUM [METAMUCIL] - (Prescribed by Other Provider; 2 wafers
2x/d) - Dosage uncertain
Discharge Medications:
Not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceaseed
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
Completed by:[**2130-2-13**]
|
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icd9cm
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[
[
[]
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icd9pcs
|
[
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]
] |
10301, 10310
|
7320, 9100
|
328, 334
|
10363, 10372
|
5034, 6973
|
10428, 10595
|
4412, 4519
|
10262, 10278
|
10331, 10342
|
9126, 10239
|
10396, 10405
|
4534, 5015
|
1336, 1644
|
251, 290
|
362, 1282
|
1666, 4123
|
4139, 4396
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,502
| 171,971
|
16696
|
Discharge summary
|
report
|
Admission Date: [**2180-1-27**] Discharge Date: [**2180-2-2**]
Date of Birth: [**2114-3-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a 65 yo Cantonese-speaking man w/hx of stage IV NSCLC
dx [**12-29**] who presented to the ED with acute onset SOB yesterday
with exertion. He was found to have right mainste PE with
extension into apical RUL, RML, and RLL segemnt. A head CT was
performed which showed stable brain mets. He was started on
heparin. On the OMED service, he was transitioned to lovenox.
On admission, his HR was 110s-120s in sinus.
.
Patient triggered on the floor for tachycardia to 150s at 9 PM
on the evening of his admission with a stable blood pressure.
He also had an increasing oxgyen requiring ment from 91% on RA
on admission to 92% on 4LNC and ultimately to a NRB. His HR
remained stable between 92 - 146/69-103. He given 1L NS and his
respiratory status worsened. He was tachypneic to the 30s and
unable to speak in full sentences. He denies chest pain, chest
pressure, fevers, chills, cough.
Past Medical History:
Past Oncologic History (per medical record):
- presented [**2179-12-21**] with SOB and was found to have stage IV
lung cancer with mets to the spine, sternum, ribs and basal
ganglia, with pathologic fractures of T2 and T5 and malignant
effusion on teh left. The primary lesion is in the left lung
apex with invasion into the anterior chest wall.
- thoracentesis [**2179-12-22**] showed adenocarcinoma with CK7 and TTF-1
positive, consistent with NSCLC. Bronchial biopsy [**2179-12-23**]
confirmed this diagnosis. EGFR testing reported L858R mutation
in exon 21 on [**1-20**] by [**Company 2475**].
- received WBXRT and XRT of C7-T6 spine, completed [**2180-1-11**]
.
Other Past Medical History:
none
Social History:
Home: lives with wife; immigrated from [**Country 651**] 18 years ago
Occupation: previously worked in markets
EtOH: Denies
Drugs: Denies
Tobacco: [**11-20**] PPD x 20 years
Family History:
Father - died of lung cancer
Mother - died of liver cancer
Physical Exam:
GEN: elderly male, in respiratory distress, tachypneic, unable
to speak in full sentences
VS: afebrile, HR 140s a. fib, BP 130
CV: tachycardic, irregular rate, no murmurs, rubs, gallops
PULM: increased work of breath, accessory muscle use, crackles
at bases bilaterally,
ABD: soft, non-tender, non-distended
LIMBS: no edema
SKIN: no rash
Pertinent Results:
ABG 7.44/24/93/19
.
.. \ 12.1 /
7.7 ------ 144
.. / 36.0 \
.
125 | 95 | 12 /
-------------- 104
4.5 | 16 | 0.6 \
.
Ca 8.3
Mg 1.7
Phos 3.9
.
Imaging:
CTA [**2180-1-27**] (prelim read): R main PE with extsn into apical RUL,
RML, and RLL segments
.
Head CT [**2180-1-27**] (prelim): no ICH
.
CXR. [**2180-1-28**].
interval development of pulmonary edema with increased left
pleural effusion.
Lower extremity ultrasound [**2180-1-28**]:
IMPRESSION: No evidence of DVT in the bilateral lower
extremities.
CXR [**2180-1-30**]:
Increasing parenchymal opacity is seen at the right lung
diffusely,
particularly in the upper lobe as well as in the left lower and
mid lung
zones. The pattern is most consistent with a combination of
alveolar and
interstitial disease. There is a left-sided pleural effusion
that appears
similarly to the prior study. The heart size is not changed
substantially
since the prior study and there is no PTX.
IMPRESSION: Worsening airspace disease nonspecific - pneumonia,
CHF or ARDS should be considered.
CXR [**2180-2-1**]:
FINDINGS: In comparison with the study of [**1-31**], the monitoring
and support
devices remain in place. Diffuse bilateral pulmonary
opacifications have
somewhat decreased, especially in the upper zones. These are
superimposed
upon known pulmonary metastases.
[**2180-2-1**] 04:26AM BLOOD WBC-7.3 RBC-3.54* Hgb-10.2* Hct-31.3*
MCV-88 MCH-28.8 MCHC-32.6 RDW-17.0* Plt Ct-129*
[**2180-2-1**] 04:26AM BLOOD Neuts-56 Bands-26* Lymphs-3* Monos-1*
Eos-0 Baso-0 Atyps-1* Metas-8* Myelos-5* NRBC-1*
[**2180-2-1**] 04:26AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-1+ Ovalocy-1+ Schisto-1+
Burr-1+ Stipple-OCCASIONAL
[**2180-2-1**] 04:26AM BLOOD PT-18.5* PTT-87.1* INR(PT)-1.7*
[**2180-1-31**] 05:00PM BLOOD Glucose-240* UreaN-22* Creat-1.8*#
Na-131* K-4.0 Cl-98 HCO3-18* AnGap-19
[**2180-2-1**] 04:26AM BLOOD Glucose-194* UreaN-26* Creat-2.6* Na-126*
K-4.3 Cl-92* HCO3-19* AnGap-19
[**2180-2-1**] 02:41PM BLOOD Glucose-85 UreaN-30* Creat-3.0* Na-127*
K-4.8 Cl-92* HCO3-18* AnGap-22*
[**2180-2-1**] 04:26AM BLOOD ALT-1594* AST-2651* AlkPhos-268*
Amylase-86 TotBili-0.9
[**2180-2-1**] 02:41PM BLOOD Calcium-6.4* Phos-5.5* Mg-1.3*
[**2180-2-1**] 04:26AM BLOOD Cortsol-31.5*
[**2180-2-1**] 04:26AM BLOOD Digoxin-1.4
[**2180-2-1**] 11:14AM BLOOD Type-[**Last Name (un) **] Rates-34/0 Tidal V-420 PEEP-12
FiO2-90 pO2-46* pCO2-52* pH-7.21* calTCO2-22 Base XS--7
AADO2-557 REQ O2-90 -ASSIST/CON Intubat-INTUBATED
[**2180-2-1**] 12:03PM BLOOD Type-ART Temp-38.1 Rates-34/0 Tidal V-420
PEEP-12 FiO2-90 pO2-141* pCO2-42 pH-7.24* calTCO2-19* Base XS--8
AADO2-472 REQ O2-79 Intubat-INTUBATED Vent-CONTROLLED
[**2180-2-1**] 03:00PM BLOOD Type-ART Rates-34/ Tidal V-380 PEEP-12
FiO2-100 pO2-137* pCO2-44 pH-7.24* calTCO2-20* Base XS--8
AADO2-535 REQ O2-89 -ASSIST/CON Intubat-INTUBATED
[**2180-1-28**] 05:52AM BLOOD Lactate-1.9
[**2180-1-31**] 05:53AM BLOOD Lactate-1.6
[**2180-1-31**] 01:19PM BLOOD Lactate-5.2*
[**2180-2-1**] 03:00PM BLOOD Lactate-7.0*
[**2180-1-27**] 09:07PM URINE Hours-RANDOM Creat-43 Na-65
[**2180-1-27**] 09:07PM URINE Osmolal-508
[**2180-1-31**] 4:06 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2180-1-31**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
RESPIRATORY CULTURE (Preliminary): RESULTS PENDING.
Brief Hospital Course:
Mr. [**Known lastname **] is a 65 yo M w/hx of stage IV NSCLC admitted with large
right mainstem bronchus PE complicated by new onset atrial
fibrillation with RVR and respiratory distress.
1. Respiratory Distress/ARDS. Patient is known to have large
PE and was anticoagulated with lovenox. On arrival to the ICU,
patient was in A. fib with RVR to 150s. CXR demonstrated
pulmonary edema likely secondary to fluids and rapid ventricular
rate. ABG demonstrated respiratory alkalosis and hypoxia with
PAO2 of 93 on NRB. Additionally, Mr. [**Known lastname **] was noted on chest CT
to have worsening interstitial disease secondary to malignancy
progression. He was initially diuresed with lasix, rate
controlled with diltiazem and treated with BiPAP, his status
worsened and he required intubation. Subsequent CXRs were
consistent with ARDS. Ventilator setting were titrated to
ARDSnet protocol low tidal volume ventilation. He had
significant dyssynchrony, and was subsequently paralyzed. His
hypoxia and acidemia gradually improved.
2. Tachycardia. The patient initially in atrial fibrillation
with RVR and was started on a diltiazem drip with resolution of
his RVR. It was thought that his new onset atrial fibrillation
was likely secondary to respiratory distress from known
pulmonary processes. He was switched to po digoxin and converted
to sinus rhythm. As his respiratory status deteriorated, he
intermittently converted back to atrial fibrillation with rates
in the 150s. This improved once he was mechanically ventilated
3. Pulmonary Embolism. Patient presented with large right
pulmonary artery PE. He was started on anticoagulation with
enoxaparin. Bilateral LE ultrasounds were performed, to see if
patient warranted consideration of IVC filter placement, but
were negative for DVT. An TTE was done on [**2180-1-28**] to check for
heart strain and revealed: mild symmetric left ventricular
hypertrophy LVEF: >55%. Trivial MR, trace aortic regurg, and
mild pulmonary artery systolic hypertension. No pericardial
effusion. He was switched from enoxaparin to weight based IV
heparin drip.
4. Septic Shock. Once intubated, patient developed hypotension
with BP 80/60. He was bolused NS IV initially with a good
response. Over the course of the following 24 hours, he
required pressor support, initially with phenylephrine, then
with additionally vasopressin, and norepinephrine titrated to a
MAP of 60. Mixed venous oxygen saturation was high, consistent
with sepsis. He was started empirically on vancomycin, cefepime
and levofloxacin. IVF boluses were continued. Once a MAP of 60
could not be maintained with maximal doses of 3 pressors,
dopamine was added. the patient subsequently converted to
atrial fibrillation with RVR with rates into the 150s and
dopamine was stopped. His rhythm returned to sinus and his rate
decreased to 110.
4. NSCLC. Patient NSCLC with primary left apical lesion and
mets to the spine, sternum, ribs and basal ganglia. Patient was
treated for pain with long acting morphine.
5. Goals of care. On admission patient was full code. As his
clinical status deteriorated with ARDS and septic shock, a goals
of care discussion was had with the family and social work.
Given his persistent hypotension and respiratory failure, it was
considered highly unlikely that the patient would survive this
hospitalization with maximal medical treatment, and nearly
impossible that he could return to his prior level of
functionality if he did survive. Per discussion with family, he
was initially made DNR, and subsequently made comfort measures
only. He was extubated, and treatment was directed toward
patient comfort. Patient expired at 12:30 am on [**2180-2-2**].
Medications on Admission:
Home Medications (from bottles brought in from family):
Morphine 15mg PO 1 tab PO q4H PRN pain
MS Contin 15mg PO BID
Omeprazole 40mg PO qday
Acetaminophen PRN
Coalce 100mg PO daily
Vitamin D 50,000units PO weekly
Dexamethasone 2mg "as directed"
Fluconazole 150mg daily for 2 weeks starting [**2180-1-17**]
.
Transfer meds:
Furosemide 20 mg IV ONCE
Diltiazem 5-15 mg/hr IV INFUSION HR < 120
Omeprazole 40 mg PO DAILY
Morphine Sulfate IR 15 mg PO/NG Q4H:PRN pain
Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
Docusate Sodium 100 mg PO BID
Morphine SR (MS Contin) 15 mg PO Q12H
Enoxaparin Sodium 60 mg SC Q12H
Discharge Disposition:
Expired
Discharge Diagnosis:
Acute respiratory distress syndrome
Septic Shock
Pulmonary Embolism
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"162.8",
"305.1",
"198.5",
"733.13",
"995.92",
"038.9",
"511.81",
"415.19",
"198.3",
"253.6",
"518.81",
"785.52",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10738, 10747
|
6349, 10075
|
334, 340
|
10859, 10868
|
2655, 6269
|
10924, 10934
|
2222, 2282
|
10768, 10838
|
10101, 10715
|
10892, 10901
|
2297, 2636
|
6307, 6326
|
275, 296
|
368, 1291
|
2008, 2015
|
2031, 2206
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
689
| 129,080
|
47263
|
Discharge summary
|
report
|
Admission Date: [**2183-4-1**] Discharge Date: [**2183-4-9**]
Date of Birth: [**2128-12-27**] Sex: F
Service: MEDICINE
Allergies:
Methadone
Attending:[**First Name3 (LF) 9454**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
Femoral line placement on right [**4-1**] in ED
History of Present Illness:
Ms [**Known lastname **] is a 54F with a PMHx significant for ESRD on HD,
narcotic abuse, HCV, IDDM and recent right knee infection who
presented after
she was en route to a doctor's appointment when she became
acutely altered. Per EMS she was incontinent of urine and stool.
In the ED, initial vitals were T=, BP=167/74, HR=68, RR=10,
O2sat=100% on NRB, finger stick 303. Somnolent in ED but without
complaints other than being unable to eat for the past few days,
her somnolence precluded learning more about this. The team was
able to rouse her only with painful stimuli and was concerned
about her airway. She was given narcan, pt woke up quickly, but
had become more as she waited in the ED. Her CXR was
questionable for atelectasis vs PNA. Her head CT was negative.
Access difficult, has right groin line. Renal has been called.
Pt given vanc and zosyn out of concern for sepsis and right leg
infection. ECG ok. Had foley placed and was given 1L NS.
Admitted for monitoring and work up of mental status and likely
narcotic overdose.
.
VS at the time of transfer were: 120/66 12 96% on RA HR 68
afebrile
.
On arrival to the floor the patient is somnolent and unable to
fully complete exam questions. She denies any recent narcotic
use. Reports that she is tired because she hasn't been able to
sleep for the past few days [**12-31**] diarrhea. Missed HD yesterday
due to diarrheal illness. It is unclear when the diarrhea
started. She reports going to the ED 5 days ago for leg pain and
being give oxycodone, with the diarrhea possibly starting after
this. She reports loose stool whenever she eats, more than every
hour. No fevers. She is shivering and complaining of feeling
very cold. Denies taking any other pills or drugs. Unable to
complete ROS as patient falls asleep during exam.
.
Past Medical History:
ESRD on HD (since [**10-7**])MWF at South Suburban Unit [**Hospital1 392**]
Narcotic abuse/dependence
Depression
PE (history questionable)
Hep C
IDDM
History of sexual abuse
HTN
HL
Esophagitis
Atrial flutter (resolved after d/c methadone and quetiapine)
Lymphedema
Right knee infection s/p washout (?)
History of QT prolongation on methadone
Social History:
Disabled, lives at home in apartment in [**Location (un) **]. Has three
children, daughter [**Name (NI) 1439**] and son [**Name (NI) **] are primary supports.
Uses wheelchair due to right knee pain. Widowed.
-Tobacco history: 6 cigarettes a day.
-ETOH: none
-Illicit drugs: history of cocaine and heroin abuse, last heroin
in [**2173**], last cocaine in [**2172**]. Transitioned to methadone,
tapered off in [**2181**]. Conflicting reports from patient and OMR
regarding narcotic abuse.
Family History:
Brother died of MI at 56. Father died of CVA @ 85. Mother has
SLE, HTN, asthma.
Physical Exam:
VS: T=96.0, BP=118/64, HR=72, RR=16, O2 sat=94% RA
GENERAL: Middle aged african american female. Somnlolent.
Arouses to voice. Shivering
HEENT: NCAT. Sclera anicteric. No conjunctival injection or
icterus. Disconjucate gaze corrects with effort. MMM.
NECK: Supple. S/p punctures from central line placement attempt.
No hematoma.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Mild anterior
rhonchi/wheeze. HD tunneled line in place on left is c/d/i
ABDOMEN: Soft, NTND. No HSM or tenderness. Negative [**Doctor Last Name 515**]
sign. No abdominial bruits.
EXTREMITIES: Asymmetric L>R edema. Femoral line in place, bloody
dressing. S/p right wrist surgery with some deformity. Healed
ulcer on left leg.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
On leaving AMA:
Mental status alert and oriented x 3, vitals stable, [**1-4**]
systolic murmur at LUSB
Pertinent Results:
Admission labs [**2183-4-1**]:
WBC-7.3 RBC-3.27* Hgb-10.9* Hct-33.4*# MCV-102* MCH-33.2*
MCHC-32.5 RDW-16.4* Plt Ct-141*
Neuts-60.8 Lymphs-28.1 Monos-7.0 Eos-3.7 Baso-0.4
PT-12.3 PTT-34.9 INR(PT)-1.0
Glucose-211* UreaN-70* Creat-11.3*# Na-142 K-5.5* Cl-103 HCO3-22
AnGap-23*
ALT-10 AST-12 CK(CPK)-53 AlkPhos-201* TotBili-0.4
CK-MB-NotDone cTropnT-0.31*
Calcium-7.7* Phos-8.8*# Mg-1.9
D-Dimer-2758*
BLOOD ASA-NEG Ethanol-NEG Acetmnp-17.3 Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
AMA discharge labs [**2183-4-9**]:
[**2183-4-9**] 07:50AM BLOOD WBC-7.7 RBC-2.93* Hgb-9.1* Hct-29.7*
MCV-101* MCH-31.2 MCHC-30.8* RDW-16.2* Plt Ct-190
[**2183-4-9**] 07:50AM BLOOD Glucose-457* UreaN-38* Creat-6.3*# Na-136
K-4.3 Cl-100 HCO3-26 AnGap-14
[**2183-4-9**] 07:50AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.6
Microbiology:
[**4-1**] Blood culture:
Blood Culture, Routine (Final [**2183-4-7**]):
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
[**4-1**] URINE CULTURE (Final [**2183-4-2**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
Blood and stool cultures negative
[**4-3**] Catheter tip culture
WOUND CULTURE (Final [**2183-4-10**]):
[**Female First Name (un) **] (TORULOPSIS) [**Female First Name (un) **]. >15 colonies.
DR. [**Last Name (STitle) 8496**] REQUESTED SPECIATION [**2183-4-6**].
DR. [**Known lastname **] REQUESTED Fluconazole SENSITIVITY [**2183-4-8**].
SENT TO [**State 15238**] FOR SUSCEPTIBILITY TESTING.
Refer to sendout system for results.
[**4-7**]
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
Imaging:
[**4-1**] EKG:
Sinus rhythm. Consider right atrial abnormality. Left
ventricular hypertrophy by voltage. Prolonged QTc interval is
non-specific. [**Month/Day (4) **] correlation is suggested. Since the
previous tracing of [**2183-3-6**] sinus tachycardia is absent and the
QTc interval appears longer.
[**4-1**] CT Head: No acute intracranial process.
[**4-1**] CXR:
Cardiomegaly without evidence of failure. Retrocardiac opacity
may reflect atelectasis versus early pneumonia. If needed, a
dedicated PA and lateral view may be obtained to better assess.
[**4-2**] LENI:
No evidence of DVT in the left lower extremity.
[**4-3**] Transthoracic echo:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Left
ventricular systolic function is hyperdynamic (EF>75%). The
estimated cardiac index is high (>4.0L/min/m2). 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. No
masses or vegetations are seen on the aortic valve. There are
filamentous strands on the aortic leaflets consistent with
Lambl's excresences (normal variant). There is no valvular
aortic stenosis. The increased transaortic velocity is likely
related to high cardiac output. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. No mass or vegetation is seen on the mitral
valve. There is moderate pulmonary artery systolic hypertension.
No vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
IMPRESSION: No vegetations or clinically-significant regurgitant
valvular disease seen (good-quality study). Hyperdynamic
biventricular systolic function.
Compared with the prior study (images reviewed) of [**2182-3-21**],
right ventricular function now appears quite normal. The other
findings are similar.
[**4-7**] CXR:
In comparison with the study of [**4-2**], the lungs are essentially
clear and there is no convincing evidence of vascular congestion
or pleural effusion. Dialysis catheter extends to the cavoatrial
junction or into the upper portion of the right atrium.
[**4-8**] Transesophageal echocardiogram:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. A catheter is identified in the superior
vena cava and right atrium. The catheter tip is adjacent to the
tricuspid valve. There is a small mass on the catheter that
likely represents thrombus. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Right ventricular chamber size and
free wall motion are normal. There are simple atheroma in the
aortic arch and descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened There is no mitral valve prolapse.
Trivial mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. No definite vegetation/mass is
seen on the valves. There is a very small (~2 mm) filamentous
structure on the atrial surface of the anterior mitral valve
leaflet in some views (see clips 61 and 14) which may represent
a Lambl's excrescence (an incidental finding) but a vegetation
cannot be excluded.
IMPRESSION: Small structure of unclear [**Month/Year (2) **] significance on
the mitral valve as described above. No abscess seen. Mild
symmetric left ventricular hypertrophy with preserved
biventricular systolic function. Catheter in superior vena cava
and right atrium with tip adjacent to tricuspid valve with a
small mass on the side of the catheter that likely represents
thrombus. Suggest withdrawing the cathether by 2-3 cm to avoid
contact of the tip with the tricuspid valve. Simple atheroma in
the aortic arch and descending thoracic aorta.
Brief Hospital Course:
54F with a history of narcotic abuse, ESRD on HD, HCV and IDDM
presenting with acute altered mental status and found to have
MRSA bacteremia and [**Female First Name (un) **] infection of prior tunneled HD line.
# MRSA bacteremia- She had 1/4 bottles positive for MRSA on
admission and was treated with vancomycin. She will require a
total 6 week course given TEE was unable to rule out
endocarditis. Patient will receive vancomycin dosed with HD to
maintain trough between 15-20. She will be followed by the [**Hospital **]
[**Hospital 4898**] clinic.
# [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 563**] on catheter tip- She was empirically treated
with micafungin to complete a 14 day course but left against
medical advice prior to completing course.
# Altered mental status- Differential initially included
narcotic overdose vs. infection, especially given positive UA
from the ED and indwelling tunneled dialysis line. Pt was still
altered despite resolution of hypoglycemia. The patient was
treated with supportive care initially with plan to obtain LP if
mental status did not trend towards improvement. Over the first
24 hrs, the pts mental status fortunately improved
significantly. Blood cultures grew GPCs from 1 of 4 bottles, at
which time the presumed source was thought to be the HD
catheter. IR was contact[**Name (NI) **] to remove the old tunneled line and
place a new temporary line in the groin. Mental status cleared
with HD and antibiotics.
#[**Name (NI) **] Pt was initially hypotensive in the ICU, thought
secondary to possible septic component related to
bacteremia/line infection. Supported with peripheral levophed
initially with gentle bolus IVF hydration to avoid overload
given CRF. Levophed was titrated off and BPs remained stable.
Anti-hypertensives where restarted as the BP recovered.
# ESRD on HD- Missed last dialysis session prior to admission
due to diarrheal illness. Potassium trended upward over first
several days of admission to the ICU until pt was able to be
dialyzed after the new temporary HD line was placed. Her
original tunneled line was removed and she received two
temporary HD catheters throughout stay for dialysis. She had
tunneled line placed the day prior to leaving against medical
advice.
# Home situation: patient with complicated home situation. She
reports that her daughter stole from her and left the hospital
against medical advice in order to file a police report. She
also has a 81 year-old mother who supports her but is not in
great health. There was also the question whether if she can
manage at home. PT saw the patient while inhouse and thought
that the patient would likely benefit from rehab but the patient
was not amendable.
# DM- She was on an insulin sliding scale while in the hospital.
Patient left against medical advice.
Medications on Admission:
Amlodipine 10mg daily
Nephrocaps daily
Calcium acetate TID
Gabapentin 300mg daily
Hydralazine 10mg TID (confirmed with pharmacy, written as 100mg
TID in OMR)
ISS
Levemir 17 units QHS
Omeprazole 20mg daily
Ondansetron 4mg prn
Acetaminophen prn
Simvastatin 5mg daily
Oxycodone 5-10mg Q4-6 prn
Discharge Medications:
1. Vancomycin [**Telephone/Fax (1) 1999**] mg IV HD PROTOCOL
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
5. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every
48 hours).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
10. Insulin
Please continue your home 17 units of levemir every evening.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
MRSA bacteremia with possible endocarditis
Fungemia
Altered mental status
Secondary:
End stage renal disease on hemodialysis
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 for altered mental status and
were found to have an infection in your blood. You improved
with antibiotics and changing your dialysis catheter as well as
getting hemodialysis. You had an echocardiogram of your chest
that showed a small spot on one of your heart valves concerning
for infection, and you should have a total of 6 weeks of
antibiotics. You also had yeast growing on your old
hemodialysis line and are being treated with antifungals.
Please follow-up with your PCP and see [**Name Initial (PRE) **] psychiatrist to discuss
your depression and medications. You should continue your
regular hemodialysis sessions.
The following changes were made to your medications:
1. Started vancomycin, an antibiotic, to treat your blood stream
infection. You should get this with every dialysis session
until [**5-14**].
2. Started fluconazole, an antifungal [**Doctor Last Name 360**], to treat the yeast
in your blood.
3. Stopped your percocet as the narcotics may be causing more
confusion. You should take tylenol for your pain.
You left against medical advice despite being warned about the
risks of leaving without complete results of your yeast blood
cultures. You understood that leaving put you at risk for
worsening infection, confusion and even death.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
please follow up with PCP
|
[
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"585.6",
"403.91",
"999.31",
"424.90",
"117.9",
"995.91",
"287.5",
"008.45",
"250.80",
"038.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.95",
"88.72",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
14901, 14907
|
10894, 13743
|
291, 340
|
15086, 15086
|
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|
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14928, 15065
|
13769, 14062
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15269, 16665
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3149, 4197
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6685, 7095
|
230, 253
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368, 2166
|
7104, 10871
|
15101, 15245
|
2188, 2532
|
2548, 3037
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,349
| 195,920
|
46497
|
Discharge summary
|
report
|
Admission Date: [**2161-8-4**] Discharge Date: [**2161-8-10**]
Date of Birth: [**2083-12-13**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
"I fell."
Major Surgical or Invasive Procedure:
Open-reduction, internal-fixation of L hip.
History of Present Illness:
This is a 77 yo F w insulin-dep DM c/b neuropathy and right BKA
([**11-10**]), pA-Fib, GERD now s/p fall with impacted L subcapital
femoral neck fracture who is POD1 s/p ORIF. Pt was recently
discharged [**2161-8-3**] from rehabilitation facility where she had
been since [**Month (only) **] following R BKA. She was discharged to
daughter's home, and patient unfortunately experienced a fall
with fracture of her L hip on [**2161-8-4**]. She presented to the ED,
where she was seen by orthopedic surgery, who felt that she
needed operative intervention. However, while in the ED, she
had oxygen desaturation and needed to be placed on BiPAP to keep
oxygen elevated. For this reason, she was admitted to the MICU,
and remained there until s/p ORIF by orthopedic surgery on
[**2161-8-6**].
Pt reports that for the last 4-6 weeks she had a cough
productive of thin, non-bloody sputum, worse at night. She
denies pleuritic or positional component, and at this time,
cough has resolved. Pt still with question of SOB, not actively
endorsing SOB. She denies any fevers, chills or weight loss.
No CP, diarrhea, constipation, bleeding. Does have pain at this
time, but only wants Tylenol for pain control.
Past Medical History:
- DM2 - insulin dependent x30y, c/b neuropathy.
- PVD
- GERD
- paroxysmal atrial fibrillation
- h/o gastritis
- h/o pancreatitis
- h/o stress incontinence, urinary retention
- h/o CVA (left occipital infarct)
- s/p cervical fusion, lumbar disc surgery
- glaucoma
- R eye blindness
- R BKA
Social History:
Living in rehab since [**Month (only) 1096**] until [**8-2**]. Denies tobacco,
alcohol, IVDU. Was walking with walker and performing her ADLs
fairly independently prior to recent hospitalization.
Family History:
Unable to obtain from pt.
Physical Exam:
Vitals: T: 97.8 BP: 120-141/52-65 P: 58-68 R: 18 O2: 100% (RA)
General: Alert, oriented, no acute distress; laying in bed
holding L hip
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP difficult to assess
Lungs: Bibasilar crackles with poor inspiratory effort
CV: Heart sounds difficult to auscultate [**2-3**] body habitus,
regular rate and rhythm, no appreciable murmurs, rubs, gallops
Abdomen: Obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis;
trace edema in LLE, but pulses still present and sensation
grossly intact. Some TTP in L hip and knee, but no effusions,
erythema.
Incision: C/D/I without erythema, oozing
Pertinent Results:
Admission pertinent labs:
[**2161-8-4**] 09:45PM BLOOD WBC-12.9*# RBC-3.56* Hgb-9.6* Hct-30.1*
MCV-85 MCH-27.1 MCHC-32.0 RDW-13.7 Plt Ct-221
[**2161-8-4**] 09:45PM BLOOD Glucose-153* UreaN-27* Creat-1.0 Na-141
K-4.3 Cl-102 HCO3-31 AnGap-12
[**2161-8-4**] 09:45PM BLOOD proBNP-1567*
[**2161-8-4**] 09:47PM BLOOD D-Dimer-[**Numeric Identifier 98774**]* --> pt refused CTA
.
Discharge labs:
[**2161-8-10**] 06:15AM BLOOD WBC-6.3 RBC-3.32* Hgb-9.0* Hct-27.8*
MCV-84 MCH-27.0 MCHC-32.3 RDW-13.3 Plt Ct-240
[**2161-8-10**] 06:15AM BLOOD Glucose-88 UreaN-21* Creat-1.0 Na-137
K-4.0 Cl-98 HCO3-36* AnGap-7*
.
CT pelvis w/o contrast, [**2161-8-4**]:
IMPRESSION: Left minimally impacted subcapital femoral neck
fracture.
.
Hip XR, [**2161-8-4**]:
IMPRESSION: No evidence of fracture or subluxation of the left
hip.
.
ECHO, [**2161-8-5**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Left ventricular systolic
function is hyperdynamic (EF>75%). There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
IMPRESSION: Small LV cavity size with mild symmetric LVH and
hyperdynamic LV systolic function. Abnormal LVOT systolic flow
contour without frank obstruction. Probable diastolic
dysfunction. Moderate pulmonary artery systolic hypertension.
Calcified mitral and aortic valve without significant stenosis
or regurgitation.
.
Compared with the prior study (images reviewed) of [**2160-2-8**],
overall ejection fraction appears hyperdynamic on the current
sutdy. Degree of mitral regurgitation is slightly less (may have
been OVERestimated on the prior study). Estimated pulmonary
artery systolic pressures are higher. The other findings are
similar.
.
CXR, [**2161-8-9**]:
IMPRESSION: Limited study demonstrating subsegmental
atelectasis.
.
L knee XR, [**2161-8-10**]:
IMPRESSION: No fx.
Brief Hospital Course:
Briefly, this is a 77 yo F w/ insulin-dep DM c/b neuropathy and
right BKA ([**11-10**]), pA-Fib, diastolic dysfunction, GERD who
presented s/p fall with impacted L subcapital femoral neck
fracture who had acute-onset SOB with h/o cough in the ED
requiring MICU admission.
.
# Acute diastolic congestive heart exacerbation: She was
initially placed on BiPAP with transition to NC with stable sats
in MICU. Despite elevated d-dimer, the patient and family
refused workup for pulmonary embolism. With supplemental
oxygen, saturations improved and patient was weaned to nasal
cannula. BNP elevated, but ECHO did not show any acute
worsening of cardiac function, and EKGs were without change. Pt
was taken to OR for ORIF on HD2, and from there transitioned to
floor care. However, she was clearly fluid-overloaded on
presentation to floor, responsive to diuresis with Lasix. At
time of discharge, pt with bibasilar crackles (and bibasilar
atelectasis on CXR) but good saturations on RA. In addition,
she was given nebs PRN for wheezing.
.
# Fracture: Per ortho, patient needed operative repair to regain
mobility, now POD4 s/p ORIF. Pt declined opioid medications,
and pain controlled with scheduled Tylenol and PRN tramadol. Pt
seen and evaluated by PT, and pt to have touch-down weight
bearing, per ortho. F/U in 2 weeks at ortho clinic.
.
# Insulin dependent diabetes mellitus: FSG monitored, and
especially in post-op setting, tightly controlled. Pt's
glargine increased to 23U from 20U qAM, and sliding scale
insulin used through rest of the day.
.
# UTI: pt with UA indicative of UTI, and leukocytosis on
admission. Urine cx grew E.coli sensitive to ciprofloxacin, now
s/p 3-day course of ciprofloxacin.
.
# History of atrial fibrillation: She had no episodes of atrial
fibrillation during hospitalization. Beta-blockade was
continued.
Medications on Admission:
-lantus 20u qam
-humalog sliding scale
-HCTZ 50mg daily
-metoprolol ER 200mg daily
-detrol 1mg daily
-celexa 20mg daily
-norvasc 10mg daily
-cardura 2mg qhs
-pepcid 20mg qhs
-losartan 50mg daily
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO once
a day.
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
7. Tolterodine 1 mg Tablet Sig: One (1) Tablet PO once a day.
8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Pain.
9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
11. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
12. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Losartan 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
15. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
16. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily).
17. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
18. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
19. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
20. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty Three
(23) units Subcutaneous qAM.
21. Insulin Regular Human 100 unit/mL Cartridge Sig: As Directed
Injection qACHS: Give dose as indicated on sliding scale; check
sugar QID--with meals and prior to bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 23095**] Rehabilitation & Nursing Center - [**Location 8391**]
Discharge Diagnosis:
Primary:
- Left hip fracture
- Acute diastolic heart failure exacerbation
Secondary:
- Diabetes Mellitus, Type 2 complicated neuropathy and right
below knee amputation.
- Peripheral [**Location 1106**] disease
- Gastroesophageal reflux disease
- Paroxysmal atrial fibrillation
- History of stress incontinence, urinary retention
- History of left occipital infarct
- Glaucoma
- Right eye blindness
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Confused - sometimes, but usually AOx3
Discharge Instructions:
You were admitted to the hospital after you fell and broke your
left hip. The orthopedic surgeons surgically corrected your
fracture, and you have been recovering nicely from that
procedure. Your pain has been controlled using Tylenol, as you
requested. The orthopedic surgeons request that your staples be
removed in 2 weeks, and have recommendations for physical
therapy while you are at your rehabilitation facility. You have
an appointment to see an orthopedic doctor for follow-up on [**8-18**], and will need to get Xrays prior to that appointment (see
below).
You were also noted to have shortness of breath in the emergency
room, so you were initially admitted to the medical intensive
care unit and had to be temporarily placed on positive-pressure
ventilation. You also had fluid taken out of your lungs using a
medication called Lasix. You have now been weaned from all
oxygen, and you're breathing well just with room air.
There have been several changes to your medications during this
hospitalization. You rehab facility should follow the
medication list provided for you at discharge. The primary
changes to your medications are as follows:
- START Calcium and Vitamin D supplements.
- START Tylenol 1000mg every 6 hours as needed for pain. DO NOT
take more than 4g (4000mg) of this medication in a 24-hour
period, because you can seriously harm your liver.
- START Tramadol as needed for pain.
- START Lovenox injections to prevent blood clot formation.
- We increased your lantus dose to 23 units in the morning and
increased your insulin sliding scale to get better glucose
control.
- We also started colace, senna, and bisacodyl to prevent
constipation as well as albuterol as needed for shortness of
breath.
It was a pleasure taking part in your medical care.
Followup Instructions:
You have the following followup appointments scheduled:
Department: ORTHOPEDICS
When: TUESDAY [**2161-8-18**] at 1:20 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: ORTHOPEDICS
When: TUESDAY [**2161-8-18**] at 1 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
You should also follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5456**], within [**1-3**]
weeks of your discharge from your rehabilitation facility. You
can contact Dr.[**Name (NI) 56701**] office at [**Telephone/Fax (1) 5457**] to arrange an
appointment.
|
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icd9cm
|
[
[
[]
]
] |
[
"79.35"
] |
icd9pcs
|
[
[
[]
]
] |
9353, 9454
|
5322, 7175
|
282, 327
|
9897, 10019
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54,922
| 148,483
|
41929
|
Discharge summary
|
report
|
Admission Date: [**2102-10-10**] Discharge Date: [**2102-11-15**]
Date of Birth: [**2043-6-18**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 2080**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Left groin exploration with proximal and distal thrombectomy
([**2102-10-10**])
Four-compartment fasciotomy of the left lower extremity
([**2102-10-10**])
Right internal jugular central venous line placement
Left PICC placement ([**2102-11-6**])
Right subclavian central venous line placement ([**2102-11-7**])
Right chest tube placement ([**2102-11-7**])
Left PICC placement ([**2102-11-10**])
Right chest tube removal ([**2102-11-11**])
History of Present Illness:
Ms. [**Known lastname **] is a 59 F with PMH anxiety and depression who was
initially admitted on [**2102-10-10**] for ischemic left foot s/p
heparinazation and thrombectomy with left leg fasciotomy.
Course complicated by hypotension and hypoxia after extubation,
found to have PCP pneumonia, HIV with CD4 11. The patient was
transferred to MICU for treatment of her PCP [**Name Initial (PRE) 1064**]. Was
started on bactrim, as well as steroid taper. Her O2
requirements while in the unit were 4L NC, satting in the low to
mid 90s. The patient frequently desatted while in the unit to
the mid 80s in the context of taking off her nasal cannula or
any physical activity. Her O2 sats improved with putting on NC
and resting. The patient had an interesting affect in the unit
and based on CD4 count, it was decided that brain imaging was
indicated.
CVL pulled night prior to ICU transfer. Increased delirium the
morning of transfer. Looked ill-appearing, more so than usual.
Dropped sats into 70s on facemask, and then switched to NRB and
went back up to 100% but then was unresponsive, glaced over, not
responding to commands. Increased lethargy and was becoming
more and more altered. Received 40 mg IV lasix on transit to
ICU.
The patient was then transferred to the floor.
1. PCP [**Name Initial (PRE) 11091**]: While she was there she was continued on her bactrim
and prednisone taper for her PCP [**Name Initial (PRE) 1064**].
2. acute occipital stroke: The patient had subsequent head
imaging on the floor, which revealed an acute occipital stroke,
most likely embolic. Work up for embolic stroke included bubble
echo that did not show e/o right to left shunt or thrombosis.
TEE not done because at the time pt was too sick to tolerate it.
3. new HIV dx: ID was following the patient while on the floor.
CMV viral load was 20,000. ID recs re: valacyclovir still
pending. ID was concerned about cryptococal meningitis, but the
patient has been refusing LP. ID did not want to start HAART
before cryptococal was ruled out because of [**Doctor First Name **]. Antigen
negative, but patient refused LP. ID thought it was ok to start
HAART. But LFTs a/n still a barrier to starting HAART.
4. diarrhea: stool studies pending; up to 6 BMs daily
5. vascular still following: when erythema stops expanding, then
will consider amputation. Not going to happen this
hospitalization. Con't heparin/coumadin. [**Doctor First Name **] was d/ced
6. sinus tachycardia: had intermittent bursts of tachycardia;
looked sinus on tele, but no 12 lead was done.
Past Medical History:
1. Depression
2. Anxiety
Social History:
Ceased tobacco use 12 weeks ago, formerly smoked 1 ppd x 30
years, denies EtOH consumption, and denies recreational drug use
Family History:
No history of lung or heart disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
T: 98.2 P: 93 BP: 114/57 RR: 18 O2sat: 100% on RA
General: awake, alert, NAD
HEENT: NCAT, EOMI, anicteric, teeth stained red from red italian
ice consumed earlier
Heart: RRR
Lungs: normal excursion, no respiratory distress
Abdomen: soft, NT, ND
Pelvis: deferred
Neuro: decreased movement/sensation in L foot
Extremities: RLE WWP, cyanotic and mottled L foot from ankle
down
with tenderness and prolonged capillary refill, palpable B
radial/femoral/popliteal, palpable R DP/PT, non-dopplerable L
DP/PT
Skin: cool/mottled L foot
Pyschiatric: flat affect
.
DISCHARGE PHYSICAL EXAM
99.0 118/72 74 18 95% RA
General: 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: Faint crackles in posterior fields improved from prior.
Abdomen: soft, nontender, nondistended
Ext:
Left LE: necrotic distal metatarsals, sutures in place on medial
and lateral left shin: healing well
Neuro: alert, oriented x3, CNs [**1-14**] grossly intact
Pertinent Results:
ADMISSION LABS:
[**2102-10-10**] 04:15PM BLOOD Neuts-91.6* Lymphs-5.3* Monos-1.8*
Eos-1.3 Baso-0.1
[**2102-10-10**] 04:15PM BLOOD PT-13.3 PTT-27.2 INR(PT)-1.1
[**2102-10-27**] 09:13PM BLOOD WBC-9.6 Lymph-3* Abs [**Last Name (un) **]-288 CD3%-55 Abs
CD3-158* CD4%-4 Abs CD4-11* CD8%-51 Abs CD8-147* CD4/CD8-0.1*
[**2102-10-10**] 04:15PM BLOOD Glucose-85 UreaN-20 Creat-0.6 Na-140
K-3.4 Cl-109* HCO3-22 AnGap-12
[**2102-10-10**] 04:15PM BLOOD ALT-20 AST-59* AlkPhos-95 TotBili-0.2
[**2102-10-10**] 09:23PM BLOOD ALT-20 AST-68* CK(CPK)-1068* AlkPhos-90
[**2102-10-10**] 04:15PM BLOOD Lipase-30
[**2102-10-10**] 04:15PM BLOOD cTropnT-<0.01
[**2102-10-10**] 09:23PM BLOOD CK-MB-22* MB Indx-2.1 cTropnT-<0.01
[**2102-10-11**] 03:09AM BLOOD CK-MB-33* MB Indx-2.1 cTropnT-<0.01
[**2102-10-10**] 09:23PM BLOOD Calcium-7.5* Phos-3.5 Mg-1.6
[**2102-10-11**] 11:31AM BLOOD calTIBC-109* TRF-84*
[**2102-11-4**] 11:40AM BLOOD Triglyc-276* HDL-53 CHOL/HD-3.8
LDLcalc-92 LDLmeas-109
[**2102-10-27**] 01:57AM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE
[**2102-10-27**] 09:13PM BLOOD HIV Ab-POSITIVE *
[**2102-10-27**] 01:57AM BLOOD HCV Ab-NEGATIVE
[**2102-10-10**] 06:49PM BLOOD Type-ART pO2-121* pCO2-51* pH-7.26*
calTCO2-24 Base XS--4 Intubat-INTUBATED
[**2102-10-10**] 06:49PM BLOOD Glucose-117* Lactate-1.3 Na-136 K-2.7*
Cl-109*
[**2102-10-10**] 06:49PM BLOOD freeCa-1.12
[**2102-10-24**] galactomannan negative
[**2102-10-24**] beta D glucan 327
.
MICRO:
[**10-10**], 9, 13, 15, 20, 21, 22, 23 BLOOD CULTURES NEGATIVE
[**10-25**] sputum BAL positive for PCP
[**11-1**] DIF positive for HSV-2 from buttock scraping
[**11-3**] HIV-1 Viral Load/Ultrasensitive 1,729,277 copies/ml.
[**11-3**] serum toxoplasma, RPR, HBV, HCV, cryptococcus negative
[**11-3**] CMV VL 20,200 copies/ml
.
IMAGING
[**11-3**] MRI HEAD TECHNIQUE: Sagittal T1, axial T1, axial FLAIR,
axial T2, axial T2 star and diffusion-weighted MR imaging of the
brain was obtained without the administration of contrast.
COMPARISON: None available.
FINDINGS: There is an area of restricted diffusion in the right
occipital
lobe with corresponding hypointensity on ADC images consistent
with acute
infarction. Small foci of hemorrhage are seen within this
region. There is
surrounding edema and cortical swelling. No evidence of mass
effect is seen. No shift of normally midline structures. The
ventricles and uninvolved sulci are within normal limits for a
patient of this age. The major intracranial vessel flow voids
are preserved.
IMPRESSION: Right occipital infarction with small areas of
hemorrhage. No
shift of normally midline structures.
.
[**11-7**] CT HEAD INDICATION: Patient with altered mental status
requiring intubation, new
diagnosis of HIV and occipital stroke.
COMPARISONS: MR brain of [**2102-11-3**] and CT brain of
[**2102-11-4**]
TECHNIQUE: MDCT-acquired contiguous images through the brain
were obtained
without intravenous contrast at 5-mm slice thickness. Coronally
and
sagittally reformatted images were displayed.
FINDINGS:
There is no evidence of hemorrhage, mass effect, recent
infarction, or shift
of normally midline structures. Confluent hypodensity involving
right
occipital lobe (2:20), corresponds to the area of patient's
known occipital
infarction and appears slightly more conspicuous from [**2102-11-4**]
exam. The
sulci and ventricles are prominent, likely age related
involutional changes.
Basal cisterns are patent.
Mucosal thickening of the sphenoid sinus is noted. Otherwise,
paranasal
sinuses and mastoid air cells appear well aerated. No acute
fracture is seen.
IMPRESSION:
Focal hypodensity involving the right occipital lobe,
corresponds to patient's
known area of infarction, and appears slightly more conspicuous
from [**2102-11-4**]
CT exam.
.
[**11-7**] CT CHEST: HISTORY: HIV. PCP [**Name Initial (PRE) 1064**]. Subclavian central
venous line, evaluate
pneumothorax.
TECHNIQUE: Multidetector helical scanning of the chest was
performed without
the indication for intravenous contrast [**Doctor Last Name 360**], read in
conjunction with
conventional chest radiographs as recent as 2:20 p.m. on
[**11-7**] and a
preceding chest CT on [**10-24**].
FINDINGS:
Moderate right pneumothorax collects anteriorly, and could be
larger than it
was on the chest radiograph earlier today. There is no
indication of
hemodynamic tension. Despite improvement in widespread
ground-glass pulmonary
opacification compared to [**10-24**], there is a much more
pronounced
consolidation. While some of this, in the right lung could be
atelectasis
secondary to the pneumothorax, the great bulk of it is
infectious, possibly a
second pathogen in addition to pneumocystis which was almost
exclusively
ground glass in quality on [**10-24**]. Bacterial pathogens are
more likely
than fungal, but the appearance is entirely nonspecific. An
endotracheal tube
is in standard position. A subcentimeter right upper lobe lung
nodule,
detected on the earlier study is still present and should be
followed, 2:18.
Previous mild central adenopathy has not changed. There is no
pericardial or
pleural effusion. ET tube is in standard placement. Nasogastric
tube passes
to the mid stomach, the lowest level of imaging. This study is
not designed
for subdiaphragmatic diagnosis but shows there is no adrenal
mass.
IMPRESSION:
1. Moderate right pneumothorax, not loculated, collected
anteriorly, may have
increased since 2:20 p.m.
2. Although previous widespread PCP alveolitis has improved,
extensive
consolidation has worsened and could be due to infection by a
second pathogen.
No appreciable pleural or pericardial effusion. Mild adenopathy,
unchanged.
3. Subcentimeter right upper lobe lung nodule should be
followed.
.
DISCHARGE LABS:
===============
[**2102-11-15**] 09:18AM BLOOD WBC-3.6* RBC-2.76* Hgb-8.3* Hct-25.0*
MCV-91 MCH-30.3 MCHC-33.4 RDW-20.1* Plt Ct-554*
[**2102-11-15**] 09:18AM BLOOD PT-20.7* PTT-77.4* INR(PT)-2.0*
[**2102-10-27**] 09:13PM BLOOD WBC-9.6 Lymph-3* Abs [**Last Name (un) **]-288 CD3%-55 Abs
CD3-158* CD4%-4 Abs CD4-11* CD8%-51 Abs CD8-147* CD4/CD8-0.1*
[**2102-11-15**] 09:18AM BLOOD Glucose-83 UreaN-13 Creat-0.8 Na-134
K-4.0 Cl-104 HCO3-22 AnGap-12
[**2102-11-13**] 06:38AM BLOOD ALT-82* AST-35 LD(LDH)-157 AlkPhos-70
TotBili-0.0
.
STUDIES PENDING AT DISCHARGE:
=============================
HIV Genotyping
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
===================================
Ms. [**Known lastname **] is a 59 F with PMH anxiety and depression who was
initially admitted on [**2102-10-10**] for ischemic left foot with
hospital course complicated by occipital stroke, new HIV
diagnosis, high grade CMV viremia with concern for CMV colitis,
and recurrent episodes of hypoxia secondary to PCP pneumonia and
superimposed HCAP.
.
ACTIVE ISSUES:
==============
# Respiratory failure: Required multiple intubations and
admissions to ICU. The primary process was PCP pneumonia but
also it appears that patient developed developed superimposed
bacterial infection (HCAP). There may also have been CMV
pneumonia as well given CMV antigen from BAL. Patient saturating
well on room air at time of discharge.
.
# PCP [**Name Initial (PRE) **]: Initial CXR with diffuse radiologic opacities,
and positive fluorescence stain consistent with acute PCP
[**Name Initial (PRE) 1064**].
-- Completed 21 day course of bactrim and steroids
-- Will continue additional 5 days of steroids to taper
-- Will start prophylactic dose Bactrim after therapy is
completed
.
# Health Care Associated Pneumonia: Developed late in course of
hosptilazation and required reintubation but responded rapidly
to antibiotics.
- Completed full course of Vancomycin/Zosyn, 8 days
.
# Diarrhea: Extensive workup for stool pathogens was
unremarkable. Given that patient had CMV viremia and severe
diarrhea in the setting of CD4 count of 11, the patient was
started on treatment for CMV colitis. GI was consulted for
possible biopsy to confirm the diagnosis, however flex [**Name Initial (PRE) 65**] has
poor negative predictive value for ruling out CMV colitis,
therefore decision was made to treat regardless because of
clinical suspicion. Also possible that diarrhea is antibiotic
related or that this is HIV enteropathy. Multiple negative Cdif
tests.
-- 3-6 weeks of Gancicyclovir IV with duration to be determined
at ID follow-up with Dr. [**Last Name (STitle) **]
-- PRN loperamide now that most infectious causes ruled out.
.
# Anemia. Stable. Likely secondary to production deficit given
inappropriately low retic count. Multiple causes may be
contributing including acute illness, suppression from virus
(CMV, HIV) or medications (antivirals, bactrim). Patient did
have guaiac + stool but no frank melena.
-- could consider bone marrow biopsy to eval for infiltrative BM
process although given other explanations, likely should wait
until acute illnesses resolving before considering.
.
# New diagnosis of HIV. CD4 count 11. Patient was started on
HAART with darunavir, ritonavir and truvada. Unclear how patient
acquired the HIV infection as no history of IV drug use, blood
transfusions, or multiple sexual partners. She continues to be
very distressed by how she acquired the infection and she
received counseling for this new diagnosis while inpatient.
-- HIV genotype still pending at discharge. Will be followed-up
by Dr. [**Last Name (STitle) **] with medication changes made if neccessary.
-- continue prophylaxis with azithromycin and bactrim
.
# CMV infection: CMV detected by PCR in CSF. Also CMV early
antigen in BAL specimen. Clinical suspicion of CMV colitis as
discussed above. Opthalmology evaluated patient in hospital and
ruled out CMV retinitis, but did detect HIV retinopathy.
-- 3-6 weeks of Gancicyclovir IV with duration to be determined
at ID follow-up with Dr. [**Last Name (STitle) **]
.
# Acute encephalopathy. Improved. Most likely toxic/metabolic
encephalopathy from severe illness that improved with treatment
of underlying conditions. Patient also had acute occipital
stroke. In addition patient had CMV pcr in CSF. LP was
otherwise unremarkable for Toxo, Crypto, Syphilis.
.
# Depression: Psychiatry was involved inpatient due to
depression with superimposed delirium.
- Home dose of sertraline was increased to 150mg daily
- Aripiprazole 2mg daily was added as adjunctive therapy
- Home clonazepam was stopped
- Patient will need outpatient follow-up after resolution of
acute illness
.
# Acute Occipital Stroke: Most likely embolic, but with negative
bubble study X 2. Given absence of vascular risk factors patient
likely to have hypercoagulable state which may be related to HIV
or an undiagnosed malignancy. Testing for acquired
predispositions to arterial thrombosis was unremarkable.
-- Age appropriate cancer screening for origin of
hypercoagulability. Defered to outpatient after resolution of
acute illness.
.
# HSV2 vesicles: Improved with antivirals
-- There should be less chance of reactivation with initiation
of HAART
-- Gancyclovir also provides coverage for HSV2
.
# Limb ischemia: s/p thrombectomy for ischemic left foot and
fasciotomy caused by an acute arterial thrombus. In discussion
with vascular surgery, it was decided that patient should go to
rehab to recover strength first before undergoing any further
surgery.
-- Patient will follow-up with Dr. [**Last Name (STitle) **] in vascular surgery for
possible amputation once patient's strength is improving.
-- Patient non-weight bearing on the left
-- continue heparin gtt for bridge to coumadin. Goal INR [**1-5**].
Discharge INR 2 after receiving 3 mg warfarin x 3 days. Please
monitor INR closely and adjust warfarin as necessary. Her
sensitivity to warfarin at discharge was high, requiring a very
low dose.
.
# Pneumothorax. Complication of subclavian line placement.
Patient had chest tube placed, which was removed on [**2102-11-10**].
Still small apical PTX present on [**11-13**] but asymptomatic
.
# Malnutrition, severe: Patient with poor appetite and weight
loss for several weeks prior to this admission. While inpatient
she was aspirating initially and therefore had a NG tube placed
for feeding. When her respiratory status improved she had a
video swallow eval which cleared her for PO intake. Most likely
the etiology is her severe underlying illness including AIDS and
the other superimposed infections causing increased caloric
needs and decreased appetite.
-- Nutrition consult at rehab. Continue ensure plus with meals
for now.
.
TRANSITIONAL ISSUES:
====================
- Repeat CT chest 6 weeks from [**2102-10-12**] to f/u pulmonary nodules
- Age appropriate cancer screening for origin of
hypercoagulability. Defered to outpatient after resolution of
acute illness.
- Please schedule outpatient PCP [**Name9 (PRE) 702**] with [**Name9 (PRE) **] resident
clinic ([**First Name8 (NamePattern2) **] [**Last Name (un) 14740**])
- Please check twice weekly labs of CBC w/diff and Chem-7 faxed
to [**Telephone/Fax (1) 1419**] attn: Dr. [**Last Name (STitle) **]
- Patients needs Ophthalomology follow-up in ~2 weeks post
discharge for evaluation of HIV retinopathy
- Patient needs vascular surgery follow up with Dr [**Last Name (STitle) **].
- Communication: Patient does not want sister or father to know
any details about her care. She requested that her HCP be [**Name (NI) **]
[**Name (NI) 91028**] (boyfriend) [**Telephone/Fax (1) 91029**].
- Studies pending at discharge: HIV genotyping
Medications on Admission:
Sertraline
Clonazepam
Discharge Medications:
1. aripiprazole 1 mg/mL Solution [**Telephone/Fax (1) **]: Two (2) mg PO DAILY
(Daily).
2. sertraline 50 mg Tablet [**Telephone/Fax (1) **]: Three (3) Tablet PO DAILY
(Daily).
3. warfarin 1 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO Once Daily at 4
PM: Goal INR [**1-5**].
4. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral
Solution [**Month/Day (3) **]: One (1) gtt Intravenous ASDIR (AS DIRECTED): D/C
when INR stabilized in therapeteutic range.
5. miconazole nitrate 2 % Cream [**Month/Day (3) **]: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for ITCH/FUNGAL RASH.
6. lidocaine-prilocaine 2.5-2.5 % Cream [**Hospital1 **]: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed for pain.
7. emtricitabine-tenofovir 200-300 mg Tablet [**Hospital1 **]: One (1) Tablet
PO DAILY (Daily).
8. darunavir 400 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
9. ritonavir 80 mg/mL Solution [**Hospital1 **]: One Hundred (100) mg PO
DAILY (Daily).
10. sulfamethoxazole-trimethoprim 200-40 mg/5 mL Suspension [**Hospital1 **]:
Ten (10) ML PO once a day.
11. azithromycin 600 mg Tablet [**Hospital1 **]: Two (2) Tablet PO 1X/WEEK
(TU).
12. ganciclovir sodium 500 mg Recon Soln [**Hospital1 **]: Three Hundred
(300) mg Intravenous Q12H (every 12 hours).
13. prednisone 5 mg/mL Concentrate [**Hospital1 **]: Twenty (20) mg PO DAILY
(Daily) for 5 days: last dose 12/19.
14. loperamide 2 mg Capsule [**Hospital1 **]: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
15. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily) for 5 days: Last dose
[**2102-11-20**].
16. morphine 2 mg/mL Syringe [**Month/Day/Year **]: 1-2 mg Injection Q4H (every 4
hours) as needed for pain.
17. ondansetron HCl (PF) 4 mg/2 mL Solution [**Month/Day/Year **]: One (1)
Injection Q8H (every 8 hours) as needed for nausea: give 30
minutes before morning meds.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for [**Hospital 91030**] Medical Care
Discharge Diagnosis:
Primary Diagnoses:
Acquired Immune Deficiency Syndrome
Pneumocystis [**Hospital **]
Hospital Acquired Pneumonia
Arterial Thrombus
Distal Left Foot Infarction
Right Occipital Stroke
Cytomegalovirus Viremia
CMV Colitis (not confirmed by biopsy)
Pneumothorax
HIV retinopathy
Secondary Diagnoses:
Anemia
HSV-2 Ulcers
Depression
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital with ischemia in your left
foot. During an operation for this, you developed difficulty
breathing and were eventually diagnosed with pneumocystis
pneumonia. This type of infection is typically seen in people
with decreased immune system function, and you were diagnosed
with HIV after a workup for immune deficiency. Your
pneumocystis pneumonia was treated with a course of antibiotics
and steroids. During your stay, you also developed a secondary
bacterial pneumonia which was treated with an additional course
of antibiotics.
Your hospital course was complicated by a stroke caused by a
blood clot in the right occipital lobe of your brain, likely
related to the same process that caused your arterial thrombus
and foot ischemia. Blood tests and echocardiography were
perfomed to help determine what caused these blood clots, but no
clear cause was found.
You developed diarrhea, which was likely caused by CMV infection
of the colon. You were found to have the CMV virus in your
blood, and were treated with antiviral medications, which will
need to be continued for a long course. You had an eye exam to
rule out CMV infection of the retina. No evidence of this
infection was found, but you were found to have HIV retinopathy.
Once your acute issues were stabilized and you were able to take
oral medications, treatment for your HIV infection was also
started. This regimen may need to be adjusted based on the
results of viral genotyping, which is still pending.
The Infectious Disease service will be following after discharge
to help manage your future treatment. You will need eventual
followup with Vascular Surgery for surgical treatment of your
ischemic foot, likely with an amputation.
Your home medication regimen was significantly changed during
your stay. You should refer to your discharge medication sheet
for your new medication regimen and dosing instructions.
You have had a long and difficult hospitalization, but are
clearly improving and on the road to recovery. You are being
discharged to a rehab facility for your ongoing treatment of
your infections and to start aggressive physical therapy. It
has been a pleasure caring for you here at [**Hospital1 18**].
Followup Instructions:
Department: INFECTIOUS DISEASE
When: TUESDAY [**2102-11-21**] at 9:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: VASCULAR SURGERY
When: THURSDAY [**2102-12-7**] at 2:45 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
Your rehab will schedule you an appointment with your new
primary care doctor (Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 14740**] at [**Hospital1 **] resident clinic).
Dr. [**Last Name (STitle) 14740**] is one of the doctors who took [**Name5 (PTitle) **] of you at [**Hospital1 18**].
You should see an opthalmologist in approximately 2 weeks for a
recheck of your eyes.
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15,057
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47560
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Discharge summary
|
report
|
Admission Date: [**2127-5-20**] Discharge Date: [**2127-5-23**]
Date of Birth: [**2064-3-13**] Sex: M
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Demerol / Ambien / Strawberry / Wheat Bran
/ Hydrochlorothiazide / Aldactone / Inspra
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
63M with CAD s/p CABG ([**2123**]), severe ischemic cardiomyopathy (EF
20%), s/p BiV/ICD, DM2, HTN, OSA, recently started on coumadin
for L apical thrombus during recent hospitalization at [**Location (un) 620**]
([**Date range (1) 23494**]/09), sent in from vascular clinic to ED with increased
SOB, N/V, and fatigue, dry cough x 2 days. Had dyspnea overnight
more than baseline orthopnea ([**3-5**] pillows at home). Wife notes
likely dietary indiscretion 2 days prior.
.
Patient had recent admission to [**Hospital1 **] [**Location (un) 620**] [**Date range (1) 23494**]/09 for
fatigue, body aches, and dyspnea. Found to have worsening EF by
ECHO, and apical thrombus for which he was started on coumadin.
Discharged on increased dose of [**Date range (1) **] and 5 day course of
levofloxacin for empiric tx of bronchitis/PNA.
.
Today in [**Hospital1 18**] ED, initial vitals were T99.8, HR91, BP174/113,
RR30s, O2 sat 88% -> mid 90s on NRB. Diaphoretic, found to be in
respiratory distress, worried about persistent tachypnea ->
intubated with etomidate/succ/midazolam. Denied chest pain at
this time. CXR consistent with fluid overload. ECG showed V
pacing, unchanged from prior. Given rectal ASA, SL nitro,
started on nitro gtt. Bedside ECHO showed mild left ventricular
hypertrophy with marked ventricular dilation and severe global
hypokinesis. Mild to moderate MR, mild pulm HTN. No obvious LV
clot but cannot be excluded. 1st set enzymes negative, BNP 1095.
Cards consult called, plan for admit to CCU for likely
decompensated heart failure. Planned for [**Hospital1 **], but not given
due to low BP. Foley placed, 100cc urine output on own. Vitals
on transfer were HR60, 97/53, RR20, O2 100%, vent settings CMV,
TV 500, FiO2 80, PEEP 5.
.
On arrival to CCU, patient sedated, but able to respond to
questions appropriately, denied chest pain. Able to recognize
family.
.
Full ROS unable to be obtained as patient intubated with
sedation but denies any chest pain, hemoptysis, changes in bowel
movements. Had 1 day of cough without sputum.
.
Cardiac review of systems is notable for absence of chest pain,
palpitations, syncope or presyncope.
Past Medical History:
. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: CAD, s/p CABG (4 vessel CABG on [**2123-3-4**] (LIMA
to LAD, SVG to OM, ramus, RCA); Ischemic cardiomyopathy (EF
15-25%)
-PACING/ICD: BiV pacer for ventricular
arrhythmias
3. OTHER PAST MEDICAL HISTORY:
1. HTN
2. Prostatitis
3. Melanoma s/p excisions
4. DM2
5. Afib in past, prior to BiV pacer
6. GERD
7. gout
8. Sleep apnea
9. s/p hemorrhoidectomy
10. bilateral Iliac artery aneurysm s/p repair ([**2119**]),
Infrarenal AAA of 3 cm s/p repair [**2119**]
11. Hypertensive cardiomyopathy
12. Hypercholesterolemia
13. Cervical radiculopathy
14. Recurrent PNA
Social History:
He lives with his wife in [**Name (NI) **].
-Tobacco history: Ex-smoker, with 40 pack-year smoking history
-ETOH: None, with no history
-Illicit drugs: None
Family History:
Father with MI in 50s
Physical Exam:
VS: T= 98.9 BP= 114/53 HR= 65 RR= 16 O2 sat= 100% on CMV TV 500,
FiO2 100, PEEP 5
GENERAL: Middle aged man intubated, sedated, able to wake up
with verbal stimulation and answer questions by nodding
appropriately
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 15 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
heard
LUNGS: Rhonchorous anteriorly
ABDOMEN: Soft, obese, possible fluid wave, NT. No abdominial
bruits.
EXTREMITIES: 1+ pitting edema to knee, R>L
SKIN: old venous stasis changes bilaterally
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
TTE ([**2127-5-20**]): The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is severely dilated. There is severe global left
ventricular hypokinesis (LVEF = 20-25 %). The left ventricular
apex is heavily trabeculated, and a left ventricular
mass/thrombus cannot be excluded. Right ventricular chamber size
and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic arch is mildly dilated. The aortic valve
leaflets (3) are mildly thickened. The study is inadequate to
exclude significant aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. An eccentric jet
of mild to moderate ([**1-3**]+) mitral regurgitation is seen. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mild left ventricular hypertrophy with marked
ventricular dilation and severe global hypokinesis. Mild to
moderate mitral regurgitation. Mild pulmonary hypertension.
Compared with the report of the prior study (images unavailable
for review) of [**2127-5-6**], a left ventricular apical thrombus is
not definitively seen. A supravalvular aortic membrane is not
clearly identified.
EKG ([**2127-5-20**]): Sinus rhythm with ventricular demand pacing.
Pacemaker rhythm - no further analysis. Since previous tracing
of [**2126-9-20**], the heart rate has increased.
CXR 1V ([**2127-5-20**]): In comparison with study of [**10-27**], there is
huge enlargement of the cardiac silhouette consistent with
cardiomyopathy. However, there has been substantial increase
engorgement of pulmonary vascularity consistent with the
clinical impression of superimposed congestive failure.
Pacemaker device remains in place.
CXR 1V ([**2127-5-21**]): Significant interval improvement in pulmonary
edema has been demonstrated which is almost completely resolved.
Left retrocardiac opacities are most likely due to atelectasis
rather than residual pulmonary edema. Cardiomegaly is severe and
unchanged. The position of the biventricular pacemaker leads is
unchanged. There is small most likely bilateral pleural
effusion, decreased since the prior study.
TTE ([**2127-5-22**]): There is an apical left ventricular aneurysm.
There is severe global left ventricular hypokinesis (LVEF = 20
%). No masses or thrombi are seen in the left ventricle. There
is no pericardial effusion. IMPRESSION: No apical thrombus.
[**2127-5-23**]
WBC-6.9 Hgb-10.9* Hct-34.6* MCV-82 Plt Ct-121*
Neuts-79.5* Lymphs-13.4* Monos-4.4 Eos-2.3 Baso-0.4
PT-22.5* PTT-35.5* INR(PT)-2.2*
Glucose-78 UreaN-39* Creat-2.2* Na-145 K-3.3 Cl-102 HCO3-33*
ALT-41* AST-40 LD(LDH)-278* CK(CPK)-138 AlkPhos-126* TotBili-0.9
Lipase-79*
cTropnT-0.01 > 0.04* > 0.04*
proBNP-1095*
Digoxin-1.0
CK(CPK)-138 > 105 > 102
Brief Hospital Course:
63 year-old male with coronary artery disease, dilated
cardiomyopathy (EF 20%) status-post BiV/ICD, diabetes mellitus
type II, hypertension, obstructive sleep apnea, recently started
on coumadin for left apical thrombus admitted with respiratory
distress secondary to decompensated heart failure. Hospital
course was as follows.
1. Respiratory failure: Patient was intubated in emergency
department for tachypnea, hypoxia. Decompensated heart failure
was most likely underlying etiology given exam consistent with
fluid overload, fluid congestion on chest radiograph, elevated
BNP, and recent history of dietary noncompliance. Patient was
diuresed and extubated within hours of admission to CCU.
2. Decompensated systolic heart failure: Patient with known
hypertensive cardiomyopathy followed by Dr. [**First Name (STitle) 437**] in heart
failure service. s/p BiV/ICD interrogated in [**3-10**] with no
problems. EF 15-20% from recent ECHO in [**Location (un) 620**]. Exam consistent
with volume overload including JVD, crackles, and lower
extremity edema. Effusions were seen on chest radiograph. Recent
diet and fluid restriction noncompliance as inciting factor for
decompensated heart failure. As above, patient was intubated in
ED for hypoxia. Nitro gtt was started, and rapidly weaned off in
CCU. Patient was diuresed successfully with [**Location (un) 11573**] 100mg IV, then
downtitrated to [**Location (un) 11573**] 60mg IV and finally [**Location (un) 11573**] 100mg PO qAM and
60mg PO qPM. He was continued on digoxin, lisinopril,
beta-blocker. He was given a low-salt diet and fluid restricted,
and was counseled on the importance of sodium and fluid
restriction.
3. CORONARIES: Known CAD s/p CABG. No chest pain or indications
of ACS. Troponin was elevated but CK flat. ECG paced and without
evidence of ischemia. He was continued on ASA, beta-blocker, ACE
inhibitor, and statin.
4. RHYTHM: Atrial and ventricular paced (underlying rhythm is
sinus brady). On amiodarone for afib in past. Patient was
continued on amiodarone. He reported having been on coumadin
several years ago particularly for atrial fibrillation but had
been stopped for an unknown reason. As below, he recently had
been restarted on coumadin for a separate reason.
5. Recent possible left apical clot: Noted on TTE at [**Hospital1 **]
[**Location (un) 620**]. Repeat TTE with Definity showed no evidence of a clot.
Coumadin was thus held.
6. Diabetes mellitus, type II: Continued home Lantus and
Humalog sliding scale.
7. Chronic kidney disease: Stable from discharge on [**2127-5-9**].
Likely related to diabetes, hypertension.
8. Dyslipidemia: Continued Lipitor per home regimen.
9. Depression: Continued escitalopram per home regimen.
**Communication: [**Name (NI) **] (wife), ([**Telephone/Fax (1) 100532**]
Medications on Admission:
- [**Telephone/Fax (1) 11573**] 60-100 mg daily (Discharged on [**5-7**] with 100mg daily x 3
days then 80mg daily)
-Coumadin 5mg, then INR to be checked
-s/p 5 day course of levofloxacin (500 mg daily for 5 days on
[**5-7**] for empiric treatment for bronchitis and pneumonia)
-folic acid 1 mg daily
-Lexapro 20 mg daily,
-lisinopril 10 mg daily
-allopurinol 200 mg b.i.d.
-amiodarone 200 mg daily
-aspirin 81 daily
-carvedilol 25mg b.i.d.
-digoxin 0.125 mcg every other day
-Lipitor 80 mg at bedtime
-Klonopin 0.5 mg t.i.d. p.r.n.
-Flexeril 10 mg p.r.n.
-Protonix 40 mg b.i.d.
-Zantac 300 daily
-Zetia 10 mg at bedtime
-Lantus 70 units subcutaneous b.i.d.
-Humalog sliding scale
-ASA 81mg daily
-Advair daily
-Flomax .4mg daily
-Lexapro 20mg daily
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
12. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
14. Lantus 100 unit/mL Solution Sig: Seventy (70) units
Subcutaneous twice a day.
15. Omega-3 Fish Oil 1,000-5 mg-unit Capsule Sig: One (1)
Capsule PO once a day.
16. 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*
17. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: as per
sliding scale units Subcutaneous three times a day: before
meals.
18. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
19. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
20. Furosemide 20 mg Tablet Sig: Five (5) Tablet PO once a day:
early in the morning.
Disp:*150 Tablet(s)* Refills:*2*
21. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO once a day:
at 1-2pm.
22. Omega-3 Fish Oil 1,000-5 mg-unit Capsule Sig: One (1)
Capsule PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic Systolic Congestive Heart Failure
Diabetes Mellitus Type 2
Transaminitis
Hypertension
Discharge Condition:
Hemodynamically stable. Maintaining O2 saturation with
ambulation, on room air. Continues to diurese well.
Discharge Instructions:
You had an episode of congestive heart failure where fluid
filled up your lungs causing you to be intubated. We
aggressively diuresed you with intravenous [**Month/Day (4) **] and
transitioned you to oral [**Month/Day (4) **] before discharge. Your current
weight is 233 pounds. You goal weight is likely around 220-225
pounds or when you are able to lie almost flat to sleep and you
have no swelling in your legs. It is very important to follow
your low sodium diet and limit your fluid intake to 1500cc per
day or about 6 cups of fluid. Please also be sure to count the
fluid from a popsicle in the daily total. Please take your first
dose of [**Month/Day (4) 11573**] early in the morning and the second dose about
1-2pm. If you limit your fluids, you should not be up at night
to urinate.
.
Medicine changes:
1. Warfarin (coumadin): you do NOT have to continue this as the
Echocardiogram did not show a clot.
2. Furosemide: 100mg in the morning, 60 mg at night
3. Please talk to Dr. [**Last Name (STitle) 1407**] about whether to continue your
inhalers
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500cc or 3 Poland spring [**1-3**] liter bottles
Followup Instructions:
Primary Care:
[**Last Name (LF) **],[**First Name3 (LF) 20**] R. Phone: [**Telephone/Fax (1) 1408**] Date/Time: Tuesday [**5-27**]
at 3:30pm.
Cardiology Heart Failure:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **]
Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2127-6-2**] 1:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2127-5-28**]
|
[
"518.81",
"V58.67",
"272.4",
"403.90",
"274.9",
"V45.81",
"414.00",
"V45.02",
"585.3",
"790.4",
"428.23",
"428.0",
"427.31",
"327.23",
"530.81",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
12802, 12808
|
7224, 10041
|
389, 401
|
12955, 13063
|
4285, 7201
|
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|
3442, 3465
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10841, 12779
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12829, 12934
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10067, 10818
|
13087, 14316
|
3480, 4266
|
2686, 2865
|
329, 351
|
429, 2583
|
2896, 3252
|
2605, 2666
|
3268, 3426
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,817
| 186,095
|
8754
|
Discharge summary
|
report
|
Admission Date: [**2174-12-6**] Discharge Date: [**2174-12-9**]
Date of Birth: [**2106-1-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
SOB, chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
68yo male with hx COPD, HTN, prostate CA s/p bilateral
orchectomy, hypercholesterolemia p/w SOB, cough, and L sided
pleritic chest pain. Patient first noticed cough on [**2174-11-25**]
which temporarily improved over the weekend but then worsened.
Cough productive of white sputum. Patient denies n/v, fever,
chills, recent travel, sick contacts. [**Name (NI) **] received a flu shot in
[**10-6**].
ED course: Vitals 99.2 107 85/39 24 96% on 4L
The patient was tachycardic, febrile, tachypnic, and
hypotensive. He did not show an adequate response to 3L NS and
met sepsis criteria. In the ED, he received combivent and
albuterol nebs, azithromycin, solumedrol, toradol, ceftriaxone,
and was started on a levophed gtt titrated to SBP > 100. He was
admitted to the MICU service for sepsis protocol. CTA chest
revealed a foci of consolidation in the lingula, RUL, and RLL.
Central venous O2 saturation was initially 77. Stress dose
steroids with hydrocortisone 50mg IV q6h were started.
Ceftriaxone and azithromycin were continued for a combined
diagnosis of sepsis/pneumonia. The patient's chest pain was
alleviated with toradol.
Past Medical History:
1. COPD
2. HTN
3. hypercholesterolemia
4. prostate CA, [**Doctor Last Name **] score 8, s/p bilateral orchectomy
[**2170-7-13**]
5. osteoporosis
Social History:
History of tobacco use 2ppd and now at 1ppd. Total > 100
pack-years. Lives in [**Location (un) **], alone. Veteran of Korean
War. Has a daughter.
Family History:
NC
Physical Exam:
G: Dyspneic male
HEENT: Dry MM, anicteric
Lungs: Distant BS, occ crackles/wheezes
CV: Distant S1S2, No M/R/G
Abd: Soft, NT, ND, BS decr
Ext: No E/C/C
Neuro: Grossly intact
Pertinent Results:
Admission labs:
[**2174-12-5**] 11:55PM PT-13.1 PTT-25.5 INR(PT)-1.1
[**2174-12-5**] 11:55PM PLT COUNT-545*
[**2174-12-5**] 11:55PM NEUTS-86.8* LYMPHS-8.4* MONOS-4.5 EOS-0.2
BASOS-0.2
[**2174-12-5**] 11:55PM WBC-15.7*# RBC-4.30* HGB-12.8* HCT-37.4*
MCV-87 MCH-29.7 MCHC-34.1 RDW-12.6
[**2174-12-5**] 11:55PM CALCIUM-9.9 PHOSPHATE-3.4 MAGNESIUM-2.2
[**2174-12-5**] 11:55PM CK-MB-NotDone cTropnT-<0.01
[**2174-12-5**] 11:55PM CK(CPK)-56
[**2174-12-5**] 11:55PM GLUCOSE-128* UREA N-37* CREAT-1.6* SODIUM-133
POTASSIUM-4.6 CHLORIDE-93* TOTAL CO2-30* ANION GAP-15
[**2174-12-6**] 02:05AM LACTATE-1.6
[**2174-12-6**] 02:05AM COMMENTS-GREEN TUBE
[**2174-12-6**] 03:00AM PT-13.7* PTT-28.7 INR(PT)-1.2
[**2174-12-6**] 03:00AM PLT SMR-HIGH PLT COUNT-447*
[**2174-12-6**] 03:00AM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2174-12-6**] 03:00AM NEUTS-94.3* BANDS-0 LYMPHS-4.0* MONOS-1.6*
EOS-0.1 BASOS-0
[**2174-12-6**] 03:00AM WBC-17.5* RBC-3.40* HGB-10.1* HCT-30.1*
MCV-89 MCH-29.6 MCHC-33.5 RDW-12.7
[**2174-12-6**] 03:00AM CRP-18.16*
[**2174-12-6**] 03:00AM CORTISOL-324.9*
[**2174-12-6**] 03:00AM ACETONE-NEGATIVE OSMOLAL-291
[**2174-12-6**] 03:00AM ALBUMIN-3.4 CALCIUM-7.9* PHOSPHATE-2.8
MAGNESIUM-1.9
[**2174-12-6**] 03:00AM LIPASE-28
[**2174-12-6**] 03:00AM ALT(SGPT)-17 AST(SGOT)-17 ALK PHOS-65
AMYLASE-79 TOT BILI-0.5
[**2174-12-6**] 03:00AM GLUCOSE-147* UREA N-32* CREAT-1.2 SODIUM-132*
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-23 ANION GAP-12
[**2174-12-6**] 03:37AM LACTATE-1.6
CT CHEST W/CONTRAST [**2174-12-6**] 12:16 AM
CT CHEST W/CONTRAST; CT 150CC NONIONIC CONTRAST
IMPRESSION:
1) No pulmonary embolus detected.
2) Consolidative and ground-glass opacities in the lingula and
right upper lobe may represent pneumonia. Irregular right lower
lobe consolidative opacity is also noted. Follow-up examination
after treatment should be considered within three months to
assess for change or resolution.
3) Emphysema.
4) Calcified pleural plaques suggesting prior asbestos exposure.
CHEST (PORTABLE AP) [**2174-12-6**] 2:57 AM
IMPRESSION:
1) Internal jugular line in right atrium.
2) Probable mild failure. Patchy opacities in both lungs may
represent pneumonia.
Brief Hospital Course:
68M with hx COPD (>100 pack-years), HTN, prostate CA s/p
bilateral orchectomy p/w cough and pleuritic CP. The patient
noted that he developed the cough on [**11-25**], and that it
initially improved over the weekend, but then yesterday got
dramatically worse. The MUST protocol was initiated after his
SBP 74 did not increase significantly with 3L NS. Levophed GTT
was started. He was given combivent/albuterol nebs, azithro/CTX
for CAP, solumedrol 125mg IV, toradol 30mg IV. His exam in the
ED was notable for diffuse expiratory wheezes. CXR was normal
initially, repeat for RIJ confirmation also showed RLL
infiltrate. He was placed on droplet precautions for flu. CTA
was negative for PE/dissection, notable for emphysema, calcified
pleural plaques suggesting asbestos exposure, and ground-glass
opacities in the lingula possibly c/w infection, and irregular
RLL consolidative opacity. EKG was notable for sinus tachy at
114, no changes. Admitted to MICU on [**12-6**] for sepsis/pneumonia.
Ceftriaxone and azithromycin continued. Stress dose steroids
with hydrocortisone 50mg IV q6h started. After 1 day in MICU,
dramatically improved with no oxygen or pressor requirement.
Tolerating POs. No wheezes on exam. Transferred to medicine
[**Company 191**]. Prednisone and azithromycin continued. Started on
atrovent, fluticasone, and serovent MDI. Received nursing
training for proper usage of MDI.
Assessment/Plan:
1. Pneumonia:
--Ceftriaxone 1g IV q24h
--Azithromycin 500mg PO q24h
-- nicotine TD and bupropion for smoking cessation
-- Physical therapy consult
-- prednisone 60mg PO qd, plan taper over 6 days
2. Anemia
- Last HCT 27.4
- guiaic stools
- iron studies, B12 pnd
3. Hyperglycemia
- Likely steroid induced
- RISS, qid fingersticks
4. Constipation
- bisacodyl, docusate
5. PPX: pantoprazole, sc heparin
Medications on Admission:
1. lisinopril 20mg PO qd
2. hctz 25mg PO qd
3. calcium
4. simvastatin 40mg PO qd
5. prostate CA meds
Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours):
Please take one pantoprazole on each day you take prednisone.
Disp:*6 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*30 Patch 24HR(s)* Refills:*2*
3. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO twice a
day.
Disp:*14 Capsule(s)* Refills:*0*
4. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 1* Refills:*2*
5. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One
(1) Disk with Device Inhalation Q12H (every 12 hours).
Disp:*60 Disk with Device(s)* Refills:*2*
6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO see
instructions below: Day 1: 30mg
Day 2: 30mg
Day 3: 20mg
Day 4: 20mg
Day 5: 10mg
Day 6: 10mg.
Disp:*12 Tablet(s)* Refills:*0*
10. Atrovent 18 mcg/Actuation Aerosol Sig: One (1) Inhalation
twice a day: Start twice a day but use up to three times a day
if needed.
Disp:*1 1* Refills:*2*
11. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO twice a
day.
Disp:*60 Capsule(s)* Refills:*2*
12. Tums 500 1,250 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO twice a day.
Disp:*60 Tablet, Chewable(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
pneumonia/sepsis
Discharge Condition:
Good
Discharge Instructions:
Please return to the emergency room should you experience
worsening shortness of breath, chest pain, severe dizziness,
loss of consciousness, or other alarming symptom. Please
discuss your decision to stop smoking with your primary care
physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 30627**] so that he assist with this goal.
Followup Instructions:
Please call you primary care physician [**Last Name (NamePattern4) **]. [**Known firstname 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 30627**] to
make an appointment following your discharge from the hospital.
It is recommended that you have repeat chest CT imaging once
your pneumonia resolves.
|
[
"501",
"038.9",
"305.1",
"785.52",
"V10.46",
"995.91",
"491.21",
"486",
"564.00",
"272.0",
"401.9",
"786.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7995, 8001
|
4348, 6184
|
331, 337
|
8061, 8067
|
2055, 2055
|
8461, 8781
|
1844, 1848
|
6335, 7972
|
8022, 8040
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6210, 6312
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8091, 8438
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1863, 2036
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276, 293
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365, 1495
|
2072, 4325
|
1517, 1664
|
1680, 1828
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,789
| 173,650
|
42834
|
Discharge summary
|
report
|
Admission Date: [**2102-3-30**] Discharge Date: [**2102-4-3**]
Date of Birth: [**2042-8-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
simvastatin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
coronary artery disease
Major Surgical or Invasive Procedure:
coronary artery bypass graftsx2(LIMA-LAD,SVG-DG) [**2102-3-30**]
History of Present Illness:
This 59 year old white male notes about a two month history of
anterior neck
pain. Initially he was aware of it most of the day, but more
recently it has seemed to correlate only with exertion such as
ambulating briskly for [**Age over 90 **] yards. The discomfort typically
resolves with rest but he has tried SL nitroglycerin which has
been effective. He denies any chest discomfort or dyspnea.
Exercise stress testing was notable for throat discomfort
and 2mm ST depression in V5 and V6. He has since been put on
Aspirin,a beta blocker and Plavix and is referred for left heart
catheterization. Catheterization earlier revealed diffuse Left
Cx and LAD
disease. He was referred for coronary revascularization and is
admitted as a same day surgery.
Past Medical History:
Hypertension
Dyslipidemia
Psoriatic arthritis
Allergic Rhinitis
Vasovagal syncope x 2 in the setting of medical
valuation/procedures
Anal fissure
Herpes Simplex Type I
s/p Umbilical hernia repair
s/p [**2097**] resection of melanoma from back
Social History:
Race: Caucasian
Last Dental Exam: 1 month ago with temp crown placed
Lives with: Wife - Married with three children.
Occupation: Social studies teacher
Contact for discharge: [**Doctor First Name **]- [**Name (NI) **] [**Name (NI) 59917**] (wife) - [**Telephone/Fax (1) 92509**]
Cigarettes: Smoked no [x] yes [] last cigarette
Other Tobacco use:
ETOH: < 1 drink/week [] 1 drink per week [**2-14**] drinks/week [] >8
drinks/week []
Illicit drug use - none
Family History:
Family History:Premature coronary artery disease
Father is 85 with angina. Grandfather with a "heart
condition", dying at age 84.
Physical Exam:
Pulse:57 Resp:20 O2 sat:100% RA
B/P Right:119/61 Left:131/78
Height: 5'9" Weight:195#
General: AAOx 3 in NAD
Skin: Dry [x] intact [x] Psoriasis lower extremities, Rosea on
cheeks
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:cath site Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right:none Left:none
Pertinent Results:
[**2102-4-1**] 03:45AM BLOOD WBC-9.6 RBC-3.21* Hgb-9.3* Hct-29.8*
MCV-93 MCH-28.9 MCHC-31.1 RDW-13.1 Plt Ct-130*
[**2102-4-3**] 04:40AM BLOOD WBC-6.9 RBC-3.21* Hgb-9.1* Hct-30.1*
MCV-94 MCH-28.5 MCHC-30.4* RDW-13.1 Plt Ct-179
[**2102-4-3**] 04:40AM BLOOD UreaN-10 Creat-0.8 Na-138 K-4.2 Cl-103
Brief Hospital Course:
He was taken directly to the Operating Room where surgery was
done uneventfully. He weaned from bypass easily and transferrred
to the ICU. He awoke, weaned and was extubated. Beta blockers
were begun and he was diuresed towards his preoperative weight.
He was transferred to the floor on POD1. and Physical Therapy
worked with him. CTs and wires were removed per protocols
uneventfully. A routine CXR on the day after CT removal was
notable for a 3cm right pneumothorax and he was assymptomatic.
A repeat film the next day showed the lung to have partially
resolved and he remained well.
At discharge wounds were healing well, he was independently
ambulating and all follow up appointments were made.
Medications on Admission:
ATORVASTATIN 10 mg Tablet daily
BISOPROLOL FUMARATE 5 mg daily
CLOPIDOGREL 75 mg qam
LISINOPRIL 20 mg Tablet daily
NITROGLYCERIN 0.4 mg Tablet PRN
ASCORBIC ACID 500 mg daily
ASPIRIN 81 mg Tablet daily
MULTIVITAMIN
SALMON OIL-OMEGA-3 FATTY ACIDS [SALMON OIL-1000] daily
Discharge Medications:
1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
6. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 3765**] Hospice Program
Discharge Diagnosis:
coronary artery disease
s/p coronary bypass grafts
dyslipidemia
psoriatic arthritis
s/p resection of malignant melanoma
hypertension
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 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**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon:Dr.[**Last Name (STitle) **]([**Telephone/Fax (1) 170**]) on [**4-10**]/512 at 10:30am
Cardiologist:Dr.[**Last Name (STitle) 7526**] on [**2102-4-11**] at 10:30am
Wound check in [**Last Name (un) 6752**] 2A on [**2102-4-13**] at 10:30am
Please call to schedule appointments with:
Primary Care: Dr.[**First Name11 (Name Pattern1) 5279**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 59917**]([**Telephone/Fax (1) 21640**]in [**4-13**] 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:[**2102-4-3**]
|
[
"401.9",
"272.4",
"285.1",
"512.1",
"414.01",
"413.9",
"458.29",
"696.0",
"V10.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
5034, 5101
|
3128, 3834
|
301, 368
|
5278, 5500
|
2810, 3105
|
6340, 7047
|
1926, 2043
|
4154, 5011
|
5122, 5257
|
3860, 4131
|
5524, 6317
|
2058, 2791
|
238, 263
|
396, 1153
|
1175, 1420
|
1436, 1895
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,408
| 165,144
|
16460
|
Discharge summary
|
report
|
Admission Date: [**2120-7-26**] Discharge Date: [**2120-7-27**]
Date of Birth: [**2092-1-9**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
asthma exacerbation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
28 year old male with a hx. of asthma, Hep. C with polysubstance
abuse, antisocial personality disorder as well as malinger for
admissions to avoid incarceration admitted for acute asthma
exacerbation.
As per patient he presented to his pulmonologist's office c/o
increased dyspnea for the past week. His peak flow in office
was 275 after 2 clinic albutrol nebulizers (baseline 500-550).
Patient does not relate a clear history leading up to these
events, but as per ED note, he was hospitalized at [**Hospital1 2025**] last week
for a few days, seen at [**Hospital1 2177**] yesterday and started on prednisone.
He presented to [**Hospital1 **] from his PCPs office today for continued SOB
with no relief from home neb treatments. Peak flow at best 500,
currently 200.
Has hx of frequent hospitalizations for asthma and has been
intubated in the past. He has had 2 hospitalizations in the last
month and multiple po courses of prednisone; recent IV steroids
[**Date range (1) **]. Vital signs: BP 118/87, hr 83, O2 98% wt 224 ht 69.
In the ED, initial VS were: 97.5 76 126/80 16 100% RA
He apparently became somnelent and dyspneic with 02 sats -->low
90s, and his peak expiratory flow rate was 200 (baseline 500).
He received solumedrol 125 mg, 3 stacked nebs then continuous
nebs, Mg, azithromycin x1, as well as 1mg IV ativan.
ABG showed: 7.45 37 197
On arrival to the MICU, patient was in some respiratory distress
with waxing and [**Doctor Last Name 688**] mental status (somnolence) and variable
compliance with interview and exam. VS with sinus tachycardia
(109) BPs 122/62, O2 96% on continuous nebs.
Past Medical History:
1) Asthma; has history of 4 prior intubations
2) Bipolar disorder
3) Seizure disorder, thought to be related to drug withdrawal
4) Depression/PTSD
5) Polysubstance abuse, has history of heroin abuse/dependence,
cocaine, and other substances
6) Hep C diagnosed in [**2118-1-31**]
7) antisocial personality disorder
8) History of malingering with multiple admissions determined to
be faking symptoms to avoid incarceration
Pertinent Results:
[**2120-7-26**] 01:00PM BLOOD WBC-8.0 RBC-5.05 Hgb-15.1 Hct-45.0 MCV-89
MCH-30.0 MCHC-33.7 RDW-13.8 Plt Ct-275
[**2120-7-27**] 05:38AM BLOOD Glucose-214* UreaN-11 Creat-0.8 Na-137
K-4.4 Cl-105 HCO3-22 AnGap-14
[**2120-7-27**] 05:38AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.9
[**2120-7-26**] 02:12PM BLOOD Type-ART pO2-197* pCO2-37 pH-7.45
calTCO2-27 Base XS-2
[**2120-7-26**] 06:44PM BLOOD Type-ART pO2-99 pCO2-34* pH-7.37
calTCO2-20* Base XS--4
Brief Hospital Course:
#Asthma Exacerbation: There was no clear precipitant, although
thinking was likely [**1-4**] erratic inhaler usage adn allergen
exposure. Patient had several exacerbations and admissions
including multiple intubations in the past. CXR was performed
which did not reveal an acute process. He was improved on
nebulizers adn solumedrol. Given severity of disease, patient
was advised to stay and be transferred to floor. However,
patient refused to stay despite our stating the risks of
premature discharge from hospital. He ripped out IV and left
AMA.
# Murmur: Given his history of polysubstance abuse concern does
exist for endocarditis. However, patient was afebrile and has a
previously documented murmur. Blood cultures were drawn, which
were negative as of [**2120-7-28**] but still pending. The day after
admission, murmur was no longer apparent on auscultation,
suggesting high flow state was likely driver.
#Polysubstance abuse: Reported last drug usage 3 days ago,
though the substance was unkown. Somnolent on exam during
arrival to ICU. Held sedating medications and CIWA protocol was
started. Patient left AMA.
#Antisocial personality disorder: Sedating medications were held
in context of respiratory distress. Patient left AMA.
Medications on Admission:
1. Albuterol Inhaler 2 PUFF IH Q6H
2. Quetiapine Fumarate 200 mg PO HS
3. Gabapentin 800 mg PO QID
4. Clonazepam 0.5 mg PO TID
5. BuPROPion 200 mg PO BID
6. CloniDINE 0.1 mg PO BID
7. PredniSONE Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H
2. Quetiapine Fumarate 200 mg PO HS
3. Gabapentin 800 mg PO QID
4. Clonazepam 0.5 mg PO TID
5. BuPROPion 200 mg PO BID
6. CloniDINE 0.1 mg PO BID
7. PredniSONE Dose is Unknown PO Frequency is Unknown
Discharge Disposition:
Home
Discharge Diagnosis:
Asthma exacerbation
Discharge Condition:
Patient left AMA
Discharge Instructions:
Patient left AMA
Followup Instructions:
Patient left AMA
Completed by:[**2120-7-28**]
|
[
"301.7",
"300.00",
"304.20",
"724.2",
"493.92",
"070.70",
"785.2",
"304.00",
"V65.2",
"296.50",
"309.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4704, 4710
|
2910, 4156
|
323, 329
|
4773, 4791
|
2447, 2887
|
4856, 4903
|
4443, 4681
|
4731, 4752
|
4182, 4420
|
4815, 4833
|
264, 285
|
357, 1984
|
2006, 2428
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,200
| 118,320
|
29280
|
Discharge summary
|
report
|
Admission Date: [**2131-12-3**] Discharge Date: [**2131-12-8**]
Date of Birth: [**2072-11-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Palpitations and lightheadedness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
59 year old female with sarcoidosis, LBBB (known for at least 3
years) presents with lightheadedness and palpitations that
lasted for 2 hours on day of admission. She went to OSH where
she was found to be in wide complex tachycardia. She was given
ASA 325 x 1. Apparently, she has been told she has a bundle
[**Last Name (un) **] block in the past, and it was felt she may be in SVT with
aberrancy. They gave her adenosine which broke her out of SVT
and back into sinus rhythm with left bundle, HR 80. She denies
any chest pain with this episode. She denies any fevers, chills.
.
She states very rarely, if she is startled awake from sleep, she
will experience palpitations that may last 10-15 minutes, but
this has only happened once in the past year.
.
She was evaluated by a cardiologist 3 years ago when she had
epigastric discomfort, later thought [**1-18**] to GERD. She had a
normal exercise stress test. Echocardiogram performed at OSH in
[**2127**] revealed EF of 40-45%.
.
She reports that she was diagnosed with sarcoidosis
approximately [**2123**] at which time she was found to have
hilar/mediastinal LAD. It is not clear whether she has known
pulmonary involvment beyond this, but has been seen by
pulmonologist, Dr. [**Last Name (STitle) **], at [**Hospital1 **].
.
Following conversion of her tachyarrhythmia, she was transferred
to [**Hospital1 18**] for further evaluation by electrophysiology.
Past Medical History:
Sarcoidosis
LBBB
Left breast ca s/p lumpectomy and XRT
h/o hyperthyroidism
Osteoporosis
Social History:
Lives with husband. 2 daughters live in [**Name (NI) 2848**]. No tobacco. 1
drink EtOH with dinner, no other drug use.
Family History:
Mother with CAD s/p CABG
Father with CAD s/p CABG and "valve replacement"
Physical Exam:
97.8F HR 90 BP 128/79 RR 18 96%RA
Gen: awake, alert, pleasant, sitting up in bed, NAD
HEENT: PERRL, EOMI, OP clear, MMM
Neck: supple, no JVD
CV: Distant HS, normal S1, S2 without mrg, RRR
Pulm: CTAB, no w/r/r
Abd: Normoactive BS, soft, ND/NT
Ext: WWP, no edema
Pertinent Results:
[**12-3**] CXR: Symmetric interlobular septal thickening in bilateral
lower lobes. This can be due to chronic congestive heart
failure, however, there is no acute evidence of pulmonary edema
or acute failure. The possibility of underlying interstitial
lung disease cannot be totally excluded. Please correlate
clinically, especially with PFT.
.
[**12-5**] Cardiac MRI:
1. Severely dilated left ventricular cavity size with severe
global hypokinesis and focal inferior akinesis and mid-basal
septal akinesis/dyskinesis. The LVEF was severely depressed at
28%. The effective forward LVEF was severely depressed at 22%.
No MR evidence of prior myocardial scarring/infarction.
2. Normal right ventricular cavity size and function. The RVEF
was normal at 59%. No MR evidence of right ventricular fatty
infiltration/dysplasia.
3. Moderate to severe mitral regurgitation. Mild tricuspid
regurgitation.
4. The indexed diameters of the ascending and descending
thoracic aorta were normal. The main pulmonary artery diameter
index was mildly increased.
5. There was a 1 cm lymph node in the supracarinal region.
Findings indicate an LV cardiomyopathy. (However, cannot exclude
ischemic etiology; coronary arteries were not assessed). The
findings were not suggestive of cardiac sarcoid, although this
diagnosis cannot be definitely excluded.
.
[**12-6**] Cardiac catheterization:
1. Selective coronary angiography of this right dominant system
revealed no evidence of coronary artery disease. The LMCA, LAD,
LCX, and RCA had no flow-limting lesions. The LAD had a distal
myocardial brige.
2. Resting hemodynamics revealed a normal PCPW of 8mmHg. Cardiac
index
was normal at 2.6l/min/m2.
3. Left ventriculography revealed global hypokinesis with a
calculated
ejection fraction of 23%.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Severe systolic ventricular dysfunction.
.
Brief Hospital Course:
59 year old female with sarcoidosis and history of LBBB who
presented with palpitations, lightheadedness and wide complex
tachycardia.
.
# Arrhythmia: Rhythm from OSH was reviewed by EP and appeared
most likely ventricular tachycardia as opposed to SVT with
aberrancy given a change in axis. She had one episode on the
floor at [**Hospital1 18**], associated with lightheadedness, self limited,
which also appeared consistent with VT. Given her history of
sarcoidosis and LBBB, there was certainly concern for
infiltrative granulomatous cardiac disease. A cardiac MRI was
obtained to further evaluate for evidence of cardiac sarcoid,
which revealed severe LV hypokinesis (EF 28%); however, was not
consistent with cardiac sarcoid. Cardiac catheterization was
done which did not reveal evidence of coronary artery disease.
She had an electrophysiology study at which time she went into
complete heart block and she was transferred to the CCU with a
temp wire for further monitoring prior to device placement. On
[**2131-12-7**], she had a permanent pacemaker and ICD placed. She
tolerated the procedure well. At the time of discharge, she was
[**Date Range 1988**] follow up with Dr. [**Last Name (STitle) **] in [**Hospital **] clinic, as well as
with the device clinic.
.
# Left Ventricular Systolic Dysfunction: An echocardiogram was
obtained to evaluate her known LBBB which revealed global
hypokinesis with ejection fraction of [**9-30**]%. She has never had
symptoms of heart failure, but was started on beta blocker and
ACEI for LV systolic dysfunction. Cardiomyopathy workup
revealed normal thyroid function tests, normal iron studies, and
SPEP/UPEP. As above, she underwent cardiac MRI to further
evaluate the possibility of cardiac sarcoid, which was not
consistent with this diagnosis. She also underwent cardiac
catheterization which revealed normal coronary arteries.
.
# Sarcoidosis: She was originally diagnosed in approximately
[**2123**] when she was found to have hilar/mediastinal LAD on
imaging. She was on prednisone and methotrexate for years for
ocular involvement, having just discontinued both recently
within the last several months.
Medications on Admission:
actonel qSunday
Multivitamin
calcium 1500mg/day
Discharge Medications:
1. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Ventricular tachycardia
Sarcoidosis
Discharge Condition:
Stable without symptoms of heart failure, no palpitations
Discharge Instructions:
Please call your doctor or return to the emergency room if you
develop palpitations, lightheadedness, chest pain or any other
symptoms that concern you.
.
Please follow up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**] below.
.
Followup Instructions:
.
Please follow up with Dr. [**Last Name (STitle) 27772**] (at Dr.[**Name (NI) 69032**] office)
([**Telephone/Fax (1) 70383**] [**2130-12-28**] at 3:15pm.
.
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**]
Date/Time:[**2132-1-11**] 3:00. Please have echocardiogram about [**12-18**]
weeks prior to appointment with Dr. [**Last Name (STitle) **]. Order already in
POE but no appointment has been made.
.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2131-12-13**]
10:30
|
[
"V10.3",
"401.9",
"426.3",
"427.1",
"733.90",
"429.9",
"135",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.72",
"37.23",
"37.83",
"88.56",
"88.72",
"37.26",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
6895, 6901
|
4335, 6510
|
350, 356
|
6990, 7050
|
2440, 4214
|
7356, 7936
|
2068, 2143
|
6608, 6872
|
6922, 6969
|
6536, 6585
|
4231, 4312
|
7074, 7333
|
2158, 2421
|
278, 312
|
384, 1803
|
1825, 1915
|
1931, 2052
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,448
| 116,629
|
4903
|
Discharge summary
|
report
|
Admission Date: [**2118-9-28**] Discharge Date: [**2118-10-1**]
Date of Birth: [**2052-6-1**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Imdur / Haldol
Attending:[**First Name3 (LF) 2234**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
66 F c CAD/CHF, diabetes, hypertension, [**First Name3 (LF) 20440**] [**First Name3 (LF) 20441**],
schizoaffective disorder, who presents with shortness of breath.
The pt recalls that she started to have trouble breathing this
morning. it came on gradually and worsened slowly. It was
initally associated with non-radiating chest pain over her left
chest and sternum, which was pressure like, pleuritic and
positional as well as intermittent and resolved completed
already when "the paramedics started working on me". On further
questioning the patient reports shortness of breath already
overnight as well as 3-pillow orthopnea. She also recalls a more
pronounced LLE over the last three days. She denies any dietary
indiscretion, however reports sometimes eating salt, "but not
too much". She reports taking her medications diligently.
.
ROS: She reports intermittent fevers, ongoing for several months
as well as night sweats. She also has had about a 20lb weight
loss over the last months since her hospitalization. Also
positive for constipation for three months, mild "abdominal
cramping". Denies cough, diarrhea, blood in the stool or urine,
dysuria. No recent sedentary episodes but at baseline not very
mobile.
.
ED course: Pt arrived to the ED on BIPAP. VS 64 172/86 24 100%,
settings unknown. Pt had received Lasix iv by the paramedics.
Nitro gtt was started for BP control. The patient then was
titrated down to 100% facemask and continued to do well. CXR was
done and showed mild pulmonary edema. BNP was elevated at 5000.
Past Medical History:
CAD: NSTEMI [**2-17**] s/p PCI w/ DES to proximal and distal LCX.
CHF (diastolic dysfunction w/ EF >55%, 1+ AR and 2+MR)
H/o rheumatic heart disease w/ mild AR
[**Month/Year (2) **] [**Month/Year (2) 20441**]
DM 2, diet controlled
HTN
Schizoaffectie disorder
Hypercholesteronemia
? COPD
Restricitve pattern on Spirometry in [**2113**]
History of pulmonary embolus in [**2080**], while taking oral
contraceptives, s/p IVC "interruption procedure")
H/o thyroiditis
H/o seizure disorder from infancy to age of 17
.
PSH:
- Status post C5 to C7 anterior decompression fusion.
- Status post cholecystectomy.
- Status post repair of carpal tunnel syndrome.
Social History:
She lives alone, her daughter, [**Name (NI) **], who lives nearby and
visits her frequently and helps her managing her medications.
Currently uses walker for walking. Has home nurse [**First Name (Titles) **] [**Last Name (Titles) **]
her regularly for daily acitivity as well; Tobacco abuse: 30
pyrs, quit in [**2118-4-14**], social drinker; no illicit drugs
Family History:
CAD in mother at age 68. No history of coagulation problems in
her family.
Physical Exam:
Aspirin 81 mg PO DAILY
Amlodipine 10mg DAILY
Atorvastatin 20 mg PO DAILY
Folic Acid 1 mg PO DAILY
Hexavitamin PO DAILY
Cymbalta 20mg DAILY
Metoprolol Tartrate 175 mg PO BID
HCTZ 25mg DAILY
Protonix 40mg [**Hospital1 **]
Ipratropium Bromide 2puff QID
Hydroxychloroquine 200 mg Tablet PO
Sulfasalazine 500 mg PO BID
Quetiapine 50mg DAILY
Mirtazapine 15mg DAILY
Florinef 0.1mg DAILY
Imdur 30mg DAILY
FeS 325mg DAILY
Vitamin D, Calcium
Pertinent Results:
Admit labs: [**2118-9-28**] 05:50PM
WBC-9.0# RBC-3.18* Hgb-10.7* Hct-31.7* MCV-100* MCH-33.6*
MCHC-33.7 RDW-15.1 Plt Ct-257 Neuts-84.2* Lymphs-10.4* Monos-3.7
Eos-1.3 Baso-0.3 PT-11.8 PTT-27.2 INR(PT)-1.0
Glucose-120* UreaN-17 Creat-1.3* Na-142 K-4.0 Cl-105 HCO3-26
AnGap-15
Calcium-9.1 Phos-4.4 Mg-2.0
.
[**2118-9-28**] 05:50PM BLOOD CK-MB-4 cTropnT-0.01 proBNP-5022*
CK(CPK)-145*
[**2118-9-29**] 12:23AM BLOOD CK-MB-3 cTropnT-<0.01 CK(CPK)-169*
[**2118-9-29**] 04:07AM BLOOD CK-MB-4 cTropnT-<0.01 CK(CPK)-121
.
[**2118-9-29**] 04:07AM BLOOD VitB12-568 Folate-GREATER TH
[**2118-9-29**] 04:07AM BLOOD TSH-2.1
.
PAST STUDIES:
Stress Mibi [**5-24**]:
No anginal type symptoms or ischemic EKG changes. No reversible
myocardial perfusion defect is identified.
.
[**Month/Year (2) **]:
The left atrium is mildly dilated. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers (however images suboptimal; cannot
exclude). There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened. There is no aortic
valve stenosis. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is at least moderate pulmonary
artery systolic hypertension. There is a small pericardial
effusion.
.
Spirometry in [**2113**]:
mild restricitve pattern
.
CT chest [**9-26**]:
Interval increase in size of the dominant right upper lobe
pulmonary
nodule. The interval growth and CT morphology are highly
suspicious for malignancy. Although slightly below the size
threshold for reliability of PET imaging, PET-CT may still be
potentially helpful if it produces a positive result. Other
options include short-term followup CT in 3 months or VATS
biopsy/resection.
2) Two other subpleural right upper and lower nodules are
stable. Tiny lingular and left lower lobe nodules were
previously obscured by atelectasis on the study of [**2118-5-12**].
3) Stable, ectatic thoracic aorta.
.
CURRENT STUDIES:
.
[**9-28**] EKG: SR, HR 67, NA, NI, no ST/TW changes
.
[**2118-9-28**] CHEST XR (PORTABLE AP): There is vascular pedicles
engorgement. The pulmonary vessels are indistinct with mild
cephalization. These findings are consistent with hydrostatic
edema. There is a tortuous aorta. The cardiac silhouette is
enlarged. No definite blunting of the costophrenic angles is
seen to suggest large effusion. There is no pneumothorax.
Incidental note is made of cervical fusion plate. Since the
prior exam, the nasogastric tube has been removed. IMPRESSION:
Mild cardiogenic hydrostatic edema. Repeat radiography following
appropriate diuresis recommended to assess for underlying
infection.
Brief Hospital Course:
66 year old Female with CAD/CHF, diabetes, hypertension,
[**Month/Day/Year 20440**] [**Month/Day/Year 20441**],
schizoaffective disorder, and lung nodule who presents with
shortness of breath, most likely due to CHF with component of
mild COPD exacerbation. The following issues were addressed on
this admission.
.
1. Hypoxia: likely due to CHF with component of mild COPD
exacerbation. MICU team's suspicion for PE was low given the
clinical context, no recent sedentary episodes, and no clinical
concern for DVT. However they did consider that she might be at
increased risk for coagulation as her recent CT findings were
suspicious for malignancy. Clinically and based on absence of
leukocytosis, they did not suspect infection. Patient given
lasix by EMS and started on nitro drip in emergency room. Over
the first night of admission in the ICU the patient was weaned
from BIPAP to 3L nasal cannula. She continued to diurese from
the lasix administered by EMT. Repeat CXR in the morning showed
minimal change in pulmonary edema. Nitro drip was weaned over
first night of admission, transitioned to oral nitrates. The
patient was placed on daily lasix, 40mg daily, and continued to
diurese. She was transferred to the floor on the evening of
[**9-29**]. By [**9-30**] she was satting in the high 90's on room air. By
[**10-1**] she was satting mid 90's with ambulation on room air.
Felt secondary to heart failure and possibly underlying COPD.
See below.
.
2. Heart Failure, diastolic: no clear precipitating factor for
exacerbation, however most likely dietary indiscretion and
possibly hypertension. EKG unremarkable and cardiac enzymes
were negative times 3. TSH was checked given history of
thyroiditis and was normal. Florinef was held, as it could
contribute to CHF symptoms and there was no clear indication in
past notes for its continued use. Patient diuresed over course
of admission about [**4-17**] pounds. Daily lasix of 40mg institutued.
Patient reports she had been on 120mg lasix in the past for
"fluid in her lungs". Patient maintained on metoprolol
throughout. Dose changed from 175mg [**Hospital1 **] to 200mg [**Hospital1 **] for
compliance reasons. Would consider addition of ACE inhibition
as outpatient. Recent [**Hospital1 113**] with preserved ejection fraction.
Could consider repeat stress testing although given severe
debilitation and [**Hospital1 20440**] [**Hospital1 20441**], would need chemical
stress. Imdur dosing increased from 30mg to 60mg daily.
.
3. Coronary Artery Disease: History of PCI in [**2115**]. Ruled out
for MI here. Aspirin, beta blocker and statin maintained.
Consider ace as outpatient. Beta blocker titrated as above.
Imdur dose titrated as above.
.
4. Hypertension: BP elevated on admission, unclear if causitive
of heart failure or in response to heart failure, extremis. The
patient was placed on nitro drip in ER and weaned off the nitro
drip overnight of admission with the sequential addition of
Amlodipine at 10mg, Metoprolol (increased from 175mg [**Hospital1 **] to to
200mg [**Hospital1 **]), and shortacting Isosorbide Dinitrate. HCTX was
discontinued on hospital day 2 as it was thought the patient
would benefit from greater diuresis from low dose Lasix as
outpatient rather then HCTZ. Short acting isordil changed to
imdur on [**9-30**].
Discharged on imdur 60, metoprolol 200bid, amlodipine 10mg
daily.
Consider adding ace inhibition as outpatient as indications
include chf, cad and ckd.
.
5. COPD exacerbation: mild, no clear precipitating factor, no
evidence of infection. Patient reportedly was not on inhaled
steroids. Patient was provided with Fluticasone INH [**Hospital1 **],
Albuterol INH prn, and Ipratropium standing. Discharged on
flovent and albuterol.
.
6 Pulmonary nodule: Recent outpatient CT demonstrated suspicious
pulmonary nodule in RUL. Findings discussed with patient and
patient informed to have follow up PET scan as outpatient.
Patient needs outpatient PET/CT for follow-up. I have emailed
Dr. [**Last Name (STitle) 9006**] about this finding and with summary of hospitalization.
.
7. Chronic Kidney Disease: Creatinine stable and at baseline
between 1.3 and 1.5. Will need creatinine check this week given
addition of lasix. Likely due to HTN and Diabetes.
.
8. Anxiety/Depression: The patient was continued on Duloxetine
and Quetiapine
.
9 Diabetes mellitus: The patient has managed her diabetes with
diet. She was started on a RISS while in the hospital. FS
generally less than 150 while here.
.
10. [**Last Name (STitle) **] [**Last Name (STitle) 20441**]: The patient was continued on
outpatient hydroxychloroquine and sulfazalazine.
.
11. Hypercholesterolemia: Patient was continued on outpatient
Atorvastatin
Patient to follow up with Dr. [**Last Name (STitle) 9006**] this week. Spoke with
patient's sister on day of discharge and gave patient explicit
instructions regarding medication changes and need for follow
up.
Medications on Admission:
Aspirin 81 mg PO DAILY
Amlodipine 10mg DAILY
Atorvastatin 20 mg PO DAILY
Folic Acid 1 mg PO DAILY
Hexavitamin PO DAILY
Cymbalta 20mg DAILY
Metoprolol Tartrate 175 mg PO BID
HCTZ 25mg DAILY
Protonix 40mg [**Hospital1 **]
Ipratropium Bromide 2puff QID
Hydroxychloroquine 200 mg Tablet PO
Sulfasalazine 500 mg PO BID
Quetiapine 50mg DAILY
Mirtazapine 15mg DAILY
Florinef 0.1mg DAILY
Imdur 30mg DAILY
FeS 325mg DAILY
Vitamin D, Calcium
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Amlodipine 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
4. Atorvastatin 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
5. Duloxetine 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
8. Hexavitamin Tablet [**Hospital1 **]: One (1) Cap PO DAILY (Daily).
9. Metoprolol Tartrate 100 mg Tablet [**Hospital1 **]: Two (2) Tablet PO
twice a day.
Disp:*120 Tablet(s)* Refills:*0*
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*2*
12. Atrovent HFA 17 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) puffs
Inhalation four times a day.
13. Hydroxychloroquine 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO
DAILY (Daily).
14. Sulfasalazine 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
15. Seroquel 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
16. Mirtazapine 15 mg Tablet [**Hospital1 **]: One (1) Tablet PO at bedtime.
17. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
[**Hospital1 **]: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
18. Furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
19. Ferrous Sulfate 325 (65) mg Tablet [**Hospital1 **]: One (1) Tablet PO
DAILY (Daily).
20. CALCIUM 500+D 500 (1,250)-400 mg-unit Tablet, Chewable [**Hospital1 **]:
One (1) Tablet, Chewable PO twice a day.
21. Outpatient Lab Work
CBC, Chem-10 to be collected once the week of [**10-3**]. Results to
Dr. [**First Name8 (NamePattern2) **] [**Last Name (STitle) 9006**], [**Telephone/Fax (1) 1247**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
1. Heart Failure, diastolic
2. Pulmonary Nodule
3. Hypertension
4. COPD
Secondary:
1. Chronic kidney disease, stage II
2. Coronary Artery Disease
3. Type II Diabetes mellitus, controlled
4. Depressoni
5. [**Hospital **] [**Hospital **]
Discharge Condition:
Stable, ambulating with walker which is baseline. Taking good
PO, no longer short of breath, oxgyen saturation on room air
with ambulation is 93%
Discharge Instructions:
Follow up with Dr. [**Last Name (STitle) 9006**] this week.
.
Take all your medications as prescribed. I have made the
following changes:
1)I have started you on lasix, which is a "water pill" for the
fluid in your lungs. You will need to have your creatinine
checked this week on this medication along with your potassium
since it can affect your kidney function. (I have given you a
prescription for this)
2)I have stopped your hydrochlorothiazide. Do not take this
until you are seen by Dr. [**Last Name (STitle) 9006**].
3)I have increased the dose of your Imdur from 30mg to 60mg
daily. I have given you a prescription for this.
4)I have discontinued your florinef. Do not take this until you
are seen by Dr. [**Last Name (STitle) 9006**].
5)I have increased your metoprolol dose to 200mg twice a day
from 175mg twice a day.
6)I have added flovent inhaler. You should take this because of
your history of smoking and "COPD".
..
If you have return of your shortness of breath or develop any
chest pain, nausea, vomiting, fevers, chills or any other new
concerning symptoms, contact your doctor or go to the emergency
room.
.
On the CT scan of your chest done on the 13th, you were noted to
have a "pulmonary nodule" as we discussed. This needs further
studies to determine if it is a cancer. Make sure to follow up
with Dr. [**Last Name (STitle) 9006**]. You will likely need a "PET" scan as an
outpatient.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 9006**] this week. Please call on Monday to
make an appointment for this week. I will contact her to let
her know you should be seen this week. her number if [**Telephone/Fax (1) 8693**].
You also have the following appointments scheduled in the
future:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2118-10-19**]
2:10
Provider: [**Name Initial (NameIs) 11595**] (RHEUM LMOB) [**Doctor Last Name 11596**] Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2118-10-19**] 3:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 20442**], MD Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2118-10-18**] 5:00
|
[
"491.21",
"396.3",
"272.0",
"518.89",
"295.70",
"428.33",
"250.00",
"585.2",
"428.0",
"714.0",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14188, 14246
|
6404, 11355
|
305, 311
|
14534, 14682
|
3486, 6381
|
16151, 16924
|
2943, 3019
|
11837, 14165
|
14267, 14513
|
11381, 11814
|
14706, 16128
|
3034, 3467
|
246, 267
|
339, 1877
|
1899, 2550
|
2566, 2927
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,676
| 126,844
|
9050
|
Discharge summary
|
report
|
Admission Date: [**2131-9-7**] Discharge Date: [**2131-10-10**]
Date of Birth: [**2069-1-8**] Sex: F
Service: SURGERY
Allergies:
Lisinopril / Sulfonamides / Penicillins / Fentanyl / Clindamycin
/ Evista / Zestril / Iodine; Iodine Containing / Latex
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
abdominal pain with vomiting
Major Surgical or Invasive Procedure:
[**2131-9-7**]:
1. Exploratory laparotomy.
2. Duodenal resection from D2 to the jejunum, with near-complete
resection of the afferent loop.
3. Resection of prior gastroenterostomy with reconstruction of
the stomach and a Roux-en-Y duodenojejunostomy.
[**2131-9-11**]:
1.Exploratory laparotomy.
2.Abdominal washout.
3.Revision of jejunostomy.
4.Abdominal closure
History of Present Illness:
62F with a history of a Billroth II gastrectomy by Dr. [**Last Name (STitle) **]
in [**2122**] for PUD who comes in now with 12 hours of abdominal and
back pain. The pain was accompanied by nausea and bilious
vomiting. In the ED, her labs initially pointed towards
gallstone pancreatitis, but RUQ US showed complex intraabdominal
fluid. A CT scan was obtained to further evaluate, and this
showed obstructed afferent loop with perforation. An NGT was
placed, levo/flagyl given, and surgery called. Of note, on EGD
several years ago, the patient was noted to have an anastomotic
ulcer. She was treated with prilosec and sucralfate. On ROS,
the patient denies fever/chills, hematemasis,
diarrhea/constipation, and dysuria.
Past Medical History:
- Gastric resection times two for ulcer
- Hypertension
- Iron-deficiency and B12 deficiency anemia
- Severe back pain secondary to disk disease and osteoarthritis,
on chronic narcotics
- Bipolar disease
- Status post cholecystectomy
- Status post hysterectomy
- Melanoma
Social History:
She is widowed, has one child. Retired teacher. Denies smoking,
alcohol, or drug abuse.
Family History:
Mother with [**Name (NI) 5895**] disease in her 70s, father with kidney
cancer with mets to brain.
Physical Exam:
Gen: NAD, AOX3
CVS: RRR, no m/r/g
Pulm: CTAB
Abd: soft, ND, NT, healing midline surgical incision, J-tube in
place. Presacral pigtail drain in place.
Ext: 1+ edema, no c/c
Pertinent Results:
Admission Labs:
WBC-12.7*# RBC-4.39 Hgb-14.3 Hct-45.0 MCV-103* MCH-32.7*
MCHC-31.9 RDW-14.6 Plt Ct-372
Neuts-93.9* Lymphs-2.8* Monos-2.8 Eos-0.2 Baso-0.3
Glucose-293* UreaN-30* Creat-0.8 Na-140 K-4.5 Cl-103 HCO3-21*
AnGap-21*
ALT-822* AST-2205* AlkPhos-330* TotBili-1.8*
Lipase-3023*
Calcium-9.5 Phos-4.3 Mg-1.7
Discharge Labs:
[**2131-10-8**] 05:42AM BLOOD WBC-7.7 RBC-2.94* Hgb-9.5* Hct-30.0*
MCV-102* MCH-32.2* MCHC-31.5 RDW-21.2* Plt Ct-501*
[**2131-10-8**] 05:42AM BLOOD Plt Ct-501*
[**2131-10-9**] 03:49AM BLOOD Glucose-96 UreaN-9 Creat-0.5 Na-138 K-4.0
Cl-106 HCO3-26 AnGap-10
[**2131-9-29**] 02:38AM BLOOD ALT-9 AST-17 LD(LDH)-183 AlkPhos-287*
TotBili-1.1
[**2131-9-20**] 01:51AM BLOOD Lipase-23
[**2131-10-9**] 03:49AM BLOOD Calcium-9.4 Phos-4.7* Mg-1.7
[**2131-9-17**] 01:12AM BLOOD Triglyc-117
RUQ U/S [**9-7**]:
1. Complex free fluid with a markedly distended loop of bowel.
Further evaluation with CT is recommended.
CT Abd/Pelvis [**9-7**]:
1. Status post gastrectomy and Billroth II with markedly dilated
afferent limb with site of kinking/twisting near the
gastrojejunal anastomosis and surrounding free fluid and air.
These findings are consistent with an obstructed afferent loop
with resultant perforation. Findings consistent with
pancreatitis and hepatitis with possible resultant ascending
cholangitis, all likely from afferent loop obstruction.
CT Abd/Pelvis [**9-21**]:
1. Large complex multiloculated and multiseptated gas fluid
collection
primarily in the right lower quadrant with significant extension
through the
abdomen and pelvis, as described above, with other smaller fluid
collections
as well. Discussed with [**Doctor First Name 31289**] [**Doctor Last Name 31290**] at 22:45 on [**2131-9-21**].
These may in
part be postsurgical, or from leaking anastomoses, cannot
exclude infection.
2. Postsurgical changes from abdominal surgeries with most
recent status post
abdominal washout, revision of jejunostomy, and abdominal
closure. Two
surgical drains also present.
3. Unchanged intrahepatic and extrahepatic biliary dilation as
above.
4. New mild right pelvicaliectasis likely from compression of
the ureter from
the large complex gas fluid collection.
5. New small right pleural effusion with adjacent atelectasis.
6. Anasarca.
EGD [**9-29**]:
Blood in the whole stomach
Friability and erythema in the stomach
(thermal therapy)
Otherwise normal EGD to passed gastro-jejunal anastomosis, did
not get as far as duodeno-jejunostomy
Brief Hospital Course:
Mrs. [**Known lastname 12226**] was admitted to the surgery service on [**2131-9-7**] with
sepsis due to an afferent loop obstruction and possible
perforation. She was taken emergently to the operating room for
an exploratory laparotomy. Duodenal resection, revision
gastrectomy and R-en-Y duodenojejunostomy were performed. Her
abdomen was left open, packed, two [**Doctor Last Name 406**] drains were place in
the abdominal cavity, two [**Location (un) 1661**]-[**Location (un) 1662**] drains above the plastic
closure. One jejunostomy tube was placed on the right side with
its tip in the region of the duodenojejunostomy.
The patient was transferred to the Trauma ICU postoperatively.
Mrs [**Known lastname 12226**] was taken back to the OR on [**2131-9-11**] for abdominal
washout, duodenojejunostomy revision and abdominal closure. One
extraBlake drain was placed in the pelvis in the area where
there was some slight extra bilious material. A follow-up CT
scan was performed on HD14 as part of the workup for increased
WBC and episodic fevers (highest 102F) and showed: "Large
complex multiloculated and multiseptated gas fluid collection
primarily in the right lower quadrant with significant extension
through the
abdomen and pelvis." A pigtail drain was placed in this large
fluid collection on HD17, wich drained bilious fluid. A second
pigtail was placed in the pre-sacral portion of the collection
on HD20 and bilious output was noted. All her JP drains were
taken out prior to discharge with exception of the pre-sacral
pigtail which was still draining modest amounts of brown-colored
fluid (about 50cc per day).
Neurologic: the patient was initially intubated and sedated with
propofol. Intermittent IV dilaudid and fentanyl were given for
pain control with good results.
Cardiovascular: required pressors (levophed and vasopressin)
postoperatively. Pressors were weaned on HD4.
Pulmonary: the patient was intubated and mechanically
ventilated. She was able to be weaned off the ventilator and be
extubated on HD12.
GI: was made NPO, NGT was placed. TPN was started on HD 4. JP
output was closely monitored. Increased bilious output was noted
from JP#1 (RLQ) on HD10 (about 1000ml in 24hrs) and decreased
significantly during her hospital stay and the drain was taken
out prior to discharge. Bile was re-fed through J-tube flushes
while the drain output was still significant. An EGD was
perfomed on HD22 as part of the workup for melena and falling
Hct and revealed:"evidence of gastritis in the stomach, with
some minimal oozing around the sutures and in one particular
area in the stomach that was consistent with gastritis. The G-J
anastomosis was not bleeding and there were no ulcers". A gold
probe was applied for hemostasis successfully in the an area of
gastritis. She was started on a pantoprazole infusion.
GU/FEN: foley was placed on HD1 and was taken out on HD32. The
patient failed a voiding trial and the foley was replaced. She
is being discharged with a foley catheter in place. TPN was
started on HD 4. Tube feeds through J-tube started on HD6 and
were advanced to goal rate of 75 as tolerated. TPN was weaned as
tube feeds were advanced. Patient was started on a lasix drip on
HD5, goal: -1L. On HD18 she was triggered for marked nursing
concern secondary to a K level of 2.8. An EKG was performed and
was within normal limits. The K was repleted IV and the level
was stabilized. The patient remained asymptomatic. At the time
of discharge her electrolyte levels were stable. On HD26 she was
started on a clear liquid diet and tolerated it well. The
following day the patient was started on a regular
post-gastrectomy diet. Tube feeds were cycled during the night.
Heme: Hct was monitored daily and the patient received PRBX1 on
HD21 for a falling Hct (21 from 25.6) in the setting of
melanotic stool. She received additional 5 units on HD22 and her
Hct stabilized around 30.
ID: IV antibiotics were started on HD1 and regimen was adjusted
according to colture results. Peritoneal Cx resulted positive on
HD4 for yeast. Sputum grew yeast on HD9. Blood Cx were positive
for MSSA on HD6. TEE was performed on HD11 to rule out
endocarditis in the setting of sepsis and resulted negative. WBC
was closely monitored: peaked at 25.1 on HD13 and trended down
to 7.7 at the time of discharge. On HD29 the antibiotics were
discontinued due to negative coltures.
Endo: Glycemia was checked regularly and sliding scale Insulin
was administered when necessary.
Prophylaxis: DVT: boots; stress ulcers: H2 blockers, PPI
Medications on Admission:
acetaminophen-isometh-dichloral 65-325-100 caps [**1-6**]
PO at onset of HA, valium 5mg PO QID, methadone 30mg PO BID,
lopressor 50mg [**Hospital1 **], omeprazole EC 40mg PO BID, zofran prn,
percocet prn, sucralfate 1gm PO TID, triamterene HCTZ 37.5-25 PO
daily, colace, citracal - D3
Discharge Medications:
1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day). Tablet(s)
2. Acetaminophen 650 mg/20.3 mL Solution Sig: 1000 (1000) mg PO
every eight (8) hours as needed for pain.
3. Oxycodone 5 mg/5 mL Solution Sig: 10-15 mg PO every four (4)
hours as needed for pain.
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Acetazolamide 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. Methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble
PO BID (2 times a day).
8. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
9. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
10. loperamide 2 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 685**] [**Location (un) **]
Discharge Diagnosis:
Sepsis from duodenal necrosis.
Respiratory failure
Anastomotic leak- controlled
Hypokalemia
Pelvic abscess
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:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-14**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
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:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**], MD Date/Time:[**2131-12-19**] 9:00
Please call Dr.[**Name (NI) 1482**] office for a follow-up appointment
in [**7-14**] days.
Completed by:[**2131-10-10**]
|
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icd9cm
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[
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[
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[
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10547, 10614
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,360
| 103,133
|
42852
|
Discharge summary
|
report
|
Admission Date: [**2118-3-17**] Discharge Date: [**2118-3-31**]
Date of Birth: [**2056-4-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
EDG
[**Last Name (un) **] placement
Tracheal intubation
TIPS procedure
CPR
Transfusion of blood products
History of Present Illness:
61 YOM with history fo HCV genotype 2 cirrhosis complicated by
mild encephalopathy and varices s/p EGD with banding 3 weeks ago
presets to ED with CC of melena. Patient reports that over the
last 3-4 days he has had increasing dark stools. This morning he
had some mild epigastric discomfort and rpesented to the ED for
eval. No hematemsis, no BRBPR. No Dyspnea. + Light heasded ness
this afternoon.
.
With regards to his HCV cirrhosis, He has remote IVDU history
int he 60s' as well as a period of heavy drinking in the [**2096**]'s.
In [**2115**] he had a major Gi bleed requiring banding. In [**2107**] he
apprently bled while in [**State 622**].
.
He was seen by GI in [**Month (only) **] who scheduled him for EGD on
[**2118-2-25**]. He underwent the procedure with visualization of
grade 2 varices. Was banded and discharge din stable condition.
.
In the ED he underwent NG lavage wtih 100cc of BRB returned but
nothign further. He had no other episodes of bleeding and was HD
stable. He was transferred to te MICU in stable condition with
plans for EGD in the evening or AM.
.
VS prior to transfer
VS HR 90 BP 135/70 T 97.6 RR 18 Sattign 100% RA
.
A Loquacious gentleman, nn arrival to the MICU, he is stable
with no complaints or distress.
Past Medical History:
Chronic hepatitis C, genotype 2.
Cirrhosis.
Portal hypertension with a history of esophageal varices.
Tonsillectomy at age ten.
Social History:
Former smoker, quit 25 years ago. Occasional EtOH once every
other week but drank [**9-23**] drinks/night in late [**2096**]/early [**2106**]
for [**3-18**] yrs. IV drug use in late [**2066**]. Works in a Nucor Plant.
Travels in US by RV.
Family History:
Denies FH of diabetes, CAD, liver disease, liver cancer
Physical Exam:
ADMISSION EXAM:
VS: T 98, HR 70, BP 116/65, RR 19, POx 97%RA
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Abdominal: Tender: epigastric, splenomegaly
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Movement: Not assessed, Tone: Not assessed
.
DISCHARGE EXAM
VS: 97.6 108/64 74 20 96% RA
I/O 1280/800 BM x 2
GENERAL: Comfortable, appropriate.
NECK: Supple with JVP 6 cm
CARDIAC: RRR, S1 S2 without murmurs, rubs or gallops.
LUNGS: Resp were unlabored. crackles bilaterally to 1/3 up back
ABDOMEN: Distended but Soft, non-tender to palpation.
EXTREMITIES: Warm and well perfused. 2+ [**Location (un) **] bilaterally to
knees.
NEURO: CN II-XII intact grossly, strength 5/5 on L [**5-19**] on R
Pertinent Results:
ADMISSION LABS:
[**2118-3-17**] 10:45PM BLOOD WBC-4.9 RBC-3.45* Hgb-11.1* Hct-31.2*
MCV-90 MCH-32.1* MCHC-35.5* RDW-15.3 Plt Ct-94*
[**2118-3-17**] 10:45PM BLOOD Neuts-73.7* Lymphs-19.4 Monos-4.0 Eos-2.3
Baso-0.6
[**2118-3-17**] 10:45PM BLOOD PT-14.2* PTT-33.8 INR(PT)-1.3*
[**2118-3-17**] 10:45PM BLOOD Glucose-122* UreaN-21* Creat-0.7 Na-134
K-5.7* Cl-104 HCO3-24 AnGap-12
[**2118-3-17**] 10:45PM BLOOD ALT-151* AST-267* AlkPhos-68 TotBili-1.3
[**2118-3-17**] 10:45PM BLOOD Albumin-3.3* Calcium-9.0 Phos-3.0 Mg-2.0
[**2118-3-17**] 10:50PM BLOOD Lactate-1.7
[**2118-3-18**] 01:08PM BLOOD Glucose-201* Lactate-3.8* K-4.2
[**2118-3-18**] 03:15PM BLOOD Glucose-112* Lactate-1.6 Na-139 K-4.1
Cl-110*
.
DISCHARGE LABS
[**2118-3-31**] 04:21AM BLOOD WBC-4.5 RBC-3.26* Hgb-10.5* Hct-30.3*
MCV-93 MCH-32.2* MCHC-34.7 RDW-18.5* Plt Ct-104*
[**2118-3-31**] 04:21AM BLOOD PT-20.6* PTT-35.9 INR(PT)-2.0*
[**2118-3-31**] 04:21AM BLOOD Glucose-100 UreaN-10 Creat-0.7 Na-136
K-4.0 Cl-109* HCO3-24 AnGap-7*
[**2118-3-31**] 04:21AM BLOOD ALT-99* AST-202* LD(LDH)-251*
AlkPhos-210* TotBili-19.9*
[**2118-3-31**] 04:21AM BLOOD Albumin-2.4* Calcium-7.8* Phos-2.3*
Mg-2.1
.
CXR [**2118-3-18**]:
Endotracheal tube is seen terminating at least 2.5 cm from the
carina while neck is in flexion. Right-sided catheter sheath is
seen entering the right IJ and terminating within the superior
vena cava. Proximal end of this sheath is kinked.
.
[**2118-3-24**]
As compared to the previous radiograph, there is no relevant
change. The monitoring and support devices are in constant
position.
Constant size of the cardiac silhouette. Moderate pulmonary
edema with
bilateral areas of pleural effusions and subsequent areas of
atelectasis.
Interval appearance of focal parenchymal opacity suggesting
pneumonia.
.
AXR [**2118-3-18**]:
Cross-table lateral and supine frontal views of the abdomen are
obtained.
Note is made of Sengstaken-[**Last Name (un) **] tube, with esophageal and
gastric
balloons inflated. There is large gaseous distention of the
colon and small bowel in a pattern suggesting ileus. There is no
evidence of pneumoperitoneum on the cross-table lateral image.
.
CT head [**2118-3-23**]
IMPRESSION: Multifocal hypodensities in the right frontal, left
occipital,
and cerebellar regions concerning for subacute infarction given
the clinical history. If there is no contraindication, MRI of
the brain is recommended for further characterization.
.
MRI/MRA head and neck
There are bilateral multiple foci of restricted diffusion,
predominantly in the cortex of the frontal and parietal lobes.
There is also some involvement of the temporal lobes. No
abnormality is noted in the hippocampi or the basal ganglion.
Focal restricted diffusion is also seen in the right occipital
lobe which could represent an acute infarction.
Intracranial flow voids are maintained.
MRA of the circle of [**Location (un) 431**] demonstrates the proximal
vasculature to be
patent. The study is technically limited for evaluation of the
distal
branches. No aneurysm is noted. There is a hypoplastic left A1.
The left
distal vertebral artery is not visualized and may terminate as a
PICA.
MRA of the neck demonstrates mild plaquing at bilateral ICAs. No
high-grade stenosis is seen. Both vertebral arteries are patent.
The origins of the vertebral arteries are not well visualized
due to technique. The left distal vertebral artery is
hypoplastic.
There is a probable lipoma in the right suboccipital region.
IMPRESSION:
Hypoxic injury in the bilateral cerebral cortices. Acute
ischemia in the
right occipital lobe.
No vascular abnormalities.
.
CT Abdomen Pelvis [**2118-3-23**]
1. TIPS is patent.
2. Thrombosed right posterior portal vein branch is seen
secondary to
covering of the origin of that vessel by the stent.
3. Subacute/chronic SMV thrombosis.
4. Liver cirrhosis.
5. Splenomegaly.
6. Gallbladder sludge and stones are seen.
7. Bilateral small pleural effusion with secondary atelectases
.
RUQ US
1. Patent TIPS shunt with normal-appearing flow and pulse
Doppler waveforms.
No evidence of portal vein thrombosis.
2. Cirrhotic liver with splenomegaly.
3. Gallstones but no bile duct dilatation.
.
TTE
The left atrium is elongated. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. 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. No masses or thrombi are seen in the
left ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. No
masses or vegetations are seen on the aortic valve. The mitral
valve appears structurally normal with trivial mitral
regurgitation. No mass or vegetation is seen on the mitral
valve. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
.
MICROBIOLOGY
blood cultures negative [**3-17**], [**3-19**], [**3-20**]
Urine culture negative [**3-19**], [**3-20**]
GRAM STAIN (Final [**2118-3-20**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2118-3-22**]):
RARE GROWTH Commensal Respiratory Flora.
Brief Hospital Course:
61 YOM with history of HCV cirrhosis complicated by 2 prior
variceal bleeds and intermittent hepatic encephalopathy, s/p
banding of known grade 2 varices on [**2118-2-25**] presenting on
[**2118-3-17**] with melena and NG lavage demonstrating BRB.
.
# GI bleed: Upper source. Concern for sentinal bleed from varix
vs arterial bleed from ulcer in the setting of recent banding.
Admission Hct was 31 from baseline 39. Pt was intubated for
airway protection after active bleeding was found on EGD on [**3-18**],
during the second attempt following intubation he became
hypotensive and had a PEA arrest. Pt was resuscitated and
received massive transfusion (10 units PRBC, 4 units FFP, 1 bag
platelets, 2 bags cryoprecipitate); [**Last Name (un) **] was placed and
emergent TIPS was performed, with gradient reduction from 11-->4
mm Hg. The balloons were deflated on [**3-19**] and the [**Last Name (un) **] was
removed on [**3-21**]. Pt had melenic stool but no further evidence of
GI bleed following TIPS. Octreotide drip was continued from
[**Date range (1) 71218**]. Patient was transferred to the floor where HCT remained
stable and stools were noted to be guaiac negative. He was
initially given an IV PPI and was transitioned to PO PPI prior
to discharge. His home lasix restarted at 40 mg daily however
with instructions to hold this medication if systolic blood
pressure is less than 90. Nadolol was started at a low dose in
place of his home propanolol
.
# Possible aspiration pneumonia: Pt was intubated in the
setting of EGD on [**3-18**] (as above). Developed fever to 101.2, GNR
on sputum gram stain; 8 day course of vanc/zosyn was started on
[**3-20**]. WBC and fever curve trended down [**3-21**], [**3-22**], sputum culture
grew only commensal flora, CXR improved following diuresis [**3-21**].
Pt was successfully extubated morning of [**3-22**]. He remained
afebrile without signs of infection throughout the remainder of
his hospitalization.
.
# Abnormal LFTs: Pt has had transaminitis throughout admission
(ALT/AST 151/267 on admission, discriminant function 16).
Transaminases peaked [**3-20**] with ALT/AST 226/348, trending down
since. Tbili trending up after TIPS, from 1.3 on admission to
14.3 (11.8 direct) on [**3-22**]. TIPS patent per abdominal CT [**3-23**] and
RUQ US on [**3-29**]. There was also no evidence of bilary dilitation
on US to suggest obstructive etiology. Fracination demonstrated
a direct hyperbilirubinemia making hemolysis unlikely. Possible
etiology for the elevation includes relative liver hypoperfusion
in ther setting of TIPS placement. Bili was noted to trend
downward and was 19.9 at discharge from a peak value of 22.6.
Patient will need a repeat EGD in 1 month.
.
# Peripheral/pulmonary edema- Patient received a large amount of
volume in the setting of massive transfusion. He was markedly
volume overloaded on exam. He was initially diuresed in the ICU
with 10 mg IV lasix boluses. Diuresis on the floor was
complicated by hypotensions. Patient was still net negative for
length of stay at the time of discharge. His weight was 214Ibs
from a baseline of 207.6 lbs. It was felt given his recent bleed
initiation of nadolol was more important than diursis as his
respiratory status was stable. His home lasix was restarted at
the time of discharge as above. The patient will follow-up with
Dr. [**Last Name (STitle) **] regarding restarting this medication.
.
# HCV Cirrhosis: Was on lactulose intermittently and propranolol
at home, has never been on rifaximin or SBP prophylaxis at home.
On vanc/zosyn as inpatient. Developed encephalopathy s/p TIPS
(and PEA arrest) which improved with lactulose and rifaximin. He
will likely require evaluation for possible liver transplant as
an outpatient.
.
# Stroke: CT head was performed on [**3-22**] to look for watershed
infarcts after PEA arrest given L>R arm and leg strength, slow
recovery of mental status. Imaging revealed multifocal
hypodensities concerning for subacute infarcts R frontal, L
occipital, bilateral cerebella. TTE was performed to look for
embolic source and showed no evidence of vegitation or septal
defects. Patient underwent MRI/MRA which demonstrated bilateral
multiple foci of restricted diffusion, predominantly in the
cortex of the frontal, parietal, and occipital lobes, in
addition to ,mild plaquing of bilateral ICAs but with other
vessels patent. He was evaluated by neurology who felt
presentation was most consistent embolic events in the setting
of PEA arrest. They did not recommend anti-coagulation as the
patient had a recent severe [**Hospital1 **] bleed. Patient will follow-up
with neurology as an outpatient.
.
TRANSITIONAL ISSUES
- Patient will follow-up at the liver clinic and with neurology
- Patient possibly require evaluation for liver transplant
- Patient will discuss restarting diuretics with Dr. [**Last Name (STitle) **]
- Patient was full code throughout this admission
Medications on Admission:
1. Lasix 40 mg p.o. daily.
2. Hydromorphone 2 mg p.r.n. pain.
3. Lactulose 10 gram/15 mL solution titrating to one to two
bowel movements a day.
4. Propranolol 10 mg p.o. three times a day.
5. Omeprazole
Discharge Medications:
1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
3. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
5. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q4H (every 4 hours) as needed for
sob/whz/bronchospasm.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: please
hold for SBP < 90.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnosis
Upper GI bleed
[**Hospital **]
Hospital Acquired Pneumonia
.
Secondary diagnosis
Chronic hepatitis C cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **],
It was a pleasure participating in your care while you were
admitted to [**Hospital1 69**]. As you know
you were admitted because you were having bleeding from one of
the vessels in your esophagus. You had a large amount of
bleeding and required intubation to protect your airway. You
also developed a pneumonia for which you were treated with
anti-biotics. You experienced some weakness and a MRI of your
head showed that you had a small stroke. You were seen by the
neurologists who did not feel that there was anyhting that
needed to be done right now. Our physical therapist did feel
you would benefit from a stay at a rehab facility and therefore
you were discharged to rehab.
We made the following changes to your medications
1. STOP lasix 40 mg dialy (you should discuess restarting this
medication with Dr. [**Last Name (STitle) **]
2. START nadolol 20 mg daily
3. STOP propanolol
4. START tramadol as needed for pain
You should continue to take all other medications as instructed.
Please call with any questions or concerns
Followup Instructions:
Department: LIVER CENTER
When: THURSDAY [**2118-4-7**] at 11:15 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: NEUROLOGY
When: MONDAY [**2118-5-23**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
]
] |
14833, 14903
|
8793, 13739
|
314, 421
|
15076, 15076
|
3297, 3297
|
16319, 16885
|
2126, 2184
|
13998, 14810
|
14924, 15055
|
13765, 13975
|
15227, 16296
|
2199, 3278
|
266, 276
|
449, 1699
|
3313, 8770
|
15091, 15203
|
1721, 1851
|
1867, 2110
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Discharge summary
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report
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Admission Date: [**2118-11-4**] Discharge Date: [**2119-1-4**]
Date of Birth: [**2054-3-3**] Sex: F
Service: SURGERY
Allergies:
Iodine-Iodine Containing / Tape [**12-11**]"X10YD / Amiodarone
Attending:[**Doctor First Name 5188**]
Chief Complaint:
Perforation of small bowel at the site of the ileostomy with
purulent peritonitis.
Major Surgical or Invasive Procedure:
[**2118-11-16**] Laparoscopic loop ileostomy
[**2118-12-6**] Hemorrhoid banding
[**2118-12-26**] Exploratory laparotomy, takedown of
loop ileostomy, small bowel resection, creation of end
ileostomy and mucous fistula.
History of Present Illness:
The patient is a 64-year-old woman with a previous medical
history significant for Crohn's disease. She presently has
evidence of a stricture in the distal terminal ileum, and
because of that, the patient recently underwent laparoscopic
creation of a diverting loop ileostomy. It should be added that
the patient had this more conservative surgical treatment rather
than a cecal resection because of poor heart condition and
severe COPD, both of which were considered contraindications for
more extensive surgical procedures.
The ileostomy was created approximately 1 month ago, and since
then the patient has been doing well up until yesterday when the
ileostomy output suddenly stopped and the patient developed
significant abdominal pain. Initial imaging studies with KUB and
CT scan were consistent with small bowel obstruction close to
the ileostomy, and there was some concern whether the patient
had intraluminal content that created a mechanical obstruction.
The KUB and CT scan did not show any evidence of free air. The
patient was initially
managed with a nasogastric tube and a Foley was also placed in
the afferent loop of the ileostomy yielding large amount of
small bowel content, whereafter the abdomen became less a tender
and distended. Today, however, the abdominal pain has continued
and worsened, and her abdominal exam has also worsened and we
are concerned of peritonitis why the patient now was taken to
the operating room for exploration.
Past Medical History:
- Crohn's Disease first diagnosed in approximately [**2102**].
- History of esophagitis and a duodenal ulcer
- Colonic polyps
- Diverticulosis
- Intra-abdominal abscess from perforated viscous in [**2110**]
- Pulmonary embolus many years ago with IVC filter
- GI bleed and rectus abdominous hematoma while on heparin
- Remote history of sarcoidosis
- COPD
- Right-sided astrocytoma treated with radiation
- History of stroke
- V-fib arrest in [**2108**] s/p placement of a defibrillator.
- Hypertension
- Coronary artery disease with previous PCI and stent placement
- Congestive heart failure ejection fraction 30% in [**2110**]
- Atrial fibrillation
- Degenerative joint disease, worse in the back
- Hypothyroidism
Social History:
Lives with husband at home. He assissts her in ADLs. Prior to
this hospitalization she was ambulated independently and was
able to perform advanced ADLs.
Employment - retired
Tobacco - remote, 27pks yrs; EtOH - denies; Drug use denies
Family History:
- Brain cancer grandfather
- Breast cancer mother
- MI @ 67 grandmother
Physical Exam:
PHYSICAL EXAM:
VS:98.3, 75, 108/57, 18, 99 % RA
General: alert and oriented x3, depressed mood,teary, no acute
distress
HEENT: op clear, mmm, no lesions; no cervical LAD
Neck: supple, no LAD, no thyromegaly
Cardiovascular: RRR, no MRG
Respiratory: CTA bilat w/o wheezes/rhonchi/rales
Back: no spinous process tenderness, no CVA tenderness
Gastrointestinal: +bs, soft, mild TTP, non-distended, mucus
fistula, ostomy - pink
Musculoskeletal: moving all extremities, no joint swelling or
effusion
Lymph: no inguinal LAD
Skin: midline wound packed w/granulation tissue, no purulence,
R PICC line no erythema or TTP
Pertinent Results:
ADMISSION LABS:
[**2118-11-4**]
WBC-7.7 Hgb-10.9 Hct-34.4 MCV-88 Plt Ct-369
Neuts-68 Bands-2 Lymphs-18 Monos-8 Eos-3
PT-14.9 PTT-22.5 INR-1.3
Glu-119 BUN-9 Cr-0.9 Na-140 K-3.0 Cl-102 HCO3-27 Ca-8.8 Ph-3.5
Mg-1.9
ALT-13 AST-17 AlkPhos-33 TotBili-0.6 Lipase-15 Albumin-3.5
cTropnT-<0.01
[**2118-11-5**] CRP-19.5
[**2118-11-6**] 04:11AM BLOOD ESR-0
[**2118-11-5**] URINE Color-[**Location (un) **] Appear-Cloudy Sp [**Last Name (un) **]-1.020 Blood-SM
Nitrite-NEG Protein-30 Glucose-NEG Ketone-10 Bilirub-NEG
Urobiln-NEG pH-5.5 Leuks-NEG RBC-7* WBC-3 Bacteri-FEW Yeast-NONE
Epi-0
URINE UreaN-612 Creat-144 Na-31 K-59 Cl-97 Uric Ac-78.0
Osmolal-578
MICROBIOLOGY:
MRSA Screen [**2118-11-17**]: No MRSA found
BLOOD CULTURE [**2118-11-20**]: MRSA+
BLOOD CULTURE [**2118-11-21**]: negative
BLOOD CULTURE [**2118-11-22**]: negative
URINE CULTURE [**2118-11-20**]: +Yeast >100,000
CATHETER TIP [**2118-11-21**]: no growth
RADIOLOGY:
ABDOMINAL XR [**2118-11-4**]: Small bowel obstruction, similar to
prior, without free air.
CT ABDOMEN/PELVIS W/CONTRAST [**2118-11-5**]:
1. Persistent small bowel obstruction upstream of ileal
stricture with
associated stranding and mesenteric lymphadenopathy, suggestive
of possible acute on chronic inflammation, without evidence of
abscess, fistula, or perforation.
2. Moderate right and small left pleural effusions with
associated
atelectasis.
3. Interval decrease of small abdominal ascites.
4. Cholelithiasis.
5. Mild anasarca.
6. Diverticulosis.
TRANSTHORACIC ECHO [**2118-11-8**]:
LVEF 30%. Severe regional and global left ventricular systolic
dysfunction, c/w CAD. Mild to moderate ischemic mitral
regurgitation.
ABDOMINAL XR [**2118-11-21**]:
1. Dilated loops of small bowel, likely postoperative ileus;
however, small-bowel obstruction cannot be ruled out.
2, Intra-abdominal free air believed to be secondary to recent
laparoscopic surgery.
TRANSTHORACIC ECHO [**2118-11-22**]:
Cannot fully exclude a vegetation on the mitral valve; no
vegetations seen elsewhere. Moderate to severe mitral
regurgitation. Dilated left ventricle with moderate to severe
regional and global systolic dysfunction.
.
TEE [**11-23**]- Two mobile right atrial echodensities associated with
the pacing leads consistent with vegetation (vs thrombus) as
described above. ?Aortic valve Lambls excrecent (vs.
vegetation). Moderate to severe mitral regurgitation.
Dr [**First Name (STitle) **] notified of the results by telephone.
.
CXR [**12-1**]-PA and lateral upright chest radiographs were reviewed
in comparison to [**2118-11-26**].
The pacemaker leads terminate in expected location of right
atrium and right ventricle. The right PICC line tip is at the
level of cavoatrial junction. Cardiomediastinal silhouette is
stable. Small amount of right pleural effusion cannot be
excluded. Lungs are essentially clear.
.
KUB [**2118-12-12**]-IMPRESSION: No obstruction or free air.
.
ECHO [**2118-12-12**]- Severe focal LV hypokinesis consistent with CAD.
Moderate to severe mitral regurgitation, likely due to leaflet
tethering.
Compared with the report of the prior study (images unavailable
for review) of [**2118-11-22**], the findings are probably similar.
.
KUB [**12-16**]- IMPRESSION: No obstruction or free air.
[**2118-11-4**] 11:31AM LACTATE-1.9
[**2118-11-4**] 11:20AM GLUCOSE-119* UREA N-9 CREAT-0.9 SODIUM-140
POTASSIUM-3.0* CHLORIDE-102 TOTAL CO2-27 ANION GAP-14
[**2118-11-4**] 11:20AM estGFR-Using this
[**2118-11-4**] 11:20AM ALT(SGPT)-13 AST(SGOT)-17 ALK PHOS-33* TOT
BILI-0.6
[**2118-11-4**] 11:20AM LIPASE-15
[**2118-11-4**] 11:20AM cTropnT-<0.01
[**2118-11-4**] 11:20AM ALBUMIN-3.5 CALCIUM-8.8 PHOSPHATE-3.5
MAGNESIUM-1.9
[**2118-11-4**] 11:20AM WBC-7.7# RBC-3.93* HGB-10.9*# HCT-34.4*
MCV-88 MCH-27.6 MCHC-31.5 RDW-17.1*
[**2118-11-4**] 11:20AM NEUTS-68 BANDS-2 LYMPHS-18 MONOS-8 EOS-3
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2118-11-4**] 11:20AM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-1+
[**2118-11-4**] 11:20AM PLT SMR-NORMAL PLT COUNT-369
[**2118-11-4**] 11:20AM PT-14.9* PTT-22.5 INR(PT)-1.3*
Brief Hospital Course:
64 year-old woman with Crohn's disease, recent admission for a
flare and bowel ischemia on CT, s/p high dose steroids,
discharged on [**2118-11-2**] reportedly tolerating PO who then
re-presented with bilious emesis, inability to take PO and
malaise within 48 hours. She was felt to have failed the trial
of PO steroids, and was restarted on IV high dose steroids. NGT
was placed, with good effect, and decompressed the patient. She
was initially admitted to the ICU [**Date range (3) 12812**] for
hypotension, and was later transferred to the medical floor.
She had an SBO that was attributed to a stricture in the
mid/distal ileum that had superimposed inflammation. Initially
managed with steroids. TPN started on [**2118-11-9**]. The patient also
had significant edema in her legs, arms, and breast--more
prominently on the left side. Diuresis given with small dose
Lasix with good effect and not resulting in hypotension.
On [**2118-11-16**] she underwent a diverting loop ileostomy with Dr.
[**Last Name (STitle) **]. Post-op, the patient was transferred back to the
ICU for management of post-op hypotension. Pressors were used
for a short duration of pressors and IV fluids. Late afternoon
on [**2118-11-18**], the patient was returned to the medicine floor with
stable blood pressure.
On the floor, she was continued on TPN and allowed to trial
clear diet which she tolerated fairly well. She continued to
have significant edema that was causing her great discomfort.
Lasix was restarted at the same dose as was used pre-op to
attempt to reduce the edema that was still present in her legs,
arms, and breast--more so on the left side. Ectopy noticed on
telemetry, but Metoprolol not titrated up given lower SBP in
90's and HR in 40's. On the evening of [**2118-11-19**], the patient was
in Afib with RVR. Given that her SBP was in the 90's, she was
transferred back to the ICU for further management.
In the ICU, IVF were given to the patient to raise the blood
pressure. Metoprolol was up titrated to try to achieve better
rate control, but later discontinued and switched to Digoxin.
Blood cultures drawn revealed a new bacteremia, likely
PICC-associated. Organism isolated is MRSA. TTE was not
conclusive in ruling out valve vegetation, so TEE was performed
which revealed vegetations on her ICD lead.
.
BY PROBLEMS:
1. MRSA PICC-associated bacteremia, endocarditis of intracardiac
device:
ID and electrophysiology were consulted. Given the clearance of
blood cultures, lack of fevers or significant leukocytosis the
patient was treated conservatively as removal of her lead would
be difficult given that it is an ICD lead and that it is several
years old and may would require a thoracotomy (per Dr.
[**Last Name (STitle) **]. She was treated with vancomycin, rifampin and
gentamycin. However on [**2118-12-6**] she developed ATN from the
gentamycin, and antibiotics were held pending her renal function
improving. She is being sent home on Vancomycin and Rifampin and
will need to follow-up with the [**Hospital **] clinic (scheduled) and
receive safety labs through the duration of her course, which
will be completed on [**2119-1-9**]. Pt underwent repeat echo on [**12-12**]
that was stable.
2. Small Bowel Obstruction [**1-11**] acute on chronic Crohn's flare:
Medically treated at first but given recurrence a diverting loop
ileostomy was performed. This was complicated by post op
hypotension which required an ICU stay and use of 1 pressor. She
was able to be weaned from the pressor and sent to the regular
medical floor. Her SBO was definitively treated with this
surgical procedure.
3. Lower GI bleed/Crohns disease/Hemorrhoidal Bleeding:
This occurred on [**11-27**] while on prednisone 40mg daily. She had
maroon stools without blood clots, HCT remained stable and the
source was likely a stricture related to her Crohn's disease.
There was no bleeding into the ostomy bag. The bleeding
continued despite treatment with mesalamine. On [**12-5**] the nurse
noted the mesalamine being excreted in the ostomy bag, and her
mesalamine was changed to enema which was given via the ostomy,
as well as adding Cortifoam enemas via the ostomy. A flexible
sigmoidoscopy was performed which noted grade 3 hemorrhoids,
which were banded on [**12-6**] by the colorectal surgery team. This
resolved the bleeding for the most part. On [**12-14**] to [**12-15**] pt
reported small amounts of BRBPR, but received 1 unit PRBCs and
this resolved. Given ongoing irritation of her hemorrhoids her
Cortef enemas were discontinued. Given concern that Mesalamine
was contributing to her renal failure this was also
discontinued. She is being discharged on a Prednisolone taper
with close follow-up with Dr.[**Last Name (STitle) 79**].
4. Atrial Fibrillation with Rapid Ventricular Response:
As her blood pressures improved her beta blocker was up titrated
up and she was started on digoxin with a load of 0.5mg daily x 2
days then on digoxin 125mcg daily. Her Digoxin level remained
wnl at 0.6-0.7 despite the occurrence of renal failure. The
level should be checked weekly until renal function is stable.
on [**2118-11-29**] per cardiology digoxin was no longer needed.
5. Anasarca and asymmetric breast edema:
Related to steroid use in the setting of systolic congestive
heart failure with an EF of 30%. Steroids were weaned post
operatively and she was diuresed initially with Bumex 0.5mg po
daily. L breast swelling was evaluated with Mammogram and
ultrasound and found to be subcutaneous edema without other
underlying pathology. She was seen by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD
from breast surgery and he diagnosed her with truncal lymphedema
related to total body fluid overload and stated the recovery is
a slow process but it should recovery with tapering of steroids
and diuresis.
6. Depression/Anxiety:
Psychiatry was consulted as the depression and anxiety became
overwhelming and the patient was unable to participate in her
care. She was initially managed with Ativan, and Celexa was then
added. Subsequent to this, her Ativan was changed to clonazepam
with excellent results. Pt was followed by social work. She was
also provided with daily encouragement and support.
7. Acute Renal Failure, Acute Tubular Necrosis
Thought to be due to Gentamycin toxicity vs. salicylate
toxicity. Renal function slowly improved with discontinuation of
Gentamycin and Mesalamine, and then plateaued at 1.7 prior to
discharge, thought to be secondary to mild dehydration for which
she was encouraged to increase her PO intake. She was also
started on Imodium and banana flakes to decrease fluid losses
through her ostomy. If her renal function does not improve
following discharge she should be referred to Nephrology for
further evaluation.
8. Stoma prolapse on evening of [**12-16**]. This was reduced at the
bedside successfully with sugar. This did not reoccur. Surgical
team explained this occurrence and significance to the family.On
[**2118-12-25**] had increase abdominal pain, decrease stoma output. A CT
scan was done that showed an SBO at loop ileostomy site. An NGT
and foley catheter was placed to decompress stomach. However she
continued to have abdominal pain with peritoneal signs and
leukocytosis 20 K. On [**2118-12-26**] patient was taken emergently to
the operating room and was found to have a perforation of small
bowel at the site of the ileostomy with purulent peritonitis.
She underwent a takedown of her loop ileostomy, small bowel
resection and creation of end ileostomy and mucous fistula. A
wound swab from the OR grew Lactobacillus and VRE. Ciprofloxacin
and Metronidazole were started on [**12-26**]. Postoperatively was on
intubated and on sedatives and transferred to the [**Hospital Unit Name 153**]. She was
bolused for decrease urine output was given intravenous fluids
and Albumin. On [**2118-12-27**] was extubated, off sedation and was
started 100 mg hydrocortisone IV. On [**2118-12-28**] decrease hematocrit
from 30.5 to 22.4, transfused with 2 units red blood cell. on
[**2118-12-29**] went into paroxysmal afib,which was rate controlled.
Cardiology were consulted and metoprolol dose was increased and
recommended no digoxin. Overnight developed paranoia,
antidepressants were restarted on [**2118-12-30**]. On [**12-30**] her
antibiotic were transitioned to Daptomycin and
Piperacillin/tazobactam + rifampin. She had immediate return of
bowel function after surgery, the stoma is pink and protruding
with liquid stool. She has been receiving intermittent
intravenous fluid boluses for high ostomy output. Left mucous
fistula with scant drainage. She wears an abdominal binder at
all times. She has been encouraged to increase her nutritional
status. She is on calorie counts and Ensure. Ms. [**Known lastname 12811**]
complains of intermittent abdominal pain which increases with
movement, she has been encouraged to take her oral analgesia as
needed. She is ambulating with a walker and assist. POD 7
[**2118-12-30**], Prelone 21 mg PO taper was started and he will continue
her Prelone taper per her gastroenterologist Dr. [**Last Name (STitle) 79**] refer to
GI note. POD 9 she had approx 50 cc of blood from rectum, a
stat hematocrit was drawn,35.2 and had no further episodes and
is stable for transfer to rehabilitation center. Ms. [**Known lastname 12811**]
will continue on her antibiotics, Zosyn, Daptomycin and Rifampin
until [**2119-1-9**] refer to infectious disease note for monitoring of
her renal function.
Medications on Admission:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for SOB.
2. atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): LIPITOR.
3. Entocort EC 3 mg Capsule, Sust. Release 24 hr Sig: Three (3)
Capsule, Sust. Release 24 hr PO once a day: START on SUNDAY
[**2118-11-6**].
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours).
5. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day.
6. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual as needed as needed for chest pain.
9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day: PROTONIX.
11. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily): SPIRIVA.
12. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
13. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
DIOVAN.
14. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day:
CLARITIN.
16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): COLACE.
17. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
18. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation: MIRALAX.
19. multivitamin Capsule Sig: One (1) Capsule PO once a day.
20. mesalamine 500 mg Capsule, Sustained Release Sig: Three (3)
Capsule, Sustained Release PO three times a day: PENTASA.
21. prednisone 10 mg Tablet Sig: Five (5) Tablet PO DAILY
(Daily) for 3 days: LAST DAY [**11-5**]. Start entocort on Sunday. .
22. bumetanide 0.5 mg Tablet Sig: One (1) Tablet PO twice a day.
23. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 1 months.
24. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 1 months.
25. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO
every eight (8) hours.
Discharge Medications:
1. prednisolone sodium phosphate 15 mg/5 mL Solution Sig: Twenty
One (21) mg PO daily () as needed for crohn's disease: To be
decreased by 2 mL (6mg) every five days. You will take 7 mL
(21mg) on [**1-24**]. You will then take 5mL (15mg) [**Date range (1) 12813**].
You will then take 3mL (9mg) [**Date range (1) 12814**]. You will then take 1mL
(3mg) [**Date range (1) 12815**]. Please call Dr.[**Last Name (STitle) 79**] with any questions
regarding this taper.
Disp:*3 week's supply* Refills:*0*
2. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID
(3 times a day).
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation QID (4 times a day).
5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze.
6. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
10. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
12. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
13. rifampin 300 mg Capsule Sig: One (1) Capsule PO Q 8H (Every
8 Hours).
14. white petrolatum-mineral oil Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed for dry breasts.
15. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
16. dextrose 50% in water (D50W) Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
17. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
18. sodium chloride 0.9 % 0.9 % Parenteral Solution Sig: One (1)
ML Intravenous Q8H (every 8 hours) as needed for line flush.
19. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
20. daptomycin 500 mg Recon Soln Sig: 350 mg Recon Solns
Intravenous Q24H (every 24 hours).
21. piperacillin-tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q6H (every 6 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
Crohn's flare
Ileal stricture
Systolic Congestive heart failure
Edema
Endocarditis
Bacteremia
Anemia
Acute renal failure
Perforation of small bowel at the
site of the ileostomy with purulent peritonitis.
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 Crohn's flare and
underwent surgery for this. You also suffered an infection of
your blood stream which may have caused an infection of your
implanted defibrillator lead and you are being treated with an
extended course of antibiotics. A complication of your
antibiotics and Crohn's treatment is transient renal failure.
You will be discharged to the rehabilitation center for
monitoring of your renal function and management of your
ileostomy, mucous fistula, abdominal wound dressing and
administration of your intravenous antibiotics which will
continue until [**2119-1-9**]. Please continue to walk several
times daily for your recovery. We would also like you to
encourage your oral intake and continue taking your Ensure
supplements. You will also continue on your Prednisone taper as
instructed by your gastroenterologiost Dr. [**Last Name (STitle) 79**]. Please call and
schedule post operative an appointment with Dr.[**Last Name (STitle) 5182**].
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12816**] at [**Telephone/Fax (1) 12817**] to
schedule a follow up appointment within 1 week of discharge.
Please call and schedule a follow up appointment with Dr. [**Last Name (STitle) 79**].
Department: DIV. OF GASTROENTEROLOGY
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]
Completed by:[**2119-1-4**]
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"555.0",
"996.61",
"401.1",
"276.8",
"427.31",
"584.5",
"041.12",
"458.9",
"V12.51",
"421.0",
"311",
"455.2",
"V58.65",
"611.72",
"244.9",
"715.90",
"414.01",
"569.69"
] |
icd9cm
|
[
[
[]
]
] |
[
"48.23",
"88.72",
"46.10",
"46.01",
"46.20",
"45.62",
"49.45",
"46.51",
"99.15",
"38.97",
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] |
icd9pcs
|
[
[
[]
]
] |
22470, 22544
|
8000, 17527
|
405, 625
|
22792, 22792
|
3852, 3852
|
23999, 24734
|
3129, 3202
|
19968, 22447
|
22565, 22771
|
17553, 19945
|
22975, 23976
|
3233, 3833
|
282, 367
|
653, 2121
|
3868, 7977
|
22807, 22951
|
2143, 2861
|
2877, 3113
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,577
| 144,014
|
18944
|
Discharge summary
|
report
|
Admission Date: [**2144-12-17**] Discharge Date: [**2144-12-23**]
Date of Birth: [**2092-8-6**] Sex: M
Service: MEDICINE
Allergies:
Zestril
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Per MICU admit note
HPI: 52yo M w/hx of motorcycle trauma w/bl open Monteggia
fractures, admitted [**Date range (1) 51787**] during which time had ex lap,
trach and peg admitted s/p PE arrest. Per his wife, he was
feeling dyspnicon the day of admission, + b/l swelling. She
notes that on leaving [**Hospital1 **] that he had increased upper
airway sounds that she attributed to respiratory distress. The
patient and his wife proceeded to his outpt appointments. At his
last appointment, Dr. [**Last Name (STitle) **] noted that the patient
appeared to have labored breathing and recommended that EMS take
him to the ED. On the way out of the building, the patient
requested to go to the bathroom. He had a bowel movement and was
pale, diaphoretic per his wife. The patient himself reports
feeling dizzy. As he was getting back onto the stretcher, he
slumped over. Per EMS, he was pulseless. Code blue was called.
CPR was intitiated and continued for 3min w/o defibrillation or
medication administration. He was placed on a monitor and found
to be bradycardic to 40's, BP was 100/50. Pt was given 1mg IV
Atropine X 1 with HR response to 135. During this episode, he
was noted to have vomited and vomitous was suctioned from his
trach. Sent to ED.
.
In ED, the patient was arousable but drowsy. CXR was read as
normal. CTA neg for PE. No EKG changes. The patient received
levo/flagyl for aspiration PNA.
Past Medical History:
motorcycle trauma with BL open Monteggia fractures, R knee
degloving injury, hypotension, facial laceration
s/p ex-lap, ORIF R and L elbows, trach and peg
acute on chronic renal failure (previous baseline creatinine
2.0, now 2.7)
hypernatremia
anemia of chronic renal disease
morbid obesity s/p lap gastric band ([**Doctor Last Name **]) [**12-25**], now removed
DM2
CAD s/p stenting x2 ([**12-19**] at [**Hospital1 1774**])
HTN
hypercholesterolemia
CHF, diastolic
OSA- did not tolerate CPAP/BIPAP
Back Pain
Psoriatic Arthritis
L shoulder pain
Social History:
Lives with wife, 3 children. On disability, former truck driver.
Former smoker, quit [**9-24**] after 80 pack year history. No current
ETOH, former heavy drinker. No illicits.
Family History:
Father - leukemia, [**Name2 (NI) 32071**] heart disease. Mother - [**Name (NI) 2320**].
Sister - [**Name (NI) 2320**].
Physical Exam:
Exam on Admission:
VS Temp 100.6 HR65 BP 128/63 RR 63
Gen: drowsy but arousable - > later awake, alert, communicative
HEENT: no JVD but diff ass with thick neck, trach in place w/o
erythema or swelling
Pulm: no labored breathing, rhonchi on LLL and coarse crackles
in RLL
CV: regular rate and rhythm, no murmurs, rubs, gallops
Abd: soft, somewhat TTP along midline inciscion, incision with
erythema but no discharge, dressing in place
Ext: + edema, but more diffusely swollen; pt has various
surgical incisions that are starting to heal well
Skin: psoriasis
Pertinent Results:
[**2144-12-17**] 01:35PM BLOOD WBC-8.5 RBC-3.07* Hgb-9.1* Hct-27.3*
MCV-89 MCH-29.6 MCHC-33.3 RDW-14.1 Plt Ct-195
[**2144-12-17**] 01:35PM BLOOD Neuts-80.9* Lymphs-12.0* Monos-5.2
Eos-1.9 Baso-0.1
[**2144-12-17**] 01:35PM BLOOD PT-16.2* PTT-32.6 INR(PT)-1.4*
[**2144-12-17**] 01:35PM BLOOD Glucose-198* UreaN-35* Creat-2.0* Na-138
K-4.8 Cl-99 HCO3-25 AnGap-19
[**2144-12-17**] 01:35PM BLOOD ALT-24 AST-26 LD(LDH)-225 CK(CPK)-72
AlkPhos-143* TotBili-0.4
[**2144-12-17**] 01:35PM BLOOD Lipase-46
[**2144-12-17**] 01:35PM BLOOD cTropnT-0.06*
[**2144-12-17**] 01:35PM BLOOD CK-MB-NotDone proBNP-2260*
[**2144-12-17**] 10:09PM BLOOD CK-MB-NotDone cTropnT-0.10*
[**2144-12-18**] 04:21AM BLOOD CK-MB-NotDone cTropnT-0.11*
[**2144-12-17**] 01:35PM BLOOD Calcium-8.6 Phos-5.5* Mg-2.3
[**2144-12-18**] 04:21AM BLOOD Hapto-410*
[**2144-12-19**] 02:31AM BLOOD WBC-8.3 RBC-2.66* Hgb-8.1* Hct-23.7*
MCV-89 MCH-30.4 MCHC-34.1 RDW-14.0 Plt Ct-154
[**2144-12-19**] 02:31AM BLOOD Glucose-109* UreaN-31* Creat-2.3* Na-140
K-4.3 Cl-102 HCO3-30 AnGap-12
[**2144-12-22**] 05:31AM BLOOD WBC-4.7 RBC-2.61* Hgb-7.7* Hct-22.6*
MCV-87 MCH-29.3 MCHC-33.8 RDW-13.6 Plt Ct-205
[**2144-12-22**] 05:31AM BLOOD PT-15.7* PTT-32.1 INR(PT)-1.4*
[**2144-12-22**] 05:31AM BLOOD Glucose-105 UreaN-33* Creat-1.8* Na-138
K-4.7 Cl-101 HCO3-31 AnGap-11
.
[**2144-12-17**] Head CT: no acute intracranial process
.
[**2144-12-17**]: Chest Xray: Bilateral diffuse alveolar opacities,
which could represent pulmonary edema, aspiration, or diffuse
infectious process. Satisfactory positioning of tracheostomy
tube. No pneumothorax.
.
[**2144-12-17**] CTA Chest/Abd/Pelvis: no PE, bilateral basilar
consolidation suggestive of atelectasis, pneumonia, or
aspiration. Mild pulmonary vascular congestion but no pleural
effusion. Interval removal of gastric band; however,
gastrostomy tube is still present within the stomach. Mild
anasarca. Multiple mediastinal and hilar nodes which could be
reactive, but would recommend follow up imaging evaluation for
resolution. Left anterior intraabdominal nodule, not seen on
prior study and may represent a lymph node. Follow up
examination is recommended to evaluate for interval change.
.
[**2144-12-18**] CT Abd/Pelvis: 1. Minimal amount of free fluid in the
perihepatic space and deep pelvis, new when compared to prior
exam. No evidence of retroperitoneal bleed. 2. Otherwise, no
significant change.
Discharge Labs:
[**2144-12-23**] 06:19AM BLOOD WBC-4.9 RBC-2.86* Hgb-8.3* Hct-25.2*
MCV-88 MCH-29.2 MCHC-33.1 RDW-14.0 Plt Ct-218
[**2144-12-22**] 05:31AM BLOOD WBC-4.7 RBC-2.61* Hgb-7.7* Hct-22.6*
MCV-87 MCH-29.3 MCHC-33.8 RDW-13.6 Plt Ct-205
[**2144-12-23**] 06:19AM BLOOD Glucose-113* UreaN-33* Creat-1.8* Na-139
K-4.6 Cl-101 HCO3-32 AnGap-11
[**2144-12-22**] 05:31AM BLOOD Glucose-105 UreaN-33* Creat-1.8* Na-138
K-4.7 Cl-101 HCO3-31 AnGap-11
[**2144-12-23**] 06:19AM BLOOD Calcium-8.7 Phos-4.3 Mg-2.1
Brief Hospital Course:
The patient was admitted to the hospital with loss of conscious
and bradycardia. He was thought to have possibly had a mucous
plug in the setting of pneumonia and CHF with edema. It is
unclear if he was pulseless, however a pulse could not be felt
and chest compressions were started. When hooked up to the
monitor, he was in sinus rhythm at a rate of 40. He was given
atropine and HR improved. In the ED, a CTA of the chest showed
no PE and CT of the abd/pelvis showed no intra-abdominal
pathology. On arrival to the MICU, he was given Vanc/Zosyn for
possible pneumonia. The Zosyn was stopped the following day and
the Vancomycin continued for MRSA in the sputum, later felt to
be a contaminate or colonization given his improvement. His CXR
showed pulmonary edema and he was given Lasix for diuresis.
Telemetry showed no arrhythmias. ECG showed no ischemic changes
and cardiac enzymes were negative. He was diuresed and
improved. Echo showed normal systolic function but severe
diastolic dysfunction. It was felt that he did not have a
pneumonia and that his sputum was likely colonization and the
vancomycin was stopped. He improved with diuresis and he likely
had pulmonary edema contributing to his respiratory status. He
was weaned from the ventilator over 4 days and tolerated a trach
mask for several days before discharge. His Metoprolol was
initially held due to his bradycardia but this was restarted
prior to discharge as his heart rate tolerated it. He was
restarted on a lower dose of Metoprolol of 25mg PO BID due to
bradycardia on admission. This can be titrated up as tolerated
to his home dose of 50mg PO BID. He was restarted on 25 mg
Cozar on [**2144-12-23**] for blood pressure control. His aspirin,
imdur, amlodipine and hydralazine were continued for blood
pressure control and coronary artery disease. He was continued
on his Lantus and insulin sliding scale for diabetes management.
.
He was anemic upon admission which was not new. His hematocrit
trended down to 19 on [**2144-12-18**] and he was transfused 1 unit
PRBCs. His hematocrit increased to 23. He was stable without
symptoms and no source of bleeding. He was guaiac negative.
Iron studies showed iron-deficiency and he was started on iron.
His retic count was 2%. He was transfused a second unit of
PRBCs on [**2144-12-22**] and his hematocrit came up to 25.2 on [**2144-12-23**].
He was discharged with instructions for a repeat CBC within [**4-21**]
days, and also has a follow-up appointment with outpatient
hematology to further assess this.
.
Mr. [**Known lastname **] had a worsening creatinine on admission to 2.3 which
improved to 1.8 at the time of discharge. He has a history of
renal failure associated with his prior trauma.
.
The trauma surgery team evaluated his wounds and recommended wet
to dry dressings [**Hospital1 **]. He was evaluated by the wound care
nursing team who recommended aquacel dressings to the abdominal
incision. This was discussed with the surgery team who agreed.
He should have aquacel dressings placed on his abdominal
incisions as described below.
.
WOUND RECOMMENDATIONS:
Recommendations are as follows:
Pressure relief per pressure ulcer guidelines
Support surface: Atmos Air
Turn and reposition every 1-2 hours and prn off back
Heels off bed surface at all times
If OOB, limit sit time to one hour at a time and sit on a
pressure relief cushion, 4" Foam
Elevate LE's while sitting.
Moisturize B/L LE's and feet [**Hospital1 **] with Aloe Vesta Moisture
Barrier Ointment.
.
ABD and Right groin incisional wounds:
Commercial wound cleanser to irrigate/cleanse ABD and Rightgroin
wounds.
Pat the tissue dry with dry gauze.
Apply moisture barrier ointment to the periwound tissue with
each DRG change.
Apply Aquacel AG (silver ion)dsg to decrease local bacterial
bioburden, absorb drainage and provide for moist wound healing.
Cover with dry gauze, ABD
Secure with Soft cloth tape.
Change dressing daily.
.
Keep skin folds clean and dry.
Apply Critic Aid Clear Moisture Barrier Ointment to skin
foldsand intergluteal, gluteal tissue daily and prn
Support nutrition and hydration.
.
For abd and right groin wounds: After applying Aquacel AG,
dampen with normal saline. Upon removal, if the Aquacel AG is
adhered to the wound bed or dry, moisten with normal saline
prior
to removal.
.
RECOMMENDATIONS REGARDING PASSY-MUIR VALVE:
1. ALWAYS DEFLATE CUFF PRIOR TO PLACING THE PASSY-MUIR VALVE!
2. Monitor O2 Sats / respiration while valve is in place.
3. Do not allow the patient to sleep with the valve in place.
4. If the patient is taking PO's, please deflate the cuff
and place the PMV for eating and drinking.
5. PMV wear schedule is up to the discretion of the
nurse and/or respiratory therapist.
.
RECOMMENDATIONS REGARDING NUTRITION:
1. Suggest a PO diet of thin liquids and soft consistency
solids.
2. PMV in place for all POs.
3. Pills whole with thin liquids.
.
FOLLOW-UP
The patient should follow-up with Dr. [**Last Name (STitle) **] from general
surgery, Dr. [**Last Name (STitle) **] from vascular surgery, and Dr.
[**Last Name (STitle) **] from orthopedics as scheduled. He has appointments
scheduled in 4 weeks. He has an appointment with hematology to
evaluate his anemia in [**Month (only) 1096**] as per discharge plan. It is
likely he will be able to have the tracheostomy gradually
reduced and removed as well as the g-tube in the future. This
was discussed with the surgery team and will be done as an
outpatient.
Medications on Admission:
Albuterol inhaler q2 hours as needed
Amlodipine 5mg PO qday
Phoslo 667mg PO TID
Lasix 20mg PO qday
Gemfibrozil 600mg PO qday
Hydralazine 25mg PO TID
Hydromorphone .5-2mg IV q3hours PRN for pain
Glargine 25 units SC qHS
Imdur 20mg PO qday
Lactulose 30ml PO BID
Lorazepam .5-1mg PO qHS PRN insomnia
Metoclopramide 5mg/ml solution 1 q6 hours
Metoprolol 50mg PO BID
Nystatin suspension PO QID PRN
Seroquel 12.5mg PO qHS
Ranitidine 150 PO qday
Triamcinolone 0.025% cream [**Hospital1 **]
Acetaminophen solution q6hours PRN
ASA EC 81mg PO qday
Bisacodyl 10mg 1 suppository PR qday PRN
Colace liquid 100mg PO BID
Regular Insulin Sliding Scale
MVI
Senna 1 tab [**Hospital1 **]
Thiamine 100mg PO qday
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation every 6-8 hours
as needed for SOB, wheezing.
2. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
5. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous qday at dinner.
12. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
14. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for HR<55 or SBP<100.
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
19. 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.
20. Humalog 100 unit/mL Solution Sig: One (1) unit Subcutaneous
QACHS: as per sliding scale.
21. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hold for SBP < 100 or HR < 60.
22. Acetaminophen 160 mg/5 mL Solution Sig: Five (5) mL PO Q6H
(every 6 hours) as needed.
23. Sliding scale insulin
please see attached sliding scale
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Primary Diagnosis:
1. Loss of Consciousness
.
Secondary Diagnoses:
2. Congestive Heart Failure
3. Diabetes Mellitus
4. s/p motorcycle accident
5. Anemia
6. Coronary Artery Disease
Discharge Condition:
afebrile, hemodynamically stable, tracheostomy mask without
ventilator, able to eat
Discharge Instructions:
You were admitted to the hospital after losing consciousness.
You were found to have worsening heart failure and were given
diuretics to remove fluid from your lungs. You were given 3
days of antibiotics but these were stopped after you improved
and you were not felt to have a pneumonia.
.
You were evaluated by the trauma surgery service, the orthopedic
service, the wound care team and the nutrition team. You should
follow-up as an outpatient with orthopedics and trauma surgery
and you have appointments in 4 weeks. You should see a
hematologist for your anemia in [**Month (only) 1096**].
.
You were started on iron during this admission and should
continue to take this 325mg by mouth every day. You should take
a stool softener to prevent constipation. Your metoprolol was
decreased to 25mg PO twice per day. You should continue to take
this lower dose unless instructed by your doctors.
.
You should return to the hospital or call your primary care
doctor for any fevers > 100.4, chills, night sweats, shortness
of breath, chest pain, abdominal pain, dizziness or
lightheadedness, swelling in your legs, blood in your stool,
nausea or vomiting, or any other symptoms that concern you.
Followup Instructions:
You should follow up with your primary care doctor within a week
of discharge from rehab.
Hematology appointment for anemia workup: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD.
[**Telephone/Fax (1) 9645**]. Date/time: [**2145-2-5**] 2PM, [**Hospital Ward Name 23**] 9B.
.
Provider: [**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 24317**], MD Phone:[**Telephone/Fax (1) 6429**]
Date/Time:[**2145-1-12**] 1:00
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2145-1-12**] 1:55
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2145-1-12**] 2:15
You should have your CBC checked within 3-4 days of leaving the
hospital. Please have this done at rehab.
|
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"V44.0",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
14483, 14530
|
6137, 11646
|
273, 279
|
14754, 14840
|
3203, 4532
|
16087, 16919
|
2490, 2610
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12388, 14460
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14551, 14551
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11672, 12365
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14864, 16064
|
5623, 6114
|
2625, 2630
|
14618, 14733
|
230, 235
|
307, 1713
|
4541, 5606
|
14570, 14597
|
2644, 3184
|
1735, 2280
|
2296, 2474
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,811
| 136,973
|
30964
|
Discharge summary
|
report
|
Admission Date: [**2105-5-3**] Discharge Date: [**2105-5-11**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac cath
History of Present Illness:
This is a [**Age over 90 **]-year-old female with a history of NSTEMI in [**2101**]
(no cath or stents), moderate AS (AoVA 0.8-1.19cm2 on TTE in
[**2101**]), HTN, COPD/emphysema transferred from [**Hospital1 **] [**Location (un) 620**] for
cardiac catheterization after having been worked up for CP x2
days and found to have an NSTEMI.
.
The patient does not recall having had chest pain ever in the
past (despite a h/o MI and having been on Nitro SL prn). Last
Thursday, she was visited by her cousins and developed 60 min
lasting midsternal, pressure-like chest pain (w/o radiation)
that night. It was [**2108-5-28**] in severity and responded immediately
to one dose of SL nitro. She went to her PCP the next morning
and was sent to the [**Hospital1 **] [**Location (un) 620**]. Of note, she has noticed
bilateral ankle edema for about one week. In addition, she had
been short of breath on mild exertion for about one year. She
notes SOB after having walked from her bedroom to her kitchen.
She denies any orthopnea or PND. Also no aggravation of SOB over
the last week although her ankle edema developed since then.
.
At [**Hospital1 **] [**Location (un) 620**], her VS were stable in the ED (T 99.9, HR 89, BP
159/76, RR 18, 96% on RA). The initial EKG showed PR
prolongation, LAD, TWI in I, aVL, later also with TWI in V1 to
V6 which persisted throughout the hospital stay. She was found
to have an NSTEMI with peak troponin of 0.94. CXR was without
any acute findings at the time of admission. During her hospital
stay, she was started on an IV heparin drip, and received
Plavix, Lopressor and oxygen. She had four more episodes of
chest pain (twice yesterday and twice today) which were managed
with IV Lopressor, IV morphine and IV nitroglycerin with
occasional BP drops on higher doses of nitro. Her last episode
of CP was associated with radiation to the right of her lower
chest. She was eventually kept on Nitro and Heparin drip until
she was transferred to [**Hospital1 **] [**Location (un) 86**] for cardiac catheterization in
the morning.
.
REVIEW OF SYSTEMS:
Positive for chronic dry cough (secondary to emphysema per
patient). Denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, hemoptysis, black stools or red stools.
Denies recent fevers, chills or rigors. Denies exertional
buttock or calf pain. All of the other review of systems were
negative.
.
Cardiac review of systems positive for CP, SOB and ankle edema
as above. Negative for paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope.
Past Medical History:
PAST MEDICAL HISTORY:
* Pneumonia ([**2101**], requiring admission to [**Hospital1 **] [**Location (un) 620**])
* COPD / Emphysema (per pt, due to excessive second smoking of
her husband)
* CAD with small MI 4-5 years ago (? NSTEMI, no cath or stent)
* Hypertension
* History of hyperglycemia secondary to steroids for COPD flare
* Right hip fracture years ago, s/p three pins
* Chronic low back pain (? arthritis per pt)
* Shingles x3 in the past
* s/p C-section
.
Cardiac Risk Factors: -Diabetes, +Dyslipidemia, +Hypertension
.
Cardiac History: no previous cath, stent, CABG
Social History:
Has smokes only a few cigarettes in her lifetime but was exposed
to excessive second hand smoking of her husband. Denies any
recent EtOH use but used to drink Whiskey sour occasionally in
the past. Lives at [**Location (un) **]. Has a 70 year old son in
[**Name (NI) 4565**]. His name is [**Name (NI) **] and his phone number is
([**Telephone/Fax (1) 73188**].
Family History:
Her son had an MI at age 28 (?, per patient), her brother died
at age 55 of a "heart condition", which was likely an MI as well
per the patient. There is no family history of sudden death.
Physical Exam:
VS: T 100.0, BP 122/75, HR 91, RR 24, O2 97% on 2L NC
Gen: Younger than age appropriate appearing [**Age over 90 **] year old female
in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Very dry MM and old, dried blood on hard palate
Neck: Supple with JVP of approximately 7 cm.
CV: RR, normal S1, S2. [**2-24**] harsh, holosystolic murmur at USB
(L>R) without radiation to carotids and no significant
alteration with Valsalva. No rub or gallop. No thrills, lifts.
No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Mild crackles over left
lower lung fields, no wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. No abdominial bruits.
Ext: No clubbing or cyanosis. Trace ankle edema (R>L)
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Multiple, large bruises on upper and lower extremities (chronic,
due to Plavix per patient, which has been decreased to qod one
year ago for that reason).
.
Pulses:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
At [**Hospital1 **] [**Location (un) 620**]: Hb 15, WBC 7.5, Cr 1.0, BUN 24.
CK: [**Telephone/Fax (3) 73189**]
Troponin: 0.52 - 0.94 - 0.77
CK-MB: 69 - 50 - 27
Index: 25.7 - 21.6 - 17.5
.
Initial EKG at [**Hospital1 **] [**Location (un) 620**] demonstrated prolonged PR interval
(236), LAD, TWI in I, aVL, later also with TWI in V1 to V6 which
persisted throughout the hospital stay. EKG at [**Hospital1 **] [**Location (un) 86**] showed
also a PR prolongation of about 240, similar TWIs in
anterolateral leads and one ST elevation in V2 (less than 1 mm).
.
2D-ECHOCARDIOGRAM performed on [**2102-9-6**] demonstrated:
Views were extremely limited. LA normal size. LV and RV not well
visualized. Unable to assess EF. Asc aorta moderately dilated.
The aortic valve leaflets are moderately thickened. Moderate AS
(AoVA 0.8-1.19cm2). No AR. MV leaflets mildly thickened. No
pericardial effusion.
.
CXR: [**2105-5-1**] at [**Hospital1 **] [**Location (un) 620**] with no acute cardiopulmonary
process. Admission CXR at [**Hospital1 **] [**Location (un) 86**] also without any acute
findings (prelim read).
.
Cardiac cath:
1. Selective coronary angiography of this right dominant system
revealed
two vessel disease. The LMCA had mild plaquing but no critical
stenoses.
The LAD had a complex calfified, ulcerated 90% stenosis in the
mid-vessel after the D1 branch, which had 50% ostial and 70% mid
stenoses. The LCx had mild diffuse disease. The RCA was totally
occluded
proximally and filled via left to right collaterals.
2. Limited resting hemodynamics revealed an opening aortic
pressure of
133/68mmHg.
3. Left ventriculography was deferred.
4. The mid LAD lesion was predilated with 1.5 mm, 2.0 mm and 2.5
mm
balloons, stented with 2.5 mm and a 3.0 mm bare metal stents and
post
dilated with a 3.0 mm balloon with lesion reduction from 90 to
0%. The
final angiogram showed TIMI III flow with no residual stenosis,
no
dissection and no embolisation. (see PTCA comments)
5. Successful closure of the R femoral arteriotomy with a 6F
angioseal
device. (see PTCA comments)
.
TTE [**2105-5-5**]:
The left atrium is normal in size. The estimated right atrial
pressure is
16-20 mmHg. There is mild symmetric left ventricular hypertrophy
with normal cavity size. There is moderate regional left
ventricular systolic dysfunction with near akinesis of the
distal half of the anterior septum and anterior wall and apex.
There is mild hypokinesis of the remaining segments. No
intraventricuclar thrombus is seen. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size is normal with
focal hypokinesis of the apical free wall. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (area <0.8cm2). No aortic regurgitation is seen.
The mitral valve leaflets and supporting structurs are mildly
thickened. Moderate (2+) mitral regurgitation is seen. There is
severe pulmonary artery systolic hypertension. There is a
prominent, partially echo-filled anterior space which most
likely represents a fat pad. IMPRESSION: Severe aortic valve
stenosis. Symmetric left ventricular hypertrophy with regional
left and right ventricular systolic dysfunction and severely
depressed overall systolic dysfunction c/w CAD. Severe pulmonary
systolic hypertension. Moderate mitral regurgitation.
.
Labs on discharge:
Cr 1.5
WBC 20.4
Hct 40.7
Plt 255
.
Blood cx [**5-7**]: 4/4 bottles positive MRSA
Blood cx [**5-9**]: 1/4 bottles postive for GPC, awaiting speciation
Blood cx [**5-11**]: NGTD
Urine cx [**5-7**]: Negative
Brief Hospital Course:
This is a [**Age over 90 **]-year-old female with a history of NSTEMI in [**2101**]
(no cath or stents), moderate AS (AoVA 0.8-1.19cm2 on TTE in
[**2101**]), HTN, COPD/emphysema transferred from [**Hospital1 **] [**Location (un) 620**] for
cardiac catheterization after having been worked up for CP x2
days and found to have an NSTEMI. A repeat TTE prior cath showed
worsening of her AS from moderate to severe (AoVA 0.4cm2). Pt
underwent cath which showed two vessel disease. A BMS was placed
to LAD. She was CP free since then. Course was complicated by
MRSA bacteremia and new onset fib with RVR.
.
1) Ischemia/CAD: s/p small NSTEMI in [**2101**] (no cath or stents).
Transferred from [**Hospital1 **] [**Location (un) 620**] after having been diagnosed with
NSTEMI (Troponin peaked at 0.94 at [**Hospital1 **] [**Location (un) 620**]). Initial EKG at
[**Hospital1 **] [**Location (un) 620**] demonstrated prolonged PR interval, LAD, TWI in I,
aVL, later also with TWI in V1 to V6 which persisted throughout
the hospital stay. EKG at [**Hospital1 **] [**Location (un) 86**] showed also a PR
prolongation of about 240, similar TWIs in anterolateral leads
and one ST elevation in V2 but less than 1 mm. CP was managed
with Morphine IV and Nitro SL, then with Nitro gtt. A repeat TTE
prior to cath showed worsening of her AS from moderate to severe
(AoVA 0.4cm2). Pt underwent cath which showed two vessel
disease. A BMS was placed to LAD. She was CP free since then.
Patient was continued on ASA, Plavix (at home qod b/o easy
bruising, now increased to qd again). She was also continued on
Lipitor. Lopressor was changed to 25 [**Hospital1 **].
.
#) Bacteremia/Sepsis: Patient spiked a fever, had rigors, and
became hypotensive despite 1L IVF on [**5-6**]. WBC was up to 29.
Lactate was 1.8, then 2.1. BP meds were held. She was started on
Cipro, Flagyl and Vanc for empiric coverage. A femoral line was
placed on [**5-7**]. Blood cultures came back positive for MRSA. A
lasix gtt had to be started as she was volume overloaded after
1L IVF complicated by her low EF and severe AS. No clear source
was identified. Patient was continued on Vanco until she lost IV
access on [**5-10**]. The patient clearly stated that she did not
want to have a new IV placed for any reason so her antibiotics
were changed to Linezolid PO. She will need a 6-week course of
antibiotics to empirically treat her for endocarditis given her
severe valavular disease. Her CBC should be monitored weekly
given the risk of pancytopenia.
.
#) Afib with RVR: New onset during this admission. Responded to
IV metoprolol. Patient was loaded on Amiodarone the next day.
Heparin drip was started, however this was discontinued when her
IV access was lost. After consideration, a decision was made
not to anticoagluate given her age and risk of bleeding. She
was continued on amiodarone and BB for rate control.
.
#) Rhythm: PR prolongation at [**Hospital1 **] [**Location (un) 620**] and here (also on an
EKG from [**2101**]). Likely due to age-related conduction
disturbances. Patient was kept on tele.
.
#) Pump: TTE with EF of 25% and progression of AS from moderate
to severe. LE edema for one week and DOE for one year. I/Os,
1.5L fluid restriction, Lasix IV prn, transiently also on Lasix
gtt. Discharged on 80mg [**Hospital1 **] to be adjusted as necessary [**Name8 (MD) **] MD
at rehab.
.
#) Valves: Moderate AS on TTE in [**2101**], now severe (AoVA of 0.4).
Systolic murmur on exam consistant with AS. Attempted to avoid
venodilators (nitrates) and negative inotropes (BB, CCB).
Patient is not a surgical candidate.
.
#) Hyperlipidemia: Continued statin.
.
#) HTN: BP of 122/75 on admission. Was on low-dose BB at [**Hospital1 **]
[**Location (un) 620**]. Continued BB at lower dose of 25BID.
.
#) COPD: H/o emphysema secondary to second hand smoking.
Continue home regimen of Advair and Combivent. Also was given
nebs prn.
.
#) DM: H/o steroid-induced hyperglycemia in [**2101**]. She was placed
on a RISS while in house.
.
#) Renal: Normal BUN/Cr at [**Hospital1 **] [**Location (un) 620**]. ARF on [**5-6**] with Cr 2.0
(baseline 1.0), likely prerenal given urinary Na less than 10
and high urine osms. However, pt became fluid overloaded after
1L IVF during an attempt to treat the prerenal state. Therefore,
a Lasix gtt was started on [**5-7**] with good UOP and stable but
high Cr. Her Cr trended down to 1.5 on the day of discharge and
she maintained good urine output.
.
#) FEN: Cardiac diet.
.
#) PPX: Pneumoboots, bowel regimen, ASA, no PPI needed currently
.
#) Code: DNR/DNI
.
#) Communication: Son [**Name (NI) **] from [**State 4565**]. His phone number
is ([**Telephone/Fax (1) 73188**].
Medications on Admission:
AT HOME:
* Lopressor 75mg [**Hospital1 **]
* Advair 250/50 one puff [**Hospital1 **]
* Combivent two puffs qid
* Plavix 75mg qod (qd one year ago but decreased to pod b/o skin
bruising)
* Imdur 30mg [**Hospital1 **]
* Nitro 1/150 SL prn CP
* Diltiazem (Cartia XT) 120 mg qd
* (Lipitor 10mg qd) stopped months ago b/o leg ache
* Aspirin 81mg qd
.
UPON TRANSFER:
1. Lopressor 12.5 p.o. twice daily.
2. Aspirin 325 once daily.
3. Advair 250/50 twice daily.
4. Combivent 2 puffs 4 times daily.
5. Plavix 75 once a day.
6. Zocor 40 once a day.
7. Nitroglycerin drip to be titrated for patient comfort.
8. Heparin drip.
9. Morphine p.r.n. for pain.
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours) as needed.
8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
9. Amiodarone 200 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).
11. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 6 weeks.
12. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
neb Inhalation Q6H (every 6 hours) as needed.
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain, fever.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] - [**Location (un) 620**]
Discharge Diagnosis:
myocardial infarction
congestive heart failure
aortic stenosis
Discharge Condition:
Afebrile. Tolerating PO. Hemodynamically stable.
Discharge Instructions:
You were admitted for chest pain and for treatment of a
myocardial infarction.
.
You had a stent placed in one of your coronary arteries that was
blocked.
.
It is very important that you take your Plavix for 1 month.
Your beta blocker dose has been changed, please take as
prescribed.
.
While in the hospital you developed an infection in your blood.
You will need to take an antibiotic called Linezolid for 6
weeks.
.
If you experience any chest pain, shortness of breath, bleeding
or pain at your catheter site please seek medical attention.
Followup Instructions:
please follow up with your primary care doctor in [**12-23**] weeks.
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 28634**]
|
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72,335
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36615
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Discharge summary
|
report
|
Admission Date: [**2104-1-30**] Discharge Date: [**2104-2-11**]
Date of Birth: [**2042-6-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Cardiac cathetherization
PROCEDURE:
1. Coronary artery bypass graft x4; left internal mammary
artery to the left anterior descending artery and
saphenous vein grafts to the diagonal, posterior
descending coronary artery and obtuse marginal artery.
2. Endoscopic harvesting of the long saphenous vein.
History of Present Illness:
61 year old spanish speaking female with complaints of [**3-5**] days
of dyspnea associated with a cough. Over the proceding month,
she had decribed worsening chest pain associated with activity.
Her cough was productive of brown to white sputum.
.
Patient arrived at [**Last Name (un) 4199**] ED on [**2104-1-30**] for dyspnea and denied
chest discomfort. EKG revealed 2mm ST depressions in leads v3-v6
and tropI came back at 23. Her vitals were 90-110 Sinus Rhythm/
sinus tachy, BP 120-130-s/50's-60's, temp 98.1, sa02 100% on 2L
nc. She received 3 neb treatments in ED with improvement of
dyspnea. She also had difficulty lying flat. She was taken
directly to the cath lab and was found to have [**3-5**] vessel
disease not opitimal for stenting. She was admitted to the [**Hospital1 1516**]
service for cardiac surgery evaluation.
.
On the floor, she continues to deny chest pain.
.
On review of systems, she denies recent fevers, chills or
rigors, nausea, vomiting. All of the other review of systems
were negative.
The patient is a 61yo Hispanic female with a history of reactive
airway disease and acute diastolic CHF who recently developed
increasing DOE as well as chest pressure with activity. She had
an episode of SOB and chest pain early this morning, for which
she was admitted to an OSH. She ruled in for NSTEMI and was
transferred to [**Hospital1 18**]. Cath revealed 2VD and surgical consult is
now requested.
Past Medical History:
Congestive Heart Failure
Asthma
Diabetes Mellitus Type 2
Hypertension
GERD
Hyperlipidemia
Coronary Artery Disease
Social History:
Single lives with family. Tobacco: none ETOH: none
Family History:
Mother:DM
Siblings: CAD
Mother:DM
Father
Siblings: CAD
Offspring
Other
Physical Exam:
VS: T= 97.5 BP= 111/42 HR= 80 RR= 18 O2 sat= 99% 2L NC
GENERAL: WDWN female in NAD. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple without JVD.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Bilateral end
expiratory wheezing
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT dopplerable
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
[**2104-2-10**] 06:39AM BLOOD WBC-9.7 RBC-3.56*# Hgb-10.2*# Hct-30.4*#
MCV-85 MCH-28.6 MCHC-33.6 RDW-15.1 Plt Ct-178
[**2104-2-9**] 06:29AM BLOOD WBC-10.1 RBC-2.63* Hgb-7.3* Hct-22.5*
MCV-85 MCH-27.8 MCHC-32.6 RDW-15.3 Plt Ct-156#
[**2104-2-10**] 06:39AM BLOOD Glucose-155* UreaN-12 Creat-0.8 Na-141
K-4.1 Cl-102 HCO3-27 AnGap-16
Admission labs [**1-29**]:
WBC-9.0 RBC-3.95* Hgb-11.1* Hct-33.5* MCV-85 MCH-28.2# MCHC-33.2
RDW-15.0 Plt Ct-226
PT-12.7 PTT-65.0* INR(PT)-1.1
Glucose-274* UreaN-20 Creat-0.8 Na-140 K-4.2 Cl-105 HCO3-25
AnGap-14
CK(CPK)-904* CK-MB-62* MB Indx-6.9* cTropnT-1.65*
Imaging:
[**1-29**] Cardiac Cathetherization:
HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.78 m2
HEMOGLOBIN: 11.9 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} 19/16/15
RIGHT VENTRICLE {s/ed} 48/19
PULMONARY ARTERY {s/d/m} 48/20/29
PULMONARY WEDGE {a/v/m} 34/31/20
AORTA {s/d/m} 100/45/69
**CARDIAC OUTPUT
HEART RATE {beats/min} 90
RHYTHM NSR
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 27
CARD. OP/IND FICK {l/mn/m2} 8.2/4.6
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 527
PULMONARY VASC. RESISTANCE 88
**% SATURATION DATA (NL)
PA MAIN 81
AO 98
OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed.
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA DISCRETE 60
2) MID RCA DISCRETE 60
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA NORMAL
4) R-PDA NORMAL
4A) R-POST-LAT NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN NORMAL
6) PROXIMAL LAD NORMAL
6A) SEPTAL-1 NORMAL
7) MID-LAD DISCRETE 50
8) DISTAL LAD NORMAL
9) DIAGONAL-1 NORMAL
10) DIAGONAL-2 NORMAL
11) INTERMEDIUS NORMAL
12) PROXIMAL CX DISCRETE 90
13) MID CX NORMAL
13A) DISTAL CX DISCRETE 50
14) OBTUSE MARGINAL-1 NORMAL
15) OBTUSE MARGINAL-2 NORMAL
16) OBTUSE MARGINAL-3 NORMAL
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 37 minutes.
Arterial time = 21 minutes.
Fluoro time = 6.7 minutes.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 95 ml
Premedications:
Midazolam 1 mg IV
Fentanyl 50 mcg IV
ASA 325 mg P.O.
Anesthesia:
1% Lidocaine subq.
Other medication:
Furosemide 40mg IV
COMMENTS:
1. Selective coronary angiography in this right dominant system
demonstrated two vessel disease. The LMCA had no
angiographically
apparent disease. The LAD had a long 50% mid vessel stenosis.
The Cx had
a heavily calcified 90% stenosis at the origin of the vessel as
well as
a 50% distal stenosis. The RCA had a 60% proximal stenosis and a
60% mid
vessel stenosis.
2. Limited resting hemodynamics revealed elevated right and left
filling pressures with an RVEDP of 19 mmHg and a PCWP of 20
mmHg. There
was moderate pulmonary hypertension with a PASP of 48 mmHg. The
Central
aortic pressure was noted to be 100/45 mmHg. The cardiac index
was
slightly elevated at 4.6 L/min/m2.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Moderate left and right ventricular diastolic dysfunction.
3. Moderate primary pulmonary hypertension.
[**1-30**] Echocardiogram:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with infero-lateral
hypokinesis. No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2103-8-17**],
regional LV systolic dysfunction is new.
Brief Hospital Course:
61 year old spanish speaking female with history of DM, HTN, HL
who presents with NSTEMI and cath showing 2 vessel disease and
moderate diastolic dysfunction.
# CORONARIES: Patient had NSTEMI noted at outside hospital with
ST depressions in V3-6 and troponin I at 23 and was transferred
to [**Hospital1 18**] for cardiac cathetherization. Cath showed 2 vessel
disease with moderate diastolic dysfunction. Echocardiogram
showed new regional LV systolic dysfunction with EF reduced to
45-50% from 70% in [**8-8**]. She was medically managed with
aspirin, full dose statin, beta blocker, and heparin drip until
she completed her post-cath plavix washout and was sent for
CABG...
# PUMP: She has a history of hypertension with new regional LV
systolic dysfunction seen on echocardiogram with EF 45-50%. She
was continued on her home Diovan and HCTZ. Given her diastolic
dysfunction seen on cath, she was diuresed with lasix.
# RHYTHM: sinus
# Tracheobronchial malasia/Asthma: Her home albuterol,
singulair, ipratropium, advair, fluticasone nasal spray,
loratadine were continued. Her symptoms were suggestive of
asthma/COPD exacerbation, and she was on prednisone 40mg and
azithro for total of 5 days.
# DM: Her home insulin regimen of 14 lantus and Humalog ISS was
continued.
# GERD: Her home omeprazole was continued.
The patient was brought to the operating room on [**2103-2-5**] where
she underwent cabgx4 with Dr. [**First Name (STitle) **]. See op report for
details. Overall the patient tolerated the procedure well and
post-operatively was transferred to CVICU for invasive
monitoring. POD 1 found the patient extubated, alert and
oriented and breathing comfortably. She was neurologically
intact and hemodynamically stable on neosynephrine. This was
weaned and beta blockade was initiated. The patient was
transferred to the telemetry floor on POD 2. She was diuresed.
Interventional pulmonology was consulted for pulmonary
management, as she has an extensive pulmonary history. Their
recommendations were carried out, and we appreciate the input.
The patient was weaned from oxygen without difficulty. She did
receive 2 units of PRBC for a hct of 22. Hct rose to 30 and
remained stable. Insulin was adjusted for blood glucose
control. Minimal serous sternal drainage was noted and the
patient was started on Kefzol. She remained afebrile with a
normal WBC. Drainage lessened over the following days. She was
discharged to rehab on POD 6.
Medications on Admission:
Received at [**Last Name (un) 4199**]:
nebulizer treatments x3, 2gm magnesium IV, Rocephin 1gm IV, 500
mg of Azithromycin, 125mg solumedrol, 5000 unit boulus of
heparin and heparin drip at 1000units/hr, 325 mg of aspirin
.
Home meds per outside records:
ALBUTEROL nebs q6 PRN
FLUTICASONE PROPIONATE (BULK) - (Prescribed by Other Provider) -
100 % Powder - 1 inhalation daily each nostril
FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth daily
GABAPENTIN [NEURONTIN] 400mg TID
IBUPROFEN - (Prescribed by Other Provider) - 600 mg Tablet - 1
Tablet(s) by mouth 4 times a day as needed for pain as needed
for
as needed for pain
INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) - 100
unit/mL Cartridge - inject 14 units q hs
INSULIN LISPRO [HUMALOG KWIKPEN] - (Prescribed by Other
Provider) - 100 unit/mL Insulin Pen - 5 units sc three times
daily
IPRATROPIUM-ALBUTEROL - (Prescribed by Other Provider) - 0.5
mg-2.5 mg/3 mL Solution for Nebulization - 0.5-2.5mg/3ml 3ml
four
times daily
LORAZEPAM - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth twice daily as needed
MONTELUKAST [SINGULAIR] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth every evening
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth twice daily
Advair 500-50 q12
Theophylline 300mg [**Hospital1 **]
Diovan-HCT 160-12.5mg daily
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet - 1
Tablet(s) by mouth daily
CALCIUM CARBONATE-VITAMIN D3 [OS-CAL 500 + D] - (Prescribed by
Other Provider) - Dosage uncertain
LORATADINE - (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
3. Theophylline 100 mg Tablet Sustained Release 12 hr Sig: Three
(3) Tablet Sustained Release 12 hr PO BID (2 times a day).
4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
8. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours) as needed for wheezing.
10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever/pain.
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks: 40mg daily for 2 weeks, then 20mg daily until
further instructed.
14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
15. Insulin Glargine 100 unit/mL Solution Sig: One (1)
Subcutaneous q am: 32 units glargine with breakfast.
16. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous four times a day: dose according to sliding scale.
17. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO four times
a day for 1 weeks. Capsule(s)
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] center
Discharge Diagnosis:
coronary artery disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet p
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Primary Care Dr. [**Last Name (STitle) **] in [**2-2**] weeks
Cardiologist Dr. [**Last Name (STitle) **] in [**2-2**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2104-2-11**]
|
[
"788.20",
"519.19",
"401.9",
"458.29",
"V58.65",
"410.71",
"530.81",
"493.22",
"285.9",
"356.9",
"428.33",
"V58.67",
"428.0",
"416.8",
"414.01",
"272.4",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"88.57",
"37.23",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
13267, 13321
|
7150, 9624
|
327, 642
|
13389, 13483
|
3129, 5011
|
14221, 14697
|
2328, 2402
|
11405, 13244
|
13342, 13368
|
9650, 11382
|
6116, 7127
|
13621, 14198
|
2417, 3110
|
5030, 6099
|
280, 289
|
670, 2103
|
2125, 2241
|
2257, 2312
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,244
| 102,332
|
17478
|
Discharge summary
|
report
|
Admission Date: [**2139-2-27**] Discharge Date: [**2139-3-10**]
Service:
ADMITTING DIAGNOSIS: Barrett's esophagus with high grade
dysplasia.
DISCHARGE DIAGNOSES:
1. Barrett's esophagus with high grade dysplasia.
2. Status post trans-hiatal esophagectomy.
3. Aspiration.
4. Myocardial infarction.
5. Cardiogenic shock.
6. Anoxic encephalopathy.
7. Death.
HISTORY OF PRESENT ILLNESS: The patient is an 84 year old
male who had a long standing history of gastroesophageal
reflux disease and Barrett's esophagus and had high grade
dysplasia diagnosed on recent endoscopy. The patient elected
to have an esophagectomy performed.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Question renal insufficiency.
3. Gastroesophageal reflux disease.
MEDICATIONS:
1. Norvasc.
2. Prilosec.
3. Carafate.
PHYSICAL EXAMINATION: On admission, the patient is an
elderly man in no acute distress. Vital signs are stable.
Afebrile. Chest is clear to auscultation bilaterally.
Cardiovascular is regular rate and rhythm without murmur, rub
or gallop. Abdomen is soft, nontender, nondistended without
masses or organomegaly. Extremities are warm, not cyanotic
and not edematous times four. Neurological is grossly
intact.
HOSPITAL COURSE: The patient was taken to the Operating
Room on [**2139-2-27**], where he underwent transhiatal
esophagectomy without significant complication. In the
postoperative course, he was initially admitted under the
Intensive Care Unit care and kept in the Post Anesthesia Care
Unit overnight. The patient was seen to have a low urine
output and both metabolic and respiratory acidosis and was
given approximately 8.5 liters of Crystalloid in the
perioperative period, including OR.
The patient was briefly agitated in the Post Anesthesia Care
Unit and discontinued his nasogastric tube. On postoperative
day number one, the patient was doing well with a fairly
normalized blood gas of 7.35/43/94/25/minus 1 and was
transferred to the floor.
On postoperative day two, the patient was seen to have a
baseline oxygen requirement of 70% face mask in the morning
but was saturating well and otherwise seemed to be doing
relatively well.
The patient had a white count of 22.1 which prompted a chest
x-ray showing bilateral pleural effusion and patchy bibasilar
atelectasis but no focal infiltrates. Over the course of the
day, the patient had deteriorating in his respiratory status
and became increasingly tachypneic with wheezing and coarse
breath sounds.
An EKG was performed which showed atrial fibrillation but no
ischemic changes. A baseline arterial blood gas was obtained
at that point which was 7.37/47/86/28/zero, again on 70% face
mask.
Intravenous fluids were then stopped and the patient was
begun on 20 mg of intravenous Lasix and albuterol nebulizers.
The patient was transferred to another floor for Telemetry
purposes and cycled for myocardial infarction. His
respiratory status during transfer seemed somewhat improved.
Upon arrival to the other floor, the patient stopped
respiring briefly and went bradycardic. Upon stimulation, he
was tachycardic to the 110s with a blood pressure 130/70.
Immediately subsequent to that the patient went pulseless and
into respiratory and cardiac arrest and was down for
approximately two to three minutes. CPR was begun and the
patient intubated and 15 to 20 cc. of brownish fluid was
suctioned from the endotracheal tube post intubation.
The patient regained pulse and cardiac activity and was
transferred to the Intensive Care Unit.
Cardiac consultation at that time recommended aspirin,
cycling enzymes and agreed with probable aspiration event.
They suggested a heparin drip but not is surgically
contraindicated. A heparin drip was not started. The
patient ruled in for myocardial infarction with a troponin of
26.5.
In the patient's Intensive Care Unit stay, he was supported
with a dopamine drip and diuresed for fluid overload.
Pressors were weaned off on postoperative day number eight.
Respiratory function was supported throughout his Intensive
Care Unit course appropriately with mechanical ventilation.
The patient was noted to be unresponsive after the aspiration
event, with some slow return of responsiveness over the next
several days, but no purposeful movement. To evaluate
possible neurologic injury, a CT scan was obtained after the
patient was felt to be stable enough to be transferred.
On postoperative day six, the CT scan showed no acute
intracranial event but was consistent with chronic
microvascular infarction. EEG was also obtained which
revealed diffuse widespread encephalopathy. There was a
question of possible seizure activity involving the left
upper extremity and phenytoin was begun empirically.
A repeat EEG was obtained on postoperative day number 10 and
again showed moderately severe diffuse encephalopathy with no
seizure focus.
A Neurology consultation was obtained and assessed the
patient to have minimal chance for a meaningful recovery.
In accordance with the patient's living will, the family's
wishes and discussion with the surgical attending, the
patient was made comfort measures only and expired on
postoperative day number 11.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**]
Dictated By:[**Last Name (NamePattern1) 5745**]
MEDQUIST36
D: [**2139-3-24**] 10:08
T: [**2139-3-28**] 16:18
JOB#: [**Job Number 48824**]
|
[
"272.0",
"507.0",
"348.3",
"427.5",
"997.3",
"276.4",
"401.9",
"530.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"42.42",
"42.52",
"96.04",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
173, 373
|
1250, 5475
|
838, 1231
|
403, 647
|
104, 152
|
669, 814
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,667
| 119,112
|
47083+58977
|
Discharge summary
|
report+addendum
|
Admission Date: [**2180-8-25**] Discharge Date: [**2180-8-31**]
Date of Birth: [**2125-12-21**] Sex: F
Dictating for: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old
female with a history polysubstance abuse including
as a recent homeless (of about 1-year duration) who presented
from her [**Hospital3 **] facility with decreased mental
status and hypotension.
The patient was found by an [**Hospital3 **] facility worker
and was noted to have decreased mental status. The patient
was also known to have fallen two days previously. The
Medical Center Emergency Department.
PAST MEDICAL HISTORY:
1. Polysubstance abuse; distant intravenous drug use and
persistent prescription opioid and sedative abuse.
2. Anxiety with obsessive-compulsive disorder tendencies
and known panic attacks; question of bipolar disorder
diagnosis.
3. Depression.
4. Dysfunctional uterine bleeding; status post hysterectomy
and single oophorectomy.
5. Chronic back pain; status post surgery for herniated
disk.
6. Migraine headaches.
7. Hypertension.
8. Temporomandibular joint dysfunction; status post jaw
surgery.
9. Gastroesophageal reflux disease.
10. Hepatitis C.
11. Chronic obstructive pulmonary disease.
12. Coronary artery disease; status post stent placement and
angioplasty in [**2179-11-30**].
ALLERGIES: ERYTHROMYCIN (the patient gets a rash); CODEINE
(the patient could not describe, allergy was found in old OMR
records).
MEDICATIONS ON ADMISSION:
1. Dexamethasone 0.75 mg p.o. q.a.m.
2. Advair 500/50 diskus 1 puff b.i.d.
3. Combivent 2 puffs inhaled t.i.d.
4. Albuterol 2 puffs inhale as needed (for shortness of
breath).
5. Tamoxifen citrate 20 mg p.o. q.d.
6. Seroquel 200 mg p.o. b.i.d.
7. Ambien 20 mg p.o. q.h.s. as needed (for insomnia).
8. Zestril 20 mg p.o. q.d.
9. Lopressor 25 mg p.o. b.i.d.
10. Norvasc 10 mg p.o. q.h.s.
11. Protonix 40 mg p.o. q.h.s.
12. Aspirin 81 mg p.o. q.d.
13. Celexa 40 mg p.o. q.h.s.
14. Nitro-Quick 0.4 mg sublingually (for angina).
15. Ibuprofen 400 mg p.o. q.4-6h. as needed (for pain).
16. Tetracycline hydrochloride 500 mg p.o. q.6h. (times 12
days).
17. Metronidazole 500 mg p.o. t.i.d. (times 12 days).
18. Bismuth subsalicylate chewable 2 tablets p.o. q.i.d.
(for 12 more days).
FAMILY HISTORY: A family history of uterine cancer,
depression, and multi-substance abuse.
SOCIAL HISTORY: The patient has been divorced since [**2169**];
and until [**2178**] she was living with her daughter. Secondary
to the patient's drug abuse, the daughter evicted the patient
who was then homeless for about one year. In [**2180-4-29**],
the patient took up residence at [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] House. In
early [**2180-7-30**], the patient was admitted to an
[**Hospital3 **] facility ([**Hospital1 **] at [**Hospital1 1426**]) by the
[**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] House. The patient has a history of
polysubstance abuse including prescription opioids and
benzodiazepines as well as distant intravenous drug use. The
patient denies alcohol abuse. The patient has roughly a
30-pack-year history of smoking (one pack per day for about
30 years).
PHYSICAL EXAMINATION ON DISCHARGE: Upon discharge from the
[**Hospital1 69**], the patient's vital
signs were temperature of 98.4, heart rate was 47 to 70,
blood pressure was 150 to 174/84 to 104, respiratory was 18,
and oxygen saturation was 98% on room air. In general, an
obese Caucasian female in no apparent distress who had a
cushingoid appearance. Skin was warm and well perfused.
Head, eyes, ears, nose, and throat revealed normocephalic
with ecchymoses over her right eyebrow. Pupils were equal,
round, and reactive to light. Mucous membranes were moist.
Lungs revealed occasional wheezes in the bilateral lower
lobes that were reversible with the patient's inhalers.
Otherwise, no crackles or rales. Heart had a regular rate
and rhythm. Second heart sound and second heart sound were
present. No murmurs, rubs, or gallops. The abdomen was
obese, soft, and nontender. Bowel sounds were present.
Extremities revealed 2+ pedal pulses. No pedal edema.
Neurologically, cranial nerves II through XII were grossly
intact. Psychiatrically, the patient was occasionally
agitated; but otherwise showed no signs of depression or
anxiety.
PHYSICAL EXAMINATION/LABORATORY AT OUTSIDE HOSPITAL: Upon
presentation to the [**Hospital6 1708**] the
patient's blood pressure was found to be 62/36. She was also
found to have a potassium of 6.3, a hematocrit of 27.7, and
an eosinophil count of 13.5%. The patient's urine toxicology
was positive for benzodiazepines. There serum toxicology and
urine toxicology were otherwise negative for ingestions.
EMERGENCY DEPARTMENT COURSE: In the Emergency Department,
the patient was given 10 units of insulin and calcium
gluconate, from which her calcium corrected to 5.4. The
patient was also given 2 units of Narcan; after which she was
noted to be mildly more arousable. The patient was seen to
be hypercarbic from her arterial blood gas of 7.23, PCO2
of 48, and PO2 of 64. The patient was then intubated and
admitted to the Medical Intensive Care Unit. Suspecting
adrenal insufficiency, the team then gave the patient doses
of hydrocortisone. The patient responded, and her
hemodynamics stabilized. Later on hospital day one, the
patient was able to be extubated.
HOSPITAL COURSE: [**Hospital **] hospital events by systems were
as follows.
1. GASTROINTESTINAL: On hospital day two, the patient was
noted to be passing bright red blood per rectum. A
gastrointestinal workup by colonoscopy revealed internal
hemorrhoids, but no other colonic lesions. An upper
gastrointestinal and small-bowel follow-through film showed
no abnormalities of her upper gastrointestinal tract or
symptoms of bleeding.
On hospital day three, the patient had required 2 units of
blood; but otherwise her hematocrit stabilized into the
lower 30s. This was thought to be due to a hemorrhoidal
bleed. The patient's gastrointestinal bleed will be followed
by her primary care physician.
2. ENDOCRINE: The patient has an initial cortisol of 3.1.
The patient was subsequently put on hydrocortisone 100 mg
q.8h. Over the next two days, the patient's hydrocortisone
was tapered to 50 mg q.6h. A cortisol stimulation test on
hospital day four showed physiological levels of cortisol
with a baseline cortisol of 32. This result was felt to reflect
her hydrocortisone doses, and she was switched to dexamethasone.
Decision was made to repeat the [**Last Name (un) 104**] stim test as an outpatient.
For a further workup, the patient will be following with
Dr. [**Last Name (STitle) 99814**] at the [**Hospital **] Clinic, on the [**Location (un) 1773**], on
Wednesday, [**9-6**] at 12:30 p.m. The Endocrine team also
wished for a magnetic resonance imaging of the patient's head
and neck to further rule out malignancy. However, during
this admission, the patient received a magnetic resonance
imaging but yet could not sit still for the study. Hence, if
the Endocrine team wishes for a further magnetic resonance
imaging study, the patient can complete one as an outpatient.
3. INFECTIOUS DISEASE: During this admission, the patient
tested negative for human immunodeficiency virus and
tuberculosis. The patient tested positive for Helicobacter
pylori. The patient was subsequently treated with a 14-day
course of antibiotics.
The patient's hepatitis B surface antigen, hepatitis B
surface antibody, and hepatitis C antibody were pending.
These results can be followed up with the patient's primary
care physician by calling [**Telephone/Fax (1) 16116**] and given the
patient's [**Hospital1 69**] medical record
number of [**Numeric Identifier 99815**]. At this point, the primary care physician
can have the results faxed to him.
4. NEUROLOGY: Upon admission, the patient was minimally
responsive to painful stimulation, and her speech was
garbled. The patient was also only transiently aware of her
surroundings and of her person.
Over the hospital admission, the patient slowly improved
until she was at her baseline upon hospital day five. The
patient's mental status was thought to be secondary to
electrolyte imbalances caused by her Addisonian crisis.
5. PULMONARY: The patient was stable on her current
pulmonary medications. The patient can follow up for further
treatment of her chronic obstructive pulmonary disease and
asthma with her primary care physician.
6. CORONARY ARTERY DISEASE: The patient's blood pressure
remained high throughout the hospitalization. She was
started on a beta blocker, and it was increased in dose. The
patient was to be discharged on her new beta blocker as well
as on her current regimen of a calcium channel blocker and an
ACE inhibitor.
The patient was to follow up with her primary care physician
for further management of her blood pressure.
7. HEMATOLOGY: The patient presented with a normocytic
anemia; likely to be secondary to her blood loss via her
gastrointestinal bleed. The patient's hematocrit stabilized
in the low 30s. This should be followed by her primary care
physician.
8. PSYCHIATRY: The patient was seen by the Psychiatry
Service here at the [**Hospital1 69**].
The patient has an outpatient psychiatrist (Dr. [**First Name8 (NamePattern2) 504**] [**Last Name (NamePattern1) **])
with whom she will follow up with upon discharge.
9. TOXICOLOGY: The patient presented with a urine
toxicology showing the presence of benzodiazepines. The
patient is not currently on any benzodiazepines at her
[**Hospital3 **] facility. The [**Hospital3 **] facility was
aware of this and will further monitor her medications while
she is there.
The patient also presented on multiple sedatives and pain
medications including Roxicet, clonazepam, multiple doses of
Seroquel, ibuprofen, and Neurontin.
The patient was to be discharged on the pain and sedation
medications which she required during this hospitalization.
These included Seroquel 200 mg p.o. b.i.d. and Ambien 20 mg
p.o. q.h.s. as needed (for insomnia), as well as
ibuprofen 400 mg p.o. q.6h. If the patient requires further
pain medications or sedatives, she can receive these from her
primary care physician or psychiatrist.
10. SUMMARY: In general, the patient presented with what
appeared to be an Addisonian crisis and with hydrocortisone,
her hemodynamics stabilized. However, we are uncertain of
the cause of the adrenal crisis at this time. Hence, further
follow up with Endocrine is crucial. The patient is to
receive a Medic-Alert bracelet. Her primary care physician
agreed to arrange this. The patient will also be discharged
on a dexamethasone pen in case of further Addisonian crises.
CONDITION AT DISCHARGE: The patient was discharged in stable
condition.
DISCHARGE DISPOSITION: The patient to be discharged to her
[**Hospital3 **] facility.
DISCHARGE DIAGNOSES:
1. Adrenal insufficiency.
2. Gastrointestinal bleed.
3. Mental status changes.
MEDICATIONS ON DISCHARGE:
1. Dexamethasone 0.75 mg p.o. q.a.m.
2. Advair 500/50 diskus 1 puff b.i.d.
3. Combivent 2 puffs inhaled t.i.d.
4. Albuterol 2 puffs inhale as needed (for shortness of
breath).
5. Tamoxifen citrate 20 mg p.o. q.d.
6. Seroquel 200 mg p.o. b.i.d.
7. Ambien 20 mg p.o. q.h.s. as needed (for insomnia).
8. Zestril 20 mg p.o. q.d.
9. Lopressor 25 mg p.o. b.i.d.
10. Norvasc 10 mg p.o. q.h.s.
11. Protonix 40 mg p.o. q.h.s.
12. Aspirin 81 mg p.o. q.d.
13. Celexa 40 mg p.o. q.h.s.
14. Nitro-Quick 0.4 mg sublingually (for angina).
15. Ibuprofen 400 mg p.o. q.4-6h. as needed (for pain).
16. Tetracycline hydrochloride 500 mg p.o. q.6h. (times 12
days).
17. Metronidazole 500 mg p.o. t.i.d. (times 12 days).
18. Bismuth subsalicylate chewable 2 tablets p.o. q.i.d.
(for 12 more days).
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 99816**], M.D. [**MD Number(1) 99817**]
Dictated By:[**Name6 (MD) 8564**]
MEDQUIST36
D: [**2180-8-31**] 15:21
T: [**2180-8-31**] 16:39
JOB#: [**Job Number 99818**]
cc:[**Hospital1 99819**]
Name: [**Known lastname 11326**], [**Known firstname 194**] Unit No: [**Numeric Identifier 15996**]
Admission Date: [**2180-8-25**] Discharge Date: [**2180-8-31**]
Date of Birth: [**2125-12-21**] Sex: F
Service:
ADDENDUM: The Endocrine Team during this hospitalization
wished for the patient to be discharged on Dexamethasone Pen.
Upon consultation with the pharmacy, no such commercial drug
exists. If the Endocrine team wishes for the patient to have
this as an outpatient, they must prescribe it when they
follow up with her on [**2180-9-6**] at 12:30 PM. The
patient also has a follow up appointment with her primary
care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 15997**] [**Hospital1 15998**] [**Hospital 15999**]
Health Center on [**9-6**], at 3:45 PM.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16000**], M.D. [**MD Number(1) 16001**]
Dictated By:[**Last Name (NamePattern1) 16002**]
MEDQUIST36
D: [**2180-8-31**] 15:38
T: [**2180-8-31**] 16:54
JOB#: [**Job Number 16003**]
|
[
"496",
"041.86",
"276.7",
"401.9",
"455.2",
"255.4",
"285.1",
"584.9",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
11035, 11099
|
2394, 2470
|
11120, 11203
|
11230, 13455
|
1572, 2377
|
5567, 10947
|
10962, 11011
|
3360, 5549
|
241, 681
|
704, 1545
|
2487, 3344
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,144
| 105,479
|
23135
|
Discharge summary
|
report
|
Admission Date: [**2191-1-16**] Discharge Date: [**2191-2-3**]
Date of Birth: [**2112-8-1**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p Motor Vehicle Collision
Major Surgical or Invasive Procedure:
ORIF R patella
Tracheostomy
G-tube
History of Present Illness:
78f s/p head-on MVC, restrained passenger,+EtOH,30 mph with
extensive front end damage & deployment of airbag, GCS 15,
complain of chest pain/back pain. L chest tube placed at OSH for
decreased breath sounds on Left. Transfer to [**Hospital1 18**] intubated,
hypotensive ontransfer, respond to fluid bolus, repeat
hypotension, DPL neg, FAST neg, Right chest tube placed with min
output, then 2nd Left chest tube placed with gush of air,also
noted L patellar fx on eval.
Past Medical History:
breast ca,L mastectomy, asbestos, COPD,neck tumor s/p excision
and radiation, hypothyroid,mitral stenosis,Rheumatic heart
disease,scarlet fever, prior fall w sternal fx, back fx, rib fx,
also compression back fx 2 mo prior to admit
Social History:
N/A
Family History:
non-contributory
Physical Exam:
96.6/133/146/77,15,91 AC 500/16/5/0/100
intub sedated
Bilat pupils sluggish
tachycardic
chest coarse bilaterally, with chest tubes
abd soft, non distended,stable pelvis
+fem/DP bilateral,
R knee deformity, L ant. tib lac
nl tone guaiac neg
back no step-off, deformity
Pertinent Results:
[**2191-2-2**] 02:56AM BLOOD WBC-12.0* RBC-3.42* Hgb-10.0* Hct-31.4*
MCV-92 MCH-29.3 MCHC-31.9 RDW-15.6* Plt Ct-389
[**2191-2-1**] 02:31AM BLOOD WBC-11.7* RBC-3.75* Hgb-11.1* Hct-33.6*
MCV-90 MCH-29.6 MCHC-33.1 RDW-15.6* Plt Ct-370
[**2191-1-31**] 04:28AM BLOOD WBC-13.4* RBC-3.94* Hgb-11.5* Hct-35.9*
MCV-91 MCH-29.2 MCHC-32.0 RDW-15.9* Plt Ct-394
[**2191-1-30**] 02:10AM BLOOD WBC-11.2* RBC-3.93* Hgb-11.9* Hct-34.6*
MCV-88 MCH-30.4 MCHC-34.4 RDW-16.1* Plt Ct-322
[**2191-1-29**] 02:49AM BLOOD WBC-9.9 RBC-3.74* Hgb-10.9* Hct-33.1*
MCV-88 MCH-29.1 MCHC-32.9 RDW-16.1* Plt Ct-276
[**2191-1-28**] 01:18AM BLOOD WBC-12.1* RBC-3.63* Hgb-10.8* Hct-32.9*
MCV-91 MCH-29.7 MCHC-32.8 RDW-15.8* Plt Ct-246
[**2191-1-27**] 04:00AM BLOOD WBC-10.8 RBC-3.80* Hgb-11.1* Hct-34.1*
MCV-90 MCH-29.3 MCHC-32.7 RDW-15.8* Plt Ct-228
[**2191-1-26**] 02:40AM BLOOD WBC-10.6 RBC-3.46* Hgb-10.2* Hct-31.5*
MCV-91 MCH-29.4 MCHC-32.4 RDW-15.7* Plt Ct-190
[**2191-1-25**] 01:48AM BLOOD WBC-11.4* RBC-3.66*# Hgb-10.7*# Hct-32.3*
MCV-88 MCH-29.3 MCHC-33.2 RDW-16.1* Plt Ct-164
[**2191-1-24**] 05:21PM BLOOD Hct-30.3*
[**2191-1-23**] 10:15PM BLOOD WBC-11.8*# RBC-2.81* Hgb-8.3* Hct-24.8*
MCV-88 MCH-29.7 MCHC-33.6 RDW-15.8* Plt Ct-168
[**2191-1-23**] 02:24PM BLOOD Hct-24.2*
[**2191-1-23**] 01:35AM BLOOD WBC-7.7 RBC-2.95* Hgb-8.8* Hct-26.1*
MCV-88 MCH-29.8 MCHC-33.8 RDW-15.8* Plt Ct-142*
[**2191-1-22**] 03:11PM BLOOD Hct-26.1*
[**2191-1-22**] 07:46AM BLOOD Hct-27.7*
[**2191-1-22**] 02:15AM BLOOD WBC-5.9 RBC-2.89* Hgb-8.6* Hct-26.1*
MCV-90 MCH-29.8 MCHC-33.0 RDW-15.8* Plt Ct-126*
[**2191-1-21**] 08:24PM BLOOD Hct-26.4*
[**2191-1-21**] 02:41PM BLOOD Hct-25.7*
[**2191-1-21**] 02:14AM BLOOD WBC-6.9 RBC-3.04* Hgb-9.0* Hct-26.8*
MCV-88 MCH-29.6 MCHC-33.6 RDW-15.6* Plt Ct-122*
[**2191-1-20**] 02:08AM BLOOD WBC-6.2 RBC-3.20* Hgb-9.6* Hct-28.2*
MCV-88 MCH-30.0 MCHC-34.0 RDW-15.6* Plt Ct-104*
[**2191-1-19**] 02:13AM BLOOD WBC-6.1 RBC-3.14* Hgb-9.4* Hct-27.6*
MCV-88 MCH-29.8 MCHC-34.0 RDW-15.5 Plt Ct-109*
[**2191-1-18**] 05:31PM BLOOD WBC-6.5 RBC-3.18* Hgb-9.5* Hct-27.7*
MCV-87 MCH-29.8 MCHC-34.2 RDW-15.7* Plt Ct-108*
[**2191-1-18**] 01:30PM BLOOD Hct-26.0* Plt Ct-114*
[**2191-1-18**] 02:09AM BLOOD WBC-6.8 RBC-3.23* Hgb-9.6* Hct-27.7*
MCV-86 MCH-29.7 MCHC-34.6 RDW-15.8* Plt Ct-92*
[**2191-1-17**] 05:48PM BLOOD Hct-30.2* Plt Ct-102*
[**2191-1-17**] 09:02AM BLOOD Hct-32.4*
[**2191-1-17**] 01:22AM BLOOD WBC-7.6 RBC-3.80*# Hgb-11.5*# Hct-32.4*
MCV-85 MCH-30.4 MCHC-35.7* RDW-15.4 Plt Ct-72*
[**2191-1-16**] 05:53PM BLOOD Hct-32.5*#
[**2191-1-16**] 12:31PM BLOOD WBC-6.7 RBC-3.03* Hgb-8.9* Hct-25.8*
MCV-85 MCH-29.5 MCHC-34.6 RDW-13.7 Plt Ct-110*
[**2191-1-16**] 11:43AM BLOOD Hct-26.9*
[**2191-1-16**] 05:49AM BLOOD WBC-11.9* RBC-2.73* Hgb-7.9* Hct-23.7*
MCV-87 MCH-28.8 MCHC-33.2 RDW-14.0 Plt Ct-86*
[**2191-1-16**] 04:16AM BLOOD WBC-9.5# RBC-2.39*# Hgb-7.2*# Hct-20.7*#
MCV-87 MCH-30.0 MCHC-34.5 RDW-13.8 Plt Ct-72*#
[**2191-1-16**] 01:00AM BLOOD WBC-21.7* RBC-4.81# Hgb-14.7# Hct-42.7#
MCV-89 MCH-30.5 MCHC-34.4 RDW-13.5 Plt Ct-149*
[**2191-1-15**] 11:20PM BLOOD WBC-19.3* RBC-3.68* Hgb-11.2* Hct-33.2*
MCV-90 MCH-30.3 MCHC-33.7 RDW-13.6 Plt Ct-158
[**2191-1-26**] 02:40AM BLOOD Neuts-93.9* Bands-0 Lymphs-3.3* Monos-2.1
Eos-0.7 Baso-0.1
[**2191-2-2**] 02:56AM BLOOD Plt Ct-389
[**2191-1-15**] 11:20PM BLOOD Plt Ct-158
[**2191-1-25**] 12:07PM BLOOD PT-13.6 PTT-25.4 INR(PT)-1.2
[**2191-1-15**] 11:20PM BLOOD PT-17.5* PTT-40.9* INR(PT)-1.9
[**2191-1-15**] 11:20PM BLOOD Fibrino-136*
[**2191-1-16**] 04:16AM BLOOD Fibrino-211#
[**2191-2-2**] 02:56AM BLOOD Glucose-116* UreaN-24* Creat-0.4 Na-141
K-4.0 Cl-104 HCO3-32* AnGap-9
[**2191-1-16**] 01:00AM BLOOD Glucose-295* UreaN-19 Creat-0.6 Na-142
K-3.2* Cl-112* HCO3-21* AnGap-12
[**2191-1-29**] 02:49AM BLOOD ALT-20 AST-29 AlkPhos-236* Amylase-50
TotBili-1.9*
[**2191-1-16**] 01:00AM BLOOD ALT-133* AST-286* LD(LDH)-680*
CK(CPK)-236* AlkPhos-106 Amylase-54 TotBili-0.5
[**2191-1-16**] 01:00AM BLOOD Lipase-23
[**2191-1-16**] 01:00AM BLOOD CK-MB-10 MB Indx-4.2 cTropnT-0.02*
[**2191-2-1**] 02:31AM BLOOD Calcium-7.7* Phos-3.1 Mg-2.0
[**2191-1-16**] 04:16AM BLOOD Calcium-8.0* Phos-3.3 Mg-2.2
[**2191-1-29**] 02:49AM BLOOD TSH-2.4
[**2191-1-15**] 11:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2191-2-2**] 02:33PM BLOOD Type-ART pO2-84* pCO2-52* pH-7.42
calHCO3-35* Base XS-7
[**2191-1-16**] 12:55AM BLOOD Type-ART pO2-65* pCO2-52* pH-7.19*
calHCO3-21 Base XS--8
[**2191-2-2**] 02:33PM BLOOD Glucose-135*
[**2191-1-16**] 12:04AM BLOOD Glucose-295* Lactate-4.9* Na-139 K-3.4*
Cl-112 calHCO3-20*
[**2191-2-2**] 02:33PM BLOOD freeCa-1.08*
[**2191-1-16**] 12:55AM BLOOD freeCa-1.03*
Brief Hospital Course:
78F s/p MVC (see HPI for list of injuries). Pt admitted to
Trauma ICU, remaned intubated. Neurosurgery consulted regarding
multiple vertebral fractures, TLSO brace and C-collar
recommended. Due to increased risk, IVC filter placed by
interventional radiology [**1-19**]. ORIF Right patellar fracture,
Trach and PEG [**1-21**]. Pt advanced on tube feeds to goal. Pt with
increased stool output, c diff positive, PO flagyl then PO
Vancomycin instituted. Pt. had prolonged vent wean, chest tubes
removed Right on [**1-24**], Left [**1-26**]. Sputum culture grew Staph Aureus
coag positive, GNR, Blood Cultures grew Staph Coag negative and
gram +cocci, with appropriate antibiotics added. Pt continued to
Improve, following commands and interacting, still requiring
rehabilitation services and vent weaning expected to be
prolonged therefore pt screened for vented rehab, felt to be
ready for discherge to such on [**2190-2-2**].
Medications on Admission:
lasix, prevacid,nicoderm,synthroid, prinivil
Discharge Medications:
1. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl
Ophthalmic PRN (as needed).
2. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: Two
(2) Packet PO BID (2 times a day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Acetaminophen 160 mg/5 mL Elixir Sig: [**1-23**] PO Q4-6H (every 4
to 6 hours) as needed for temp spike.
6. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
8. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day) as needed.
9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
12. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H ()
as needed.
13. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to
6 hours) as needed.
14. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*30 Tablet(s)* Refills:*2*
16. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
17. Piperacillin-Tazobactam 4-0.5 g Recon Soln Sig: One (1)
Recon Soln Intravenous Q8H (every 8 hours).
18. Vancomycin HCl 10 g Recon Soln Sig: One (1) gm Intravenous
Q12H (every 12 hours).
19. Hydromorphone HCl 2 mg/mL Syringe Sig: One (1) Injection
Q2-4 PRN ().
20. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
once a day.
21. Vancomycin HCl 250 mg Capsule Sig: One (1) Capsule PO every
six (6) hours for 14 days: start [**2190-1-25**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
s/p Motor Vehicle Collision
C7 fracture, c spine ligamentous injury,
T 10, L2, L4, Coccyx fractures,
bilateral rib fractures with Left tension pneumothorax,
manubrium fracture,
anterior chest wall hematoma,
epidural hematoma T4-10 with cord compression at T10,
spinal stenosis at L4-L5,
Right patella fracture,
bilateral pulmonary contusion,
ARDS, Congestive Heart Failure, splenic laceration.
Discharge Condition:
stable
Discharge Instructions:
d/c to vented-rehab facility for prolonged wean. TLSO brace at
alltimes, C-collar on at all times. Please call with questions,
follow up as indicated
Followup Instructions:
Trauma Clinic 1-2 weeks after d/c (call for appointment)
Orthopedic surgery 1-2 weeks after d/c (call for appointment)
|
[
"860.0",
"E812.1",
"486",
"805.2",
"865.09",
"805.07",
"038.19",
"922.1",
"822.0",
"995.91",
"724.01",
"E849.5",
"V10.3",
"394.0",
"805.4",
"807.2",
"518.81",
"398.91",
"861.21",
"008.45",
"496",
"501",
"244.9",
"807.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"79.36",
"33.24",
"38.93",
"96.72",
"96.6",
"43.19",
"34.04",
"99.04",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
9109, 9181
|
6158, 7085
|
340, 377
|
9624, 9632
|
1490, 6135
|
9830, 9952
|
1168, 1186
|
7180, 9086
|
9202, 9603
|
7111, 7157
|
9656, 9807
|
1201, 1471
|
273, 302
|
405, 876
|
898, 1131
|
1147, 1152
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,848
| 138,286
|
29030
|
Discharge summary
|
report
|
Admission Date: [**2198-12-21**] Discharge Date: [**2199-1-1**]
Date of Birth: [**2126-1-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest Pain and Nausea
Major Surgical or Invasive Procedure:
[**2198-12-26**] - Pericardectomy with partial MAZE procedure
History of Present Illness:
72F who p/w AF in setting of pleuritic CP 5 days ago and
admitted to [**Hospital1 18**] for w/u. Of note, she is status post placement
of a permenant pacemaker 1 month prior. A TTE showed [**Hospital1 1192**]
pericardial effusion and a pericardial drain/pericardiocentesis
was performed with resolution of tamponade however she continued
to drain [**Hospital1 1192**] amounts of fluid. Given her reaccumulation of
fluid, the cardiac surgery service was consulted for surgical
management.
Past Medical History:
Tachy-brady syndrome
HTN
Rectocele
Spinal stenosis
Hypothyroid
Remote lung disease
s/p PPM 1 month ago
Social History:
Former librarian. Lives with significant other. Uses alcohol
socially. Smoked 1.5 ppd for 30 years quitting in [**2181**].
Family History:
Father died of PE at age 54.
Physical Exam:
88 123/75 178lbs 70"
GEN: NAD
SKIN: Unremarkable
HEENT: Unremarkable
LUNGS: Clear
HEART: RRR, Nl S1-S2
ABD: Soft, nontender, nondistended, NABS
EXT: Warm, well perfused, no edema, 2+ pulses, no varicosities.]
NEURO: Nonfocal
Discharge
Vitals 98.4, Afib 78, B/P 96/60, RR 20, 95% RA Sat wt 85.3kg
Neuro: alert and oriented x3 nonfocal
Pulm: lungs clear except decreased Right base (sm pleural
effusion)
Cardiac: irregular, no murmur/rub/gallop
Sternal incision: no erythema, no drainage sternum stable
Abd soft nontender, nondistended, + bowel sounds
Ext warm, pulses palpable, +1 edema
Pertinent Results:
[**2199-1-1**] 10:10AM BLOOD WBC-7.6 RBC-3.36* Hgb-10.5* Hct-32.4*
MCV-96 MCH-31.2 MCHC-32.4 RDW-13.7 Plt Ct-331
[**2198-12-21**] 09:05PM BLOOD WBC-12.2* RBC-3.72* Hgb-12.1 Hct-34.9*
MCV-94 MCH-32.5* MCHC-34.7 RDW-13.8 Plt Ct-203
[**2199-1-1**] 10:10AM BLOOD Plt Ct-331
[**2199-1-1**] 10:10AM BLOOD PT-17.8* PTT-31.5 INR(PT)-1.7*
[**2198-12-21**] 09:05PM BLOOD PT-47.3* PTT-37.6* INR(PT)-5.5*
[**2199-1-1**] 10:10AM BLOOD Glucose-154* UreaN-22* Creat-1.2* Na-141
K-4.2 Cl-101 HCO3-31 AnGap-13
[**2198-12-21**] 09:05PM BLOOD Glucose-205* UreaN-40* Creat-1.2* Na-140
K-4.3 Cl-107 HCO3-19* AnGap-18
[**2198-12-25**] 03:45AM BLOOD ALT-586* AST-119* AlkPhos-72 TotBili-0.7
[**2198-12-23**] 04:00PM BLOOD ALT-682* AST-236* AlkPhos-70 TotBili-1.0
[**2198-12-25**] 03:45AM BLOOD Albumin-3.7 Calcium-8.4 Phos-2.9 Mg-2.2
[**2198-12-23**] 04:00PM BLOOD calTIBC-290 Ferritn-240* TRF-223
[**2198-12-22**] 05:16AM BLOOD Triglyc-77 HDL-43 CHOL/HD-2.8 LDLcalc-61
[**2198-12-23**] 05:47AM BLOOD TSH-2.2
[**2198-12-23**] 05:47AM BLOOD Free T4-1.3
[**2198-12-24**] 05:44AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV
Ab-POSITIVE
CXR [**1-1**]
PA AND LATERAL VIEWS OF THE CHEST: The small left apical
pneumothorax is unchanged. A [**Month/Year (2) 1192**]-sized right pleural
effusion is stable. The cardiomediastinal contours are
unchanged, again demonstrating postoperative changes. A dual
lead left-sided cardiac pacer device is in stable position. The
appearance of the lungs are unchanged compared to [**2198-12-30**].
TEE [**12-26**]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.3 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 5.2 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.5 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.7 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.8 cm
Left Ventricle - Fractional Shortening: *0.19 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 40% to 45% (nl >=55%)
Aorta - Valve Level: 2.3 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.2 cm (nl <= 3.4 cm)
Aorta - Arch: 2.5 cm (nl <= 3.0 cm)
Aorta - Descending Thoracic: 2.3 cm (nl <= 2.5 cm)
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement. Elongated LA. Mild spontaneous
echo contrast
in the LAA. Depressed LAA emptying velocity (<0.2m/s) Cannot
exclude LAA
thrombus.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter
or pacing wire
is seen in the RA and extending into the RV. No ASD or PFO by
2D, color
Doppler or saline contrast with maneuvers. Dilated coronary
sinus (diameter
>15mm).
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D
images. Normal LV wall thickness. Normal LV cavity size. Normal
regional LV
systolic function. Mildly depressed LVEF.
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal anterior
- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid
anteroseptal -
hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal
inferior -
hypo; mid inferior - hypo; basal inferolateral - hypo; mid
inferolateral -
hypo; basal anterolateral - hypo; mid anterolateral - hypo;
anterior apex -
hypo; septal apex - hypo; inferior apex - hypo; lateral apex -
hypo; apex -
hypo;
RIGHT VENTRICLE: Mild global RV free wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in
aortic root. Normal ascending aorta diameter. Focal
calcifications in
ascending aorta. Normal aortic arch diameter. Simple atheroma in
aortic arch.
Normal descending aorta diameter. Simple atheroma in descending
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Mild to [**Month/Year (2) 1192**] ([**1-8**]+) MR.
TRICUSPID VALVE: Mild to [**Month/Day (2) 1192**] [[**1-8**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: Trivial/physiologic pericardial effusion. No
echocardiographic
signs of tamponade.
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 rhythm appears to be atrial fibrillation. The
patient has runs
of a supraventricular tachycardia. Results were personally
reviewed with the
MD caring for the patient.
Conclusions:
1. The left atrium is mildly dilated. Mild spontaneous echo
contrast is
present in the left atrial appendage. The left atrial appendage
emptying
velocity is depressed (<0.2m/s). A left atrial appendage
thrombus cannot be
completely excluded but doubt the presence of a clot..
2. No atrial septal defect or patent foramen ovale is seen by
2D, color
Doppler or saline contrast with Valsalva release.. The coronary
sinus is
dilated (diameter >15mm).
3. Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. Initial examination revealed [**Month/Day (2) 1192**] global LV
hypokinesis
that subsequently improved. Overall left ventricular systolic
function
improved to mild global hypokinesis.
4.Initial examination revealed [**Month/Day (2) 1192**] global RV hypokinesis
that
subsequently improved. Overall right ventricular systolic
function improved to
mild global hypokinesis.
5. There are simple atheromas in the aortic arch and in the
descending
thoracic aorta.
6.The aortic valve leaflets (3) appear are mildly thickened with
good leaflet
excursion. There is no aortic valve stenosis. Trace aortic
regurgitation is
seen.
7. The mitral valve leaflets are mildly thickened. At initiation
of exam, the
MR [**First Name (Titles) **] [**Last Name (Titles) 1192**] in severity. With improved LV function mild to
[**Last Name (Titles) 1192**] ([**1-8**]+)
mitral regurgitation was seen.
8. No echocardiographic evidence of pericardial effusion is
seen.
9. Bilateral pleural effusions were noted.
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2198-12-21**] via transfer
from [**Hospital6 3872**] for further workup of her EKG
changes. She was taken directly to the catheterization lab
however prior to catheterization, a large pericardial effusion
was discovered by echocardiogram. As her INR was elevated at 4.2
and her vital signs were stable, she was admitted to the CCU for
vitamin K and fresh frozen plasma. The electrophysiology service
was consulted for reprogramming of her pacemaker given her new
atrial fibrillation. Rate control was initiated with amiodarone.
On [**2198-12-22**], she was taken to the cardiac catheterization lab
where she underwent drainage of 600cc of bloody fluid and a
pigtail catheter was placed. As she continued to drain fluid and
achocardiogram revealed evidence of a recurrent pericardial
effusion, the cardiac surgical service was consulted for
surgical management. She was worked-up in the usual preoperative
manner and was taken to th eoperating room on [**2198-12-26**] where she
underwent a pericardectomy with a partial MAZE procedure.
Postoperatively she was taken to the cardiac surgical intensive
care unit for monitoring. She was weaned from sedation, awoke
neurologically intact and was extubated. She remained in atrial
fibrillation which was rate controlled with amiodarone and beta
blockade. On postoperative day one, she was transferred to the
step down unit for further recovery. As she complained of
hoarseness, the speech and swallow service was consulted.
Although she had tongue deviation to the right, her ability to
swallow was normal. She worked with physical therapy and
activity has increased. She was restarted on coumadin for
atrial fibrillation which is rate controlled. She remains
hemodynamically stable and ready for discharge to rehab on post
operative day 6.
Medications on Admission:
Atenolol
Androgel
Levoxyl
Coumadin
Cozaar
Ativan
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg twice a day for 1 week then decrease to 400mg once
a day for 1 week then decrease to 200mg once a day.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 5 days.
10. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab
Sust.Rel. Particle/Crystal PO twice a day for 5 days.
11. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day:
please give 3mg [**1-1**] and [**1-2**] - check INR [**1-3**] for further
dosing goal inr 2-2.5 .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Pericardial Effusion
Paroxysmal AF w/ cardioversions in past
HTN
Tachy-brady syndrome
Hypothyroid
PPM
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. No bathing or swimming
for 1 month. Use sunscreen on incision if exposed to sun.
5)No lifting greater then 10 pounds for 10 weeks.
6)No driving for 1 month.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) **] in 1 week after discharge from rehab
[**Telephone/Fax (1) 3658**]
Call all providers for appointments
Completed by:[**2199-1-1**]
|
[
"401.9",
"584.9",
"244.9",
"423.9",
"285.9",
"427.31",
"V45.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"34.09",
"37.31",
"37.0",
"37.33"
] |
icd9pcs
|
[
[
[]
]
] |
11056, 11201
|
7897, 9757
|
309, 373
|
11347, 11354
|
1829, 7874
|
11865, 12129
|
1173, 1203
|
9857, 11033
|
11222, 11326
|
9783, 9834
|
11378, 11842
|
1218, 1810
|
248, 271
|
401, 890
|
912, 1017
|
1033, 1157
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,360
| 128,967
|
27838
|
Discharge summary
|
report
|
Admission Date: [**2164-10-22**] Discharge Date: [**2164-10-26**]
Date of Birth: [**2095-3-26**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Aspirin / Latex / Terfenadine
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
[**2164-10-22**] Aortic Valve Replacement (23mm [**Last Name (un) 3843**]-[**Doctor Last Name **]
Pericardial Valve)
History of Present Illness:
69 yo F with known AS who developed chest discomfort inJune.
She was transferred to [**Hospital1 18**] where cardiac cath showed branch
vessel CAD and moderate AS. Echo confirmed [**Location (un) 109**] 0.8 cm.
Past Medical History:
--CHF
--AS as above
--COPD
--DM2
--HTN
--DYSLIPIDEMIA
--Colon CA s/p colectomy + chemotherapy
Social History:
50 pack yr tob hx. occasional etoh. no illicit drugs.
Family History:
- father CAD and metastatic CA
- mother breast CA age 83
- brother w/ CABG
- sister s/p aortic valve replacement
Physical Exam:
72 14 138/70
WDWN F in NAD
Warm dry no CCE, R thigh resolving area of erythema from spider
bite
NCAT PERRL anicteric sclera
OP benign edentulous
Lungs CTAB
RRR 3/6 SEM
Abd benign
No peripheral edema
Pertinent Results:
[**2164-10-26**] 06:10AM BLOOD Hct-26.1*
[**2164-10-24**] 06:30AM BLOOD WBC-12.9* RBC-3.29* Hgb-9.3* Hct-27.5*
MCV-83 MCH-28.2 MCHC-33.8 RDW-14.7 Plt Ct-147*
[**2164-10-24**] 06:30AM BLOOD Plt Ct-147*
[**2164-10-26**] 06:10AM BLOOD K-4.5
[**2164-10-24**] 06:30AM BLOOD Glucose-160* UreaN-21* Creat-0.8 Na-139
K-4.7 Cl-105 HCO3-28 AnGap-11
Brief Hospital Course:
She was taken to the operating room on [**2164-10-22**] where she
underwent an AVR with a #23 pericardial valve. She was
transferred to the SICU in critical but stable condition. She
was extubated later that same day, and She was weaned from her
vasoactive drips and transferred to the floor on POD #1. Given
that she is allergic to aspirin she was started on plavix. She
did well postoperatively, and was ready for discharge on POD #4.
Medications on Admission:
metformin, lasix, lisinopril, norvasc, toprol, lovastatin,
xanax, lantus, [**Last Name (LF) **], [**First Name3 (LF) 42298**] 3, ca, B-12, MVI
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
2. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*0*
3. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*0*
4. Lovastatin 40 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Lantus 100 unit/mL Solution Sig: One (1) 30 Subcutaneous at
bedtime.
Disp:*1 * Refills:*0*
7. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Aortic stenosis, congestive heart failure
Chronic obstructive pulmonary disorder
Hypertension
Diabetes Mellitus Type II
Hypercholesterolemia
Colon cancer s/p chemotherapy and colectomy
History of bradycardia (junctional escape) requiring temporary
pacing wire
Bilateral lumpectomy
Tubal ligation
Bilateral lens surgery
Discharge Condition:
good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use creams, lotions, or powders on wounds.
Call our office for temp>101.5, sternal drainage.
Followup Instructions:
Please see [**Doctor Last Name **] [**Last Name (Prefixes) **] (cardiac surgeon) in [**3-15**] weeks
([**Telephone/Fax (1) 11763**].
Please see [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17025**] (PCP) in [**12-12**] weeks ([**Telephone/Fax (1) 35953**].
Please see Dr. [**Last Name (STitle) **] (cardiologist) in [**12-12**] weeks.
Completed by:[**2164-10-29**]
|
[
"401.9",
"424.1",
"428.0",
"250.00",
"278.00",
"V10.05",
"V58.67",
"272.0",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"35.21",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
3004, 3059
|
1588, 2026
|
306, 425
|
3422, 3429
|
1225, 1565
|
3757, 4141
|
875, 990
|
2219, 2981
|
3080, 3401
|
2052, 2196
|
3453, 3734
|
1005, 1206
|
259, 268
|
453, 666
|
688, 785
|
801, 859
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,855
| 138,113
|
21420
|
Discharge summary
|
report
|
Admission Date: [**2182-9-25**] Discharge Date: [**2182-11-1**]
Date of Birth: [**2119-11-6**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Acute on Chronic Right Chest pain
Shortness of Breath
Major Surgical or Invasive Procedure:
radiation treatment
PICC placement
CT guided bone biopsy
History of Present Illness:
62yo male with PMHx of end stage COPD and non-small cell Lung
Cancer s/p resection in [**2177**] presents c/o 2 wks of worsening
acute on chronic right sided chest pain. Pt lives on 3L NC
oxygen at home and is also c/o has [**Month (only) **] energy, [**Month (only) **] exercise
tolerance, having trouble making it to the bathroom on time. He
complains of a significant weight loss of approx 25lbs over the
last two months. He is also c/o odynophagia, difficulty
swallowing and a sensation of "cold" burning in his throat. Pt
has developped recurrent hiccups assoc with eating. He has a
chronic cough with yellow sputum production, scant hemoptysis
that has been present for over 6mths. Pt denies fevers/chills &
bloody stool in his ileostomy. Pt denies dysuria.
Past Medical History:
1. Non-small cell lung cancer, s/p R upper lobectomy, partial R
fifth rib resection c/b chronic pain. No chemo or radiation.
2. COPD w/ severely reduced DLCO, FEV1 42%, and FEV1/FVC ratio
59%; stage= moderate IIB
3. h/o MRSA and pseudomonas PNA
4 Ulcerative colitis - s/p multiple surgeries, most recently in
late 80s. S/P total colectomy and ileostomy
5. Steroid induced hyperglycemia
6. PFO
7. h/o cardiomegaly
8. h/o depression
9. h/o hospitalization with intubation for resp. failure
Social History:
- Married, 2 daughters, lives on the [**Name (NI) **].
- Not current smoker, quit in [**2177**] w/ dx of lung cancer, 40
pack-yr history.
- Occasional EtOH use. Worked as a painting contractor, retired
after lung
cancer surgery.
Family History:
- Father died of lung cancer, age 75
- Mother died of [**Name (NI) 2481**].
- Grandfather died of bowel CA
- Denies HTN or DM
Physical Exam:
T-97.1 BP-146/70 HR-85 RR-18 Sats 97% on 3L
GEN: NAD, trembling bilateral upper/lower extremities
HEENT: NCAT, MMM, clear oropharnyx, good dentition, no LAD
Skin: pink, warm, no petecchia
HEART: RRR no m/r/g
Resp: CTAB no w/r/crackles, blowing breath sounds,
coarse/rhoncherous cough
Abd: diffusely scarred, NTTP, NABS, soft, ileostomy bag over R
mid quadrant.
Extr: wasted, warm, pink, +DP/PT pulses bilaterally
Pertinent Results:
[**2182-10-31**] 06:17AM BLOOD WBC-7.7 RBC-3.22* Hgb-9.3* Hct-29.4*
MCV-91 MCH-28.8 MCHC-31.5 RDW-16.9* Plt Ct-187
[**2182-10-25**] 11:16AM BLOOD WBC-10.5 RBC-3.16*# Hgb-9.1*# Hct-28.4*#
MCV-90 MCH-28.8 MCHC-32.0 RDW-17.2* Plt Ct-196
[**2182-10-18**] 11:35AM BLOOD WBC-9.7 RBC-3.30* Hgb-9.6* Hct-29.2*
MCV-89 MCH-29.1 MCHC-32.8 RDW-18.5* Plt Ct-253
[**2182-9-24**] 09:30PM BLOOD WBC-9.9 RBC-3.63* Hgb-9.9* Hct-30.8*
MCV-85 MCH-27.2 MCHC-32.2 RDW-17.3* Plt Ct-274
[**2182-10-31**] 06:17AM BLOOD Plt Ct-187
[**2182-9-29**] 05:02AM BLOOD Plt Ct-235
[**2182-9-29**] 05:02AM BLOOD PT-12.4 PTT-25.6 INR(PT)-1.1
[**2182-9-25**] 10:05AM BLOOD PT-63.6* PTT-39.6* INR(PT)-7.9*
[**2182-10-31**] 06:17AM BLOOD Plt Ct-187
[**2182-9-25**] 05:20PM BLOOD Inh Scr-NEG
[**2182-9-25**] 05:20PM BLOOD Fact II-20* Fact V-156* FactVII-8*
FacVIII-GREATER TH Fact IX-66 Fact X-5*
[**2182-9-25**] 05:20PM BLOOD Thrombn-21.7*
[**2182-10-29**] 05:06AM BLOOD Glucose-93 UreaN-28* Creat-1.0 Na-144
K-4.4 Cl-108 HCO3-29 AnGap-11
[**2182-10-13**] 07:43AM BLOOD Glucose-139* UreaN-21* Creat-1.1 Na-139
K-3.6 Cl-99 HCO3-31 AnGap-13
[**2182-9-24**] 09:30PM BLOOD Glucose-234* UreaN-29* Creat-1.5* Na-138
K-4.9 Cl-103 HCO3-21* AnGap-19
[**2182-10-25**] 05:29AM BLOOD ALT-6 AST-6 AlkPhos-86 TotBili-0.3
[**2182-9-25**] 01:00PM BLOOD ALT-13 AST-12 LD(LDH)-169 AlkPhos-94
TotBili-0.2
[**2182-9-25**] 10:05AM BLOOD CK(CPK)-29*
[**2182-9-30**] 04:46AM BLOOD CK-MB-4 cTropnT-0.01
[**2182-9-29**] 05:02AM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2182-9-29**] 01:08AM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2182-10-26**] 05:53AM BLOOD Calcium-8.6 Phos-4.0 Mg-1.2*
[**2182-9-24**] 09:30PM BLOOD Calcium-8.3* Phos-3.6 Mg-1.0*
[**2182-10-9**] 12:58PM BLOOD Hapto-355*
[**2182-9-25**] 05:20PM BLOOD Acetone-NEGATIVE
[**2182-10-18**] 11:35AM BLOOD Vanco-20.2*
[**2182-9-25**] 05:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2182-10-14**] 05:46PM BLOOD Type-ART pO2-66* pCO2-43 pH-7.47*
calTCO2-32* Base XS-6
[**2182-9-26**] 08:21PM BLOOD Type-ART Rates-12/ Tidal V-500 PEEP-5
FiO2-100 pO2-255* pCO2-46* pH-7.23* calTCO2-20* Base XS--8
AADO2-420 REQ O2-72 -ASSIST/CON Intubat-INTUBATED
[**2182-9-26**] 08:21PM BLOOD Glucose-259* Lactate-1.2 Na-139 K-3.9
Cl-111
[**2182-10-13**] 10:30AM BLOOD O2 Sat-50
[**2182-9-26**] 08:21PM BLOOD freeCa-1.09*
TEST RESULT EXPECTED VALUES
---- ------ ---------------
Aspergillus Ag, S 0.052 < 0.5 Index
Test
----
Fungitell (tm) Assay for (1,3)-B-D-Glucans
Results Reference Ranges
------- ----------------
188 pg/ml Negative Less than
60 pg/ml
Indeterminate 60 - 79
pg/ml
Positive Greater
than or equal to
80 pg/ml
----
Fungitell (tm) Assay for (1,3)-B-D-Glucans
Results Reference Ranges
------- ----------------
112 pg/ml Negative Less than
60 pg/ml
Indeterminate 60 - 79
pg/ml
Positive Greater
than or equal to
80 pg/ml
Test Result Reference
Range/Units
VITAMIN D, 25-OH, TOTAL 8 L 20-100 NG/ML
VITAMIN D, 25-OH, D3 8 NG/ML
VITAMIN D, 25-OH, D2 <4 NG/ML
[**2182-10-15**] 05:17AM BLOOD B-GLUCAN-Test
[**2182-10-15**] 05:17AM BLOOD B-GLUCAN-Test
UPRIGHT AP CHEST: There is no short interval change in the
appearance of the chest, or lung parenchyma in particular. There
is no evidence of edema or other new opacities. Cardiac and
mediastinal contours are stable. There is no evidence of
pneumothorax. The right PIC tip overlies the cavoatrial
junction. Calcifications in the abdomen are noted related to
chronic pancreatitis.
IMPRESSION: No short interval change in the appearance of the
chest.
MRI brain: IMPRESSION: Signal abnormality in the right temporal
lobe now demonstrates peripheral enhancement. In addition, a
small punctate area of enhancement is identified along the
midline in left posterior frontal lobe. Given the presence of
two lesions, metastatic disease is suspected. No mass or
hydrocephalus seen.
Transfusion History:
Three non-reactive transfusion at [**Hospital1 18**] (unit from [**2182-9-29**] was
[**Doctor Last Name **]-negative)
One non-reactive plasma transfusion
DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Mr. [**Known lastname **] has a new
diagnosis of Anti-K antibody. K-antigen is a member of the [**Doctor Last Name **]
blood
group systems. Anti-K antibody is clinically significant and
capable of
causing hemolytic transfusion reactions. The unit of blood Mr.
[**Known lastname **]
received on [**2182-9-29**] was K-antigen negative; thus there is no
special
concern for delayed hemolytic transfusion reaction due to a
K-antibody
interaction with that unit. Approximately 91% of ABO compatible
blood
will be K-antigen negative. A wallet card and a letter stating
the
above will be sent to the patient.
DIAGNOSIS:
FNA, 8th rib lesion: The tumor cells are positive for
cytokeratin, consistent with epithelial phenotype. Please see
cytology report (C-[**Numeric Identifier 56567**]) for diagnosis.
Clinical: 62 year old male with history of lung ca with
pathologic rib fracture.
Gross: Received are cytospin slides (C07-44856S) form cytology
for immunocytochemical studied.
FNA, 8th rib lesion:
POSITIVE FOR MALIGNANT CELLS, consistent with metastatic
non-small cell carcinoma.
ECHO - Conclusions
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is moderate to
severe regional left ventricular systolic dysfunction with near
akinesis of the distal half of the septum and anterior walls and
apex. The basal inferolateral wall contracts best and the
inferior wall is not well seen (LVEF = 20-25 %). No masses or
thrombi are seen in the left ventricle. The right ventricular
cavity is mildly dilated. There is focal hypokinesis of the
apical free wall of the right ventricle. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Extensive regional left ventricular hypokinesis c/w
multivessel CAD. Pulmonary artery systolic hypertension.
Compared with the prior study of [**2182-3-28**], regional left
ventricular systolic function is more depressed (distal
septum/anterior walls and apex c/w interim distal LAD territory
ischemia. The estimated puomonary artery systolic pressure is
similar.
CLINICAL IMPLICATIONS:
Based on [**2181**] 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.
Video swallow - IMPRESSION:
Laryngeal penetration and aspiration with thin liquid
consistency not responsive to chin tuck maneuver.
Please note that a barium swallow was subsequently attempted,
however, the patient was too dyspneic to allow the procedure to
be performed
CT HEAD WITHOUT CONTRAST: There is no intracranial hemorrhage,
edema, mass effect or shift of normally midline structures or
hydrocephalus. Density values of brain parenchyma are within
normal limits. [**Doctor Last Name **]-white matter differentiation is preserved.
The appearance of the surrounding soft tissues and osseous
structures is unchanged.
There is minimal mucosal thickening in the right maxillary
sinus.
IMPRESSION: No evidence of acute intracranial hemorrhage.
CTA chest - IMPRESSION:
1. Right eigth rib fracture with concern for pathologic fracture
secondary to malignant pleural process or soft tissue mass.
Aggressive infection causing a similar appearance is another
possibility (e.g. actinomycosis). Recommend clinical
correlation. PET- CT may be of benefit to help exclude neoplasm.
2: Secretions in airway with concern for aspiration as
described.
3: No evidence of pulmonary artery embolism.
4. Status post right upper lobe resection with persistent right
apical pleural space. Diffuse severe emphysema and extensive
bullous change.
5. Apparent CXR left mid lung pulmonary nodules likely secondary
to intervening foci of more normal parenchyma coalescing due to
architectural distortion by emphysema.
SWALLOWING ASSESSMENT:
The pt was seen with ice chips, thin liquids (cup, straw),
nectar
thick liquids (cup, straw), purees, pills whole with purees and
bites of cracker. Oral transit was grossly wfl and without oral
cavity residue. He had intermittent coughing after thin liquids
not seen after the nectar thick liquids. Laryngeal elevation
appeared timely and wfl to palpation.
SUMMARY / IMPRESSION:
The pt does have excess secretions s/p extubation, but appears
able to return to the previous diet of nectar thick liquids and
soft consistency solids. His understanding of the need for
nectar
thick liquids is limited, but he did not recognize the
difference
when I gave it to him without stating it was thicker and I do
expect he will drink adequate amounts. He can take pills with
purees.
This swallowing pattern correlates to a Dysphagia Outcome
Severity Scale (DOSS) rating of 5, mild dysphagia.
RECOMMENDATIONS:
1. Suggest a PO diet of nectar thick liquids and soft
consistency
solids.
2. Pills whole with purees.
3. Assistance during meals for feeding.
4. We will f/u Wed to determine if he might be able to be
advanced as his respiratory status improves, but noted he
reports
difficulty at baseline and he might not be able to be advanced.
These recommendations were shared with the patient, nurse and
medical team.
Brief Hospital Course:
# Resp distress/Hypoxia Ventilator associated pneumonia: On Hosp
Day 2, pt reported having a mechanical fall impacting his right
shoulder/chest wall and head on the edge of his bed. There was
no evidence of bruise, hematoma or MS changes in am. Non
contrast head CT was attempted and pt was unable to lie flat due
to respiratory distress and anxiety. Pt came back to the floor
and was noted by nursing to be having mental status changes and
increasing respiratory distress. Pt was placed on a
non-rebreather and sats were between 73-90%, coarse breath
sounds noted throughout lung fields, pt was diaphoretic,
somnolent and having trouble clearing secretions. Pt was
transferred to the MICU for respiratory distress and mental
status changes. IN MICU, he was intubated on [**2182-9-27**] and sputum
cx subsequently grew MRSA and pseudomonas. He was treated with
Cefepime and Vancomycin. For COPD flare, he was started on a
steroid taper. He continued to have copious secretions failing
extubation X 1 secondary to thick secretions. His coverage was
broadened empirically to double cover for pseudomonas with
meropenam and then amikacin. Amikacin from [**Date range (1) 56568**]. On
[**10-5**], he was extubated and did well. He will need 3 weeks of
Vanc and cefepime total. He has completed the course of
antibiotics at discharge.
Likely some aspiration as well and patient to maintain
aspiration precautions. refer to video swallow and the swallow
evaluation as above.
# Lung cancer - seen by oncology but given many co-morbidities
and patient denial for any other treatment specific to the
cancer - no oncology treatment was offered. XRT as below. The
patient has an overall poor prognosis.
# COPD/Emphysema: Course as above. End stage disease with
emphysematous changes, chronically on 3L NC. He continued his
home regimen of Fluticasone, Montelukast, Albuterol, Tiotropium
& Prednisone. He will need O2 and intermittent suction as
needed.
# Coagulopathy: On admission, INR significantly elevated at 7.2,
PTT at 63.9. Lab has been repeated x 2. Subsequently, all of
his vitamin K dependent factors were low. His INR normalized
after receiving PO and SC Vitamin K 10mg.
# Right sided chest pain: Has worsening pleuritic right sided
chest pain, CT showed fracture with adjacent pleural reaction
and adjacent periosteal reaction. Likely a pathological
fracture given hx of non-small cell lung Ca & signif wt loss.
Palliative care consult to assist with pain management, and he
was well pain controlled with methadone and PRN dilaudid. Rad
onc consulted and patient was given palliative XRT for pain.
Bone biopsy was done and results as above.
# Acute Renal Failure: BUN/creatinine ratio was elevated on adm,
this is was pre-renal due to poor po intake. This improved
rapidly with fluids.
# Acute systolic heart failure - transiently in ICU and resolved
at discharge.
# Diabetes: h/o steroid induced DM, no risk of DKA as he has
endogenous insulin production. Pt is very malnourished and would
really like a regular diet while inpatient. Given poor appetite,
the sugars were fluctuating and will need to be monitored at
rehab with dose of insulin adjusted.
# Anemia: close to baseline, no acute GI bleed. Developed
antibodies as above with transfusion.
# Depression: On paroxetine. Likely related to his overall
health.
Has a picc line for access.
MRSA precautions.
DNR/DNI form in chart.
PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Hospital3 4298**] MD [**Telephone/Fax (1) 56569**])
Medications on Admission:
Paroxetine HCl 20 mg PO daily
Pantoprazole 40 mg PO bid
Prednisone 10 mg PO DAILY
Docusate Sodium 100 mg PO bid
Zolpidem 5 mg PO HS prn
Acetaminophen 650mg q6h prn
Tiotropium Bromide inh once daily
Methadone 20 mg PO TID prn pain control
Glipizide 5 mg PO BID
Singulair 10 mg PO once a day
DuoNeb q6h PRN
Advair Diskus 500-50 mcg/Dose Disk [**Hospital1 **]
.
Discharge Medications:
1. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed for cough.
7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for constipation.
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
11. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q4H (every 4 hours) as needed for shortness of
breath or wheezing.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
13. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
14. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
15. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
16. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
17. Oxycodone 5 mg Tablet Sig: 20-30 mg PO Q4H (every 4 hours)
as needed for pain.
18. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
19. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
20. Methadone 5 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
21. Methadone 10 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
22. Methadone 10 mg Tablet Sig: One (1) Tablet PO NOON (At
Noon).
23. Insulin Glargine 100 unit/mL Solution Sig: Four (4) units
Subcutaneous at bedtime.
24. Humalog sliding scale as attached
25. HYDROmorphone (Dilaudid) 2-4 mg IV Q4H:PRN pain
hold for sedation or RR<12
Discharge Disposition:
Extended Care
Facility:
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**] Hospital
Discharge Diagnosis:
MRSA and Pseudomonas Pneumonia, hypoxemia
Ventilator associated pneumonia, MRSA
Delirium
Metastatic lung cancer, bone metastases, rib fracture
Diagnosis of Anti-K antibody after transfusion
COPD, history of Diabetes mellitus type 2
Depression
History of Ulcerative colitis s/p colectomy and ileostomy
Discharge Condition:
Fair. Discharged to hospice level care
Discharge Instructions:
You were treated for pneumonia, lung cancer (radiation
treatment). You still require some oxygen and nebulizer
treatment.
The physicians at rehab will care for your further needs. Please
inform them if you hav any new complaints or pain.
Followup Instructions:
The physicians at rehab will care for the patient's further
needs.
If any questions occur regarding the radiation treatment - you
can call Dr [**Last Name (STitle) 3929**] at [**Telephone/Fax (3) 56570**].
|
[
"428.21",
"733.19",
"E932.0",
"311",
"518.81",
"482.1",
"198.3",
"491.21",
"799.02",
"428.0",
"584.9",
"V09.0",
"V10.11",
"285.9",
"293.0",
"251.8",
"198.5",
"286.9",
"482.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"77.41",
"92.29",
"96.6",
"96.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
18989, 19092
|
12750, 16289
|
326, 385
|
19437, 19478
|
2538, 9631
|
19766, 19976
|
1963, 2090
|
16699, 18966
|
19113, 19416
|
16315, 16676
|
19502, 19743
|
2105, 2519
|
9654, 12727
|
233, 288
|
413, 1184
|
1206, 1698
|
1714, 1947
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,855
| 116,641
|
28091
|
Discharge summary
|
report
|
Admission Date: [**2151-12-15**] Discharge Date: [**2151-12-17**]
Date of Birth: [**2131-9-1**] Sex: F
Service: MEDICINE
Allergies:
Haldol / Morphine / Percocet / Dilaudid / Demerol
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Status asthmaticus, vocal cord dysfunction
Major Surgical or Invasive Procedure:
None
History of Present Illness:
20F h/o asthma and vocal cord dysfunction admitted in status
asthmaticus in the setting of 3 days URI symptoms. She was most
recently discharged [**2151-11-24**] after a similar asthma exacerbation.
Three days prior to presentation, she completed the prednisone
taper from that previous admission. On that same day, she
developed increased symptoms including cough, chest tightness,
and wheezing.
On ROS, she denies fevers, chills, sweats, chest pain although
does feel tightness. Frequent coughing with scant sputum
production. At home has been taking advair, combivent inhaler,
[**Doctor First Name 130**], and singulair. Today she took duonebs x3 due to
worsening of symptoms and presented to PCP for visit given her
shortness of breath. In the office was minimally wheezy but
congested and reported ambulatory stridor; peak flow was 240.
She was sent to the ED for evaluation, but decided to go to her
dorm first where she became more short of breath and notified
campus police who called EMS.
In the ED initial vitals: 99.2, 128, 138/87, 21, 99% on RA. Exam
wheezy, tachycardic, tachypnic. Given ativan, nebs, solumedrol
with no significant improvement so started on heliox which led
to subjective improvement but once removed she developed
coughing fits and subjective shortness of breath. Admitted to
the ICU for ongoing care.
Past Medical History:
Depression
Anxiety
Paradoxical vocal cord motion (diagnosed per ENT fiberoptic exam
[**10/2150**]; repeat exam by MEEI physician [**2151**] told she did not have
vocal cord problems)
Asthma - Patient had been treated for asthma since [**2148**], with
home medications including prednisone, albuterol,ipratropium,
montelukast, and fluticasone. Additionally, pt had been
hospitalized with "asthma flares" requiring intubation (3x, last
[**10-24**]) - PFTs have been normal multiple times.
Social History:
She is a nursing student at [**University/College **]. She lives in a
dorm. She denies tobacco, alcohol, and other illicit drugs.
Family History:
# Brother: Seasonal allergies
# Father died of MI in his 40s
Physical Exam:
T 97.6 HR 116 BP 131/47 RR 19 SaO2 100%
General: Speaking in full sentences, no acc muscle use, appears
in mild respiratory distress
HEENT: PERRL, EOMi, anicteric sclera, conjunctivae pink
Neck: supple, trachea midline, no thyromegaly or masses, no LAD,
no stridor
Cardiac: RRR, s1s2 normal, no m/r/g, no JVD
Pulmonary: +Tachypnea, +intermittent dry cough, scattered exp
wheezes, poor air movement, no stridor
Abdomen: +BS, soft, nontender, nondistended, no HSM
Extremities: warm, 2+ DP pulses, no edema
Neuro: A&Ox3, speech clear and logical, CNII-XII intact, moves
all extremities
Pertinent Results:
Admission Labs:
WBC-10.2 RBC-4.84 Hgb-13.5 Hct-39.1 MCV-81* MCH-28.0 MCHC-34.6
RDW-14.3 Plt Ct-315
Neuts-66.0 Lymphs-28.9 Monos-3.7 Eos-0.9 Baso-0.5
Glucose-104 UreaN-14 Creat-1.0 Na-140 K-3.7 Cl-102 HCO3-20*
Glucose-143* Lactate-4.2* Na-143 K-3.7 Cl-100
freeCa-1.12
[**2151-12-15**] CXR: IMPRESSION: No acute intrathoracic process.
Brief Hospital Course:
20F h/o asthma and vocal cord dysfunction admitted with
respiratory distress, likely secondary to status asthmaticus and
vocal cord dysfunction.
# Status asthmaticus - The patient presented in status
asthmaticus in the setting of a URI, finishing a recent
prednisone taper, and recent colder weather. The patient was
continued on oral steroids, 60mg po daily. Heliox was
discontinued upon patient arrival to the ICU. She was initially
on continuous albuterol nebulizer treatments, and her lung exam
rapidly improved, though she continued to have intermittent
coughing fits. The morning after admission, she was breathing
comfortably on RA with normal oxygen saturation and a clear lung
exam. She was transitioned to prn xopenex nebulizer treatments
and continued on her home regimen. She was given a 5 day course
of oral azithromycin as well given the initial severity of her
symptoms. She was discharged to home to complete a prednisone
taper and to continue her home regimen. She will have close
follow-up with her primary care physician.
# Vocal cord dysfunction - given initial concerns for stridor,
rapid resolution of her symptoms, and known past history, VCD
was thought to be a contributing factor for this flare. This
diagnosis was discussed with [**Known firstname **], and we discussed techniques
for managing her VCD. She was given low dose lorazepam with
good effect. She was discharged to home with a limited amount of
ativan to be used as needed.
# Depression - Her home Lamictal was continued. No active
issues during this admission.
# Anemia ?????? Hct 34 with a slightly low MCV. Stable from previous
admission.
Medications on Admission:
ALBUTEROL Nebulization Q4H prn shortness of breath or wheezing
CROMOLYN - 800 mcg Aerosol - 3 puffs INH 20 min before exercise
[**Doctor First Name **]-D 24 HOUR - 240 mg-180 mg SR 24 hr - 1 tab PO qam
ADVAIR DISKUS - 250 mcg-50 mcg - 1 INH [**Hospital1 **]
COMBIVENT inh Q4H prn
LAMICTAL 100 mg PO QHS
SINGULAIR 10 mg PO daily
PANTOPRAZOLE 40 mg PO daily
MULTIVITAMIN daily
Discharge Medications:
1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*90 Capsule(s)* Refills:*0*
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Azithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
8. Prednisone 10 mg Tablet Sig: as prescribed Tablet PO once a
day for 2 weeks: Please take 40 mg for 3 days, then 30 mg for 3
days, then 20 mg for 3 days, then 10 mg for 3 days, then 5 mg
for 3 days then stop.
Disp:*32 Tablet(s)* Refills:*0*
9. Xopenex HFA 45 mcg/Actuation HFA Aerosol Inhaler Sig: [**2-17**]
Inhalation every 4-6 hours as needed for 3 days.
Disp:*1 inhaler* Refills:*0*
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for Stridor for 5 doses.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Asthma exacerbation
Secondary Diagnoses:
1. Vocal chord dysfunction
2. Anxiety
3. Depression
Discharge Condition:
Stable, satting well on room air, breathing comfortably
Discharge Instructions:
You were admitted to the hospital for shortness of breath and an
asthma exacerbation. You were treated with steroids and
frequent nebulizer treatments and your symptoms improved.
Please take the prednisone taper as prescribed below as well as
the antibiotic azithromycin for the next 3 days. You have also
been given a few lorazepam pills to use if you are having upper
vocal chord dysfunction with upper airway stridor.
Please follow-up with your physicians as below.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 30764**], MD Phone:[**Telephone/Fax (1) 9316**]
Date/Time:[**2151-12-29**] 4:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2152-1-7**] 11:20
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2152-2-7**] 11:40
|
[
"493.91",
"300.4",
"079.99",
"465.9",
"786.59",
"285.9",
"478.5"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6758, 6764
|
3439, 5086
|
354, 360
|
6921, 6979
|
3081, 3081
|
7500, 7923
|
2399, 2461
|
5512, 6735
|
6785, 6785
|
5112, 5489
|
7003, 7477
|
2476, 3062
|
6846, 6900
|
272, 316
|
388, 1725
|
3097, 3416
|
6804, 6825
|
1747, 2235
|
2251, 2383
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,976
| 188,724
|
10361
|
Discharge summary
|
report
|
Admission Date: [**2201-3-24**] Discharge Date: [**2201-3-31**]
Date of Birth: [**2126-2-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Dehydration, anion gap metabolic acidosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 75 y.o. male with past medical history of coronary
artery disease s/p CABG, pacemaker placement, ? of cirrhosis,
and EtOH abuse who presented on [**2201-3-24**] with four or five days
of nausea/vomiting, malaise, and poor PO intake. He denied any
bloody emesis, hematochezia/melena, or diarrhea and was still
passing normal bowel movements and flatus. He reported that his
nausea wasn't constant but seemed to be increasing in frequency
and severity over the days just prior to presentation. He
reports abdominal pain was a minimal portion of this syndrome.
He reported some occasional right sided, non-radiating,
non-exertional chest pain that had been going on about a month.
In the ED, VS:T98.3 HR94 BP120/96 RR 20 98%RA. Given his
history of alcohol abuse he received thiamine, folate, K, and
NS, as well as D50 followed by NS, prochlorperazine, and
ondansetron for nausea. He continued to have non-bloody and
non-bilious but profuse emesis despite antiemetics. He
continued to vomit profusely while in the ED. Labs revealed an
elevated lactate at 2.9 and an anion gap metabolic acidosis with
HCO3 of 10. VBG with pH of 7.19, HCT 32, Tn 0.03. He was
transferred to medicine for further management. On arrival to
the floor the patient was more comfortable and vomiting less,
however, ABG showed a pH of 7.15. Given concern about the
possible dangers of this acidemia and presumed need for closer
cardiac monitoring he was transferred to the MICU.
Past Medical History:
-Coronary artery disease status post coronary artery bypass
graft in [**2197**]
-Hypercholesterolemia
-Hypertension
-Status post pacemaker placement
-Depression
-Gastroesophageal Reflux Disease
-Chronic anemia with pancytopenia
-Alcohol abuse
-History of asthma
-History of allergic rhinitis
-Status post tonsillectomy
<br>
<b><u>HOME MEDICATIONS</b></u>
-Sertraline
-Atorvastatin
-MVI
Social History:
History is significant for 10 years of smoking that ended
greater than 40 years ago (stopped at age 31). He continues to
abuse alcohol and drinks 2-4 shots/night, but he denies any
history of alcohol withdrawal or seizures. No illicit drug use.
He is separated from his wife but continues to see her
regularly and wants her informed of his condition.
Family History:
His parents both died in their 80's of malignancies.
Physical Exam:
VS: T 97.6, P 88, BP 121/61, RR 19, O2 95% on RA
Gen: Chronically ill appearing elderly man in NAD
HEENT: Normocephalic, anicteric, OP benign, poor dentition, MMM
Neck: No masses or lymphadenopathy, no thyroid nodules
appreciated
CV: RRR, no M/R/G; there is no jugular venous distension
appreciated; pacemaker in left upper chest with round nodule
superior and lateral to it
Pulm: Breathing appears unlabored and speaking in complete
sentences, expansion equal bilaterally, diffuse wheezes on
auscultation particularly at bases
Abd: Soft, NT, ND, BS+, no organomegaly or masses appreciated,
no fluid wave appreciated
Extrem: Warm and well perfused, no C/C/E, 1+ PT and DP pulses
bilaterally
Neuro: A and O*3
Psych: Pleasant, cooperative
Pertinent Results:
LABORATORY RESULTS
===================
On Presentation:
WBC-6.0 RBC-3.20* Hgb-10.6* Hct-32.0* MCV-100* RDW-13.3 Plt
Ct-172#
----Neuts-88.9* Lymphs-7.3* Monos-3.3 Eos-0.1 Baso-0.4
PT-13.4 PTT-25.2 INR(PT)-1.1
Glucose-40* UreaN-24* Creat-1.3* Na-141 K-4.7 Cl-101 HCO3-10*
AnGap-35*
ALT-22 AST-71* CK(CPK)-18* AlkPhos-123* TotBili-0.8
Calcium-7.2* Phos-3.4 Mg-1.6
Ethanol-53*
ALT-22 AST-71* CK(CPK)-18* AlkPhos-123* TotBili-0.8
On Discharge:
Hct-28.2*
PT-14.6* PTT-25.9 INR(PT)-1.3*
Glucose-121* UreaN-14 Creat-1.2 Na-140 K-4.4 Cl-112* HCO3-12*
Other Studies:
CK(CPK): 18-24*
CK-MB: NotDone-NotDone
cTropnT: 0.03*-0.03*
MICROBIOLOGY
============
Stool Culture [**2201-3-27**]:
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2201-3-28**]):
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
OTHER STUDIES
================
Right Upper Quadrant U/S [**2201-3-25**]:
IMPRESSION: Somewhat limited evaluation. Liver appears
echogenic, a finding which can be seen in fatty infiltration.
More advanced forms of liver disease, such as cirrhosis or
fibrosis cannot be completely excluded. Gallbladder is
contracted and filled with stones.
Chest Radiograph [**2201-3-28**]:
IMPRESSION:
New patchy opacity at right base of uncertain significance -- ?
new
atelectasis versus early infiltrate versus differences in
appearance due to
change in positioning. If clinically indicated, a lateral view
may help to
further assess this finding.
ECG [**2201-3-24**]: Sinus rhythm. Left atrial abnormality and
occasional ventricular ectopy. Right bundle-branch block. Left
anterior fascicular block. Probable prior inferior myocardial
infarction. Compared to the previous tracing of [**2199-10-7**]
ventricular ectopy has appeared. Otherwise, no diagnostic
interim change.
Brief Hospital Course:
This is a 75 year old male with past medical history of coronary
artery disease status post CABG, EtOH abuse, hypertension,
hyperlipidemia, and pacemaker placement who presented with
probable viral gastroenteritis causing nausea, vomiting, and
dehydration with hospital course complicated by C difficile
colitis and pneumonia.
1) Anion-Gap Metabolic Acidosis: The patient presented with an
anion gap metabolic acidosis in the context of poor PO intake
and significant vomiting. Given elevated lactic acid and
improvement with IVF this was presumed due to dehydration in the
patient's GI complaints and poor PO intake. This had resolved
by transfer to the floor and did not recur.
2) Nausea/Vomiting: Given lack of any localizing signs of acute
bacterial infection and lack of abdominal pain or other symptoms
as well as lack of diarrhea on presentation this was thought
most likely to be consistent with a rather severe case of viral
gastroenteritis with dehydration exacerbated by the patient's
generally poor self care and deconditioning. As he had some
right sided abdominal pain at presentation he also had an
ultrasound of this area, which showed no choleycystitis. The
patient's symptoms improved with anti-emetics and he had less
vomiting but he remained somewhat reluctant to eat out of fear
of nausea. He then developed C difficile colitis with frank
diarrhea and had some worsening of his baseline nausea on PO
metronidazole therapy. Prior to discharge (on [**2201-3-31**]) he was
switched to PO vancomycin given his persistent severe diarrhea
and the patient's ICU stay suggesting he met criteria for severe
disease and thus vancomycin might be the preferred [**Doctor Last Name 360**].
3) Dehydration: The patient was considerably dehydrated at
presentation, presumably due to his vomiting nausea causing
extremely poor PO intake in the context of baseline poor
nutrition and poor self care. This improved with IV fluids as
well as the patient's general symptoms. Given the patient's
continued poor PO intake and nausea he continued to require IV
fluid through the time of discharge to prevent dehydration and
hypotension.
4) Acute Kidney Injury: His creatinine was elevated at 1.3 at
presentation but had fallen back to 1.1-1.2, which is within
this patient's normal range, by time of transfer back to the
floor. This was thought to be consistent with prerenal injury
secondary to dehydration/hypovolemia.
5) Hypoglycemia: Initial blood glucose of 40 at presentation.
This was thought likely secondary to poor PO intake and alcohol
use. This resolved with dextrose and never recurred.
6) Clostridium Difficile Colitis: The patient did not have
diarrhea or abdominal pain at presentation and had no history of
antibiotic treatment. Therefore, there were no major risk
factors for C. difficile colitis and this was not checked. When
he developed diarrhea on [**2201-3-27**], however, the decision was made
to check for C difficile colitis as he was post-ICU stay. He
remained afebrile and without abdominal pain. When this assay
returned positive he was started on metronidazole on [**2201-3-28**]. He
was switched to PO vancomycin on [**2201-3-31**] given persistent nausea
and concern this could be associated with metronidazole. He
will need to take this medication for at least seven days after
discontinuation of levofloxacin for pneumonia.
7) Asthma: The patient has a history of asthma and had
persistent issues with wheezing though he was never hypoxic on
room air. This was responsive to bronchodilators. He may
ultimately need combined inhaled corticosteroid therapy or more
aggressive regimen in the long term but this was not initiated
during his acute illness and in the context of possible
pneumonia.
6) Delirium: The patient developed delirium on [**2201-3-27**] in the
context of recent transfer to the floor and dehydration. He
went from alert and oriented *3 to alert and oriented *1. He
had a history of delirium and is probably predisposed to this
due to chronic EtOH toxicity on the brain and age. Dehydration
and a possible pneumonia may have also contributed to his
general appearance of toxic-metabolic delirium. This resolved
after approximately two days and he remained at baseline mental
status.
7) Pneumonia: The patient's chest radiograph was benign at
presentation but as of [**2201-3-28**] had developed a questionable
infiltrate. He remained afebrile at that time and really had no
cough or other typical symptoms of pneumonia, but given his
delirium this was treated as there was concern an infection
could be contributing to his delirium. Possibly, the patient
had a pneumonia at presentation and this simply became more
visible on chest radiograph after hydration. He will need a
total of ten days of levofloxacin therapy. This was initially
PO but switched to IV prior to discharge given the patient's
poor PO intake and concern of malabsorption.
8) ETOH: ETOH level was 53 on presentation and the patient
continued to report last drink on the evening of [**3-23**]. He has
no history of complicated withdrawal and never showed clear
signs of alcohol withdrawal. The patient's CIWA scale was
discontinued on [**2201-3-27**] as he had been having minimal scores on
CIWA. The patient was seen by social work to discuss his
alcohol use.
9) Decubitus ulcer: The patient was incidentally noted to have a
decubitus ulcer on presentation to the CCU. This was presumably
due to his minimal mobility at home and presumably somewhat to
his poor nutrition. There was never considerable erythema
around this or frank purulence. Good wound care was instituted
and nutrition consult offered supplement suggestions that were
implemented to help healing.
10) General Deconditioning: The patient was noted to be very
weak and on examination by the PT service and was considered
unsafe to return home unsupervised. Acute rehab was recommended
and the patient was initially reluctant to go to rehab but then
agreed to go.
11) Anemia/Thrombocytopenia: This is chronic and he has
previously undergone bone marrow biopsy, which showed
hypocellularity but no strict dyserythropoesis. This is most
likely due to chronic myelosuppresion due to his alcohol use.
His anemia and thrombocytopenia remained stable throughout his
hospitalization. Haptoglobin was normal and no schistocytes on
smear.
Prior to discharge the patient was tolerating very little PO but
was intermittently consuming a low residue diet without event.
He received SC heparin for DVT prophylaxis. He was continued on
his home H2 blocker for GI ppx. He was full code. His HCP was
his separated wife, Mrs [**Name (NI) **] [**Name (NI) 653**] at [**Telephone/Fax (1) 34376**] or
[**Telephone/Fax (1) 34377**].
Medications on Admission:
-Setraline
-Atorvastatin
-MVI
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day): Use until patient is
ambulating TID.
4. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) puff Inhalation Q2H (every 2 hours) as
needed for wheezing.
10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Vitamin A 10,000 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily) for 7 days.
12. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
13. Levofloxacin 25 mg/mL Solution Sig: Seven [**Age over 90 1230**]y
(750) mg Intravenous Q48hours for 6 days: Last day of treatment
on [**2201-4-6**].
14. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 14 days: Last dose on [**2201-4-13**].
15. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea.
16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehab
Discharge Diagnosis:
Probable viral gastroenteritis
Dehydration
Pneumonia
Clostridium Difficile Colitis
Stage 4 decubitus ulcer
Discharge Condition:
With wheezes on auscultation bilaterally, 93-95% at rest on room
air, very weak and requiring help with turning or ambulation
Discharge Instructions:
You were admitted because you had what was probably a viral
infection of your digestive tract that caused your vomiting and
nausea. This led you to have problems eating and get
dehydrated. We gave you IV fluids, which helped you feel
better. While in the hospital, we also discovered you had an
infection of your lungs for which we gave you antibiotics. You
also had an infection of your colon for which you received
antibiotics. Finally, we were concerned about how weak you were
in the hospital so you were discharged to a rehabilitation
facility to work on your strength and help care for your ulcer.
Your medications have been changed. You have been started on
LEVOFLOXACIN and METRONIDAZOLE to treat pneumonia and C.
difficile colitis respectively. Please take all your
medications as presecribed.
Please return to your local ED or call your doctor if you have
chest pain, shortness of breath, inability to tolerate food by
mouth, or any other concerning changes in your health.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] about 1-2 weeks after being
discharged from rehab. Office number [**Telephone/Fax (1) 30837**].
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,727
| 103,928
|
53384
|
Discharge summary
|
report
|
Admission Date: [**2153-9-18**] Discharge Date: [**2153-10-4**]
Date of Birth: [**2079-3-29**] Sex: M
Service: MEDICINE
Allergies:
Percocet / Codeine / Demerol / Nafcillin
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Cellulitis, troponin leak
Major Surgical or Invasive Procedure:
Bedside debridement of eschar on right foot
History of Present Illness:
74 yo M with MM including PVD, DM, HTN, CAD, CRI transferred
from NWH for cellulitis/LE pain because pt's podiatric surgeon
is at [**Hospital1 18**]. Initally presented to NWH because of increasing
right foot pain and redness. At NWH, found to have EKG changes
with STD in V2-V4, though patient was asymptomatic and said he
never had chest pain. Unclear if he received abx from there per
records available. Patient was transferred here for further
management.
.
Of note, patient was recently hospitalized [**Date range (1) 91344**] in the ICU
at NWH when he was found at home unresponsive - was hypoglycemic
and in ARF. Patient states he does not remember 'anything' about
that hospital stay, the medications he was on or any events that
occurred then. Per report, he was discharged on lovenox for DVT
but when NWH ED was [**Name (NI) 653**], records there indicated that he
was started on Lovenox ppx because he was immobile and was
supposed to continue taking it until he was able to consistently
walk >100 feet. Unclear if patient has been administering the
lovenox himself as he stated that he no longer gives himself
insulin because 'it's just too complicated'.
.
On past hospitalization at NWH, also had a troponin has high as
8.8 thought be due to demand ischemia in the setting of
hypoglycemia. During that admission, he never had chest pain and
a stable percent MB fraction at 0.7. He was started on aspirin,
beta blocker and statin. An ACEi was held due to intolerance in
the past.
.
In the ED here VS: AF, hr:67, bp:130/70, rr:16 98% on RA.
Received fentanyl for pain, cards and vascular were c/s. Blood
cx were drawn. Vascular recommended vanc/zosyn given their
concern for osteo which he received. He received 50mg iv
fentanyl for pain.
.
Upon transfer to the floor, patient c/o of persistent right foot
pain. Denies fever or chills, CP, SOB, N/V/D, constipation, HA
or vision changes.
.
The patient is not a competent historian. On review of systems,
he denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. He denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems per HPI.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia, (+)HTN
2. CARDIAC HISTORY:
-CABG: [**2137**] LIMA->LAD. SVG->dRCA and SVG->D1/OM.
-PERCUTANEOUS CORONARY INTERVENTIONS: [**2150**] (no report
available), [**2147**]: 3VD, patent LIMA-->LAD, patnet SVG--> dRCA and
D1/OM, severe native vessel disease
.
-PACING/ICD: None
.
3. OTHER PAST MEDICAL HISTORY: Per OMR notes, patient states he
does not know his full medical history
PVD
CAD s/p MI in '[**49**]
HTN
Hyperlipidemia
DM2 on Insulin
Diastolic CHF
CRI (baseline 1.8-2)
h/o GI bleed
Bladder carcinoma
Cervical stenosis
Anemia
Gastroparesis
.
PAST SURGICAL HISTORY:
- Debridement of osteomyelitis with L. 5th metatarsal head
resection [**2153-4-19**]
- L CFA to BK [**Doctor Last Name **] bypass with left arm vein [**9-27**]
- L4-5 laminectomies bilat w/ resection of large disk herniation
[**4-24**]
- R 2nd second toe amp [**5-24**]
- R CFA to AK [**Doctor Last Name **] bypass using [**Doctor Last Name 4726**]-Tex [**4-23**]
- L CEA [**2-/2140**], 4 vessel CABG [**1-/2138**]
- Aorta-bifemoral bypass at NWH in [**2147**]?
Social History:
HISTORY: Unwilling to give. Per prior records, married twice,
but recently separated. He has two children. H/o EtOH abuse in
AA 35 yrs; tobacco 45 pack year history
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T=97.9 BP=140/60 HR=72 RR=20 O2 sat=93 on 2L%
GENERAL: elderly male lying in bed. Oriented x3. Mood
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. dry mmm. Poor
dentition
NECK: Supple. No JVD.
CARDIAC: RRR. s1/s2. III/VI systolic murmur heard best at LLSB.
LUNGS: clear anteriorly. patient unwilling to fully sit up for
posterior thorax exam, so limited. Heard scattered wheezes and
crackles at bases posteriorly.
ABDOMEN: Soft, NTND. +bs
EXTREMITIES: chronic venous statis changes bilaterlly. warm to
touch, DP pulses dopplerable.
RLE: 2 eshcars - one on medial aspect of foot and one on plantar
aspect of foot. Area of erythema on anterior/medial aspect of
foot with increased warmth. ?collection under foot?
SKIN: as above
Pertinent Results:
Admission laboratories:
COMPLETE BLOOD COUNT ([**9-18**]) WBC: 9.2 RBC: 3.45* Hgb: 8.3*#
Hct:27.6* MCV:80* MCH:23.9* MCHC:30.0* RDW:24.4* Plt Ct: 300
DIFFERENTIAL Neuts 87.1* Bands Lymphs 6.3* Monos 4.8 Eos 1.4
Baso 0.5
[**2153-9-18**] 07:01PM
BASIC COAGULATION (PT, PTT, PLT, INR) PT 15.0*PTT 41.8*Plt Ct
INR(PT)1.3*
Chemistry
RENAL & GLUCOSE Glucose 278* UreaN 69* Creat 2.0* Na 132* K 4.6
Cl 98 HCO3 22
EKG ([**9-20**]): Sinus rhythm. Right axis deviation. Incomplete right
bundle branch block. One to two millimeter downsloping ST
segment depression in the anterior leads extending from leads
V3-V6. Consider myocardial ischemia. Compared to the previous
tracing of [**2153-9-19**] the ST-T wave changes are pretty similar
except that the lead placement is slightly different.
Rate PR QRS QT/QTc P QRS T
72 126 114 440/461 71 121 113
WOUND CULTURE (Final [**2153-9-25**]):
KLEBSIELLA OXYTOCA. SPARSE GROWTH.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Please contact the Microbiology Laboratory ([**6-/2450**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA OXYTOCA
| STAPH AUREUS COAG +
| |
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- 8 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=1 S <=0.5 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
OXACILLIN------------- =>4 R
PIPERACILLIN/TAZO----- <=4 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=0.5 S
VANCOMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2153-9-24**]): NO ANAEROBES ISOLATED.
Imaging:
Xray of right foot ([**9-19**]):
IMPRESSION:
1. Erosive bony destructions at the first distal phalanx and at
the stump of the second proximal phalanx consistent with
osteomyelitis.
2. Severe degenerative changes in the tarsometatarsal joints and
fracture at the 3rd metatarsal, suggesting early Charcot joint
disease.
3. Significant small vessel disease.
2D-ECHOCARDIOGRAM ([**9-20**]): The left atrium is mildly dilated.
The right atrium is markedly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). There is no left ventricular outflow
obstruction at rest or with Valsalva. The right ventricular
cavity is markedly dilated with moderate global free wall
hypokinesis. There is abnormal septal motion/position consistent
with right ventricular pressure/volume overload. The ascending
aorta is moderately dilated. The aortic valve leaflets (3) are
mildly thickened. There is mild aortic valve stenosis (valve
area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**12-22**]+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. There is severe
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2151-12-16**],
the detected pulmonary hypertension has increased. There is no
change in the left ventricular systolic function.
ETT:
[**4-/2151**]:
This 72 yo man with IDDM, mild AS s/p multiple cadiac
interventions was referred to the lab for evaluation as a part
of the Spinal Cord Stimulation study. The patient exercised for
2.5 minutes on a modified [**Doctor First Name **] protocol and stopped due a
marked drop in systolic
blood pressure. This represents a very limited exercise
tolerance for
his age. The patient denied any neck, chest, arm or back
discomfort
throughout the study. In the setting of baseline abnormalities,
an
additional 0.5mm of ST segment depression was noted in V4-V5 at
peak
exercise. These changes returned to baseline by minute 3
post-exercise. The rhythm was sinus with a single VPB in late
recovery period. Marked drop in blood pressure with exercise
(136/60mmHg at rest to 98/50mmHg at peak). Post-exercise
hypertension was noted (172/60mmHg at 10 minutes of recovery).
.
IMPRESSION: Marked drop in blood pressure with exercise.
Non-specific EKG changes without anginal type symptoms.
.
CARDIAC CATH:
[**2147**]:
COMMENTS:
1. Coronary angiography of this right dominant circulation
revealed
severe native three vessel disease. The LMCA had a 30%
narrowing. The
LAD had diffuse luminal irregularities and a 70% proximal
stenosis. The mid vessel was diffusely diseased but the distal
vessel filled via a patent LIMA->dLAD. The LAD supplied a large
S2 that had an 80% lesion at its ostium. The LAD supplied two
moderate sized diagonal branches which had diffuse luminal
irregularities. The LCX tapered quickly and was totally occluded
in the proximal vessel after a small OM branch. The RCA was
diffusely diseased and totally occluded proximally.
2. Selective vein graft angiography revealed a widely patent
SVG->dRCA and a widely patent SVG->D1/OM.
3. Selective arterial conduit arteriography demonstrated a
widely patent LIMA->LAD.
4. Resting hemodynamics revealed markedly elevated right and
left
ventricular filling pressures with an LVEDP of 29 mmHg and a
mean PCW
pressure of 22 mmHg. In addition, there were V-waves to 50 mmHg
suggesting significant mitral regurgitation. There was evidence
of
moderate to severe pulmonary hypertension with PA pressures of
62/21/39 mmHg and a pulmonary vascular resistance of 209
dynes-sec/cm5. The cardiac output was preserved at 6.9 L/min.
Note was made of a 10 mmHg gradient across the aortic valve.
5. Left ventriculography was not performed due to the patient's
underlying renal insufficiency and recent non-invasive testing
documenting a preserved LV systolic function.
.
FINAL DIAGNOSIS:
1. Severe native three vessel disease.
2. Patent LIMA->LAD.
3. Patent SVG->dRCA and SVG->D1/OM.
4. Moderate to severe left ventricular diastolic dysfunction.
5. Moderate to severe pulmonary hypertension.
CT head ([**9-24**]):
IMPRESSION:
1. No acute intracranial process.
2. Sequelae of chronic infarction involving the left
parieto-occipital
region.
Renal U/S ([**9-27**]):
IMPRESSION:
Absent diastolic flow seen in the bilateral interlobar arteries
of the
kidneys. The findings are nonspecific, but indicate renal
parenchymal
disease. There is limited evaluation of the main renal arteries,
but there is no clear evidence of renal artery stenosis. There
is no hydronephrosis.
Brief Hospital Course:
Summary: 74 yo M transferred from NWH with EKG changes, trop
here to 0.87 (baseline 0.2) and RLE cellulitis, right foot
osteomyelitis, worsening acute on chronic renal failure
# Right lower extremity cellulitis and right foot osteomyelitis:
The patient presented with right lower extremity cellulitis and
was found to have osteomyelitis in the right foot. Vascular
surgery evaluated the patient and thought that treatment for the
infection and ischemia would be a below the knee amputation,
though given the patient's poor cardiac status, he would not be
a good candidate for surgery. The patient was empirically
started on Vancomycin and Zosyn. A wound culture grew Klebsiella
oxytoca and MRSA and continued on those antibiotics. Since
vascular surgery would be high risk, podiatry was consulted for
local debridement. They debrided the area locally, yet erythema
of the right foot existed. It remained unclear whether the
erythema was due to ischemia vs. a subcutaneous abscess, so they
recommended a MRI of the foot. The MRI was never performed
because after discussion with the family and primary care
physician, [**Name10 (NameIs) **] was decided for the patient to become CMO. His
antibiotics were withdrawn and wound care applied to the area.
# Acute on chronic renal failure: The patient presented with a
creatinine close to his baseline, however, after periods of
hypotension, likely due to a peri-septic state, his creatinine
starting to rise. He was given fluid boluses of 500 cc of normal
saline as needed because his urine lytes showed a FeUrea~20-25%.
Renal was consulted and thought his creatinine rise was likely
due to acute tubular necrosis secondary to a pre-renal state.
The patient was offered aluminium hydroxide for high phosphate
levels, but the patient refused it. A renal ultrasound showed no
hydronephrosis. The patient became progressively oliguric with
UOP less than 20 cc/hour. Renal thought his kidneys would
unlikely recover (his creatinine rose to 5.3 despite
interventions). The patient and his family felt that they did
not want to pursue dialysis as an option.
#Increased troponins: The patient was noted to have high
troponins and excentuated ST wave depressions in V3-V5.
Cardiology was consulted and recommended medical management with
a beta blocker, ACE inhibitor, statin, and aspirin. The patient
was started on these medications, though became persistently
hyperkalemic, and therefore, the ACEi was discontinued. Also,
his CK and LFTs were [**Last Name (LF) 28645**], [**First Name3 (LF) **] the statin dose of 80 mg was
lowered to 20 mg and eventually discontinued due to persistently
[**First Name3 (LF) 28645**] LFTs. An echocardiogram revealed no acute wall motion
abnormality, though it did show worsening tricuspid
regurgitation and increased pulmonary artery pressure.
Throughout his stay, the patient did not have any chest pain.
#Increased LFTs: The patient has a known history of alcohol
abuse and increased LFTs in the past. During his peri-septic
period, the patient was noted to have increased LFTs, likely
multifactorial due to low perfusion to the liver and also
congestion secondary to tricuspid regurgitation. The patient did
not have any complaints of abdominal pain, though, he had
hepatomegaly on exam.
#Gastrointestinal bleed: The patient has a history of a GI bleed
and was guiaic positive in the ER. In addition, he had a
persistently elevated PT/PTT, likely due to either underlying
liver or hematologic disease. The patient's hematocrit remained
stable until [**9-26**] when his hematocrit dropped from 29.0 to 25.6
and was noted to have melenic stools. He continued to have
melenic stools, so he was transfused one unit of blood and
transferred to the MICU. His aspirin was discontinued. His
hematocrit remained stable in the MICU and transferred to the
floors where there were no signs of any GI bleeding.
Altered mental status: The patient had periods where he had
altered mental status, mostly at night. His AMS was likely
multifactorial due to infection, pain and uremia. He had
significant altered mental status on one day when he appeared
more somnolent with respirations=10/min after a dose of Morphine
2mg IV. Narcane was given with some effect. A head CT showed no
acute pathology. He continued to have periods of delirium mostly
at night.
#Pruritis: The patient has been complaining of pruritis,
especially on his back, since admission. A variety of remedies
were tried for wound care. According to his son, the pruritis
has been long-standing. It might be exacerbated by his renal
failure. A side effect of Morphine is a possibility, but he
still had the itching even before the morphine. He is being
treated with skin care, sarna lotion, hydrocortisone and
doxepin.
Goals of care: The patient entered the hospital as full code.
After the renal and GI bleeding complications from his illness,
the patient and his family decided to become DNR/DNI. After a
meeting with the PCP and the family, they thought the best route
would be to become comfort measures only instead of pursuing
dialysis and being chronically cared for in a nursing home. At
first, it was thought that his beta blocker, aspirin, and
antibiotics would be continued, however, after further
conversation, these medications were discontinued and only
palliative measures for insomnia, anxiety, pain and constipation
were ordered.
Medications on Admission:
MEDICATIONS (from NWH D/C summary on [**9-11**])
acetaminophen 1 g q8hr
ASA 325 Daily
Erythropoietin 4000 units SC weekly
Ferrous sulfate 325 mg Daily
Furosemide 40 mg daily
Lovenox 30 mg SC daily until ambulatory
NPH (8 units before breakfast and dinner
Regular insulin (5 units before breakfast and dinner
Metoprolol 12.5 mg [**Hospital1 **]
MVT daily
Miralax 17 g Daily
Nystain triamcinolone cream topically twice daily
omeprazole 29 mg daily
Sarna lotion to affected area [**Hospital1 **]
senokot qHs
Sertraline 50 mg daily
simvastatin 20 mg daily
flomax 0.4 mg daily
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
4. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
8. Morphine 10 mg/5 mL Solution Sig: [**4-29**] mL PO Q4H (every 4
hours) as needed for pain, respiratory distress.
9. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal TID (3
times a day) as needed for itching.
10. Doxepin 25 mg Capsule Sig: One (1) Capsule PO BID (2 times a
day).
11. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
12. Zofran 2 mg/mL Solution Sig: Four (4) mg Intravenous every
six (6) hours as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
Cape Code Nursing & Rehabilitation Center - [**Location (un) 10072**]
Discharge Diagnosis:
Primary
-cellulitis of lower extremity
-osteomyelitis
-coronary artery disease
.
Secondary
-Hypotension
-Type II diabetes Mellitus
Discharge Condition:
Stable. Patient breathing on room air.
Discharge Instructions:
You were transferred to the hospital with right foot cellulitis
and osteomyelitis. You were started on antibiotics. Vascular
surgery evaluated the foot and were cautious to pursue surgical
intervention because you have a poor cardiac reserve. Podiatry
evaluated you and they....
.
You should come back to the hospital or call your primary care
doctor if you have chest pain, shortness of breath, weight gain,
fevers/chills or increasing pain in your right foot.
Followup Instructions:
PRN
|
[
"041.12",
"V45.81",
"416.8",
"285.1",
"428.32",
"403.90",
"790.5",
"578.1",
"250.80",
"410.72",
"V58.61",
"730.27",
"440.22",
"428.0",
"286.7",
"584.5",
"707.14",
"585.9",
"790.4",
"041.3",
"788.5",
"E935.2",
"414.8",
"276.7",
"293.0",
"276.2",
"682.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"86.22"
] |
icd9pcs
|
[
[
[]
]
] |
19349, 19445
|
12200, 16090
|
326, 372
|
19620, 19661
|
4997, 11478
|
20171, 20178
|
4170, 4188
|
18207, 19326
|
19466, 19599
|
17610, 18184
|
11495, 12177
|
19685, 20148
|
3508, 3972
|
4203, 4213
|
2969, 3213
|
4235, 4978
|
261, 288
|
400, 2865
|
16105, 17584
|
3244, 3485
|
2887, 2949
|
3988, 4154
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,002
| 192,026
|
22493
|
Discharge summary
|
report
|
Admission Date: [**2194-4-17**] Discharge Date: [**2194-4-21**]
Date of Birth: [**2135-9-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Avandia
Attending:[**Known firstname 922**]
Chief Complaint:
vertebral basilar syndrome with right innominate artery stenosis
Major Surgical or Invasive Procedure:
right aortosubclavian and right common carotid artery bypass
[**2194-4-17**]
History of Present Illness:
This 58 year old black male recently developed micturition
syncope. Additionally, he has had overall fatigue, weakness of
the right upper extremity and dizziness.
Carotid ultrasound revealed retrograde flow of the right
vertebral artery and moderate left internal artery stenosis. A
CTA of the neck subsequently showed heavy calcification of the
arch and severe stenosis of the right innominate
artery. He has not had any recurrent episodes, however, he does
continue to have right upper extremity claudication symptoms. He
has been referred to Dr. [**Last Name (STitle) 914**] for right innominate artery
bypass.
Past Medical History:
noninsulin dependent Diabetes mellitus
Hypercholesterolemia
Hypertension
Obesity
Lumbar stenosis
Central retinal artery occlusion right eye [**12-7**]
s/p permanent pacemeker implant [**2192**]
h/o stroke [**2176**]
Obstructive sleep apnea
Cardiomegaly
Peripheral vascular disease
Social History:
He smokes 1.5 PPD x many years. Drinks 44 oz beer/day.
Denies illicit drugs.
He is married and has 5 children.
He works as a bus driver.
Family History:
brother died of MI at 25; father died of MI at age 66, and all
paternal uncles died of MI in 60s.
Physical Exam:
admission:
Pulse: 65 Resp: 20 O2 sat: 100%RA
B/P: 122/77
Height: 70" Weight: 225lb
General: WDWN in NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Delayed inspiration and expiration. Lungs clear.
Heart: RRR, I/VI systolic murmur heard best in right upper chest
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] No Edema
Varicosities: None [X]
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 1+ Left: 2+
Carotid Bruit: Bilateral bruits noted Left > Right vs
innominate artery radiated bruit.
Pertinent Results:
ECHO
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV
cavity.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Normal RV systolic function.
AORTA: Normal aortic diameter at the sinus level. 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: Normal aortic valve leaflets (3). No AS. No AR. No
AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. The MR
vena contracta is <0.3cm. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
pERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications.
Conclusions
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. Septal motion is consistent with vpacing
at the time of the exam. The left ventricular cavity is
moderately dilated. Right ventricular chamber size and free wall
motion are normal. with normal free wall contractility. 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. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen.
Post procedure, exmam is unchanged. Aortic contours intact.
Biventricular function is preserved. All findings discussed with
surgeons at the time of the exam.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2194-4-17**] 16:48
[**2194-4-21**] 04:40AM BLOOD WBC-7.6 RBC-3.36* Hgb-9.6* Hct-29.3*
MCV-87 MCH-28.5 MCHC-32.7 RDW-14.1 Plt Ct-243
[**2194-4-17**] 11:33AM BLOOD WBC-9.6# RBC-3.88* Hgb-10.7* Hct-33.7*
MCV-87 MCH-27.7 MCHC-31.8 RDW-14.7 Plt Ct-204
[**2194-4-21**] 04:40AM BLOOD Glucose-104* UreaN-21* Creat-1.2 Na-140
K-4.1 Cl-102 HCO3-32 AnGap-10
[**2194-4-18**] 03:36AM BLOOD Glucose-136* UreaN-12 Creat-0.9 Na-137
K-3.7 Cl-103 HCO3-27 AnGap-11
[**2194-4-21**] 04:40AM BLOOD Mg-2.3
Brief Hospital Course:
He was admitted and taken to the Operating Room where Aorta to
right subclavian artery and right common carotid artery bypass,
epiaortic duplex scanning, adjacent soft tissue transfer of the
strap muscle to the distal anastomotic site were performed.
vPost operatively he remained intubated and was transferred to
the ICU for ongoing post operative care. He awoke neurologically
intact and was weaned and extubated.
On POD#1 he was transferred from the ICU to the stepdown unit.
He was evaluated by Physical Therapy.beta blockade was
instituted for blood pressure control and he was diuresed to his
preoperative weight. He was ambulating independently, wounds
were clean and healing well at discharge.
He was discharged on oral analgesics with good pain control and
appropriate follow up instructions.
Medications on Admission:
Citalopram 60mg daily, Clonazepam 1 mg qpm, Clopidogrel 75 mg
daily, Fenofibrate 54 mg daily, Hydrocodone-Acetaminophen 5
mg-500 mg Tablet Q 6prn pain, Indapamide 1.25 mg daily,
Lisinopril 40 mg daily, Metformin 500 mg [**Hospital1 **], Nifedipine SR 90
mg daily, Actos 45mg daily, Pravastatin 40 mg QHS, Tadalafil 20
mg PRN, Aspirin 325 mg daily,
Nicotine patch, Omega 3 fatty acids
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Citalopram 40 mg Tablet Sig: 1.5 Tablets PO once a day.
6. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
9. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
vertebral-basilar artery syndrome
right innominate artery stenosis
hypertension
hyperlipidemia
lumbar stenosis
obesity
s/p permanent transvenous pacemaker
h/o right central retinal artery occlusion
h/o strke
obstructive sleep apnea depression
Discharge Condition:
Alert and oriented x3, nonfocal.
Ambulating with steady gait.
Incisional pain managed with dilaudid
Incisions:
Sternal - healing well, no erythema or drainage
Discharge Instructions:
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**]).
**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:
Recommended Follow-up:
You are scheduled for the following appointments:
Surgeon: Dr. [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) on [**5-20**] at 1:15pm
Please call to schedule appointments with:
Primary Care: Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] ([**Telephone/Fax (1) 250**]) in [**11-30**] weeks
Vascular Surgeon: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in [**11-30**] weeks
**Please call cardiac surgery office with any questions or
concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call
person during off hours.**
Completed by:[**2194-4-21**]
|
[
"447.1",
"V12.54",
"V58.67",
"278.00",
"414.01",
"427.9",
"250.00",
"272.0",
"443.9",
"401.9",
"327.23",
"433.80",
"724.02",
"V53.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.22",
"39.59",
"89.45",
"83.77"
] |
icd9pcs
|
[
[
[]
]
] |
7540, 7595
|
5217, 6023
|
337, 416
|
7882, 8049
|
2400, 5194
|
8828, 9512
|
1538, 1638
|
6458, 7517
|
7616, 7861
|
6049, 6435
|
8073, 8805
|
1653, 2381
|
233, 299
|
444, 1061
|
1083, 1366
|
1382, 1522
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,817
| 128,681
|
40482
|
Discharge summary
|
report
|
Admission Date: [**2118-5-2**] Discharge Date: [**2118-5-25**]
Date of Birth: [**2077-1-4**] Sex: F
Service: MEDICINE
Allergies:
Latex
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
OSH transfer with BP control issues and [**First Name3 (LF) **]
Major Surgical or Invasive Procedure:
[**2118-5-4**] Fine needle aspiration of left neck mass
[**2118-5-9**] Ultrasound guided thyroid biopsy
[**2118-5-17**] Infraparathyroidectomy
History of Present Illness:
41 y/o F with PMH significant for HTN, obesity, R-MCA [**Month/Day/Year **]
syndrome, hypercalcemia [**1-19**] parathyroid adenoma s/p
parathyroidectomy [**2118-5-18**] is admitted to medicine for
monitoring of electrolytes. Pt. was first presedented to [**Hospital1 18**]
neurology service ([**2118-5-2**]) from [**Hospital **] Hospital for
evaluation of of R-MCA [**Hospital **] syndrome.
.
Per pt.'s mother, pt. was in her USOH (except 60lb wieght loss
over past year accompanied with intermittent night sweats and
dysepsia), on vacation in [**Hospital1 3597**], MA from [**State 622**] when she fell
(-LOC) in a hotel lobby accompanied by loss of speech, left
facial droop and LUE weakness.
.
She first presented 40-minutes after the fall to [**Hospital **]
hospital ED([**2118-4-30**]) where imaging showed an old L infarct but
no acute [**Month/Day/Year **] or bleed. tPA was considered but not done since
her symptoms seemed to resolve in the ED. She was then admitted
to the [**Hospital1 **] [**Hospital1 **] service where she was noted to have
residual LUE weakness and L facial droop with brain MRIs pos for
multiple acute foci in R frontal/parietal lobes. MRA of carotids
was neg and TTE showed no vegetations. BP's initially at [**Hospital1 **]
>200 and her calcium was [**11-29**] and given Pamidronate.
.
On the Neuro service here work-up has been: serial imaging
confirmed R-MCA occlusion and watershed infarcts. TEE showed no
embolic source (and normal BiV fxn). Has been on Nitro gtt,
Nicardipine gtt (weaned off [**5-5**]) and currently on Amlodipine
10, Labetalol 200 [**Hospital1 **], Metoprolol 5 IV prn. Also on 325 ASA,
Simva 10.
.
For endocrinology: R parotid lesion was found accidentally with
carotid imaging at [**Hospital1 **]. Initial imaging at [**Hospital1 18**] was
concerning for R parotid and L thyroid masses. On admission, Ca
was 12.0 (albumin
4.1) with PTH 424. IVF's and Lasix has decreased Ca to lowest
level 8.1. Thyroid u/s showed two L lobe thyroid nodules, and
another nodule lateral to the thyroid gland which was FNA'd on
[**2118-5-4**], with pathology showing parathyroid tissue.
Endocrinology and Endocrine surgery has been involved and she is
currently POD#1 for L inferior parathyroidectomy.
.
On the floor s/p parathyroidectomy, pt has been sleepy but
comfortable with moderate pain at incision site on the neck.
ROS: She denies any fevers/chills/, nausea/vomiting, chest
pain/SOB/stridor, abdominal discomfort, dysuria, edema.
Neurologically, she denies perioral/finger tip tingling,
headache, light-headedness, vision changes, diplopia, tinnitus
but left sided paresis is unchanged from admission. Speech and
left sided sensation has improved since admission.
Past Medical History:
1. ?HTN vs. "white coat hypertension" (mother says her BP is
always normal at the gyn's office, yet high at the ED; husband
says she eqivocates about this distinction)
2. obesity
3. dysmenorrhea on OCP since 19y/o; current OCP=Yaz
4. mood/depression on ?antidepressant med
5. ?OSA (husband says no formal Dx, but snores loudly, +apneic
spells at home)
6. LBP / "OA"
(denies Hx DM, HL)
(denies Hx [**Year (4 digits) **]/TIA, CAD/MI)
Social History:
Married, lives in [**Location 88678**]/[**Last Name (LF) **], [**First Name3 (LF) 622**] with husband.
Here on vacation with niece. Works as a newspaper reporter,
which has been particularly stressful over the past week per her
husband. Rarely f/u with outpatient physician; sees Gyn as a PCP
of sorts ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] @[**Location (un) 88678**], VA). Otherwise visits the ED
at [**Hospital 8300**] [**Hospital 107**] Hospital ([**Location (un) 88678**], VA)
"periodically"
(sprained ankles, LBP/"OA").
- Denies h/o EtOHism; drinks occasional single glass of wine.
- Denies h/o tobacco
- Denies h/o illicit drug use/abuse
Family History:
Husband notes +FH of EtOHism
No history of clotting disorder or bleeding disorder. No calcium
disorders. + history for DM, CAD, depression, hypo and
hyperthyroidism. No cancer history.
Physical Exam:
<on arrival here to SICU-B>
T: 97.6F
HR: 97
BP: 190/85 cuff (Left forearm / Right arm)
BP: 240/107
RR: 18-24 (mostly in the low-20s)
SaO2: 99% RA
General: Obese caucasian woman lying in med speaking little,
moving little. Awake, but lethargic. Cooperative, NAD.
HEENT: Atraumatic. Slight right parotid swelling/protrusion. No
scleral icterus. Mucous membranes are moist. No lesions noted in
oropharynx.
Neck: Obese. Supple, FROM. No carotid bruits. No goiter or LAD
appreciated.
Pulmonary: Lungs CTA bilaterally. Non-labored breathing, but a
bit tachypneic.
Cardiac: RRR, normal S1/S2; odd [**1-23**] early-to-mid-peaking
systolic murmur, loudest over LUSB; occasional rough sound,
almost like a rub, but not (hard for me to characterize exactly,
given body habitus = distant HS; TEE pending).
Abdomen: Obese. S/NT/ND. +NBS. No mass appreciated.
Extremities: WWP, no CCE. 2+ radial, DP pulses bilaterally.
*****************
Neurologic examination:
Mental Status exam:
Awake and alert, but lethargic (requires re-orientation to keep
eyes open, respond to questions. Profoundly hypophonic, but
fluent with intact repetition and comprehension when engaged.
Oriented to person, year, month, date, not quite day of week
("Sunday"). Not good at relating Hx with open-ended questioning
(had to dig it out of her), but answers specific questions
reliably. Moderate attentional impairment (spells WORLD, but
backwards gives "DLOW"). Speech is slurred with soft voice. c/o
"cold." Naming is intact to both high and low frequency objects
(pen, flashlight). Able to follow both midline and appendicular
commands.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL, 2.5 to 2mm and brisk. Visual fields are grossly full
x 4 quadrants (blink to threat).
III, IV, VI: Right gaze deviation - cannot cross midline even
with oculocephalic movements
V: Facial sensation intact and subjectively symmetric to light
touch V1-V2-V3.
VII: Mild ptosis vs. squinting of Left eye. Left facial droop.
VIII: Hearing grossly intact and subjectively equal.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: Reduced Left trapezius power (lags); R is full.
XII: Tongue protrusion is midline.
Motor:
Left hemiplegia
Delt Bic Tri WE FF FE IO | IP Q Ham TA [**Last Name (un) 938**] Gastroc
L o 0 0 0 0 0 0 1 0 0 0 0 0
R 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensory:
No deficits to light touch, pinprick, cold sensation, or
vibratory sensation in either distal lower extremity. Joint
position sense is normal in both upper (thumbs) and lower (great
toes) extremities. Eyes-closed Finger-to-[**Last Name (un) **] testing revealed
no proprioceptive deficit (did not miss [**Last Name (Titles) **]).
Cortical sensory testing:
No agraphesthesia or astereoagnosia. No extinction to DSS. Two-
point discrimination was within normal limits.
-Reflex examination (left; right):
Biceps (++;++)
Triceps (++;++)
Brachioradialis (++;++)
Quadriceps / patellar (+;++)
Gastroc-soleus / achilles (+;++)
Plantar response was EXTENSOR on the Left;
(flexor on the Right).
Coordination:
Finger-[**Last Name (Titles) **]-finger testing normal on Right with no dysmetria or
intention tremor. No dysdiadochokinesia on Right [**Doctor First Name **]. Cannot
test Left coordination (cannot move against gravity).
Gait: Deferred
DISCHARGE PHYSICAL EXAM:
Tm: 98.5F
Tc: 97.9
HR: 78 (60-70)
BP: 144/74(120-140/70-80)
RR: 18
SaO2: 98% RA
GEN: Comfortable in bed, alert and awake, oriented to self and
place, NAD, hypophonic.
HEENT: Atraumatic. Right parotid swelling/protrusion. No
scleral icterus. MMM. Oropharynx clear.
NECK: Thick neck, no thyromegaly, no palpable nodules,
nontender. Incision site clean, dry but no erythema.
CV: RRR, systolic murmur, no rubs/gallops
CHEST: CTAB (anteriorly), no crackles or wheezes, non-labored
breathing.
ABD: Soft, obese, non-distended, + bowel sounds, very mild
tenderness diffusely, no rebound/guarding.
EXT: No edema, WWP. 2+ DP pulses bilaterally,
SKIN: No discoloration, striae, or hirsuitism, skin around neck
slight red but no edema.
Neuro Exam:
[]Cranial Nerves:
Olfaction deferred. Pupils are equal and reactive to light
bilaterally (3mm-2mm). Visual fields are full. Right gaze
deviation. Facial sensation to light touch, temperature are nl.
Mild ptosis and left facial droop. Hearing is intact. Palates
elevates symmetrically. Weak shoulder shrug on the left side,
right full. Tongue protrusion midline and side-side movement nl.
[]Motor
-Left hemiplegia. 5/5 strength on the right.
[]Sensation:
-No sensory deficits to light touch and cold sensation in both
UE and LE bilaterally. No neglect
[]Reflexes
-Deep tendon reflexes 3+ on the left side and 2+ on the left
side. Babinksi reflex positive on the left side.
[]Coordination
-Finger-to-[**Doctor First Name **] testing nl on the right, unable to obtain on
the left.
-Gait deferred due to hemiplegia.
Pertinent Results:
Labs on admission:
[**2118-5-2**] 11:12AM BLOOD WBC-11.6* RBC-4.71 Hgb-14.1 Hct-40.0
MCV-85 MCH-29.9 MCHC-35.2* RDW-14.5 Plt Ct-266
[**2118-5-2**] 11:12AM BLOOD Neuts-89.8* Lymphs-5.8* Monos-3.4 Eos-0.6
Baso-0.4
[**2118-5-2**] 11:12AM BLOOD PT-12.1 PTT-19.1* INR(PT)-1.0
[**2118-5-6**] 03:55AM BLOOD Lupus-NEG
[**2118-5-6**] 03:55AM BLOOD AT-110 ProtCFn-PND ProtSFn-PND
[**2118-5-6**] 03:55AM BLOOD ACA IgG-PND ACA IgM-PND
[**2118-5-2**] 11:12AM BLOOD Glucose-117* UreaN-11 Creat-0.9 Na-140
K-3.8 Cl-108 HCO3-23 AnGap-13
[**2118-5-2**] 11:12AM BLOOD ALT-14 AST-20 CK(CPK)-23* AlkPhos-143*
Amylase-42 TotBili-0.7
[**2118-5-2**] 11:12AM BLOOD CK-MB-2 cTropnT-0.02*
[**2118-5-2**] 08:26PM BLOOD CK-MB-2 cTropnT-0.02*
[**2118-5-3**] 03:25AM BLOOD CK-MB-2 cTropnT-0.02*
[**2118-5-2**] 11:12AM BLOOD Albumin-4.1 Calcium-12.0* Phos-2.0*
Mg-2.1
[**2118-5-10**] 06:30AM BLOOD %HbA1c-5.2 eAG-103
[**2118-5-10**] 06:30AM BLOOD Triglyc-247* HDL-36 CHOL/HD-4.0
LDLcalc-58
[**2118-5-2**] 11:12AM BLOOD TSH-1.0
[**2118-5-3**] 03:25AM BLOOD TSH-0.69
[**2118-5-2**] 12:01PM BLOOD PTH-424*
[**2118-5-3**] 03:25AM BLOOD T3-119 Free T4-1.1
[**2118-5-4**] 11:47AM BLOOD PTH-DONE
[**2118-5-6**] 03:55AM BLOOD b2micro-2.5*
[**2118-5-2**] 11:28AM BLOOD Type-ART pH-7.47*
[**2118-5-2**] 11:28AM BLOOD freeCa-1.60*
[**2118-5-3**] 03:32AM BLOOD freeCa-1.48*
[**2118-5-2**] 12:58PM BLOOD VITAMIN D
Test Result Reference
Range/units
VITAMIN D, 25 OH, TOTAL 12 L 30-100 ng/mL
VITAMIN D, 25 OH, D3 12 ng/mL
VITAMIN D, 25 OH, D2 <4 ng/mL
[**2118-5-6**] 03:55AM BLOOD FACTOR V LEIDEN-FACTOR V LEIDEN (R506Q)
MUTATION NOT DETECTED
[**2118-5-6**] 03:55AM BLOOD PROTHROMBIN MUTATION ANALYSIS-THE G20210A
MUTATION NOT DETECTED
.
Labs on discharge:
XXXX
.
Imaging:
[**2118-5-10**] PARATHYROID SCAN:
Persistent uptake in the left mid-and inferior thyroid lobe and
the anterior mediastinum (substernal) concerning for parathyroid
tissue.
[**2118-5-9**] THYROID BIOPSY BY RADIO:
Technically successful ultrasound-guided fine-needle aspiration
of left mid pole thyroid nodule.
[**2118-5-6**] MR/A HEAD W/O CONTRAST:
MRA again demonstrates occlusion of the M1 segment of the right
middle cerebral artery as seen on the previous CT of [**2118-5-2**].
[**2118-5-4**] CT HEAD W/O CONTRAST:
No interval change, re-demonstrating sequela of a right MCA
territory infarction.
[**2118-5-4**] CHEST (PORTABLE AP):
In comparison with the study of [**5-3**], little change in the
appearance of the heart and lungs. Left subclavian PICC line is
in the brachiocephalic vein. The Dobhoff tube extends to the
distal stomach and possibly the duodenal bulb.
[**2118-5-4**] PARATHYROID U.S.:
1. Fine-needle aspiration performed of a left neck mass (level
3),
representing an abnormal lymph node or a parathyroid mass. Two
passes were
made with 25-gauge needles. One was sent in saline for
parathyroid hormone
levels and the other one was sent in CytoLyt to cytology. The
procedure was quite difficult due to patient motion, despite
attempts at head restraint, and the close proximity of the
carotid and subclavian arteries.
2. Within the left thyroid gland, a solid dominant vascular
nodule is present measuring up to 2.7 cm. This can be targeted
for fine-needle aspiration when the patient is capable and based
on the results of the FNA performed today.
[**2118-5-4**] GUIDANCE/LOCALIZATION FNA:
1. Fine-needle aspiration performed of a left neck mass (level
3),
representing an abnormal lymph node or a parathyroid mass. Two
passes were
made with 25-gauge needles. One was sent in saline for
parathyroid hormone
levels and the other one was sent in CytoLyt to cytology. The
procedure was quite difficult due to patient motion, despite
attempts at head restraint, and the close proximity of the
carotid and subclavian arteries.
2. Within the left thyroid gland, a solid dominant vascular
nodule is present measuring up to 2.7 cm. This can be targeted
for fine-needle aspiration when the patient is capable and based
on the results of the FNA performed today.
[**2118-5-3**] CT HEAD W/O CONTRAST:
Large acute infarction in the right middle cerebral artery
territory, increased in extent since the prior study.
[**2118-5-3**] CHEST PORT. LINE PLACEMENT:
AP single view of the chest has been obtained. Telephone contact
was established with [**Name (NI) **], who was concerned that the catheter
found resistance. Consideration was given to send patient to the
radiology
intervention laboratory for correction of line position.
[**2118-5-3**] ECHO:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast at
rest (patient unable to cooperate with maneuvers). Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are mild simple atheroma in the aortic arch and minimal in the
descending aorta to 40 cm. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no pericardial effusion.
IMPRESSION: No intracardiac source of embolism identified.
Normal biventricular systolic function.
[**2118-5-2**] CTA HEAD/NECK W&W/O C & RECON:
1. Occlusion of the right mid M1 segment of the right middle
cerebral artery with watershed distribution infarcts in the
white matter of the right MCA territory.
2. No proximal source is demonstrated.
3. Right parotid and left lobe thyroid masses. If not already
evaluated
elsewhere, consider followup thyroid ultrasound. The right
parotid mass could be evaluated further with parotid protocol
MRI, if diagnosis is not obtained histologically.
[**2118-5-2**] BILAT LOWER EXT VEINS: No evidence of deep vein
thrombosis in either leg.
[**2118-5-2**] ECG:
Sinus rhythm. Prominent voltage in leads I and aVL with ST-T
wave
abnormalities. Consider left ventricular hypertrophy with
repolarization
changes. Other ST-T wave abnormalities. No previous tracing
available for
comparison. Clinical correlation is suggested.
Rate PR QRS QT/QTc P QRS T
97 144 92 354/418 55 13 163
.
Pathology/cytology:
LEFT NECK MASS Procedure Date of [**2118-5-4**]
SPECIMEN RECEIVED: [**2118-5-4**] 11-[**Numeric Identifier **] LEFT NECK MASS
SPECIMEN DESCRIPTION: Received in cytolyt Prepared 1 ThinPrep
slide
CLINICAL DATA: Lt neck mass ? parathyroid vs enlarged lymph
node.
DIAGNOSIS: FNA, Left neck mass:
ATYPICAL.
Rare focus of parathyroid glandular tissue (see note).
Note:
The aspirate specimen contains a single group of bland-
appearing epithelial cells. Immunohistochemical stains
performed on the cell block (see S11-[**Pager number 21470**]B) demonstrate
immunoreactivity to parathyroid hormone. Cells are
negative for TTF-1 and thyroglobulin. The immunophenotype
is consistent with parathyroid tissue. Clinical and
radiologic correlation are necessary to determine if the
findings represent neoplasia (parathyroid hyperplasia,
adenoma or carcinoma).
.
SPECIMEN SUBMITTED: LEFT NECK MASS FNA FOR CELL BLOCK
(C11-[**Pager number **]B)
Procedure date Tissue received Report Date Diagnosed
by
[**2118-5-4**] [**2118-5-5**] [**2118-5-9**] DR. [**Last Name (STitle) **].
[**Doctor Last Name **]/dwc??????
DIAGNOSIS:
Left neck mass, fine needle aspiration, cell block:
Atypical; scant parathyroid tissue (see note).
Note:
Immunohistochemical stains show that cells stain positive for
parathyroid hormone; cells are negative for TTF-1 and
thyroglobulin. The immunophenotype is consistent with
parathyroid tissue. Clinical and radiologic correlation are
necessary to determine whether the findings represent neoplasia
(parathyroid hyperplasia, adenoma or carcinoma)
Clinical: ? parathyroid vs. enlarged lymph node.
Gross:
The cytology specimen container is received, labeled with the
patient's name, medical record number and "C11-16766B". A cell
block is made using the plasma-thrombin method and is entirely
submitted in cassette A for permanent section.
Brief Hospital Course:
Patient is a 41 year old right handed woman transferred from OSH
with new focal neurological deficit found to have right MCA CVA
with hospital course complicated by hypercalcemia secondary to
parathyroid adenoma s/p resection.
.
#CEREBROVASCULAR ACCIDENT: She presented with loss of speech,
left facial droop and left upper extremity weakness and was
found to have an embolic [**Doctor Last Name **] to R frontal, temporal, and
parietal lobes in the right MCA distribution on imaging (CTA of
head and neck showed M1 occlusion). She was evaluated by
neurology during her hospitalization. Her risk factors for
[**Doctor Last Name **] included hypertension and hyperparathyroidism. Her LDL
was 52 and HBA1C was 5.2. Trans-thoracic echocardiogram did not
show evidence of embolic phenomenon (including no ASD/PFO and
LVEF>55%). Her carotids were clear on MRA from the outside
hospital. She was taking Yaz OCP but no other known no other
known hypercoagulable risk factors. Hypercoagulable work-up
(Protein S Profile; Protein C Profile; Anti-Cardiolipin
Antibody; Lupus Anticoagulant; Beta 2 Microglobulin; Factor V
Leiden; Antithrombin functional; Prothrombin Mutation Analysis)
was unrevealing and fibrinogen level was at the high end of
normal. There was a concern for occult cancer given high
calcium, 70 lbs weight loss, and abnormal parathyorid nodule
found and resected as will be discussed below. She was started
on aspirin for secondary prevention. She was also started on
simvastatin for lipid control and antihypertensives as below for
blood pressure control. She continued to have left sided
weakness of upper and lower extremities with gaze deviation at
discharge. She will need to continue speech, occupational, and
physical therapy.
.
#HYPERTENSION: She was not on any anti-hypertensives as an
outpatient but was noted to be hypertensive on initial
presetnation and initially required nicardipine drip for BP
control. There was evidence of LVH noted on EKG. She was able
to be weaned off the nicardipine drip on [**5-5**] and was started on
amlodipine 10mg daily and labetalol 200mg twice daily, with
adequate control in blood pressure.
.
#HYPERCALCEMIA [**1-19**] PARATHRYOID ADENOMA: She was found to have a
calcium of 12 with a free calcium of 1.60 on admission. Her PTH
was 424. CTA head/neck showed a 2.8 x 1.8cm left thyroid mass.
Endocrinology was consulted. Parathyroid scan showed persistent
uptake in the in the left mid-and inferior thyroid lobe and the
anterior mediastinum (substernal) concerning for parathyroid
tissue. Fine needle aspiration of the mass revealed parathyroid
tissue consistent with a parathyroid adenoma. Repeat FNA of
thyroid nodule showed thyroid follicular cells that were likely
benign. General endocrine surgery performed an inferior
parathyroidectomy on [**2118-5-18**]. The pathology showed left
parathyroid tissue consistent with adenoma and unremarkable
lymph nodes. Her electrolytes were followed closely
post-operatively and there was no evidence of hungry bone
syndrome. Her calcium and parathyroid hormone normalized. Her
incision is healing well, covered with steri-strips. She was
started on calcium carbonate and vitamin D 1000 units daily.
.
#PAROTID MASS: She was found to have a lobular 1.4 cm soft
tissue density lesion in the right parotid gland. She will
require outpatient ENT evaluation for biopsy.
.
#PLEURITIC CHEST PAIN: She reported intermittent pleuritic
chest pain during the hospitalization. CT chest was negative for
PE. Doppler U/S negative for DVT. EKG was unchanged and cardiac
biomarkers negative. Nitroglycerine did not change the chest
pressure. There was no evidence of pneumonia. It was thought to
be musculoskeletal and she was started on a lidocaine patch with
good effect.
.
#DEPRESSION: This was stable during admission. She was continued
on her home fluoxetine.
.
#MENORRHAGIA: It was discussed with the patient that it is
possible that her oral contaceptive pill (Yaz) could have led to
a hypercoagulable state resulting in CVA. She was encouraged to
follow up with gynecology regarding an alternative therapy, such
as a levonorgestrel.
.
#UTI: Patient was found to have UTI with urine culture growing
>100,000 colonies of coag negative staph on [**5-10**]. She completed
a 9 day course of Bactrim.
.
#NUTRITION: Patient initially required Dobhoff for medication
and aspiration risk diet. Patient remained on ground, mechanical
soft, pureed consistency, soft dysphagia solids with thin
liquids during this admission.
.
#CONSTIPATION: She was started on a bowel regimen of colase,
senna, miralax and intermittently required an enema.
.
#DVT PROPHYLAXIS: She was maintained on heparin 5000 TID SQ
during her hospitalization. This can be continued at rehab and
then discontinued when she starts to ambulate.
.
#DISPOSITION: She will be transported by air ambulance to
[**State 622**]. She was given a copy of all of the studies performed
during this hospitalization on a CD disk as well as the reports.
We discussed the importance of obtaining a primary care
physician as well as outpatient ENT evaluation of the parotid
mass as well as endocrinology and gynecology follow up. There
were no cultures or studies pending at discharge. There was no
pathology pending at discharge.
.
Medications on Admission:
1. Yaz OCP
2. antidepressant NOS (need to clarify)
3. Tums (?for GERD)
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for [**State **], 2ndary ppx.
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for [**State **] 2ndary ppx.
3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation ppx.
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation ppx.
10. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**12-19**]
Drops Ophthalmic PRN (as needed) as needed for left eye dryness.
11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
12. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): Please stop when able to
ambulate.
13. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
14. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
15. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day) as needed for gas discomfort.
16. labetalol 100 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day): hold for SBP<100.
Discharge Disposition:
Extended Care
Facility:
UVA [**Hospital6 **]
Discharge Diagnosis:
acute right middle cerebral artery [**Hospital6 **]
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 originally admitted to the [**Hospital6 **] unit for a right
middle cerebral artery [**Hospital6 **]. Your risk factors for [**Hospital6 **]
include hypertension (high blood pressure) and
hyperparathyroidism with elevated calcium. A hypercoagulable
state (increase risk of blood clots) was also considered. You
were started on aspirin for [**Hospital6 **] protection. You were started
on simvastatin for cholesterol control. You were started on
medication to better control your blood pressure. You had a
cardiac echocardiogram which demonstrated no cardioembolic
source. You need to continue your blood pressure control. You
should not smoke. You should continue to eat a low fat healthy
diet, and follow up with your primary care physician, [**Name10 (NameIs) **]
Neurology and rehab to help rebuild your strength and
functioning of the right side.
.
Your calcium was found to be elevated and your parathyroid
hormone was high indicating your parathyroid gland was
over-secreting confirmed by imaging. Since high levels of
calcium is dangerous for your heart and increases your rate of
getting a [**Name10 (NameIs) **], your parathyroid glands were removed by
surgery and you were monitored for electrolyte abnormalities
which were persistently normal. However, the endocrine doctors
recommend [**Name5 (PTitle) **] take three tums tablets twice a day and follow up
with your primary care doctor about this.
.
You were found to have an enlargement in your parotid gland. We
discussed having you see an Ear [**Name5 (PTitle) **] and throat doctor as an
outpatient.
.
You were also constipated towards the end of your stay here and
an enema was symptom relieving. Studies have shown that some
[**Name5 (PTitle) **] pts develop constipation, after the [**Name5 (PTitle) **] so you should
follow up with your primar care doctor [**First Name (Titles) **] [**Last Name (Titles) 15414**] softeners and
bowel regimen if you don't move your bowels at least every two
days.
Followup Instructions:
1. Please obtain a primary care physician in [**Name9 (PRE) 622**]
2. Please obtain an Endocrinologist (Parathyroid specialist) in
[**State 622**]
3. Please see an Ear [**State **] and throat doctor for your parotid
gland in [**State 622**]
4. Please continue to see your gynecologist regarding the best
medication for your menstrual bleeding
|
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60,054
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29002
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Discharge summary
|
report
|
Admission Date: [**2148-8-11**] Discharge Date: [**2148-8-17**]
Service: MEDICINE
Allergies:
Phenytoin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
G-tube bleeding, dyspnea
Major Surgical or Invasive Procedure:
G tube adjustment [**8-11**]
PICC placement [**8-12**]
History of Present Illness:
[**Age over 90 **] yo man with a history of a.fib, cervical spine surgery who
presented to the ED for G-tube site bleeding. Of note, per his
son and wife he was in his usual state of health (bed-bound,
with slowly declining mental status) until friday when his PEG
tube became disloged and was replaced. Then saturday he was
noted to be more subdued, less outgoing, with vague B upper
quadrant pain and possibly B chest pain. He vomitted x 2 but no
wittnessed aspiration. He was noted afterwards to be hypoxic
(90% on RA) but this improved with supplemental oxygen. However,
this morning he was in more respiratory distress, with some
bright red blood around the G tube so was referred to the ED.
.
In the ED, VS: Tm 102.4 rectal, Hr 100 BP 150/86 RR 18 Sat 85%
RA. BP up to 183/93 with HR 110 Sat 78% RA. Hr max to 135 with
BP to 104/69. RR to 27. Sat improved to 96% on bipap. He was
given levofloxacin 750mg iv, vanco 1gm iv, and zosyn 4.5 gm.
They were unable to place a foley catheter. He was given 1.5L
ivf. He was given 1 gm tylenol pr, 325mg aspirin pr, and 10mg iv
insulin when BG 600->500 so given addl 15u sc insulin (regular).
Right femoral CVC placed.
.
ROS: No recent fevers, chills, rash, myalgias, arthralgias, HA;
? chest pain/abdominal pain yesterday; currently denies flatus
or BM. Deneis feeling thirsty.
Past Medical History:
prostate ca s/p brachytherapy on leuprolide (s/p TURP [**2120**])
CVA with left hemiparesis, h/o fall with subdural and craniotomy
CAD with MI in [**2140**], PTCA [**2138**]-[**2140**]?
DM: hgb a1c [**2148-6-29**] 8.2
HTN
h/o gallsone pancreatitis s/p ercp
dysphagia requirine peg tube: albumin [**5-5**] 3.1
h/o chf (ef unknown)
hyperlipidemia: [**6-4**]: TG 336, HDL 30, LDL 42
anemia: hct 33.4 [**5-5**], nl mcv, nl rdw, on iron
a.fib
SSS s/p PPM [**2142**]
neophrolithiasis
? h/o osteoporosis
diverticulosis s/p hemicolectomy
baseline creatinine 1.0
glaucoma
s/p cervical surgery
s/p mva with clavicle fracture
Social History:
Lives in [**Hospital 100**] Rehab for years. Remote history of smoking, quit
several years ago.
Family History:
Unknown
Physical Exam:
VS: T: 96.3 HR: 124 BP: 120/82 CVP: 16 RR: 24 Sat: 98% on Mask
ventilation: [**7-5**] 0.5
Gen: Elderly man appearing ill, fatigued
HEENT: PPV mask in place, unable to assess OP,
Neck: Supple, JVP flat but difficult to assess with tachypnea
Resp: Tachypnea, decreased BSA B bases, no discrete wheezes,
rales, rhonchi, limited by antior exam
CV: Tachycardic, regular rhythm, no murmurs, rubs, gallops
Abdomen:Very distended and tympanitic on percussion, paucity of
bowel sounds, mild tenderness to palpation without rebound or
gaurding, no masses or organomegally
Ext: No cyanosis, clubbing, edema
Neuro: Able to answer questions yes or no with mask on, appears
appropriate; 1+ DTR biceps, brachioradialis, patella right; no
response L, plantar reflex equivocal bilaterally; motor [**3-2**]
RUE/LE, 0/5 left
Skin: bronzy changes to LE, left with ecchymosis
Pertinent Results:
[**2148-8-11**] 09:50AM PT-13.1 PTT-27.8 INR(PT)-1.1
[**2148-8-11**] 09:50AM PLT COUNT-396
[**2148-8-11**] 09:50AM NEUTS-89.5* LYMPHS-6.2* MONOS-4.2 EOS-0.1
BASOS-0.1
[**2148-8-11**] 09:50AM WBC-20.5* RBC-4.30* HGB-13.7* HCT-41.3 MCV-96
MCH-31.8 MCHC-33.1 RDW-13.8
[**2148-8-11**] 09:50AM CK-MB-29* MB INDX-11.8*
[**2148-8-11**] 09:50AM cTropnT-0.60*
[**2148-8-11**] 09:50AM CK(CPK)-245*
[**2148-8-11**] 09:50AM estGFR-Using this
[**2148-8-11**] 09:50AM GLUCOSE-649* UREA N-45* CREAT-1.2 SODIUM-138
POTASSIUM-4.4 CHLORIDE-94* TOTAL CO2-26 ANION GAP-22*
[**2148-8-11**] 09:56AM LACTATE-4.8*
[**2148-8-11**] 12:56PM ALBUMIN-3.7
[**2148-8-11**] 12:56PM LIPASE-20
[**2148-8-11**] 12:56PM ALT(SGPT)-39 AST(SGOT)-65* ALK PHOS-75
AMYLASE-107* TOT BILI-0.4
[**2148-8-11**] 12:56PM GLUCOSE-575* UREA N-44* CREAT-1.2 SODIUM-138
POTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-26 ANION GAP-19
[**2148-8-11**] 12:58PM GLUCOSE->500 LACTATE-7.2*
[**2148-8-11**] 02:20PM URINE RBC-[**5-7**]* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-0-2
[**2148-8-11**] 02:20PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2148-8-11**] 02:20PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.050*
[**2148-8-11**] 02:20PM URINE HOURS-RANDOM CREAT-25 SODIUM-14
[**2148-8-11**] 03:00PM PSA-0.6
[**2148-8-11**] 03:00PM CORTISOL-100.4*
[**2148-8-11**] 03:00PM TRIGLYCER-192* HDL CHOL-48 CHOL/HDL-3.0
LDL(CALC)-57
[**2148-8-11**] 03:00PM %HbA1c-8.7*
[**2148-8-11**] 03:00PM calTIBC-291 FERRITIN-267 TRF-224
[**2148-8-11**] 03:00PM CALCIUM-10.6* PHOSPHATE-3.2 MAGNESIUM-2.5
IRON-33* CHOLEST-143
[**2148-8-11**] 03:00PM CK(CPK)-318*
[**2148-8-11**] 03:00PM CK(CPK)-318*
[**2148-8-11**] 03:00PM GLUCOSE-470* UREA N-43* CREAT-1.3* SODIUM-142
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-29 ANION GAP-17
[**2148-8-11**] 03:10PM O2 SAT-58
[**2148-8-11**] 03:10PM LACTATE-5.0*
[**2148-8-11**] 03:10PM TYPE-CENTRAL VE TEMP-36.8 RATES-/31 PEEP-8
O2-50 PO2-36* PCO2-50* PH-7.38 TOTAL CO2-31* BASE XS-2
INTUBATED-NOT INTUBA VENT-SPONTANEOU COMMENTS-AX TEMP =
[**2148-8-11**] 04:08PM HGB-12.5* calcHCT-38
[**2148-8-11**] 04:08PM LACTATE-3.6*
[**2148-8-11**] 04:08PM TYPE-ART TEMP-35.7 PO2-106* PCO2-38 PH-7.47*
TOTAL CO2-28 BASE XS-3 INTUBATED-NOT INTUBA
[**2148-8-11**] 06:01PM freeCa-1.34*
[**2148-8-11**] 06:01PM LACTATE-3.7*
[**2148-8-11**] 06:01PM TYPE-ART PO2-70* PCO2-36 PH-7.52* TOTAL
CO2-30 BASE XS-5
[**2148-8-11**] 07:06PM OTHER BODY FLUID WBC-0 RBC-0 POLYS-0 LYMPHS-0
MONOS-0
[**2148-8-11**] 07:06PM OTHER BODY FLUID GLUCOSE-55 CREAT-0 LD(LDH)-<5
AMYLASE-<3 UREA N-26
[**2148-8-11**] 10:59PM freeCa-1.32
[**2148-8-11**] 10:59PM HGB-11.9* calcHCT-36
[**2148-8-11**] 10:59PM LACTATE-2.8*
[**2148-8-11**] 10:59PM TYPE-ART TEMP-36.8 PO2-96 PCO2-37 PH-7.50*
TOTAL CO2-30 BASE XS-4
[**2148-8-11**] 11:57PM PLT COUNT-254
[**2148-8-11**] 11:57PM WBC-15.2* RBC-3.44* HGB-11.1* HCT-33.4*
MCV-97 MCH-32.1* MCHC-33.2 RDW-14.0
[**2148-8-11**] 11:57PM CALCIUM-9.9 PHOSPHATE-2.5* MAGNESIUM-2.1
[**2148-8-11**] 11:57PM GLUCOSE-210* UREA N-42* CREAT-1.2 SODIUM-144
POTASSIUM-3.5 CHLORIDE-107 TOTAL CO2-26 ANION GAP-15
CT A/P ([**8-11**]): The lung bases demonstrate dependent atelectatic
changes bilaterally. More focal patchy consolidation at the left
base may
represent infection, however. Atherosclerotic calcification of
the coronary arteries are noted. There is no evidence for
pericardial or pleural effusion. The liver is diffusely
hypodense which may represent fatty infiltration. No focal
hepatic lesion is observed and there is no biliary ductal
dilatation. The patient is status post cholecystectomy. The
spleen and adrenal glands are unremarkable. The kidneys enhance
symmetrically and excrete contrast normally and there is no
evidence of hydroureter or hydronephrosis. There are innumerable
hypodense renal cystic lesions bilaterally, many of which are
exophytic. The largest of these appear to represent simple
cysts. The pancreas demonstrates diffuse fatty atrophy. A G-tube
is present within the stomach and terminates near the gastric
antrum. Intra-abdominal loops of large and small bowel are
unremarkable, though evaluation is limited without intraenteric
contrast. There is no free air or free fluid. No pathologically
enlarged mesenteric or retroperitoneal lymph nodes are
identified. Atherosclerotic calcification of the abdominal aorta
and its branches are observed though the aorta is of normal
caliber. The rectum and sigmoid colon are unremarkable. The
bladder is collapsed. Multiple prosatic seeds are identified and
surgical clips are noted along the pelvic walls bilaterally. No
pathologically enlarged pelvic or inguinal lymph nodes are
identified. Bone windows reveal no worrisome lytic or sclerotic
lesions. A small sclerotic lesion in the T12 vertebral body
likely represents a bone island. Superior endplate compression
deformity of L3 and associated height loss are of unkown
chronicity without priors. IMPRESSION:
1. No focal intra-abdominal fluid collection. 2. Focal patchy
consolidative changes at the left base may represent early
pneumonia or aspiration. 3. Insufficiency compression deformity
of L3 of unkown chronicity. 4. Multiple bilateral renal cysts.
TTE ([**8-12**]): The left atrium is mildly dilated. The right atrium
is moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is moderate regional
left ventricular systolic dysfunction with severe hypokinesis of
the distal half of the anterior septum and anterior walls, apex,
and distal inferior wall. No apical thrombus is seen, but the
apex is not well visualized. The remaining segments contract
normally (LVEF = 35%). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). 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. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. There is mild pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a fat pad.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with regional systolic dysfunction c/w
CAD (mid LAD distribution). Increased LVEDP. Pulmonary artery
systolic hypertension. Dilated ascending aorta.
Brief Hospital Course:
[**Age over 90 **] yo man with CVA, dysphagia on TF via PEG, CAD, prostate CA,
admitted to MICU with PEG dysfunction presumably leading to
aspiration pneumona with hypoxemic respiratory failure. Also
with cardiac ischemia, elevated lactate.
.
# Respiratory failure and aspiration PNA: Initially started on
CPAP. Clinical exam and imaging consistent with LLL pneumonia,
likely due to aspiration. CHF also likely contributing.
Patient initially met criteria for severe sepsis, with elevated
lactate and signs of end-organ dysfunction involving cardiac
ischemia. Legionella urinary antigen was negative. Sputum
culture [**8-15**] had extensive contamination with upper respiratory
secretions. Blood cultures x 3 with no growth to date. He was
started on Vanc and Zosyn with plans to complete a 14 day course
to end on [**8-24**]. Fever on admission resolved, and white count
trended down from 20.5 on admission to 13.4 on discharge.
- Vanco, zosyn ?????? 14-day course to end on [**8-24**]
- Cautious diuresis, with goal -500 cc per day
- Continue Vanc/Zosyn for pneumonia
- Monitor electrolytes
- Continue active pulmonary toilet/ Chest PT
- Would avoid NIPPV in setting of copious secretions.
.
# Bleeding/PEG tube dysfunction. Initially, there was copious
dark red fluid draining about PEG tube with bilious non-bloody
fluid lavaged through lumen of tube. CT showed balloon was in
pylorus/antrum. Consulted surgery, who felt that the PEG was
causing gastric outlet obstruction. Surgery relieved the
obstruction by pulling back on tube, with resolution of the
discharge. On [**6-12**] and [**6-13**], there was bloody discharge around
the tube. The tube was replaced by interventional radiology on
the evening of [**6-13**] with larger tube. Began tube feeds [**6-14**] and
stopped in the setting of brief hypotension, then restarted.
Patient had diarrhea and dark stools that were felt likely to be
from this source. GI consult was considered but risk of
endoscopy to look for another site of bleeding would outweigh
benefit and if bleeding is along PEG tube tract, and PEG tube
bleeding would not be amenable to endoscopic repair.
- Continue to monitor Hct
- PPI
- tube feeds per nutrition recs
- can give meds via PEG
.
# Diarrhea: The patient has had diarrhea, guiaic positive, for
around 3 days now. Blood in stool most likely due to G-tube
dysfunction/repositioning. C. diff negative.
.
# Possible UTI: Three urinalyses had significant numbers of
WBCs and RBCs, however urine cultures were negative. Current
antibiotic coverage would be sufficient for most UTIs.
.
# Tachycardia ?????? The patient has had SVT (likely atrial
tachycardia) with HR as high as 170. This was well controlled
with metoprolol 25 mg PO BID. HR 64-104 on day of discharge.
.
# Acute cardiac ischemia: Suspect demand ischemia in the setting
of high demand with known CAD. Troponins have trended down
(most recently 0.58 on [**6-11**], down from peak 1.72 on [**6-10**]). TTE
showed focal wall motion abnormalities that may be from old MI,
although no old echo is available for comparison. EKG [**6-14**] depressions in I and V3-V6.
- Continue supplemental O2
- Hold ASA due to concern about GI bleeding, this should be
restarted once HCT stable
- statin
- B-blocker
- diuresis to reduce preload
.
# Hyperglycemia: The patient has known diabetes, likely
exacerbated by infection/stress. Blood sugars elevated to
500s-600s on admission, controlled with insulin drip. He was
weaned off insulin gtt and then covered with lantus and ISS.
- monitor blood sugars QID
- holding patient??????s home oral hypoglycemics while in hospital
.
# Hypercalcemia: Ionized Ca mildly elevated. Unclear etiology,
given h/o prostate ca concern for metastatic lesions. Bony
abnormality on abdominal CT read as bony island. Also consider
hyperparathyroidism.
- No further work-up at this time, but outpatient follow-up
needed
.
# Code: After lengthy discussions with son and HCP [**Name (NI) **],
patient over-all DNR/DNI and in the event of an emergency with
rapid/acute deterioration would not resuscitate him or intubate
him, however, if slow decline and not tolerating NIPPV family
would consider trial intubation.
.
# Communication: Patient, son [**Name (NI) **] (c) [**Telephone/Fax (1) 69894**], (h)
[**Telephone/Fax (1) 69895**], (other c) [**Telephone/Fax (1) 69896**].
Medications on Admission:
regular insulin [**Hospital1 **] per protocol/nph 20u qpm
lovastatin 20mg qhs
trazadone 25mg qhs
tylenol 650mg prn
lac-hydrin daily
amlodipine 2.5mg daily
melatonin 1mg qhs
artificial tears [**Hospital1 **]
dorzolamide 2% 1gtt ou [**Hospital1 **]
isosorbide dinitrate 2.5mg tid
ranitidine 150mg [**Hospital1 **]
glipizide 7.5mg q am, 15mg q pm
aspirin 81mg daily
ferrous sulfate 330mg daily
folate 1mg daily
timolol 0.5% 1 gtt ou [**Hospital1 **]
leuprolide q120 days ([**2148-6-30**])
lidocaine jelly tid prn
citalopram 5mg daily
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection Q8H (every 8 hours).
3. Atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day) as needed for constipation.
5. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for pain.
6. Insulin Regular Human 100 unit/mL Solution Sig: 0-16 U
Injection every six (6) hours: Sliding scale:
0-70 [**11-29**] amp D50
61-150 0 U
151-200 4 U
201-250 7 U
251-300 10 U
301-350 13 U
351-400 16 U
> 400 Notify MD.
7. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) U
Subcutaneous at bedtime.
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q6H (every 6 hours).
10. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours).
11. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 100**] Rehab MACU
Discharge Diagnosis:
Aspiration Pneumonia
Percutaneous Endoscopic Gastrostomy tube dysfunction with
bleeding
Systolic Congestive Heart Failure
Demand-related cardiac ischemia
Discharge Condition:
Stable.
VS: HR 80, BP 116/46, RR 25, O2 Sat 96% on 14 L face mask, NAD
Discharge Instructions:
Continue to monitor hematocrit.
Continue work on respiratory status with antibiotics, gentle
diuresis, pulmonary toilet, chest PT
Followup Instructions:
Provider: [**Name10 (NameIs) **] UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2148-9-4**]
9:00
Follow up with PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 38919**]
Completed by:[**2148-8-30**]
|
[
"427.81",
"428.0",
"285.1",
"275.42",
"518.81",
"427.31",
"785.52",
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"038.9",
"250.22",
"507.0",
"995.92",
"536.49",
"428.23",
"410.71",
"272.4",
"401.9",
"V45.81",
"578.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"97.02"
] |
icd9pcs
|
[
[
[]
]
] |
16071, 16127
|
9830, 14285
|
242, 299
|
16325, 16399
|
3323, 9807
|
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|
2423, 2432
|
14867, 16048
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16148, 16304
|
14311, 14844
|
16423, 16555
|
2447, 3304
|
178, 204
|
327, 1654
|
1676, 2294
|
2310, 2407
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,927
| 111,258
|
37934
|
Discharge summary
|
report
|
Admission Date: [**2189-8-3**] Discharge Date: [**2189-8-17**]
Date of Birth: [**2106-12-24**] Sex: M
Service: MEDICINE
Allergies:
Ibuprofen
Attending:[**First Name3 (LF) 3043**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP [**2189-8-3**]
Laparoscopic cholecystectomy [**2189-8-9**]
History of Present Illness:
82M transfer with reported cholecystitis. He is not the
best historian. He notes abdominal pain that started 3 days
ago.
He denies fevers/chills, nausea/vomiting. He has not eaten in a
day or so. He reports [**Location (un) 2452**] colored urine over the past few
days, but no [**Male First Name (un) 1658**] colored stools. He denies any recent weight
loss. He is unable to tell me his last colonoscopy.
Past Medical History:
PMH:
HTN
glaucoma
HTN
gout
hypothyroidism
Social History:
Lives with his son.
Longstanding tobacco use: quit [**2183**]
No ETOH or IVDA
Family History:
non contributory
Physical Exam:
PE
Tc 98.6, HR 76, BP 178/85, RR 16, O2sat 99%
Genl: NAD, scleral icterus
CV: RRR
Resp: expiratory wheezing
Abd: s/nt/nd; no visible scars
Extr: no c/c/e
DRE: nl rectal tone; guaiac negative
Pertinent Results:
[**2189-8-3**] 05:30AM WBC-21.4* RBC-4.70 HGB-15.0 HCT-44.4 MCV-95
MCH-32.0 MCHC-33.9 RDW-13.3
[**2189-8-3**] 05:30AM PLT COUNT-284
[**2189-8-3**] 05:30AM PT-11.5 PTT-25.9 INR(PT)-1.0
[**2189-8-3**] 05:30AM GLUCOSE-109* UREA N-42* CREAT-2.1* SODIUM-140
POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-25 ANION GAP-19
[**2189-8-3**] 05:30AM ALT(SGPT)-300* AST(SGOT)-95* LD(LDH)-285* ALK
PHOS-286* TOT BILI-9.4* DIR BILI-7.4* INDIR BIL-2.0
[**2189-8-14**] 07:07AM BLOOD WBC-15.3* RBC-3.35* Hgb-9.9* Hct-31.6*
MCV-94 MCH-29.6 MCHC-31.4 RDW-14.5 Plt Ct-501*
[**2189-8-14**] 07:07AM BLOOD Plt Ct-501*
[**2189-8-11**] 02:14AM BLOOD Fibrino-488*
[**2189-8-14**] 07:07AM BLOOD Glucose-88 UreaN-30* Creat-2.2* Na-142
K-3.7 Cl-106 HCO3-25 AnGap-15
[**2189-8-14**] 07:07AM BLOOD Glucose-88 UreaN-30* Creat-2.2* Na-142
K-3.7 Cl-106 HCO3-25 AnGap-15
[**2189-8-14**] 07:07AM BLOOD LD(LDH)-268*
[**2189-8-12**] 09:41PM BLOOD Lipase-68*
[**2189-8-13**] 02:24AM BLOOD CK-MB-5 cTropnT-0.04*
[**2189-8-14**] 07:07AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.2
[**2189-8-11**] 02:14AM BLOOD TSH-37*
[**2189-8-13**] 03:00AM BLOOD Comment-GREEN TOP
[**2189-8-13**] 03:00AM BLOOD Lactate-1.8
Echo: [**2189-8-13**]
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is unusually small. Left ventricular systolic function is
hyperdynamic (EF>75%). There is a mild resting left ventricular
outflow tract obstruction. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2189-8-4**],
the LV walls are better seen. The inferolateral wall thickness
is normal. There is discrete upper septal hypertrophy - coupled
with the hyperdynamic LV systolic function, there is functional
LVOT obstruction with a small gradient. Hypertrophic
cardiomyopathy cannot be excluded. The degree of mitral
regurgitation has increased slightly. The estimated pulmonary
artery systolic pressures have increased.
CXR: [**2189-8-13**]
COMPARISON: [**2189-8-12**].
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Unchanged retrocardiac atelectasis, unchanged right
suprabasal
atelectasis. Unchanged mild enlargement of the right hilar
structures,
presumably due to vascular crowding. No newly appeared focal
parenchymal
opacity, no evidence of overhydration, no pneumothorax.
RUQ US [**2189-8-3**] : IMPRESSION:
1. The sum of son[**Name (NI) 493**] and CT findings are concerning for
acute
cholecystitis. No biliary dilatation.
2. Pancreas not visualized
[**2189-8-3**] Abd CT :IMPRESSIONS:
1. Together with same-day son[**Name (NI) 493**] findings, CT findings are
concerning for acute cholecystitis.
2. Pancreatic cyst and vague hypodense area are likely
incidental findings.
These are incompletely evaluated and may be further assessed
with IV contrast
after resolution of acute symptoms.
2. Small hiatal hernia. Bilateral fat-containing inguinal
hernias.
3. Atherosclerotic disease with coronary artery disease.
[**2189-8-3**] ERCP : Impression: Stone and sludge in biliary tree on
cholangiography.
Successful biliary sphincterotomy performed.
One stone and sludge with a small amount of pus was retrieved
from the biliary tree using a 12mm balloon
(sphincterotomy, stone extraction)
Otherwise normal ercp to third part of the duodenum
[**2189-8-4**] Cardiac echo: Conclusions
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is normal
(LVEF>55%). There is a mild resting left ventricular outflow
tract obstruction. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are moderately
thickened. There is a minimally increased gradient consistent
with minimal aortic valve stenosis. Trace aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened.
Physiologic mitral regurgitation is seen (within normal limits).
The left ventricular inflow pattern suggests impaired
relaxation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
[**8-5**] /09 Abdominal CT: IMPRESSION:
1. Mild pancreatitis with likely beginning pseudocyst formation
posterior to
the body of the pancreas
2. Cystic lesions in the head of the pancreas are likely
incidental and may represent IPMN. Follow- up in 6 months is
recommended to ensure stability.
this could be performed with MRI.
3. Acute cholecystitis with hyperemia of the adjacent liver
parenchyma
Brief Hospital Course:
1. Gallstone pancreatitis and Choledocholithiasis: Patient
initially transferred from OSH with symptoms of biliary
obstruction (elevated LFTs and total bilirubin of 9.4) and
pancreatitis. Patient was placed on Unasyn, made NPO and
hydrated with IVF. Patient underwent ERCP with spincterectomy
and extraction of multiple stones on [**8-3**]. Abdominal pain
improved and patient placed on clear diet which he tolerated
well. WBC count decreased from 21.4 on admission to 12.9
following ERCP. On [**8-9**], patient was taken back to the
operating room for laproscopic cholecystectomy. Surgery was
reportedly technically difficult and significant venous oozing
of the liver bed was observed. He was transferred back to the
general surgery floor [**8-11**]. Postoperative course with numberous
complications including acute on chronic renal failure, acute
anemia, acute respiratory distress and rising WBC count (all
outlined below). By time of discharge, biliary obstruction had
subjectively and objectively improved. LFTs had trended down,
total bilirubin was 1.4 and patient was tolerating oral intake.
His port sites were dry and healing well.
Of note, on his initial abdominal CT a pancreatic cyst/mass was
noted at the junction of the head and the body thus prompting a
repeat abdominal CT with pancreatic protocol. His repeat CT
scan noted that the cyst was an incidenental finding and should
be followed in 6 months with a repeat scan or MRI.
2. Labile HTN: Throughout hospital course, patient had labile
HTN with systolic BP rising to as high as 180s- 200s, prompting
multiple changes in BP management. Initially, patient was
continued on his home verapamil SR 240mg daily although his ACEI
was held secondary to creatinine of 2.1 (see below). Labetolol
was added temporarily prior to lap cholecystectomy.
Postoperatively, patient was on verapamil only and had markedly
elevated blood pressure to 170-180s on [**8-12**]. At this point,
patient developed acute respiratory distress most likely
secondary to flash pulmonary edema and was transferred to
medical ICU. Blood pressure was initially controlled with
hydralazine. Lisinopril was started at home dose on [**8-13**] of
MICU stay. Labetolol was also added to blood pressure regimen,
and pressures became more well controlled and stable, with SBP
ranging mostly in 120's - 130's.
3. Acute Respiratory Distress: On [**8-12**], patient was transferred
from general surgery floor to MICU for worsening respiratory
distress. Patient was tachypnic to 40s with prominent wheeze
and a new O2 requirement of 6L NC. ABG on transfer was
7.44/23/102, with a HCO3 of 16. Initially, patient was started
on vancomycin and zosyn secondary to concern of VAP. CXR
showed increased interstitial pattern consistent with early
pulmonary edema. While patient has an extensive smoking
history, he has no known history of COPD and labs were not
consistent with chronic CO2 retention. PE was considered to be
unlikely given quick resolution of symptoms with treatment, and
prior negative LENIs. Cardiac enzymes were cycled, with
troponins .02, .04 and negative CK-MB. Nebulizer treatments
were continued for symptomatic relief. Dyspnea was thought to
be secondary to flash pulmonary edema in the setting of poorly
controlled HTN and all antibiotics were stopped. Overall
respiratory status improved, with fluid balance of -2.5 liters
during 2 days of MICU stay. Patient was weaned off oxygen
requirement. On [**8-15**], the patient did have an episode of
dyspnea on the floor. O2 sats were 94% on RA, and he responded
to albuterol nebs. His CXR also showed increased fluid, and he
was given IV lasix. By time of discharge he was saturating 97%
on room air.
4. Leukocytosis: Upon transfer to [**Hospital1 18**], patient had WBC of 24.5
with a neutrophil predominance of 92% secondary to cholecystitis
and gallstone pancreatitis. Following initial ERCP, WBC fell
to 12.9. After laproscopic cholecystectomy on [**8-9**], WBC count
again rose to the 20s although patient remained afebrile and
without focal symptoms of infection. Abdominal exam was
unremarkable, giving low suspicion for a surgical deep space
infection. Leukocytosis was felt to be an acute response to
recent stress. When patient transferred to MICU on [**8-12**] for
respiratory distress, there was initial concern for PNA given
prolonged hospital course and recent intubation. Antibiotics
were started empirically on [**8-12**], but discontinued on [**8-13**] due
to rapid resolution of symptoms. Urine culture from [**8-11**] was
negative. The positive urine culture on [**8-14**] was attributed to
bladder trauma from the previous evening (see
dementia/agitation). He remained afebrile with WBC 9.6 at
discharge.
5. AMS: Throughout hospital stay, patient exhibited waxing and
[**Doctor Last Name 688**] mental status, with predominant sun downing features.
Patient became agitated multiple nights, pulling at IV and foley
(causing foley trauma with [**Known firstname **] hematuria), requiring halidol
for behavioral control. At baseline, patient exhibited marked
cognitive impairment as indicated by mini-mental exam and his
AMS may have represented features of his dementia. Other
sources of delerium including toxic- metabolic syndrome (med
effects, electrolyte imbalance, myxedema, etc), recent surgery,
ICU psychosis. Infection as etiology was also considered esp in
setting of leukocytosis and patient had multiple blood cultures,
urine cultures, CXR, etc. At time of discharge the pt was alert
and oriented x 2 and was at baseline per son.
6. Diastolic CHF: Patient with history of diastolic CHF that
contributed to complications of postoperative course, chiefly
acute respiratory distress from pulmonary edema. Cardiac
enzymes were cycled several times during postoperative course,
and always remained negative, indicating no acute coronary
syndrome. Echo was performed on [**8-13**], showing function LVOT
with a small gradient, slightly increased mitral regurgitation,
and increased pulmonary artery systolic pressures.
7. chronic kidney disease: Creatinine has been stably elevated
during admission, with baseline ~2.0, and consistent proteinuria
on urinalysis. Creatinine did increase to 2.4 on [**8-7**] likely
from CT scan with acute dye load, but returned quickly to
baseline with hydration. Chemistries were checked daily to
monitor renal function, and he maintained good urine output.
Lisinopril was initially held on hospitalization, but restarted
on [**8-13**] without incident. After his foley catheter was removed,
the patient did have some elevated post-void residuals.
However, with encouragement, he was able to further empty his
bladder. By the time of discharge, his post-void residuals was
58 ml.
8. Hypothyroidism: While on the floor, the patient was showing
some psychomotor slowing. His TSH was found to be 37 (50 on
recheck). His free T4 was also decreased at 0.31. His
levothyroxine was increased to 112 mcg (his reported home dose)
mg daily. He should have his thryroid rechecked in 4 weeks and
adjust meds as needed at that time.
9. Glaucoma: Home eye drop treatments were continued.
10. History of gout: Allopurinol was held given recent acute
rise in creatinine above baseline elevation. Will plan to
restart if creatinine remains stable, or resume as outpatient.
Prior to his follow up visit with Dr. [**Last Name (STitle) **] he will have an
abdominal CT to evaluate the pancreas.
Medications on Admission:
Allopurinol 100mg daily
.Cosopt [**Hospital1 **]
.HCTZ 25mg daily
.Lisinopril 40mg daily
.Verapamil SR 240mg daily
.Xalatan 0.005%
.Synthroid 12.5mcg daily
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] VNA
Discharge Diagnosis:
gallstone pancreatitis
Discharge Condition:
stable
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-26**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 1231**])
Call Dr. [**First Name (STitle) **] for a follow up appointment in 2 weeks
|
[
"585.9",
"518.81",
"574.71",
"428.33",
"584.9",
"274.9",
"403.90",
"244.9",
"577.0",
"428.0",
"365.9",
"288.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.88",
"51.85",
"51.23"
] |
icd9pcs
|
[
[
[]
]
] |
13878, 13933
|
6177, 13671
|
285, 351
|
14000, 14009
|
1217, 6154
|
16023, 16163
|
971, 989
|
13954, 13979
|
13697, 13855
|
14033, 15491
|
15507, 16000
|
1004, 1198
|
231, 247
|
379, 793
|
815, 860
|
876, 955
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,539
| 167,746
|
6376
|
Discharge summary
|
report
|
Admission Date: [**2152-9-15**] Discharge Date: [**2152-9-25**]
Service: GU
Allergies:
Amoxicillin / Aldomet / Procardia / Ampicillin / Percocet /
Adhesive Tape
Attending:[**First Name3 (LF) 6157**]
Chief Complaint:
left sided psoas abscess and left sided nonfunctional kidney
with renal calculi
Major Surgical or Invasive Procedure:
left nephrectomy, drainage of psoas abscess
History of Present Illness:
81F with hyperparathyroidism leading to 20 years of urinary
calculi. Recent diagnosis of parathyroid adenoma resected.
Left kidney with multiple large obstructing calculi, found to be
non functional with a psoas abscess. She underwent bilateral
percutaneous nephrostomy tube placement, antibiotic therapy and
returned on this admission for left nephrectomy and drainage of
abscess.
Past Medical History:
CAD s/p MI at 53
HTN
CHF s/p AVR
Nephrolithiasis
PAF
L CEA
Retroperitoneal hematoma
Social History:
Pt retired and currently live in [**Doctor Last Name **].
She ambulates and still drivesTob: stopped 30 yrs agoAlc: none
Pt retired and currently live in [**Doctor Last Name **] IslandShe ambulates and
still drivesTob: stopped 30 yrs agoAlc: none
Family History:
non-contributory
Physical Exam:
Physical Exam:
T: 97.5 BP: 160/74 P: 74 RR: 18 O2: 98% RA
Gen: Pt agitated, sitting up in bed, AOx2.5
HEENT: ATNC, anicteric
neck: supple no JVD
Cardiac: [**Last Name (un) 3526**] [**Last Name (un) 3526**], SEM heard best at R sternal edge and
throughout precordium
Lungs: CTA-B
Abd: soft, NT/ND, +BS R nephrostomy c/d/i, L incision c/d/i
non-erythematous
Ext: trace edema in LE b/l, 5/5 strength in grip/bicpes/quads.
FROM throughout.
Pertinent Results:
VRE screen NEGATIVE (historical +)
MRSA screen NEGATIVE
At admit
[**2152-9-15**] 01:50PM BLOOD WBC-11.2* RBC-4.03* Hgb-10.9* Hct-33.5*
MCV-83 MCH-27.2 MCHC-32.7 RDW-15.7* Plt Ct-268
[**2152-9-15**] 07:00AM BLOOD PT-13.7* PTT-26.9 INR(PT)-1.2
[**2152-9-15**] 01:50PM BLOOD Plt Ct-268
[**2152-9-15**] 01:50PM BLOOD Glucose-184* UreaN-14 Creat-1.0 Na-140
K-4.0 Cl-107 HCO3-24 AnGap-13
[**2152-9-15**] 07:39PM BLOOD Calcium-7.6* Phos-4.5 Mg-1.8
[**2152-9-15**] 11:52AM BLOOD Type-ART Rates-7/ Tidal V-510 O2-44
pO2-165* pCO2-43 pH-7.40 calHCO3-28 Base XS-1 Intubat-INTUBATED
Vent-CONTROLLED
[**2152-9-15**] 08:13AM BLOOD Hgb-9.3* calcHCT-28
[**2152-9-15**] 10:17AM BLOOD freeCa-1.10*
S/p d/c from SICU
[**2152-9-19**] 09:00PM BLOOD WBC-10.2 RBC-4.29 Hgb-11.5* Hct-36.6
MCV-85 MCH-26.7* MCHC-31.3 RDW-16.4* Plt Ct-313
[**2152-9-20**] 06:20AM BLOOD PT-13.8* PTT-27.1 INR(PT)-1.2
[**2152-9-19**] 09:00PM BLOOD Glucose-86 UreaN-21* Creat-1.2* Na-143
K-4.0 Cl-107 HCO3-23 AnGap-17
[**2152-9-19**] 09:00PM BLOOD Calcium-8.3* Phos-3.5 Mg-2.1
[**2152-9-22**] 05:30AM BLOOD Digoxin-0.9
[**2152-9-17**] 01:38PM BLOOD Type-ART pO2-91 pCO2-35 pH-7.43
calHCO3-24 Base XS-0
[**2152-9-16**] 02:22AM BLOOD Glucose-137* Lactate-2.9*
[**2152-9-20**] 08:14AM BLOOD freeCa-1.14
CXR ([**9-16**]) -- 1) Right internal jugular central venous line with
tip at the superior vena cava/right atrial border. No
pneumothorax. 2) Mild congestive heart failure.
CT ([**9-20**]) -- IMPRESSION:
1) Stable right UPJ and left distal ureter stones. Right
nephrostomy tube
and no right hydronephrosis. 2) Extensive diverticulosis without
evidence of diverticulitis. 3) Cholelithiasis. 4) Cardiomegaly.
5) Bilateral pleural effusions. 6) Probable hepatic cysts.
Brief Hospital Course:
Pt was admitted on [**2152-9-15**] for the purpose of definitive
surgical management of a chronic L kidney failure 2nd to
ureteral calculi and L purulent perinephric psoas abcess. The
planned L radical nephrectomy/ureterectomy was without
complication or finding necessitating a change in the
pre-operative diagnosis, but given her fragile health, large
fluid shift and the 800cc of EBL (addressed with 3U PRBC) she
was maintained in the PACU overnight. R nephrostomy tube
remained in place and General Surgery was present during the
case to assist with the lysis of extensive adheions of the
abcess to surrounding structures. On POD#1, it was decided to
wean her off the vent (SIMV), and she was taken to the SICU for
immediate post-operative period. She was given a 24 hour course
of Vanco, and started on 7 days of Ceftazidine. She was
sucessfully extubated on POD#2. However at this same time, she
was noted to be in A-Fib with an inappropriate pacemaker
response and EP was consulted for a question of the PM failure
to capture. The pacemaker was interrogated on [**9-17**] and its
setting reprogrammed to VV1 60. Wide complex V-tach was noted on
[**9-18**] and runs of NSVT were noted on [**9-20**]. EP again interrogated
the PM and considered it functioning well, but her digoxin level
was 1.2-1.4, above the optimum 0.8 which they felt could have
been contributing to ventricular irritability. Thus her out-pt
digoxin dose was halves in compensate for her change in renal
fxn. Similarly, lisinopril was also stopped post-operatively.
On POD#3, pt was cleared by a Speech and Swallow Eval. Pt was
transferred to 12Reisman and out of the SICU on POD#4, with
telemetry and a sitter. Chest tube was removed on POD#3, which
was place as per standard procedure for a thoracoabdominal
incision. She was advance to a regular diet on POD#5, and
restarted on her home dose of warfarin. Throughout the
post-operative period until they were removed on POD#7, her 2 JP
drains put out >100cc of serosanguinous fluid each. Sitter was
d/c'ed on POD#8 without incident; pt remained agitated but
cooperative. Pt was ready for discharge on POD#7, but could not
be discharged due to a sitter being involved in the pt's care.
On POD#10, pt had been without sitter for >24 hours without
incident, and had notably come back negative for both VRE and
MRSA.
Medications on Admission:
Same as below with the addition of lisinopril
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO QD (once a day).
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for
21 days.
Disp:*42 Capsule(s)* Refills:*0*
7. Ativan 1 mg Tablet Sig: 1-2 Tablets PO twice a day as needed
for insomnia: as needed for sleep/agitation PRN, not to exceed
3mg/24hrs.
8. Seroquel 25 mg Tablet Sig: One (1) Tablet PO twice a day.
9. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO once a day.
10. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO once a
day: Monday, Wednesday, Friday, alt with 2mg dose.
11. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO once a
day: Tuesday, Thursday, Saturday, Sunday.
12. Ferrous Sulfate 325 (65) mg Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO once a day.
13. Calcium 500 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
Clipper House
Discharge Diagnosis:
non functional left kidney with psoas abscess
Discharge Condition:
stable
Discharge Instructions:
Follow up with Dr. [**Last Name (STitle) 4229**] in [**2-1**] weeks. Staples to be removed 2
weeks after surgery on or about [**2152-9-29**]
Discharge to rehab/[**Hospital1 1501**] facility. Keep nephrostomy tube in place
until follow up visit. Please call to schedule follow up with
Dr. [**Last Name (STitle) 4229**] in [**2-1**] weeks.
Followup Instructions:
as above
Schedule f/u as noted above.
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] F. [**Telephone/Fax (1) 10941**] Follow-up appointment
should be in 2 weeks
|
[
"592.1",
"440.1",
"590.10",
"401.9",
"428.0",
"427.31",
"427.1",
"590.2",
"728.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.51",
"34.04",
"38.93",
"89.64",
"55.02",
"99.04",
"83.02",
"59.02"
] |
icd9pcs
|
[
[
[]
]
] |
7257, 7297
|
3446, 5804
|
355, 400
|
7387, 7395
|
1696, 3423
|
7784, 7961
|
1200, 1218
|
5900, 7234
|
7318, 7366
|
5830, 5877
|
7419, 7761
|
1248, 1677
|
236, 317
|
428, 813
|
835, 920
|
936, 1184
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,879
| 131,733
|
42837
|
Discharge summary
|
report
|
Admission Date: [**2195-2-20**] Discharge Date: [**2195-2-27**]
Date of Birth: [**2154-7-22**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
S/p MVC, splenic laceration
Major Surgical or Invasive Procedure:
[**2195-2-21**]
Exploratory laparotomy for trauma and splenectomy.
History of Present Illness:
42F s/p rollever MVC, driver ejected, GCS 15 with splenic lac
Grade 4b, large hemoperitoneum, shock bowel, L post rib fx [**1-16**],
left lat rib fx [**6-17**], C6 ant/inf vb fx, neg head ct. +ETOH
Injuries
Splenic laceration Grade 4b
Large hemoperitoneum, shock bowel
Left posterior rib fx [**1-16**]
Left lateral rib fx [**6-17**]
C6 ant/inf vertebral body fx
Past Medical History:
Anxiety, ? episodic EtOH binging
PSH:
C-section x2; Tonsillectomy
Social History:
She reports that pt is divorced and has 3 children
ETOH Intake
Family History:
NC
Physical Exam:
On Admission:
Constitutional: Constitutional: intoxicated, boarded and
collared
Head/Eyes: Normocephalic, abrasion, Pupils equal, round,
reactive to light
ENT/Neck: c-coillar in placeChest/Resp: NO chest wall
tenderness or crepitus, bilateral breath sounds
Cardiovascular: Regular rate and rhythm
GI/Abdominal: Soft, diffusely tender, nondistended, + FAST
exam
GU/Flank: No Costovertebral angle tenderness
Musculoskeletal: No deformity
Skin: No abrasions, lacerations, ecchymosis
Neuro: GCS 15, spontaneously moves all extremities to
command.
Psych: Normal mood,
On discharge
98.4 70 120/70 20 94RA
Gen: No acute distress, A+Ox3
HEENT: NCAT, in c-collar, PEERL
CV: RRR, no M/G/R, mild ttp at left ribs
Pulm: Mild rhonchi, otherwise clear to auscultation bilaterally
with good air movement
Abd: soft, NTND
Ext: no C/C/E
Pertinent Results:
[**2195-2-20**] 11:25PM BLOOD WBC-16.6* RBC-3.58* Hgb-10.4* Hct-32.6*
MCV-91 MCH-29.0 MCHC-31.9 RDW-13.2 Plt Ct-190
[**2195-2-21**] 02:16AM BLOOD WBC-19.5* RBC-3.87* Hgb-11.8* Hct-34.7*
MCV-90 MCH-30.4 MCHC-33.9 RDW-13.5 Plt Ct-172
[**2195-2-22**] 10:24AM BLOOD Hct-31.5*
[**2195-2-21**] 02:16AM BLOOD Glucose-123* UreaN-18 Creat-0.6 Na-144
K-3.8 Cl-115* HCO3-17* AnGap-
[**2195-2-21**] 02:16AM BLOOD Calcium-7.3* Phos-3.9 Mg-1.3*
[**2195-2-20**] 11:28PM BLOOD pH-7.24* Comment-GREEN TOP
[**2195-2-21**] 12:31AM BLOOD Type-ART pO2-284* pCO2-40 pH-7.26*
calTCO2-19* Base XS--8
[**2195-2-21**] 02:32AM BLOOD Type-ART pO2-257* pCO2-39 pH-7.26*
calTCO2-18* Base XS--8
[**2195-2-21**] 08:08PM BLOOD Type-ART Temp-37.4 Rates-/12 PEEP-0
FiO2-40 pO2-190* pCO2-42 pH-7.38 calTCO2-26 Base XS-0
Intubat-INTUBATED Vent-SPONTANEOU
[**2195-2-22**] 02:19AM BLOOD Type-ART Temp-36.6 Rates-/15 O2 Flow-2
pO2-75* pCO2-41 pH-7.40 calTCO2-26 Base XS-0 Intubat-NOT INTUBA
[**2195-2-22**] 10:24AM BLOOD Hct-31.5*
[**2195-2-22**] 07:10PM BLOOD Hct-30.6*
[**2195-2-23**] 05:02AM BLOOD WBC-14.6* RBC-3.48* Hgb-10.1* Hct-31.6*
MCV-91 MCH-29.2 MCHC-32.1 RDW-13.7 Plt Ct-194
[**2195-2-24**] 04:19AM BLOOD WBC-18.0* RBC-3.66* Hgb-10.5* Hct-33.0*
MCV-90 MCH-28.6 MCHC-31.8 RDW-13.6 Plt Ct-252
[**2195-2-25**] 09:15AM BLOOD WBC-11.1* RBC-3.75* Hgb-10.9* Hct-34.4*
MCV-92 MCH-29.1 MCHC-31.8 RDW-13.5 Plt Ct-408#
[**2195-2-26**] 05:33AM BLOOD WBC-7.9 RBC-3.62* Hgb-10.6* Hct-32.9*
MCV-91 MCH-29.4 MCHC-32.4 RDW-14.0 Plt Ct-427
[**2195-2-22**] 02:04AM BLOOD Plt Ct-194
[**2195-2-23**] 05:02AM BLOOD Plt Ct-194
[**2195-2-24**] 04:19AM BLOOD Plt Ct-252
[**2195-2-25**] 09:15AM BLOOD Plt Ct-408#
[**2195-2-26**] 05:33AM BLOOD Plt Ct-427
[**2195-2-22**] 02:04AM BLOOD Glucose-121* UreaN-12 Creat-0.5 Na-139
K-3.9 Cl-107 HCO3-28 AnGap-8
[**2195-2-23**] 05:02AM BLOOD Glucose-91 UreaN-7 Creat-0.5 Na-135 K-3.6
Cl-100 HCO3-26 AnGap-13
[**2195-2-24**] 04:19AM BLOOD Glucose-109* UreaN-5* Creat-0.5 Na-138
K-4.2 Cl-101 HCO3-29 AnGap-12
[**2195-2-23**] 05:02AM BLOOD CK(CPK)-1874*
[**2195-2-22**] 02:04AM BLOOD Calcium-7.8* Phos-2.0*# Mg-1.5*
[**2195-2-23**] 05:02AM BLOOD Calcium-8.1* Phos-2.1* Mg-1.5*
[**2195-2-24**] 04:19AM BLOOD Calcium-8.4 Phos-2.1* Mg-1.7
[**2195-2-25**] 09:10PM BLOOD Vanco-21.0*
[**2195-2-22**] 02:19AM BLOOD Type-ART Temp-36.6 Rates-/15 O2 Flow-2
pO2-75* pCO2-41 pH-7.40 calTCO2-26 Base XS-0 Intubat-NOT INTUBA
[**2195-2-22**] 02:19AM BLOOD Glucose-112*
[**2195-2-22**] 02:19AM BLOOD freeCa-1.08*
[**2195-2-25**] 09:15AM BLOOD WBC-11.1* RBC-3.75* Hgb-10.9* Hct-34.4*
MCV-92 MCH-29.1 MCHC-31.8 RDW-13.5 Plt Ct-408#
[**2195-2-26**] 05:33AM BLOOD WBC-7.9 RBC-3.62* Hgb-10.6* Hct-32.9*
MCV-91 MCH-29.4 MCHC-32.4 RDW-14.0 Plt Ct-427
[**2195-2-27**] 05:33AM BLOOD WBC-7.7 RBC-3.75* Hgb-10.9* Hct-34.5*
MCV-92 MCH-29.0 MCHC-31.5 RDW-13.9 Plt Ct-539*
[**2195-2-25**] 09:15AM BLOOD Plt Ct-408#
[**2195-2-26**] 05:33AM BLOOD Plt Ct-427
-[**2-20**] CT A/P: High-grade splenic laceration with pseudoaneurysm
and active extravasation, with moderate amount of blood
throughout the intraperitoneal cavity and pelvis. Minimally
displaced fractures of the lateral left 7th through 11th ribs.
Minimal subjacent pulmonary contusion and overlying subcutaneous
emphysema. Acute nondisplaced fractures at or adjacent to the
costovertebral junctions of the left 2nd through 10th ribs.
-[**2-21**] LUE plain films: No fracture or dislocation.
-[**2-21**] CXR: No interval change.
-[**2-22**] Radiology Report CHEST (PORTABLE AP) Study Date of
[**2195-2-23**] 5:17 AM. No interval change
-[**2-23**] CXR IMPRESSION:
AP chest compared to [**2-22**], 5:47 a.m.: Previous right middle
lobe atelectasis is unchanged. Pulmonary vascular congestion and
mild interstitial edema are new. There is also greater
opacification in the left lower lobe, which could be atelectasis
or aspiration. In the axillary region of the right mid lung is a
region of consolidation concerning for new pneumonia. Stomach is
moderately to severely distended with air and fluid. Left lower
lobe is collapsed. Adjacent pneumonia is better demonstrated by
CTA performed subsequently and dictated separately which also
documents widespread bronchial impaction, predominantly in the
right lung.
-[**2-23**] CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of
[**2195-2-23**] 8:29 AM
IMPRESSION:
1. Multifocal pneumonia with abrupt termination of the left
lower lobe
bronchus and complete left lower lobe collapse.
2. No acute aortic pathology or pulmonary embolism.
-[**2-24**] FINDINGS: As compared to the previous radiograph, there is
an area of increasing opacity at the bases of the right upper
lobe. The atelectasis at the right lung bases is unchanged. Also
unchanged is a relatively extensive retrocardiac atelectasis. No
other changes. The rib lesions are better appreciated on the CTA
chest from [**2195-2-23**].
Brief Hospital Course:
Patient was admitted to the TSICU on [**2195-2-20**] under the Acute
Care Surgery Service.
The patient went emergency to the operating room for and
exploratory laparotomy and splenectomy: EBL 800; 2,500
crystalloid. Received 4 u PRBC prior to OR. Hemodynamically
stable on return.
Neuro:
Patient initially intubated and sedated, upon extubation
Precedex needed to be continued for agitation, eventually weaned
off. Started Dilaudid PCA with good control of her pain. Pt also
had an epidural placed for pain control.
Patient has hx of anxiety and ETOH intake, was given Ativan per
CIWA scale and prn anxiety. No signs or symptoms of alcohol
withdrawal.
Stable C6 inferior endplate fracture. Moving all fours
extremities, no neurological deficit. Recommendations for Ortho
spine were continue C-collar for 4-6 weeks, no need for log roll
precautions. Thoracic and Lumbar spine was cleared.
Cardiac:
Patient presented s/p motor vehicular accident grade 4b splenic
laceration, large hemoperitoneum. HCT on admission was 32,
received 2 U RBC, vital signs and HCT remained stable after
surgery.
Lungs:
Patient was intubated for surgical procedure, extubated without
difficulties, when transferred to the floor patient had oxygen
supplementation at 2L NC.
Multiple rib fractures ( L posterior rib fx [**1-16**], left lateral
rib fx [**6-17**] ), Minimal subjacent pulmonary contusion and
overlying subcutaneous emphysema. On incentive spirometer and
pulmonary toilet. She was transferred to the floor on HD 3, but
then became tachypneic and hypoxic the morning of HD 4. She was
transferred back to the ICU and a CT showed no PE but LLL
collapse. After improved pain control, her sats and tachycardia
improved. She was also found to have a multifocal pneumona and
started on antibiotics, vancomycin and cefepime.
GI:
S/p splenectomy for splenic laceration grade 4b. Patient
received post splenectomy vaccinations on day of discharge.
Initial NPO after surgery. Clears started on POD1 before
transfer to the floor. Famotidine while in NPO for stress ulcer
prophylaxis. Patient tolerating regular diet on the floor.
GU:
Good urinary output, creatinine stable at 0.5. Foley was
discontinued on POD1.
Hem:
Serial HCT. S/p transfusion 2RBC [**2-21**] since then HCT stable.
ID:
Her WBC increased as expected post-splenectomy, then began to
decline. On HD 5, her WBC increased again, and she was started
on antibiotics for suspected hospital-acquired pneumonia. Her
white count then normalized.
DVT Prophylaxis
Pneumo boots. Subcutaneus heparin started post op and continued
while in hospital.
Pt was transferred to the floor on HD 6. Her epidural was
discontinued and she was transitioned to oral pain medication.
Physical therapy evaluated the patient and deemed her safe to go
home. On day of discharge patient received her post splenectomy
vacciones: H. Influenza, Pneumococcus and Meningicoccus. She was
also on a regular diet. She was satting well on room air. Her
vital signs were stable as were her lab counts. She was on oral
pain medications with good pain control, and oral antibiotics
which she will continue until [**2195-3-4**].
Medications on Admission:
Ativan
Discharge Medications:
1. linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*11 Tablet(s)* Refills:*0*
2. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*5 Tablet(s)* Refills:*0*
3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation for 2 weeks.
Disp:*28 Capsule(s)* Refills:*0*
5. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation for 2 weeks.
Disp:*28 Capsule(s)* Refills:*0*
6. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QID PRN () as
needed for agitation.
Discharge Disposition:
Home With Service
Facility:
Home Health of [**Location (un) 5028**]
Discharge Diagnosis:
splenic laceration, grade 4b
Left posteior rib fractures [**1-16**]
Left lateral rib fractures [**6-17**]
C6 vertebral body fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 92515**] [**Known lastname **],
You were admitted to the Acute Care Surgery Service at [**Hospital1 1535**] after a Motor Vehicle Accident.
You were found to have the following injuries: A splenic
laceration, multiple left sided rib fractures, and a cervical
spine fracture.
We performed a splenectomy (removed your spleen). We also gave
you vaccines, as is common practice after removing the spleen.
Spine surgery saw you and recommended a cervical collar for your
spine fracture. Keep this on until your spine appointment. At
your appointment the spine doctors [**Name5 (PTitle) **] address [**Name5 (PTitle) **] much longer
you need to keep it on.
For your rib fractures we gave you pain medications. You also
developed a pneumonia while hospitalized. We are treating you
with antibiotcs for this infection. You are being discharged
with by mouth antibiotics. Please take them as prescribed for
their full course. Please continue to use your incentive
spirometer to keep your airways open.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. Do not take pain medication and drink alcohol. You
may also take acetaminophen (Tylenol) as directed, but do not
exceed 4000 mg in one day. As pain medication can cause
constipation, please take stool softeners. We have prescribed
you senna and colace for this purpose.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 20
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Incision Care:
*Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash incisions with a mild soap and warm
water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2195-3-4**] at 3:00 PM
With: [**Known firstname **] [**Last Name (NamePattern1) 92516**], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Dr [**Last Name (STitle) **] is your new physician at [**Name9 (PRE) 191**]. She works closely with
Dr [**First Name (STitle) 3535**], [**First Name3 (LF) **] both will be involved in your care. Please call
your insurance and name Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3535**] as your PCP and change
your site to [**Hospital1 **]. THIS MUST BE DONE BEFORE
YOUR APPOINTMENT.
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2195-3-17**] at 1:45 PM
With: ACUTE CARE CLINIC with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 853**]
Phone:[**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
You will need a chest x-ray prior to this appointment. Please go
to [**Hospital1 7768**], [**Hospital Ward Name 517**] Clinical Center, [**Location (un) **]
Radiology 30 minutes prior to your appointment.
We are working on a follow up appt in the Spine Center with Dr.
[**Last Name (STitle) 1352**]. You will be called at home with the appointment. If
you have not heard or have questions, please call [**Telephone/Fax (1) 8603**]
and inquire about the status.
Completed by:[**2195-2-27**]
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31,895
| 126,347
|
33217
|
Discharge summary
|
report
|
Admission Date: [**2175-12-25**] Discharge Date: [**2175-12-29**]
Date of Birth: [**2153-1-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
Tylenol overdose
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Known firstname 449**] is a 22 year old male with a history of angry and
impulsive behavior who is transferred from an outside hospital
s/p Tylenol overdose. [**Known firstname 449**] reports that he and his girlfriend
broke up last Wednesday, and that he subsequently went on an
alcohol and cocaine binge lasting from Thursday to Saturday.
During this 3 day binge, he estimates that he drank 50-60 drinks
(beer and hard liquor), sniffed cocaine every few hours, and did
not sleep. He has used alcohol and cocaine regularly in the
past, but he denies having had a binge of this quantity or
duration before. On Saturday night, [**Known firstname 449**] told his father that
he had tried to hang himself at a nearby park, but the rope had
broken. [**Known firstname 449**] claims that his story was an attempt to seek
attention, and that he never actually attempted to end his life.
He does admit to having a very brief thought of dying on
Saturday night, but he says that he could never do it, and that
he has never had any suicidal ideations in the past.
At midnight on Saturday night, [**Known firstname 449**] ingested 25-30 tablets of
Tylenol Extra Strength in an effort to come down off his cocaine
high and fall asleep. Previously, [**Known firstname 449**] would usually take [**4-23**]
tablets of Tylenol Extra Strength to come down off his cocaine
highs. He says that this time, he took 25-30 tablets at once
because he was "really out of it" and was not fully aware of how
much Tylenol he was taking. He said that he did intend to take
more Tylenol than usual because his binge had lasted so long and
because he was so tired, but denies any knowledge that the
Tylenol could kill him. He acquired the Tylenol from his
family's medicine cabinet in the house's bathroom. He denies
recent use of any other drugs, including narcotics, mushrooms or
sniffing solvents. He did not have a substantial meal during
his 3 day binge, as he only ate a slice of pizza, some potato
chips and other junk food snacks. On Sunday morning, he awoke
at 8:30am with sharp stabbing pain in the lower quadrants of his
abdomen. The pain was [**7-28**] in severity, was alleviated by
eating jello, and did not radiate elsewhere. He threw up 3-4
times, with the emesis being non-bloody, non-bilious and
consisting of the recently consumed jello. He then requested
his father to take him to the emergency room.
At the outside hospital, [**Known firstname 449**] received IV fluids, Zofran,
Phengren, and Acetylcysteine. His peak serum acetaminophen
level was 111 approximately 13 hours after ingestion, and his
initial labs included an INR of 1.2, AST 468 and ALT 389. His
labs increased to an INR of 4.1, AST 1832 and ALT 1717, and he
was transferred to [**Hospital1 18**] on Monday ([**2175-12-25**]) for further
management and possible liver transplant workup. At [**Hospital1 18**],
[**Known firstname 449**] denied suicidal ideation and expressed desire for a liver
transplant if it would help him live. He was admitted to the
MICU where he received Acetylcysteine, and CXR and abdominal U/S
studies were unremarkable. His labs peaked at an INR of 3.1,
AST 12,100 and ALT 10,340 before trending downward, and on
Wednesday ([**2175-12-27**]) he was was transferred to the Medicine
service.
[**Known firstname 449**] denies any gross blood loss, bruising or jaundice. He has
not suffered any RUQ pain, and denies any severe headaches. He
has been urinating without pain or change in urine color, and he
denies any flank pain. He denies any history of withdrawal
symptoms, and he has not experienced any tremors or
palpitations. He denies nausea, vomiting, chills or diarrhea,
but he reports sweating and fevers on Tuesday ([**2175-12-26**]) night.
He has been eating and drinking without discomfort, and has had
well-formed stools with no gross blood.
Past Medical History:
Angry and impulsive behavior
No h/o hospitalizations
Social History:
[**Known firstname 449**] finished high school, but had problems in college because
he did not go to class and struggled with some coursework. He
got into trouble for fighting and damaging property, which he
attributes to being in the wrong place at the wrong time and
hanging out with bad company. He grew up playing hockey and is
a big fan of the [**Location (un) 86**] Bruins, although he stopped playing a
few months ago because he started working in the evenings. He
currently works for Papa [**Male First Name (un) 45193**] as a pizza delivery person, and
enjoys it because he gets a lot of freedom and makes good money.
He previously worked in construction.
[**Known firstname 449**] first got drunk at his high school senior prom. He drinks
1-2 times a week, and he will consume 2-3 beers in a sitting, or
13-14 beers if he is at a party. He has felt the need to cut
down his drinking, but denies feeling annoyance, guilt or
requiring an eye opener. He has driven short distances after
drinking alcohol, but will not drive if he feels that he is too
drunk. He denies smoking cigarettes, but he has smoked
marijuana although he is not a regular user. [**Known firstname 449**] started
using cocaine 2 years ago when he was in college, and has used
it 3-4 times a week since then. He only uses by sniffing, and
has never smoked or injected it. He has also experimented with
LSD, mushrooms, percocets and vicodins, but denies any history
of IV drug use. He doesn't think that he needs to attend a drug
rehabilitation program, although he expresses some desire to
talk to a counsellor about his substance abuse. He has been
attending anger management counseling on and off for a few
months. He denies that the sessions were court-ordered, but
says that he started these sessions at his family's request.
He currently lives with his father, step-mother and [**Name2 (NI) 1685**]
sister in [**Name (NI) 392**], and reports that he is happy and gets along
well with his family. He is only rarely in touch with his
biological mother who lives in [**Name (NI) 4565**]. After discharge from
hospital, [**Known firstname 449**] hopes to move in with his maternal grandmother
in [**Name (NI) 108**], [**First Name3 (LF) **] that he can try and get his life back in order.
Family History:
# Mother with bipolar disease and impulsive behavior
No family history of hepatitis or liver disease
Physical Exam:
VITALS: T: 98.3 BP: 118/72 P: 102 RR: 18 O2 sat: 99% RA
GENERAL: comfortably lying flat in bed, NAD, well nourished and
well-appearing
HEENT: Sclera anicteric, oral mucosa pink. PERRL, EOM intact,
oropharynx clear, no cervical lymphadenopathy.
RESPIRATORY: CTAB, no wheezes or rales
CVS: RRR, normal S1, S2, no murmurs
ABDOMEN: Non-tender to deep palpation in all quadrants. Soft,
non-distended, normoactive bowel sounds, no palpable masses or
organomegaly
GENITALIA: Deferred
EXTREMITIES: Warm, well perfused, no edema, clubbing or
cyanosis.
SKIN: No rashes, no needle track marks, no bruising except at
IV sites.
NEURO: AO x 3, no asterixis, no clonus.
PSYCH: Listens and responds to questions appropriately, pleasant
and thankful to be alive.
Pertinent Results:
ADMISSION LABS:
140 104 9
============< 172
4.3 28 1.1
.
Ca: 8.6 Mg: 2.0 P: 1.8
ALT: 2157 AP: 75 Tbili: 4.5 Alb: 4.0
AST: 1535 LDH: 726
.
5.7 > 46.7 < 113
N:78.6 Band:0 L:11.0 M:2.4 E:6.1 Bas:1.9
.
PT: 25.8 PTT: 36.3 INR: 2.5
.
Albumin 3.6
=========================================================
Peak INR: 3.1
Peak AST: 12,100
Peak ALT: 10,340
PEAK T BILI: 4.5
==========================================================
FINDINGS: The liver shows no focal or textural abnormalities.
There is no biliary dilatation and the common duct measures 0.5
cm. The gallbladder is normal without evidence of stones. The
pancreas is unremarkable. The spleen is enlarged measuring 14.7
cm. Both right and left kidneys are echogenic, but neither shows
hydronephrosis or stones or solid masses. The right kidney
measures 11.8 cm and the left kidney measures 11.9 cm. The aorta
is of normal caliber throughout. There is no evidence of
ascites.
DOPPLER EXAMINATION: Color Doppler imaging and pulse Doppler
waveforms were obtained. The main portal vein, right portal vein
and left portal vein are patent with hepatopetal flow. Arterial
waveforms of the main hepatic artery, the right hepatic artery
and the left hepatic arteries show good upstrokes with RIs
ranging from 0.47 to 0.51 cm/sec. There is appropriate flow in
the IVC, the hepatic veins and the splenic veins.
IMPRESSION:
1. Patent hepatic vasculature with no liver abnormalities
identified.
2. Splenomegaly.
===========================================================
CXR: The hemidiaphragms are in normal position. Structure and
transparency of the lung parenchyma are unremarkable, no signs
of overhydration, no pulmonary opacities. The size and
configuration of the cardiac silhouette are normal.
IMPRESSION: Normal chest radiograph
=============================================================
U/A: negative
.
MICRO:
Urine cx: NGTD
Blood cx: NGTD
Brief Hospital Course:
22 year old male with a history of angry and impulsive behavior
presents with ?unintentional tylenol OD during cocaine and EtOH
binge.
.
HOSPITAL COURSE BY PROBLEM LIST
.
1) Tylenol O/D and Acute Liver Failure
The patient ingested 25-30 pills of Tylenol Extra Strength at
midnight on the night of [**2175-12-23**]. He was brought to an OSH in
the morning of [**2175-12-24**], where he had a peak serum tylenol level
of 111, approximately 13 hours after ingestion. Upon
presentation at OSH, his initial labs included an INR of 1.2,
AST 468 and ALT 389, and he was started on N-Acetylcysteine.
His labs increased to an INR of 4.1, AST 1832 and ALT 1717, and
the patient was transferred to [**Hospital1 18**] for further management and
possible liver transplant workup. In the MICU, the patient's
labs peaked at INR of 3.1, AST 12,100 and ALT 10,340 before
steadily trending downward. Hepatitis and HIV serologies were
negative, and RUQ U/S showed mild splenomegaly but no other
abnormalities. He was transferred to the Medicine service where
his labs have continued to decline, and after consultation with
hepatology and toxicology, his N-Acetylcysteine was discontinued
on [**2175-12-29**]. During his stay he did not show any signs of
encephalopathy, jaundice, or renal failure. His most recent
labs on [**2175-12-29**] showed an INR of 1.4, AST 298, ALT 3,142. There
is no need to continue following liver function tests. He can
follow up with his PCP.
.
2) ETOH/Substance Abuse
The patient reports a history of alcohol abuse, drinking [**12-20**]
times a week, and consuming 2-3 beers in a sitting, or 13-14
beers if he is at a party. He has felt the need to cut down his
drinking, but denies feeling annoyance, guilt or requiring an
eye opener. He denies smoking cigarettes, but he has smoked
marijuana although he is not a regular user. He started using
cocaine 2 years ago when he was in college, and has used it [**2-20**]
times a week since then. He only uses by sniffing, and has
never smoked or injected it. He has also experimented with LSD,
mushrooms, percocets and vicodins, but denies any history of IV
drug use. He presented to the hospital after a 3 day alcohol
and cocaine binge. He denies having had a binge of this
quantity or duration before.
.
During this hospital stay, he has no experienced no signs of
alcohol or other drug withdrawal. He had a serum tox screen
that was negative for amphetamines on [**2175-12-24**]. He denies need
for social work support or enhanced professional support for
substance abuse. He plans to discuss overdose as an outpatient.
He expresses strong determination to maintain sobriety for
months, to moderate his alcohol use in the future, and to quit
using cocaine. He received a multivitamin, folate and thiamine
during his stay.
.
3) ? Suicide Attempt and h/o Suicidal Ideation
Patient denies knowledge that Tylenol overdose could be fatal,
and upon arrival at [**Hospital1 18**] he expressed desire for a liver
transplant if it would help him live. The patient has
consistently and adamantly denied that the Tylenol overdose was
a suicide attempt. He had taken [**4-23**] Tylenol Extra Strength
tablets in the past to come down off his cocaine highs and to
help him sleep.
.
Just prior to the overdose, the patient had told his father that
he had tried to hang himself at a nearby park, but the rope had
broken. The patient claims that his story was an attempt to
seek attention, and that he never actually attempted to end his
life. He does admit to having a very brief thought of dying on
that night, but he says that he could never do it, and that he
has never had any suicidal ideations in the past. On exam,
there was no evidence of bruising on his neck.
.
4) Fever
The pateint was febrile in the MICU to 101.9([**2175-12-26**]) and woke up
with drenching sweats at that time. On [**2175-12-28**], he again spiked
a fever to 100.6, but denied feeling ill or waking up with
sweats. These fevers are likely due to liver necrosis secondary
to Tylenol overdose. Urine culture showed no growth, and blood
cultures are pending. His lungs were clear to auscultation
bilaterally. The patient was observed for 24 hours from
[**Date range (3) 77165**] and remained afebrile throughout this time.
Patient may have occasional persistent fevers but these should
resolve.
Medications on Admission:
OUTPATIENT MEDICATIONS:
none
.
MEDICATIONS ON TRANSFER FROM MICU:
n-acetylcysteine 5600mg IV Q4h
pantoprazole 40mg daily
folic acid
multivitamin
Thiamine
Discharge Medications:
None
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] 4
Discharge Diagnosis:
Primary: Acute hepatic failure secondary to Tylenol overdose
Secondary: ? Suicide attempt/suicidal ideation
Discharge Condition:
Good.
.
ALT: 3142
AST: 298
INR: 1.4
.
Temp: 97.9
Discharge Instructions:
You were admitted with acute hepatic failure after overdosing on
Tylenol. You were tested for other liver diseases, and found to
be negative for HIV, Hepatitis A and Hepatitis B.
.
Your peak blood Tylenol level was 111, approximately 13 hours
after ingestion. Tests of your liver enzymes peaked at an INR
of 4.1, AST 12,100 and ALT 10,340. You were given intravenous
N-acetylcysteine (Mucomyst) for 4 days and the levels of your
liver enzymes steadily trended downward. After consulting with
your liver doctors and the [**Name5 (PTitle) 77166**], we stopped the
N-acetylcysteine on [**2175-12-29**]. Your most recent lab values on
[**2175-12-29**] were an INR of 1.4, AST 298, ALT 3142. During your
hospital stay, you did not show any other signs of liver failure
but you were initially evaluated for possible liver transplant.
.
You had a temperature of 101.9 on [**2175-12-26**], and woke up with
drenching sweats at that time. On [**2175-12-28**], you again spiked a
fever to 100.6, but you did not feel ill or wake up with sweats.
These fevers were likely due to the liver damage you
experienced because of your Tylenol overdose. We tested your
urine and blood for infection. Your urine test was negative,
and your blood tests are pending. Your lungs were clear with no
evidence of pneumonia. We observed you for 24 hours from
[**Date range (1) 77165**] and you remained afebrile throughout this time.
If you develop any new fevers or experience night sweats or
chills, please see your primary care doctor.
.
There was concern over your emotional stability and impulsive
actions in the days leading up to your Tylenol overdose. There
was also concern about your brief suicidal thoughts prior to
your overdose. Given your family history of bipolar disease,
and after consulting with your anger management counsellor, the
psychiatrists decided that it would be useful to do an
evaluation of you as an inpatient.
.
Please call your physician if you develop any concerning
symptoms such as bleeding, jaundice, severe abdominal pain,
nausea, vomiting or suicidal thoughts.
Followup Instructions:
Inpatient psychiatry
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
|
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|
6747, 7505
|
13855, 13986
|
278, 296
|
369, 4235
|
7540, 9430
|
4257, 4311
|
4327, 6614
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,733
| 137,366
|
31173
|
Discharge summary
|
report
|
Admission Date: [**2154-8-23**] Discharge Date: [**2154-9-3**]
Date of Birth: [**2076-8-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2154-8-28**] -
1. Aortic valve replacement with a 21-mm [**Last Name (un) 3843**]-[**Doctor Last Name **]
pericardial tissue heart valve.
2. Coronary artery bypass grafting x3, left internal mammary
artery graft to left anterior descending, reverse
saphenous vein graft to the marginal branch of the
posterior descending artery.
History of Present Illness:
Mr. [**Known lastname 73582**] is a 78-year-old male who suffers from morbid
obesity and multiple problems who was followed for aortic
stenosis that became critical. He was
severely symptomatic and found by cardiac catheterization to
have severe three-vessel disease presenting for high-risk aortic
valve replacement coronary artery bypass surgery.
Past Medical History:
CAD
AS
COPD
Diabetes melliyus type 2
COPD
Sleep apnea
Hypothyroidism
Hyperlipidemia
Obesity
BPH
Depression
Anxiety
CHF
Social History:
Lives with wife in [**Name (NI) 487**], MA. Retired. 5ppd for 50 year
smoking history. Quit drinking alcohol 23 years ago.
Family History:
Mother with MI.
Physical Exam:
71 sr 20 130/60 65" 235lbs
GEN: NAD
SKIN: Lower extremity venous stasis changes.
NECK: supple, FROM
LUNGS: CTA
HEART: RRR, SEM
ABD: Obese, S/NT/NABS
EXT: Trace to 1+ pulses of LE, No edema, warm and well perfused.
Bilateral carotid bruits. No varicosities,
NEURO: Nonfocal
Discharge
98.4, 128/80, 70 SR, 20, 92% RA sat wt: 113.7 kg
Alert and oriented x3 nonfocal
Pulmonary dimished bilat bases with crackles rt base
Cardiac RRR no m/r/g
Sternal inc healing no drainage/erythema sternum stable
Abd soft, nt nd bm [**9-2**]
Ext warm +2 pitting edema pulses palpable, bilat thighs
ecchymotic
Inc: Left EVH healing old JP site with small amount serosang
drainage - no erythema - TEDS to lower extremeties
Pertinent Results:
[**2154-9-3**] 09:21AM BLOOD WBC-8.2 RBC-3.65* Hgb-11.1* Hct-32.4*
MCV-89 MCH-30.4 MCHC-34.2 RDW-15.8* Plt Ct-265#
[**2154-9-3**] 09:21AM BLOOD Plt Ct-265#
[**2154-9-3**] 07:00AM BLOOD PT-11.8 INR(PT)-1.0
[**2154-9-3**] 07:00AM BLOOD Glucose-149* UreaN-18 Creat-0.9 Na-137
K-4.8 Cl-100 HCO3-26 AnGap-16
[**2154-8-23**] 07:44PM BLOOD Glucose-143* UreaN-23* Creat-1.1 Na-139
K-4.0 Cl-103 HCO3-26 AnGap-14
[**2154-8-23**] 07:44PM BLOOD ALT-16 AST-19 LD(LDH)-177 AlkPhos-60
TotBili-0.3
[**2154-8-31**] 02:59AM BLOOD Calcium-7.6* Phos-2.8 Mg-2.4
RADIOLOGY Preliminary Report
CHEST (PA & LAT) [**2154-9-3**] 11:41 AM
CHEST (PA & LAT)
Reason: evaluate effusion
[**Hospital 93**] MEDICAL CONDITION:
78 year old man with cad/as
REASON FOR THIS EXAMINATION:
evaluate effusion
CHEST TWO VIEWS PA AND LATERAL
History of coronary artery disease and aortic stenosis.
Status post CABG/AVR. Right jugular CV line has tip located in
region of cavoatrial junction _____ for low lung volumes. No
pneumothorax. Heart size and mediastinal width are unchanged
since the previous film of [**2154-8-31**]. There are persistent
small bilateral pleural effusions and bibasilar atelectases.
DR. [**First Name8 (NamePattern2) 4075**] [**Last Name (NamePattern1) 5999**]
Cardiology Report ECG Study Date of [**2154-8-29**] 10:49:32 AM
Sinus rhythm. P-R interval 0.19. Diffuse ST-T wave abnormalities
without change
compared to the previous tracing of [**2154-8-28**].
Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
67 90 98 [**Telephone/Fax (2) 73583**]70
Cardiology Report ECHO Study Date of [**2154-8-28**]
PATIENT/TEST INFORMATION:
Indication: Intraoperative for Aortic Valve Replacement,
Coronary Artery Bypass Grafting. Evaluate Valves, Ventricular
Function, Aortic Contours
Height: (in) 65
Weight (lb): 230
BSA (m2): 2.10 m2
BP (mm Hg): 135/30
HR (bpm): 55
Status: Inpatient
Date/Time: [**2154-8-28**] at 11:48
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW1-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Suboptimal
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.5 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 4.7 cm (nl <= 5.2 cm)
Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.1 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.6 cm
Left Ventricle - Fractional Shortening: 0.29 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 50% to 55% (nl >=55%)
Aorta - Valve Level: *3.9 cm (nl <= 3.6 cm)
Aorta - Ascending: *4.2 cm (nl <= 3.4 cm)
Aorta - Arch: 2.4 cm (nl <= 3.0 cm)
Aorta - Descending Thoracic: 2.3 cm (nl <= 2.5 cm)
Aortic Valve - Peak Velocity: *3.0 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 36 mm Hg
Aortic Valve - Mean Gradient: 25 mm Hg
Aortic Valve - Valve Area: *1.0 cm2 (nl >= 3.0 cm2)
Aortic Valve - Pressure Half Time: 410 ms
Mitral Valve - Peak Velocity: 0.8 m/sec
Mitral Valve - Mean Gradient: 1 mm Hg
Mitral Valve - Pressure Half Time: 48 ms
Mitral Valve - MVA (P [**2-5**] T): 4.6 cm2
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.5 m/sec
Mitral Valve - E/A Ratio: 1.60
Mitral Valve - E Wave Deceleration Time: 167 msec
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Lipomatous hypertrophy of the
interatrial
septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild
regional LV
systolic dysfunction. Low normal LVEF.
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal inferior
- hypo; mid inferior - hypo; inferior apex - hypo;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic sinus. Focal calcifications in
aortic root.
Moderately dilated ascending aorta. 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: Moderate-severe AS (area 0.8-1.0cm2). Mild to
moderate ([**2-5**]+)
AR. Eccentric AR jet directed toward the anterior mitral
leaflet.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Physiologic MR
(within normal limits).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
No PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure.
Conclusions:
Pre Bypass: Image quality is poor overall. The left atrium is
mildly dilated.
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall
thicknesses and cavity size are normal. There is mild regional
left
ventricular systolic dysfunction with mild to moderate inferior
wall
hypokinesis. Overall left ventricular systolic function is low
normal (LVEF
50-55%). Right ventricular chamber size and free wall motion are
normal. The
aortic root is mildly dilated at the sinus level. There is focal
calcifcation
of the aortic root. The ascending aorta is moderately dilated
but poorly seen,
with measurements ranging from 3.7-4.5 cm-- recommend
correlation with CT and
clinical findings. There appear to be simple atheroma in the
ascending aorta,
but image quality is poor here.. There is complex atheroma in
the aortic arch
and the descending aorta. There is moderate to severe aortic
valve stenosis
(area averages 0.8-1.0cm2). Mild to moderate ([**2-5**]+) aortic
regurgitation is
seen. The aortic regurgitation jet is eccentric, directed toward
the anterior
mitral leaflet. The mitral valve leaflets are mildly thickened.
Physiologic
mitral regurgitation is seen (within normal limits).
Post Bypass: Patient is on epinepherine infusion at 0.02
mcg/kg/[**Last Name (LF) **], [**First Name3 (LF) **] paced.
LV function is unchanged at LVEF 45-50%. Inferior wall is now
mildly
hypokinetic. There is a bioprosthetic aortic valve insitu. Peak
gradient 9,
mean gradient 5 mm Hg. There is no perivalvular leak or aortic
insufficency.
Aortic contours are intact. Remaining exam is unchanged. All
findings
discussed with surgons at the time of the exam.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2154-9-2**] 06:56.
[**Location (un) **] PHYSICIAN:
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 73584**],[**Known firstname **],A [**2076-8-2**] 78 Male [**-8/2922**]
[**Numeric Identifier 73585**]
Report to: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]
Gross Description by: DR. [**Last Name (STitle) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name 27315**]/mtd
SPECIMEN SUBMITTED: AORTIC VALVE LEAFLETS.
Procedure date Tissue received Report Date Diagnosed
by
[**2154-8-28**] [**2154-8-28**] [**2154-9-2**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/mrr??????
DIAGNOSIS:
Aortic valve leaflets:
Valvular tissue with myxoid degeneration and calcification.
Clinical: Coronary artery disease. Aortic stenosis.
Gross: The specimen is received in saline in a container labeled
with "[**Known lastname 73582**], [**Known firstname **]" and the medical record number and "aortic
valve leaflet". It consists of a 2.8 x 2.3 x 0.6 cm aggregate of
yellow-white tissue fragments. The specimen is serially
sectioned to reveal a 0.5 x 0.5 cm area of calcification on one
of the leaflets. The specimen is represented in A following
decalcification at the bench.
Brief Hospital Course:
Mr. [**Known lastname 73582**] was admitted to the [**Hospital1 18**] on [**2154-8-23**] for surgical
management of his coronary artery disease and aortic stenosis.
He was worked-up in the usual preoperative manner including a
carotid duplex ultrasound which showed a 60-69% right and 1-39%
left internal carotid artery. On [**2154-8-28**], Mr. [**Known lastname 73582**] was taken
to the operating room where he underwent coronary artery bypass
to three vessels and an aortic valve replacement with a
pericardial valve. Please see operative note for details.
Postoperatively he was taken to the intesive care unit for
monitoring. On postoperative day one, Mr. [**Known lastname 73582**] [**Last Name (Titles) 5058**]
neurologically intact and was extubated. He developed atrial
fibrillation for which amiodarone was started. On postoperative
day three, Mr. [**Known lastname 73582**] was transferred to the step down unit
for further recovery. He was gently diuresed towards his
preoperative weight. The physical therapy service was consulted
for assistance with his preoperative strength and mobility. As
he remained in atrial fibrillation, he was started on coumadin.
Mr. [**Known lastname 73582**] continued to make steady progress and was
discharged to rehabilitation on [**2154-9-3**]. He will follow-up with
Dr. [**Last Name (STitle) **], his cardiologist and his primary care physician as
an outpatient. Dr. [**Last Name (STitle) 5017**] will manage his coumadin as an
outpatient for a goal INR of 2.0-2.5.
Medications on Admission:
Lipitor 80mg QD
Insulin sliding Scale
Trazadone 50mg QHS
Zestril 20mg QD
HCTZ 12.5mg QD
Advair
Lopid 600mg [**Hospital1 **]
Humulin NPH 30Units [**Hospital1 **]
Lasix 80mg QD
Glyburide 10mg [**Hospital1 **]
Synthroid 200mcg QD
Neurontin 300mg TID
Combivent
Cymbalta 30mg [**Hospital1 **]
Methylprednisone 4mg [**Hospital1 **]
KCL 10mEq QD
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Take 200mg twice daily for 1 week then starting [**2154-9-8**]
take 200mg once daily. .
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
7. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
8. Levoxyl 200 mcg Tablet Sig: One (1) Tablet PO once a day.
9. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
Inh Inhalation twice a day.
10. Insulin Regular Human 100 unit/mL Solution Sig: Per sliding
scale Units Injection ASDIR (AS DIRECTED): Sliding scale with
fingersticks QAC and HS.
11. Lopid 600 mg Tablet Sig: One (1) Tablet PO twice a day.
12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Nebulizer Inhalation Q6H (every 6 hours) as needed.
13. Warfarin 1 mg Tablet Sig: Does for goal INR of 2.0-2.5
Tablets PO ONCE (Once): Dose daily for goal INR of 2.0-2.5.
Monitor PT/INR daily. .
14. Combivent 103-18 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation three times a day.
15. Neurontin 300 mg Capsule Sig: One (1) Capsule PO twice a
day.
16. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
17. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO twice a day.
18. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
19. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
20. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
21. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO twice a day: while on
lasix .
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 5016**] [**Doctor Last Name 1495**] Raphaels TCU - [**Location (un) 7661**]
Discharge Diagnosis:
Aortic stenosis s/p AVR
CAD s/p CABG
Atrial fibrillation
COPD
Obesity
Diabetes mellitus type 2
Sleep apnea
Hypothyroid
Hypercholesterolemia
BPH
Depression
CHF
Anxiety
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. Please shower daily including washing your incision. No
bathing or swimming for 1 month. Use sunscreen on incision if
exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Take coumadin daily as instructed. Goal INR is 2.0-2.5 for
atrial fibrillation. Please monitor PT/INR daily. After
discharge from rehabilitation, Dr. [**Last Name (STitle) 5017**] - Office ([**Telephone/Fax (1) 72870**] Fax ([**Telephone/Fax (1) 73586**] will manage coumadin dosing. Please
contact his office to set up appointment on discharge from
rehab.
8) Take amiodarone 200mg tiwce daily until [**2154-9-8**], then take
200mg once daily until otherwise instructed by Dr. [**Last Name (STitle) 5017**]
9) Take lasix 40mg twice a day and potassium 20mEq twice a day
for one week. Weigh patient daily. Monitor and replete
electrolytes as needed. Please evaluate for further diuresis
after completion of lasix as patient was on 80mg daily
preoperatively.
10) Take insulin sliding scale with fingersticks at meals and
before bedtime.
7) Call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with cardiologist Dr. [**Last Name (STitle) 5017**] ([**Telephone/Fax (1) 65679**]
in [**2-5**] weeks for routine postoperative appointment and
immediately following discharge from rehab for coumadin
management and PT/INR testing.
Please follow-up with pcp [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**3-9**] weeks. [**Telephone/Fax (1) 41901**]
Completed by:[**2154-9-3**]
|
[
"327.23",
"285.1",
"428.0",
"300.00",
"600.00",
"427.31",
"244.9",
"414.01",
"311",
"272.0",
"424.1",
"496",
"250.00",
"997.1",
"278.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"36.12",
"39.61",
"36.15",
"99.04",
"35.21",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
13987, 14102
|
10022, 11538
|
287, 639
|
14313, 14320
|
2075, 2740
|
15897, 16404
|
1318, 1335
|
11927, 13964
|
2777, 2805
|
14123, 14292
|
11564, 11904
|
14344, 15874
|
3806, 8719
|
1350, 2056
|
237, 249
|
2834, 3780
|
667, 1019
|
8753, 9999
|
1041, 1162
|
1178, 1302
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,645
| 129,244
|
37521
|
Discharge summary
|
report
|
Admission Date: [**2180-3-10**] Discharge Date: [**2180-5-11**]
Date of Birth: [**2120-1-28**] Sex: M
Service: SURGERY
Allergies:
Biaxin / Statins-Hmg-Coa Reductase Inhibitors / Heparin Agents
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
esophageal cancer, hemoptysis
Major Surgical or Invasive Procedure:
[**2180-3-10**] Minimally invasive esophagogastrectomy and
laparoscopic feeding jejunostomy.
[**2180-3-20**] Laparotomy and reopening of cervical incision
with resection of gastric conduit, esophagostomy, resiting
of jejunostomy, change of dialysis catheter and temporary
abdominal closure
[**2180-3-28**] Abdominal closure
[**2180-3-31**] Left chest tube insertion, Chest ultrasound examination
[**2180-4-4**] Tracheostomy and placement of implanted dialysis
catheter
[**2180-4-25**] Flexible bronchoscopy through the tracheostomy
tube with repositioning of the tracheostomy tube
History of Present Illness:
59M with a recent episode of melena
in [**11-14**] -- subsequent workup with upper and lower endoscopy
revealed a mass at the GE junction. He had previoulsy been on
Coumadin for atrial fibrillation -- but was subsequently
cardioverted and has stopped anticoagulation.
He reports feeling well, with no complaints of dysphagia, cough,
or recurrent GI bleeding. He reports that he has seen his PCP,
[**Name10 (NameIs) **] oncologist, and his nephrologist, in anticipation for an
operation.
Past Medical History:
-Aflutter s/p cardioversion
-UGIB
-HTN
-gout
-CRI (2.5)
Social History:
SOCIAL HISTORY:
Cigarettes: [ ] never [x] ex-smoker [ ] current Pack-yrs:_20_
quit: __20 yrs ago____
ETOH: [x] Not currently [ ] Yes drinks/day: __1-2/d__
Drugs:
Exposure: [ ] No [ ] Yes [ ] Radiation
[x] Asbestos: involved in containment, but
not removal
Occupation: High school math teacher
Marital Status: [x] Married [ ] Single
Lives: [ ] Alone [x] w/ family [ ] Other:
Other pertinent social history: [**Location (un) 5028**], MA
Travel history:
Physical Exam:
Temp: 97.4 HR: 64 BP: 139/61 RR: 20 O2 Sat: 96RA
RRR
CTA B
abdomen benign
at presentation, by notes in OMR
Pertinent Results:
[**2180-3-10**] 11:37PM TYPE-[**Last Name (un) **] PH-7.21*
[**2180-3-10**] 11:37PM freeCa-1.06*
[**2180-3-10**] 11:23PM GLUCOSE-145* UREA N-70* CREAT-3.1* SODIUM-142
POTASSIUM-5.7* CHLORIDE-110* TOTAL CO2-21* ANION GAP-17
[**2180-3-10**] 11:23PM LD(LDH)-452*
[**2180-3-10**] 11:23PM CALCIUM-7.8* PHOSPHATE-5.2* MAGNESIUM-2.1
[**2180-3-10**] 11:23PM WBC-17.2* RBC-3.11* HGB-9.5* HCT-29.2* MCV-94
MCH-30.5 MCHC-32.4 RDW-17.0*
[**2180-3-10**] 11:23PM PLT COUNT-189
[**2180-3-10**] 09:54PM TYPE-ART PO2-89 PCO2-46* PH-7.21* TOTAL
CO2-19* BASE XS--9
[**2180-3-10**] 09:54PM LACTATE-1.3 K+-6.2*
[**2180-3-10**] 07:17PM TYPE-ART PO2-75* PCO2-49* PH-7.24* TOTAL
CO2-22 BASE XS--6
[**2180-3-10**] 07:17PM LACTATE-1.4
[**2180-3-10**] 07:17PM freeCa-1.13
[**2180-3-10**] 07:17PM LACTATE-1.4
[**2180-3-10**] 07:17PM freeCa-1.13
[**2180-3-10**] 06:05PM GLUCOSE-139* UREA N-67* CREAT-2.9* SODIUM-142
POTASSIUM-5.8* CHLORIDE-113* TOTAL CO2-20* ANION GAP-15
[**2180-3-10**] 06:05PM CK(CPK)-598*
[**2180-3-10**] 06:05PM CK-MB-7 cTropnT-<0.01
[**2180-3-10**] 06:05PM ALBUMIN-3.6 CALCIUM-8.1* PHOSPHATE-4.4
MAGNESIUM-1.9
[**2180-3-10**] 06:05PM WBC-17.8*# RBC-3.05* HGB-9.4* HCT-28.5*
MCV-94 MCH-30.7 MCHC-32.8 RDW-17.2*
[**2180-3-10**] 06:05PM PLT COUNT-186
[**2180-3-10**] 01:18PM TYPE-ART PO2-238* PCO2-43 PH-7.30* TOTAL
CO2-22 BASE XS--4 INTUBATED-INTUBATED
[**2180-3-10**] 01:18PM GLUCOSE-135* LACTATE-2.1* NA+-142 K+-5.4*
CL--112
[**2180-3-10**] 01:18PM HGB-9.5* calcHCT-29 O2 SAT-99
[**2180-3-10**] 01:18PM freeCa-1.14
[**2180-3-10**] 09:38AM TYPE-ART TEMP-37 RATES-19/ TIDAL VOL-355
O2-100 PO2-137* PCO2-47* PH-7.28* TOTAL CO2-23 BASE XS--4
AADO2-529 REQ O2-88 INTUBATED-INTUBATED VENT-CONTROLLED
COMMENTS-ONE LUNG
[**2180-3-10**] 09:38AM GLUCOSE-140* LACTATE-0.9 NA+-141 K+-4.9
CL--113*
[**2180-3-10**] 09:38AM HGB-9.5* calcHCT-29
[**2180-3-10**] 09:38AM freeCa-1.12
[**2180-3-10**] 07:10AM GLUCOSE-116* UREA N-66* CREAT-2.1* SODIUM-143
POTASSIUM-4.4 CHLORIDE-112* TOTAL CO2-21* ANION GAP-14
[**2180-3-10**] 07:10AM GLUCOSE-116* UREA N-66* CREAT-2.1* SODIUM-143
POTASSIUM-4.4 CHLORIDE-112* TOTAL CO2-21* ANION GAP-14
Brief Hospital Course:
Patient went to the operating room and underwent a min. invasive
esophagectomy on [**2180-3-10**]. He tolerated this well initially
without complication and was transferred to the SICU in stable
condition.
.
In the first few days after the OR he experienced worsening
renal failure which required placement of an HD line and
starting CVVHD. On POD 3 his Jtube feeds were started, on POD 5
his barium swallow was performed which demonstrated no leak so
his NGT was removed. Over the next few days he had difficulty
with Rapid Afib, requiring aggressive medical mgt with
Amiodarone, Diltiazem, and lopressor. He had hypotension
associated with this, also respiratory distress requiring
reintubation.
.
ON POD 10 he underwent EGD because he was becoming clinically
much more ill and a CT of his chest demonstrated pericardial and
pleural effusion. EGD demonstrated a frankly necrotic gastric
conduit. He was emergently taken back to the OR on [**3-20**] for
takedown of his conduit, washout, and esophagostomy. His
abdomen remained open at this time as well.
.
He was maintained on a heparin gtt for his Afib and his
propensity to clot off the CVVHD lines. Howeever, his plts
dropped and a HIT panel came back positive, so he was changed to
argatroban and all his lines were changed out. He continued to
have multiple episodes of rapid afib with HD instability and
required multiple cardioversions over the following days. He
was on broad spectrum antibiotics, and TPN was initiated. His
[**Location (un) 5701**] bag was tightened over the next few days and he was
eventually taken back to the OR on [**3-28**] for definitive abdominal
closure.
.
Post-op he continued to display septic physiology requiring
pressors. He also had his left pleural effusion and pericardial
effusions drained. He was taken back to the OR for tracheostomy
on [**4-4**].
.
Over the next week or so he was more stable. He was weaning
from the vent and tolerating CPAP trials. His argatroban was
transitioned to coumadin. His pain meds were weaned as well as
methadone. His Hemodynamics improved, but he still required
intermittent low doses of pressors at times. He was
transitioned back to HD once his BP was tolerating it.
He remained on CVVH, and his respiratory cultures grew
Klebsiella for which he was treated with multiple antibiotics.
His coumadin was restarted on [**4-9**], and he was ultimately
transitioned to HD from CVVH on [**2180-4-10**].
On [**2180-4-16**], the patient's mental status globally declined, and
ABG demonstrated a respiratory acidosis. His ventilatory mode
was adjusted, and sputum cultures were sent. He underwent a
head CT scan on [**2180-4-17**] to evaluate his mental status which was
negative for acute intra-cranial process. On [**2180-4-18**], CT scan of
his torso demonstrated a tracheal perforation at the level of
the ET tube balloon and a loculated R hydropneumothorax. His
tracheostomy was replaced by thoracic surgery. He remained on
antibiotics at this time
(vancomycin/meropenem/fluconazole/flagyl).
On [**4-20**], he was transitioned back to CVVH, on which he remained
until [**2180-4-25**] when he was transitioned back to HD. Overall, he
steadily improved therafter. His mental status improved slowly
with time. His pulmonary status continued to improve, and he
remained stable on pressure support ventilation with minimal
assistance, and he was tolerating trach collar trials. He was
tolerating tube feeds via his jeunostomy tube. He was helped
out of bed by excellent [**Hospital **] nursing care.
He was screened for rehab, and was stable at the time of
discharge. By system on [**2180-5-11**]:
Neuro: alert, oriented, moving all extremities; dilaudid PRN
pain
CV: history of a-flutter, s/p cardioversion, now in sinus
rhythm; receiving coumadin %mg per night, last INR 2.1 on [**5-11**])
given HITT and aflutter, with INR goal 2-2.5
Pulm: tolerating trach collar, R chest tube in place with
heimlich valve and will be backed out further by thoracic
surgery at follow-up appointment (not to be adjusted at rehab)
GI: has esophageal spit fistula, abdomen closed, receiving tube
feeds via j-tube (novasource renal full strength 45cc/hr at
goal)
Renal: on HD, last [**5-9**]
Heme: HITT type 2, now on coumadin
Endo: on insulin sliding scale, FS glucose appropriate
ID: all antibiotics weaned off by the time of discharge
Medications on Admission:
ALLOPURINOL - (Prescribed by Other Provider) - 100 mg Tablet -
2
Tablet(s) by mouth once a day
DIGOXIN - (Prescribed by Other Provider) - 125 mcg Tablet - 1
Tablet(s) by mouth once a day
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth once a day
HYDRALAZINE - (Prescribed by Other Provider) - 50 mg Tablet - 1
Tablet(s) by mouth three times a day
IRBESARTAN [AVAPRO] - (Prescribed by Other Provider) - 300 mg
Tablet - 1 Tablet(s) by mouth once a day
LEG CREAM - (Prescribed by Other Provider) - Dosage uncertain
SOTALOL - (Prescribed by Other Provider) - 80 mg Tablet -
Tablet(s) by mouth twice a day
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
6-10 Puffs Inhalation Q4H (every 4 hours) as needed for
hyperkalemia, wheeze.
2. Acetaminophen 325 mg/10.15 mL Solution Sig: [**1-8**] PO Q6H
(every 6 hours) as needed for pain, fever.
3. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q6H (every 6 hours).
4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-8**]
Drops Ophthalmic PRN (as needed) as needed for eye care.
5. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q8H
(every 8 hours) as needed for hypertension/tachycardia.
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day:
monitor INR, target 2-2.5.
10. Pantoprazole 40 mg IV Q24H
11. HYDROmorphone (Dilaudid) 0.25-0.5 mg IV Q3H:PRN pain
12. Sodium Citrate 4 % (3 mL) Syringe Sig: One (1) ML
Miscellaneous ASDIR (AS DIRECTED) as needed for catheter not in
use.
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
esophageal cancer, s/p esophagectomy with conduit necrosis
requiring re-exploration and takedown with spit fistula,
tracheal perforation
Acute on Chronic renal failure, requiring dialysis.
Tracheal perforation.
Sepsis
Atrial fibrillation
Heparin Allergy
Pericardial effusion
Discharge Condition:
stable, out of bed with assistance, tolerating tube feeds,
tolerating trach collar trials although vent-dependent
Discharge Instructions:
discharge to ventilator rehab facility
He may have trach collar wwith cuff up. [**Month (only) 116**] start Passamuer
valve in one week.
return to the ED or call Dr.[**Name (NI) 1482**] office with fevers,
chills, change in ventilatory status, increasing quantity of
drainage or change in nature of drainage, chest tube problems
Followup Instructions:
follow-up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] on a Thursday,
when rehab progressed.; please call to schedule an appointment
Completed by:[**2180-5-11**]
|
[
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"998.2",
"289.84",
"427.31",
"038.9",
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"276.2",
"997.4",
"403.90",
"584.5",
"285.1",
"518.5",
"276.7",
"585.3",
"511.9",
"998.59",
"423.9",
"707.03",
"327.23",
"151.0",
"V15.82",
"427.32",
"997.1",
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] |
icd9cm
|
[
[
[]
]
] |
[
"99.62",
"38.93",
"43.5",
"37.0",
"97.23",
"46.39",
"96.04",
"39.95",
"31.1",
"99.15",
"42.10",
"42.41",
"33.21",
"54.62",
"96.6",
"38.95",
"33.24",
"34.04",
"96.72",
"44.5"
] |
icd9pcs
|
[
[
[]
]
] |
10739, 10813
|
4425, 8804
|
352, 936
|
11131, 11247
|
2233, 4402
|
11625, 11813
|
9497, 10716
|
10834, 11110
|
8830, 9474
|
11271, 11602
|
2096, 2214
|
283, 314
|
964, 1456
|
1478, 1536
|
2034, 2081
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,367
| 151,231
|
51690
|
Discharge summary
|
report
|
Admission Date: [**2183-12-7**] Discharge Date: [**2183-12-10**]
Date of Birth: [**2137-11-1**] Sex: F
Service: SURGERY
Allergies:
Iodine; Iodine Containing / Urokinase / Heparin Calcium
(Porcine) / Aspirin / Penicillins / Streptokinase
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
transferred from [**Hospital **] Hospital for pneumomediastinum
Major Surgical or Invasive Procedure:
ex lap
swan ganz placement
arterial line placement
cvl placement
HD line placement
History of Present Illness:
Pt presented to [**Hospital **] Hospital for weakness on [**12-3**]. She had
been having 2 weeks of ongoing weakness and was finally brought
to the ED for hypoxia. On arrival, she was tachy in the 120's,
clear CXR. Her admisison labs wer entoable for a Cr of 8.3, K
6.7, bicarb 6; ABG 6.95/20/4/34. Troponin 7. A foley was placed
which showed blood thick material. She was admitted to the ICU
for further care. Impression at that time was that she had ARF
from kidney rehection with hematuria vs. cystitis and prerenal
azotemia, hypoxemia, and MI.
.
She was intubated on [**12-3**] to help manage her hypoxia [**1-15**]
metabolic acidosis. A femoral line was placed. Placed on cefepim
for UTI and URI sxs, IVF for support. Pt extubated on [**12-5**]. PPN
started on [**12-5**]. Creatinine improved over the next two days.
urine cx with strep viridans.
.
On [**12-5**], cards consult obtained who believed pt to have an
acute inferior inferolateral MI exaccerbated by her mat acidosis
and ARF. Rec cont ASA/BB/heparin, did not rec. angiography given
allergy to dye.
.
Overnight to [**12-6**], 40 mg IV lasix given. Noted to have drop in
bicarb, likely [**1-15**] PPN. Also noted to be tacycardic but unclear
why, ?pain or benzo withdrawl. Overnight from [**12-6**] to [**12-7**]: pt
was tachycardic, in resp distressed. Lasix and lopressor tried
with no effect. ABG with PO2 of 47. Pt intubated at 5 30 am,
durign which coffee grounds wer enoted and suctioned; after
intubation swellig and crepitus noted. CT done which did not
find any obvious tear. Bronchopspy was performed which showed no
tear.
.
Transferred to [**Hospital1 18**] for further care, admitted to the MICU
service.
.
On arrival, pt sedated. Does not follow commands. Appears
comfortable.
Past Medical History:
1. CAD s/p post op MI in [**7-18**] after surgery
2. HTN
3. Hyperlipidemia
4. ESRD [**1-15**] reflux nephropathy at age 13, s/p 4 renal
transplants, baseline Cr 2.0
5. Pancreatitis in [**2177**]
6. Recurrent SBO
7. Recurrent UTI
8. Hiatal hernia
9. OA
.
PSH:
.
1. Bowel surgery in [**7-18**] for SBO
2. TAH BSO
3. Nephrectomy
4. Cataract surgery
5. Renal transplant x 4
10. Herpres zoster
Social History:
married, lives with husband; retired; denies tobacco and alcohol
Family History:
1. F-died at 59 [**1-15**] liver cirrhosis
Physical Exam:
Temp 98.7
BP 99/64
Pulse 112
Resp 18
O2 sat 100% on AC 350x16 (25 actual), PEEP 5
Gen - sedated, comfortable
HEENT - post surgical pupils, anicteric, mucous membranes dry
Neck - palpable subq air bilaterally
Chest - crackles at bases, no wheezes, rhonchi throughout
CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops
Abd - Soft, nontender, min. distended, with hypoactive bowel
sounds
Back - No costovertebral angle tendernes
Extr - No clubbing, cyanosis, or edema. diff. to ascertain
pulses
Skin- no rash
Pertinent Results:
see carevue
Brief Hospital Course:
Impression: 46 F with ESRD s/p 4 kidney transplant, recent UTI,
ACS, transfered here after acute resp distress, likely pulomnary
edema, with intubation c/b pneumomediastinum. Overnight, pt was
given 1500 cc IVF for tachycardia and low CVP, maintained good
UOP. Abx held. Cont on heparin gtt for ACS. Exam this am with
new abd distention and tenderness. ICU d #2.
.
Plan:
.
1. Resp failure: Pathcy infiltrate on CXR. CHf vs. PNA (alhtough
asymetric so would consider ARDS)
-change to PS of [**4-17**], try to wean FiO2 to 40% today
-check ABGs
-hold on dieuresis as clinically appears vol depleted
.
2. Abd tenderness/distention: KUB neg for obstruction. Pt does
have fever and WBC ct. Also lower plts. DDX abscess, ischemic in
gut [**1-15**] HIT, CCY.
-transplant surgery consulted
-RUQ US, CT abd/pelvis without contrast, renal US to r/o
abscess/hydro
-check LFTS
-stop heparin
.
3. Low plts: likely HIT given 50% drop in plts. Could also
explain blueish hand and abd pain (thrombosis). Was on heparin
since [**12-3**], d/c [**12-8**].
-stop heparin, start argatroban, heme/onc consult, HIT pending,
hold all heparin products
.
4. CAD: ischemic, likely inferolateral. Elevated CEs. Heparin
stopped [**12-8**].
-BB/ASA/statin
-cont to follow CEs
-no intervention at this time
-echo
.
5. ID
a. UTI: UA here with +UA, hold on abx for now until cx returns,
follow other cultures
.
6. ESRD s/p renal transplant: Cr improving slowly with adequate
UO. Cont IVFs.
- cellcept [**Pager number **] mg tid, taper solumedrol by 10 mg qd,
cyclosporine 50 mg qam/25 mg pm all restarted [**12-7**]
-renal US to r/o abscess and hydronephrosis
-IVFs
-transplant surgery consult
.
7. Left arm cyanosis: app vasc surgery input. dopplerable
pulses. could be micro thrombi from HIT.
.
8. Tachycardia: not in obvious pain. Could be [**1-15**] vol depletion.
-IVFs to maintain UO > 40 cc/hr, CVP 10-14. also with fever,
will give tylenol and await cx results.
.
9. Anemia: unclear cause. No obvious bleed. Guiac stools. Could
be [**1-15**] renal disease. Check haptoglobin to r/o hemolysis (?
atypical PNA).
-transfuse one unit of blood
.
FEN: check lytes, FEN consul for PPN recs with renal diet
PPx: PPI, head of bed at 30 degrees, bowel regimen
Code: Full
Dispo: ICU level of care until extubated
Access: right femoral line, place RIJ [**12-7**]
Comm: with husband and mother
SURGICAL ADDENDUM
Transferred to transplant surgery service on the night of HD2
because of her concerning abdominal exam & recurrent blood loss
anemia. Our plan was to hold anticoagulation & follow serial
exams/labs was thwarted by an irreversible increase in her coag
factors & severe oozing, despite multiple transfusions with
platelets, FFP & other blood products, as well as hematology
consult & ddavp. She was resuscitated for the next 36 hours,
with a relatively stable critically ill clinical picture.
However, on the morning of [**12-10**], she decompensated, with
tachycardia, hypotension, rising lactate and pancytopenia (DIC).
She was taken to the OR despite being unable to reverse her
anticoagulation. In the OR, an ileocolectomy for perforated
distal ileum & end ileostomy was performed. Her septic picture
did not improve after the OR & her family made her CMO. She
passed a few minutes thereafter. An autopsy was declined by the
family & the medical examiner.
Medications on Admission:
Meds on trasnfer:
ativan 0.5 mg Iv prn
albuterol neb q 2 prn
solumedrol 80 mg IV q8 (d #4)
cefepime 1 gm Iv q24 ([**12-6**])
zosyn 2.25 gm Iv q 8 ([**12-7**])plavix 75 mg qd
lipitor 20 mg qd
imdur 30 mg qd
reglan 5 mg IV q 8 prn
protonix 40 mg IV q24
peridex
cefipime 1 gm IV q12 ([**Date range (1) 68316**])
lasix 40 mg IV qd
aranesp 100 mg sq (q Friday)
lopressor 25 mg PO bid
zofran 4 mg IV q8 prn
Discharge Disposition:
Expired
Discharge Diagnosis:
s/p renal transplant
myocradial infarction
CHF
bowel perforation
sepsis
septic shock
hepatitis C
CMV
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2183-12-10**]
|
[
"070.70",
"785.52",
"285.9",
"284.8",
"567.22",
"286.9",
"567.21",
"038.9",
"584.9",
"569.83",
"578.9",
"518.81",
"995.92",
"410.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"38.91",
"38.93",
"45.62",
"96.71",
"96.04",
"96.6",
"54.19",
"46.21"
] |
icd9pcs
|
[
[
[]
]
] |
7229, 7238
|
3435, 6777
|
430, 515
|
7383, 7394
|
3399, 3412
|
7446, 7482
|
2811, 2855
|
7259, 7362
|
6803, 7206
|
7418, 7423
|
2870, 3380
|
327, 392
|
543, 2300
|
2322, 2713
|
2729, 2795
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
222
| 103,002
|
48545
|
Discharge summary
|
report
|
Admission Date: [**2143-2-16**] Discharge Date: [**2143-2-25**]
Date of Birth: [**2073-7-25**] Sex: F
Service: MEDICINE
Allergies:
Lipitor / Zocor
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Please see admission note for full details of history. Ms.
[**Name14 (STitle) 102143**] is a 69 year old female with past medical history of
right lower lobe squamous cell carcinoma, status-post resection
in [**2141**], treated with chemotherapy and thoracentesis in [**11/2142**],
who brain radiation in [**12/2141**], and recent admission for
pneumonia in [**12/2142**] treated with levofloxacin. Likely
leptomeningeal spread.
.
She presented to the ED [**2-16**] with dyspnea and increasing home O2
requirement. Her home nurse had also recently noted low BP,
causing her to miss her daily amiodarone and metoprolol. Her
dyspnea progressed from exertional to at rest over days. She
also had a chest discomfort, nonpleuritic. No fevers, chills, or
change in chronic productive cough. ROS otherwise negative.
.
Her initial vital signs were a temperature of 97.0, [**Month/Year (2) **]
pressure of 110/59, heart rate of 132, respiratory rate of 20,
and 91% on room air. She was given 2 mg of morphine, 4 mg of
zofran, 150 mg bolus of amiodarone IV, 200 mg of PO amiodarone,
5 mg of roxicet, 325 mg of tylenol, amiodarone drip, fentanyl 50
mcg, and 750 mg of levofloxacin. In the ED, she was initially
tachycardic with a heart rate as high as 140, but this converted
to sinus at a rate of 70 after administration of amiodarone.
There was concern for worsening metastatic disease or PE, so she
underwent a chest CT. It was negative for a pulmonary embolism,
however it did demonstrate a worsening multifocal pneumonia and
worsening metastatic disease as compared to PET/CT from
[**2143-1-21**]. During the time in the ED, her systolic [**Year (4 digits) **] pressure
ranged from 70-90's. She was given one liter of IVF. She was
transfered to the ICU for further management given her
hypotension and high oxygen requirement.
.
In the [**Hospital Unit Name 153**], there was concern for amiodarone pulmonary
toxicity, so this medication was stopped. Cardiology followed
her and recommended continuation of low-dose beta blocker.
Antibiotics were broadened to Bactrim (for possible PCP given
chronic steroid use) and levofloxacin. There was consideration
of broncoscopy for the purpose of BAL for culture, but the
patient declined. Currently she is on a non-rebreather with good
O2 Sats. She is also on stress-dose steroids given chronic
prednisone. She was given 2 units of pRBC.
.
Goals of care were addressed and revised to include DNR and no
invasive measures. Palliative care is following. She will be
transferred to the OMED team given no desire for ICU-level
aggressive measures.
. HR 60 110/53 16 97% NRB. Got levoflox already today. 1L
positive. Also given 2u pRBC's.
.
Main goal at this time is for hospice, palliative care on board.
Not bronched per patient request. Will accept abx, but nothing
invasive.
.
Past Medical History:
Oncology History:
T2 N1 squamous cell lung cancer in the right lower lobe s/p
resection [**2142-6-11**]. Pathology notable for a positive margin,
lymphatic, and venous invasion. She is s/p chemo radiation and
resection of the right-sided lesion. She is s/p four cycles of
carboplatin and paclitaxel with the fourth cycle of chemotherapy
on [**2142-10-16**]. [**2142-11-27**] [**Year (4 digits) 4338**] of head with concern for
metastatic disease with a 5-mm enhancing lesion in the left
frontal lobe and a new 6 x 6 x 5 mm enhancing lesion in the
right parietal lobe with mild associated edema concerning for
cortical or leptomeningeal metastatic disease.
.
[**2142-12-7**] thoracentesis to drain left pleural effusion given
symptomatic cough. No evidence of malignancy with resolution of
cough but continued shortness of breath with exertion. CXR on
[**2142-12-11**] showed a persistent small left pleural effusion.
.
[**2142-12-18**] whole brain radiation therapy and radiation therapy to
her sacral metastasis with intermittent pain requiring dilaudid,
nausea and dry heaves requring compazine. She continued to have
chronic lower extremity weakness which has not changed in
severity.
.
[**2142-12-31**] Patient completed course of radiation to C2 Whole Brain
and Sacrum. She received a total dose of 3000 cGy to each site.
Of note she has had increased sacral pain and worsening nausea
and dry heaves. She was attempting Zofran, and dilaudid 2 mg Q6
as needed for pain. She also reported slight worsening of her
shortness of breath. No pleuritic chest pain. At that time o2
sat 94%RA.
Social History:
Married. Smoked in the past but quit 25 years ago, denies
alcohol or illicit drug use.
Family History:
The patient's father died of CAD as did her mother. Two
brothers have CAD. A sister has had multiple TIAs.
Physical Exam:
Vital Signs BP 110/53, HR 76, O2 Sat 96% on NRB
GENERAL: pleasant woman, appears comfortable
HEENT: slopecia, pupils small but reactive, no scleral icterus
NECK: supple, JVP not appreciated
LUNGS: decreased breath sounds and dullness to percussion over
left base, diffuse bronchial breath sounds over b/l lung fields
CARDIAC: regular, no murmurs
ABDOMEN: soft, nontender, nondistended
EXTR: warm, no edema, ecchymoses over right tibia.
NEURO: alert and oriented
PSYCH: pleasant, appropriate
.
Pertinent Results:
[**2143-2-16**] CTPA
1. No evidence of pulmonary embolism.
2. Persistent diffuse ground-glass opacity in the right upper
lobe and
worsened ground-glass within the lingula are concerning for
worsening
multifocal infection.
3. Increased size of pulmonary nodules concerning for worsening
metastatic
disease.
[**2143-2-18**] Echo
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with severe hypo/akinesis
of the basal half of the inferiorseptum, inferior, and
inferolateral walls. The remaining segments contract normally
(LVEF = 50 %). [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size and free wall
motion are normal. The 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 structurally normal. At least moderate
(2+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is an anterior space
which most likely represents a fat pad.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size with regional systolic dysfunction c/w CAD. At least
moderate mitral regurgitation suggestive of papillary muscle
dysfunction.
Compared with the prior study (images reviewed) of [**2142-6-13**], the
severity of mitral regurgitation has increased.
Brief Hospital Course:
Ms. [**Known lastname 94074**] is a 69 year old female with past medical history
of squamous cell carcinoma and atrial fibrillation who presented
with dyspnea and was found to have multifocal pneumonia.
.
#) Multifocal pneumonia: Likely related to underlying cancer,
possibly post-obstructive. O2 Sats were mostly in the upper 90s
on nonrebreather. Patient initially wanted like to continue
antibiotics, but has declined elective intubation for BAL
cultures after sputum cx contaminated. Thus she was transferred
to OMED given no desire for aggressive measures. There goals of
care were further revised ot include comfort measures only.
Antibiotics were stopped. Stress dose steroids were quickly
tapered. She was given nebulizer treatments as needed for
comfort. Because there was a question of mild volume overload,
she was also given lasix 20 mg IV as needed, which seemed to
help. A foley was placed to improve comfort of urination given
that she was becoming short of breath with any transfer.
.
#) Atrial fibrillation: Patient presented to ED in AF with RVR
in the setting of missing amiodarone. Converted to NSR with
amiodarone and beta blocker. She was not anticoagulated
secondary to history of GI bleed. Cardiology followed her. When
goals of care were revised to comfort, metoprolol PO was
continued to prevent recurrence of atrial fibrillation with RVR.
Prior to discharge she again developed atrial fibrillation but
was not uncomfortable. Metoprolol was continued.
.
#) Squamous cell lung carcinoma: Followed by Dr. [**Last Name (STitle) 3274**] as an
outpatient. Brain metastases have responded to XRT, but
worsening pulmonary disease burden. Patient is followed by Drs.
[**Last Name (STitle) 3274**] and [**Name5 (PTitle) **] here at [**Hospital1 18**]. There were no plans for
further chemotherapy, as the cancer was considered end-stage.
.
#) Anemia: She received 2 units pRBC in the ICU. When goals of
care were revised no futher labs were drawn.
.
#) Chronic renal insufficiency: Creatinine was initially below
baseline 1.1-1.2. Lab tests were stopped
.
#) Polymyalgia rheumatica: On 10 mg prednisone daily at home.
Received stress-dose steroids here in the setting of infection.
This was quickly tapered back to her home dose, which may be
continued to prevent recurrence of PMR.
.
#) Coronary artery disease: Aspirin, [**Last Name (un) **] were stopped after
goals of care were revised.
.
#) Gout: No active symptoms. Allopurinol was stopped.
.
#) Contact: [**Name (NI) **], daughter # [**Telephone/Fax (1) 102144**]
.
#) Code: Code status at discharge was DNR, DNI, no ICU transfers
or aggressive measures, with primary goal of care being comfort.
Medications on Admission:
per outpatient OMR note from [**2143-1-29**], reconcilled at that
time)
- ALLOPURINOL 100 mg daily
- AMIODARONE 200 mg daily
- CANDESARTAN 16 mg once a day
- HYDROMORPHONE 2 mg, [**11-23**] Tablet every 6 hours as needed for
pain
- METOPROLOL TARTRATE 12.5 mg twice a day
- NITROGLYCERIN - 0.3MG PRN
- NYSTATIN 100,000 unit/mL Suspension, 5 ml QID
- ONDANSETRON 4 mg Tablet, QID
- PREDNISONE 10 mg Tablet daily
- PROCHLORPERAZINE EDISYLATE [COMPAZINE] 10 mg Tablet TID PRN
- ASPIRIN 81 mg
- CALCIUM 600 + D, 1 Tablet three times a day
- DOCUSATE SODIUM PRN
- SENNOSIDES-DOCUSATE SODIUM PRN
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 656**] House
Discharge Diagnosis:
primary: metastatic squamous cell carcinoma of the lung, atrial
fibrillation with rapid ventricular response
secondary: coronary artery disease, chronic kidney disease,
Discharge Condition:
with facemask oxygen requirement
Discharge Instructions:
You came to the hospital because you were short of breath. You
were treated with oxygen. Your heart was also in an irregular
fast rhythm and you were given medications to control this. You
and your family decided to transisition to hospice care. Please
follow the attached medication list which may be adjusted at the
[**Hospital1 656**] House as needed.
Followup Instructions:
Please follow up at your hospice facility.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
Completed by:[**2143-2-26**]
|
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icd9cm
|
[
[
[]
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[] |
icd9pcs
|
[
[
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|
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296, 302
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4772, 4861
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,453
| 147,286
|
19697
|
Discharge summary
|
report
|
Admission Date: [**2195-7-14**] Discharge Date: [**2195-7-30**]
Date of Birth: [**2134-7-25**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8388**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Intubation
Chest Tube Placement
PICC Line Placement
Dialysis Catheter Placement and Dialysis
History of Present Illness:
Pt is a 60M with history of cirrhosis [**3-4**] HCV c/b
encephalopathy, SBP, varices, PV thrombosis; DM; HTN presented
with dyspnea x 4 days and left sided chest pain and
back/shoulder pain, found to have large left sided pleural
effusions. Per records, patient fell ~ 2 weeks ago, no known
injury at that time. Had been fine after fall except for some
weakness, no other known traumas. Went to PCP today with 4 day
complaint of SOB, cxr showed left sided pleural effusion and was
referred to ED for further evaluation.
In the ED, initial VS: 96 132/50 65 18 100% on 4L. CTA showed
left sided large pleural effusion with possible loculation and
resolving hemothorax; also with patchy RML infiltrate that could
represent early PNA. Labs notable for HCT 24.2, INR 3.3,
creatinine 2.4. Recieved morphine 4 mg IV for pain, Levoquin 500
mg IV x 1 and Vitamin K 10 mg. Admitted to floor for further
management.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, abdominal
pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
PMHx (per OMR, unable to verify with patient):
- Hepatitis C cirrhosis genotype 1A (c/b h/o portal
hypertension/
ascites/encephalopathy/SBP) awaiting combined liver/kidney
transplant, Hepatitis C viral load [**3-/2192**]: 401,000 IU/mL; MELD
20 on [**2194-4-17**].
- Esophageal Varices: endoscopy [**2189**]: grade I varices
- CKD (baseline Cr = 1.4-1.5): Diabetic Nephrosclerosis by
biopsy
- Diabetes (last HgA1C [**7-/2190**] 6%) with neuropathy
- Ribavirin-induced Hemolytic Anemia
- History of spontaneous bacterial peritonitis
- Pancytopenia likely d/t hypersplenism
- Chronic hyperkalemia
- Hypertension
- h/o IVDU with methadone maintenance, now off all therapy
- DVT s/p IVC filter placement ([**10/2188**])- spontaneous in setting
of
hepatic encephalopathy
- Hemmorhoids
- Hx of PV thrombosis, restarted on coumadin
Social History:
Works as a carpenter. Lives with sister. Recently quit smoking,
30 pack year history. Sister is HPA. Prior history of IVDU
heroin and cocaine quit 7 years ago. On methadone until 2 years
ago. Denies alcohol, drugs recently.
Family History:
Father died [**Name2 (NI) 53283**] at 55, no history of blood clots in family.
Physical Exam:
ADMISSION PHYSICAL:
VS: 96.9 154/73 75 20 95%2L
GENERAL: chronically ill appearing man, NAD
HEENT: MMM, OP clear, no scleral icterus, EOMI.
NECK: Supple, no JVD. no tracheal deviation.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: ABsent BS over posterior left lung fields ~3/4 up lung
[**Last Name (un) 18100**] with minimal BS the top [**2-3**]. + mild labored breathing,
but not tachypnic. Left CTA lung fields.
ABDOMEN: Soft/NT/ND, no rebound/guarding, no discernable
ascites.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes, chronic venous stasis changes in bilateral LE.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII intact, muscle grossly intact, 1
beat asterexis.
DISCHARGE PHYSICAL:
98.0 131/50 74 20 98%/2L
I/O: 1020/620
General-Patient appears well and in NAD
HEENT-PERRLA, EOMI, anicteric, oropharynx clear, MMM
Neck-Supple, Right IJ dialysis catheter, no [**Doctor First Name **]
Chest-Decreased breath sounds and crackles at lung bases L>R.
Cards-RRR, S1 and S2, No m/r/g
Ext-PICC line in place. No edema, warm, foley in place
Neuro-A&Ox3, CN II-XII grossly intact
Pertinent Results:
ADMISSION LABS:
DISCHARGE LABS:
MICRO:
[**2195-7-14**] 11:10 pm BLOOD CULTURE # 2.
**FINAL REPORT [**2195-7-20**]**
Blood Culture, Routine (Final [**2195-7-20**]):
STREPTOCOCCUS PNEUMONIAE.
Note: For treatment of meningitis, penicillin G MIC
breakpoints
are <=0.06 ug/ml (S) and >=0.12 ug/ml (R).
Note: For treatment of meningitis, ceftriaxone MIC
breakpoints are
<=0.5 ug/ml (S), 1.0 ug/ml (I), and >=2.0 ug/ml (R).
For treatment with oral penicillin, the MIC break
points are
<=0.06 ug/ml (S), 0.12-1.0 (I) and >=2 ug/ml (R).
FINAL SENSITIVITIES.
MEROPENEM = <= 0.06 MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS PNEUMONIAE
|
CEFTRIAXONE----------- 0.12 S
ERYTHROMYCIN----------<=0.25 S
LEVOFLOXACIN---------- 2 S
MEROPENEM------------- S
PENICILLIN G---------- 0.12 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
Anaerobic Bottle Gram Stain (Final [**2195-7-16**]):
Reported to and read back by DR. [**Last Name (STitle) **]. RONON ON [**2195-7-16**] AT
0115.
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
BLOOD CX, SECOND SET [**2195-7-14**]: NO GROWTH
BLOOD CX [**7-16**], [**7-17**], [**7-18**], [**7-19**]: PENDING
Legionella Urinary Antigen (Final [**2195-7-17**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
[**2195-7-15**] 2:29 pm PLEURAL FLUID
GRAM STAIN (Final [**2195-7-15**]):
4+ (>10 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 [**2195-7-18**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
STUDIES:
ECHO [**2195-7-22**]
IMPRESSION:
Mild symmetric left ventricular hypertrophy with preserved
regional and global biventricular systolic function. Moderate
pulmonary hypertension.
CT CHEST [**7-21**]
IMPRESION:
1. Multifocal pneumonia, progressed since [**7-16**], could be
bacterial, viral, eosinophilic or cryptogenic. 2. Moderate
residual of left pleural effusion, slightly smaller than on [**7-16**] following removal of the left pleural drain. Previous severe
atelectasis left lower lobe has improved. 3. Extensive
atherosclerosis, including coronaries. 4. Probable anemia.
CXR [**2195-7-14**]:
IMPRESSION:
1. New moderate left pleural effusion with associated
atelectasis.
2. Possible healing right anterior rib fractures. This can be
further
evaluated with dedicated radiographs if clinically indicated.
PLEURAL FLUID FOR CYTOLOGY:
Pleural fluid: NEGATIVE FOR MALIGNANT CELLS.
CT CHEST [**2195-7-14**]:
IMPRESSION:
1. Large left pleural effusion, partially loculated, suggestive
of resolving hemothorax. Compressive atelectasis in the left
lower lobe. Scattered ground-glass opacities in the lungs likely
represent early pneumonia.
2. Cirrhotic liver with ascites. Portal hypertension with
splenomegaly.
3. Multiple bilateral rib fractures as detailed above.
CT CHEST [**2195-7-16**]:
IMPRESSION:
1. Interval decrease in the uppermost portion of the left-sided
effusion with improved aeration of the left upper lobe. Minimal
residual pleural effusion where Pleurex catheter terminates;
however, effusion is seen above and below the tip of the
catheter and may be due to loculation or catheter obstruction.
Near complete opacification of the left lower lobe.
2. Worsening multifocal parenchymal opacities. Given the
short-interval
progression, infection is most likely.
3. Anemia.
4. Findings compatible with cirrhosis and portal hypertension.
5. Cholelithiasis.
CXR [**2195-7-19**]:
IMPRESSION:
1) Slight difference in configuration of left chest tube. No
pneumothorax
detected.
2) Left base pleural fluid and underlying collapse and/or
consolidation
grossly stable.
3) Multifocal opacities in the right lung and left mid and upper
zones again seen.
Brief Hospital Course:
Pt is a 60M with history of hep C cirrhosis c/b SBP, portal
hypertension and portal vein thrombus; Type 2DM, HTN, who was
admitted with left pleural effusion, which was found to be
parapneumonic effusion. Blood cultures grew strep pneumo., and
he was started on antibiotics. Thoracics was consulted and
placed a chest tube, but it was minimally draining and thus was
removed. Course also complicated by HRS, rising creatinine,
despite Albumin, Octreotide and Midodrine at maximum doses.
# Parapneuomonic effusion: Presented with large left-sided
pleural effusion concerning for hemothorax given recent fall,
vs. parapneumonic effusion vs. hydrothorax. Pt had thoracentesis
which showed exudative effusion. His blood cultures from the ED
grew GPC's, and was started on Vancomycin empirically. The GPC's
speciated to strep pneumonia, and Levofloxacin was added.
Thoracics was consulted and placed a chest tube, but it was
minimally draining. TPA was inserted x2 doses, but the chest
tube continued to have minimal output, and this was removed
[**7-20**]. CT chest on repeat showed worsening opacities. Antibiotics
were switched to Levofloxacin, Zosyn and vancomycin for improved
coverage. A CT chest showed worsening multifocal bilateral
infiltrates concerning for either multifocal pneumonia, ARDS or
crytptogenic organizing pneumonia. ARDSnet ventilatory volumes
were initiated at 6cc/kg ideal body weight. Failed extubation on
[**7-24**] and patient reintubated. On [**7-26**] the patient respiratory
status was improving and he was extubated. Transferred to floor
on [**7-27**] on 3L NC. Tolerated 3L NC on floor. Abx changed to
ceftriaxone only and patient remained afebrile without further
incident on Liver/Kidney service.
# Cirrhosis: Complicated by encephalopathy, SBP (on cipro),
varices, portal vein thrombosis. No evidence of decompensated
liver failure on admission. He was on Warfarin on admission
given PVT, which was discontinued during this admission given
procedures (as discussed above). He was continued on Lactulose,
Rifaximin, and Propranolol for history of varcies. Lasix was
held given acute renal failure (see below). Ciprofloxacin was
temporarily discontinued given started on Levofloxacin for PNA
as discussed above. Given history of PVT, pt should have MRI as
an outpatient to assess for portal vein patency. The patient
was restarted on coumadin on [**7-28**] for treatment of his PVT.
Cipro at ppx doses will be restarted on [**2195-7-8**] following
completiong of course of ceftrixone. The patient's transplant
coordinator, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8147**]. has been informed of these changes.
# Acute on Chronic Renal Insufficiency: Thought to be secondary
to hepatorenal syndrome. Creatinine 2.4 on admission, baseline
~1.8-2.0. Initially, improved to 2.1. However, Creatinine
worsened, concerning for HRS. He was given 50g albumin x2, and
Midodrine & Octreotide uptitrated. Despite this, his Creatnine
worsened. Pt had HD on [**7-25**]. On [**7-27**] the patient's Cr began to
stabilize and HD was discontinued. His Cr remained around 2.0
for the remainder of his hospital stay and the patient was
making good urine. His Lasix were restarted on [**7-29**]. The
dialysis catheter was removed on [**7-30**] without incident.
# Anemia: HCT 24.2, baseline high 20's. Per radiology,
possiblity of loculated hemothorax. Tbili WNL so less likely
hemolysis. No evidence of GI bleed. Hct decreased to 21.6 on
HOD#1. He was transfused for 1 unit PRBC's on [**7-16**]. Hct remained
stable in the mid-20s for the remainder of the [**Hospital 228**]
hospital stay. He was continued on ferrous sulfate 325 mg daily
# Left shoulder pain: Pt has had discomfort since fall, asking
for sling. Pt with no appreciable bony pain. X-ray with no
evidence of fracture. His pain was controlled with Tylenol and
prn oxycodone.
# h/o portal vein thrombus: INR supratherapeutic on admission,
and held warfarin given need for thoracentesis. Warfarin
continued to be held given need for chest tubes and possible
procedures. Warfarin restarted [**7-28**] and patient now therepeutic
with INR 2.0.
# Diabetes - Only on Lantus at home. Continued glargine + HISS
while in house in addition to diabetic diet.
# HTN: Normotensive durng this admission. Discontinued
amlodipine & hydralazine as BP well-controlled. Continued
propranolol 20mg TID for variceal ppx. Patient will return home
on amlodipine 10mg daily, propanolol 20mg TID and hydralazine
10mg daily.
# GERD: Continued omeprazole 20 mg [**Hospital1 **].
# HCP is sister [**Name (NI) 2048**] [**Name (NI) 31385**] [**Telephone/Fax (1) 53285**]
Medications on Admission:
Amlodipine 10 mg daily
Calcitriol 0.25 mcg MWF
Cipro 250 mg daily
ProCrit [**Numeric Identifier **] units q2weeks
Lasix 40 mg daily
Gabapentin 300 mg qam, 600 mg qpm
Hydralazine 10 mg QID
Glargine 15 units qhs
Lactulose 20g [**Hospital1 **]
Omeprazole 20 mg [**Hospital1 **]
Oxycodone 5mg QID
Propanolol 20 mg TID
Rifaximin 550 mg [**Hospital1 **]
Risedronate 35 mg weekly
Warfarin 5 mg daily
Ambium 5 mg qHS prn insomnia
Calcium - Vitamin D3 - 600-400 1 tablet [**Hospital1 **]
Ferrous Sulfate 324 mg daily
Fish Oil
Discharge Medications:
1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. Cipro 250 mg Tablet Sig: One (1) Tablet PO once a day: Please
start after completing 7 days course of ceftriaxone.
3. Procrit 40,000 unit/mL Solution Sig: One (1) Injection Every
2 weeks.
4. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a
day.
6. hydralazine 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. insulin glargine 100 unit/mL Solution Sig: One (1)
Subcutaneous at bedtime: 15 Units at Night.
8. lactulose 10 gram Packet Sig: Three (3) PO twice a day:
Titrate to 2-3BMs daily.
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
10. oxycodone 5 mg Capsule Sig: One (1) Capsule PO four times a
day as needed for pain.
11. propranolol 20 mg Tablet Sig: One (1) Tablet PO three times
a day.
12. rifaximin 550 mg Tablet Sig: One (1) Tablet PO twice a day.
13. risedronate 35 mg Tablet Sig: One (1) Tablet PO once a week.
14. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
15. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia. Tablet(s)
16. Calcium-Vitamin D 600-400 mg-unit Tablet Sig: One (1) Tablet
PO twice a day.
17. FerrouSul 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO
once a day.
18. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a
day.
19. ceftriaxone 1 gram Recon Soln Sig: One (1) Intravenous once
a day for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Primary: Pleural Effusion
Klebsiella Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**].
You were admitted here with shortness of breath and found to
have fluid in your lungs and a developing pneumonia. The fluid
was drained and the infection treated with antibiotics.
The following changes have been made to your medications:
1) You have been STARTED on Ceftriaxone which is given through
your PICC line and will be needed for an additional 7 days after
you are discharged.
2) We have INCREASED your lactulose dose from 20mg to 30mg
3) You will RESTART your home dose of ciprofloxacin after
finishing the 7 day course of Ceftrixone
Please continue all other home medications.
See follow up with your appointments below.
Followup Instructions:
Department: TRANSPLANT
When: WEDNESDAY [**2195-8-12**] at 2:40 PM
With: TRANSPLANT [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2195-7-31**]
|
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"276.2",
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"511.9",
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icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.71",
"99.10",
"34.04",
"38.95",
"38.97",
"96.04",
"96.72",
"38.91",
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icd9pcs
|
[
[
[]
]
] |
14835, 14935
|
8096, 12758
|
326, 421
|
15026, 15026
|
3898, 3898
|
15930, 16223
|
2682, 2762
|
13325, 14812
|
14956, 15005
|
12784, 13302
|
15209, 15907
|
3932, 5851
|
2777, 3879
|
265, 288
|
449, 1576
|
3915, 3915
|
5887, 8073
|
15041, 15185
|
1598, 2424
|
2440, 2666
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,633
| 179,679
|
48797
|
Discharge summary
|
report
|
Admission Date: [**2148-8-26**] Discharge Date: [**2148-9-4**]
Date of Birth: [**2070-5-23**] Sex: M
Service:
ADMISSION DIAGNOSES:
1. Esophageal cancer; status post chemotherapy and radiation
therapy.
2. History of paroxysmal atrial fibrillation.
3. Hypertension.
4. Hyperlipidemia.
5. History of anemia.
DISCHARGE DIAGNOSES:
1. Esophageal cancer; status post [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy;
status post chemotherapy and radiation therapy.
2. Paroxysmal atrial fibrillation.
3. Acute renal failure.
4. Right conjunctivitis.
5. Hypertension.
6. Hyperlipidemia.
7. Blood loss anemia.
8. Volume overload.
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
gentleman who had previously been diagnosed with esophageal
cancer and had undergone chemotherapy with cisplatin and
5-fluorouracil and radiation therapy. He had a recent
positron emission tomography scan which was found to be
negative.
When the patient initially presented, it was with an upper
gastrointestinal bleed in [**2148-4-16**] which required 4
units of packed red blood cells. An
esophagogastroduodenoscopy revealed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 15532**] esophagus with
an 8-cm fungating distal esophageal adenocarcinoma. After
this was the time in which the patient received his
chemotherapy and radiation therapy.
The patient presented to Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **] for an [**First Name9 (NamePattern2) 12351**]
[**Doctor Last Name **] esophagectomy for management of his esophageal cancer.
PERTINENT LABORATORY VALUES ON PRESENTATION: In terms of
preoperative laboratories, his white blood cell count was
6.4, hematocrit was 34, and platelets were 200. Blood urea
nitrogen was 16 and creatinine was 1.2. Potassium was 4.
PERTINENT RADIOLOGY/IMAGING: Positron emission tomography
scan results as noted.
PHYSICAL EXAMINATION ON PRESENTATION: In terms of initial
physical examination, the patient was in no acute distress.
His sclerae were anicteric. There were no palpable lymph
nodes in the neck in the supracervical or axillary region.
His lungs were clear to auscultation bilaterally. His heart
was regular in rate and rhythm. His abdomen was soft,
nontender, and nondistended. His calves were nontender, and
he had no edema. His pulses were [**2-20**] in the upper and lower
extremities.
HOSPITAL COURSE BY ISSUE/SYSTEM: The patient was admitted
on [**2148-8-26**] and underwent an [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy
by Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **], during which he had an estimated
blood loss of 800 cc. Otherwise, there were no
intraoperative complications. Intraoperatively, there was a
finding of tumor at the gastroesophageal junction and firm
celiac nodes, but no other evidence of metastasis.
Postoperatively, the patient was taken to the Postanesthesia
Care Unit where he was hypotensive. Therefore, the patient
was placed on a Levophed drip. His postoperative hematocrit
levels were 29.8 and 30; respectively.
Due to the fact that the patient required the Levophed drip,
he remained in the Postanesthesia Care Unit on postoperative
day zero and on postoperative day one.
The patient had his epidural stopped, and he was transfused
with 2 units of packed red blood cells. He was also given
aggressive fluid hydration, as his blood pressure was thought
to be secondary to his volume loss. The patient continued to
have serial hematocrit levels followed which stabilized in
the mid 20s.
On postoperative day two, the patient developed some
respiratory distress and was found to have a central venous
pressure of 11. His oxygen saturations had dropped down into
the 80s. He was treated with aggressive chest physical
therapy and nebulizers treatment, but it was felt that this
was likely secondary to volume overload as he was positive
7500 cc of fluid on postoperative day zero. His Levophed
drip had been weaned that day. His blood pressures were
returning into the 150s/60s and at times also to the 180s.
Given the patient's respiratory status, he was transferred to
the Intensive Care Unit for closer monitoring. At the time
of transfer to the Intensive Care Unit; notably, his
hematocrit was 27.6, and his blood urea nitrogen was 1.3, and
his arterial blood gas was 7.3/47/89/24 and -3. His chest
x-ray showed some left lower lobe collapse and consolidation
which was stable and an unchanged right lower lobe opacity.
While in the Intensive Care Unit, the patient was again
aggressively diuresed with intravenous Lasix. His hematocrit
remained stable and climbed to the upper 20s. The patient
was continued on aggressive pulmonary toilet.
By postoperative day four, the patient was otherwise
clinically stable but continued to have some respiratory
difficulties with a notable arterial blood gas of
7.4/45/125/29 and 2. He was started on tube feeds on this
day. He subsequently underwent a barium swallow study which
showed no abnormalities.
By postoperative day five, the patient was doing quite well
and was ready for transfer to the floor pending bed
availability. Notably, the patient did have occasional
episodes of atrial fibrillation while in the Intensive Care
Unit which were treated with intravenous Lopressor and did
resolve. Given the patient's problem with this, he was held
in the Intensive Care Unit on postoperative days five and
six.
These issues had resolved by postoperative day seven, and the
patient had been diuresing well and his atrial fibrillation
was controlled with metoprolol. He was started on a clear
liquid diet. By postoperative day seven, the patient
tolerated a clear liquid diet well. Otherwise, the patient's
chest tube was out by postoperative day eight.
By postoperative day nine, the patient was doing well and was
without complaints. He had remained afebrile. He was making
good urine. His respiratory status was good. His abdomen
looked soft and was nontender. His incision was clean. He
was tolerating his tube feeds well.
DISCHARGE DISPOSITION/CONDITION: Given that the patient was
doing well in all these aspects, it was determined that he
could be discharge to an extended care rehabilitation
facility.
MEDICATIONS ON DISCHARGE: (The patient was discharged on the
following medications)
1. Roxicet elixir 5 cc to 10 cc by mouth q.4-6h.
2. Ipratropium inhaler q.6h. as needed.
3. Albuterol inhaler q.6h. as needed.
4. Lopressor 75 mg by mouth three times per day (hold for a
systolic blood pressure of less than 90).
5. Colace 100 mg by mouth twice per day.
6. Miconazole nitrate powder one application three times per
day.
7. Lansoprazole 30-mg suspension by mouth once per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with Dr. [**First Name8 (NamePattern2) 333**]
[**Last Name (NamePattern1) **] in 10 to 14 days.
2. The patient was also to follow up with his primary care
physician.
3. The patient was instructed to follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1728**].
4. In terms of his tube feeds, he was to continue on his
tube feeds at 100 cc cycled from 8 p.m. to 8 a.m. The
patient was to continue on post gastrectomy diet with six
small meals per day. His tube feeds were Impact with fiber
at full strength.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
[**MD Number(1) 6066**]
Dictated By:[**Last Name (NamePattern1) 26688**]
MEDQUIST36
D: [**2148-9-4**] 12:33
T: [**2148-9-4**] 12:35
JOB#: [**Job Number 102543**]
|
[
"285.1",
"458.2",
"276.5",
"372.30",
"427.31",
"150.8",
"428.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"43.89",
"42.41"
] |
icd9pcs
|
[
[
[]
]
] |
352, 683
|
6365, 6823
|
6856, 7716
|
2475, 6338
|
151, 331
|
712, 2440
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,151
| 180,870
|
46173
|
Discharge summary
|
report
|
Admission Date: [**2197-1-3**] Discharge Date: [**2197-1-20**]
Date of Birth: [**2112-2-19**] Sex: F
Service: SURGERY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Anemia.
Major Surgical or Invasive Procedure:
[**2197-1-5**] Colonoscopy
[**2197-1-11**] Colonoscopy
[**2197-1-12**]
1. Open ileocecectomy.
2. Takedown splenic flexure.
3. Partial left colectomy with stapled #28 colocolostomy
History of Present Illness:
PCP:
[**Name Initial (NameIs) 7274**]: [**Last Name (LF) **],[**First Name3 (LF) 2946**] S.
Location: [**Hospital1 **] HEALTHCARE - [**State 3753**]GROUP
Address: [**State **], [**Apartment Address(1) 3745**], [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 2936**]
Fax: [**Telephone/Fax (1) 7922**]
Email: [**University/College 98191**]
Admission Date/Time:[**2197-1-3**] 2100
CC:[**CC Contact Info 98192**]
HPI: 84F who was admitted 4 months PTA with maroon colored
stools and HCT drop from 30-20. She was monitored as an
inpatient and transfused and bumped appropriately. No endoscopy
was performed. She was seen in [**Hospital **] clinic 1 day PTA with Dr. [**First Name (STitle) 452**]
and was found to have HCT of 24. No tachycardia, some minimal
RUQ pain. No SOB, fatigue more than baseline. Admits to
occasional
blood on toilet paper with bowel movements, but denies any
melana. She was sent to the ER to get a transfusion and to try
to convince her to get a c-scope which she has never had and
refused in the past.
In ER: (Triage Vitals:97.7 74 144/51 15 99) GI consult was
called who said they would see her in the morning. Given 1 of 2
units in ER. Guiac positive. LBBB in ER noted. TnI neg.
ROS:
-Constitutional: [x]WNL []Weight loss []Fatigue/Malaise []Fever
[]Chills/Rigors []Nightweats []Anorexia
-Cardiac: [x]WNL []Chest pain []Palpitations []LE edema
[]Orthopnea/PND []DOE
-Respiratory: [x]WNL []SOB []Pleuritic pain []Hemoptysis []Cough
-Gastrointestinal: see HPI
-Musculoskeletal: [x]WNL []Myalgias []Arthralgias []Back pain
-Neurological: [ x]WNL []Numbness of extremities []Weakness of
extremities []Parasthesias []Dizziness/Lightheaded []Vertigo
[]Confusion []Headache
Past Medical History:
Coronary Artery Disease, baseline LBBB
- MIBI [**1-/2196**] 1. No definite perfusion defect
2. Increased left ventricular cavity size
global hypokinesis.
3. LVEF of 45%.
Hypertension
AFIB not on coumadin
COPD [**2194**] FEV1 89% Ratio 93%
Colon CA S/P L Colectomy in [**2166**]
S/P L THR (Secondary to OA) [**2187**]
GERD
Rectocele
Achalasia [**4-13**] on esophageal motility study
Shingles
L femoral neck fx, s/p L hip arthroplasty [**12-10**]
R hip OA
L knee OA
s/p fall in [**2-10**] with L femur periprosthetic fx, now healed
T11, T12 compression fractures, now healed
L3 compression fracture s/p vertebroplasty [**2196-2-2**]
MOST RECENT COLONOSCOPY: [**4-/2191**]
Polyp at 18 cm in the rectosigmoid (biopsy, polypectomy)
Grade 2 internal hemorrhoids
Otherwise normal Colonoscopy to cecum. There was melanosisoli
involvement of the whole colon.; A small percentage of polyps or
other lesions might be missed
Social History:
Lives alone in senior citizens building in [**Location (un) 583**], 2 children
(one in [**Location (un) 4628**], one in [**State 4565**]). Husband died 20 yr ago.
Auschwitz Holocaust-survivor. Former factory worker. No history
of smoking, EtOH or illegal drugs. Has a homemaker who visits
1x/week. Has another person help her shower 3x/week and do her
shopping. Comes from [**Location (un) 98105**].
Family History:
non-contributory
Physical Exam:
VS: 96.9 67 152/79 20 100 2L
Gen: Well appearing, no acute distress, awake, alert,
appropriate, and oriented x 3, but does not remeber seeing Dr.
[**First Name (STitle) 452**] yesterday. Seems to have difficultly with memory, but
answers questions appropriately.
Skin: warm to touch, no apparent rashes.
HEENT: OP clear, no cervical LAD, no palpable thyroid nodules.
CV: II/VI systolic murmur early peaking, +S4.
Lungs: clear to auscultation
Abd: soft, NT, normal BS
Ext: No C/C/E
Neuro: strength and sensation intact bilaterally.
Pertinent Results:
[**2197-1-3**] 03:45PM URINE HOURS-RANDOM
[**2197-1-3**] 03:45PM URINE GR HOLD-HOLD
[**2197-1-3**] 03:45PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2197-1-3**] 03:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-TR
[**2197-1-3**] 03:45PM URINE RBC-2 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-0
[**2197-1-3**] 01:47PM K+-4.0
[**2197-1-3**] 01:47PM HGB-8.2* calcHCT-25
[**2197-1-3**] 01:40PM GLUCOSE-108* UREA N-70* CREAT-1.5* SODIUM-137
POTASSIUM-5.1 CHLORIDE-95* TOTAL CO2-30 ANION GAP-17
[**2197-1-3**] 01:40PM estGFR-Using this
[**2197-1-3**] 01:40PM cTropnT-0.01
[**2197-1-3**] 01:40PM WBC-6.0 RBC-2.95* HGB-7.6* HCT-23.6* MCV-80*
MCH-25.7* MCHC-32.1 RDW-16.1*
[**2197-1-3**] 01:40PM NEUTS-70.3* LYMPHS-21.5 MONOS-6.8 EOS-1.3
BASOS-0.1
[**2197-1-3**] 01:40PM PLT COUNT-190
[**2197-1-3**] 01:40PM PT-12.6 PTT-25.6 INR(PT)-1.1
[**2197-1-2**] 12:50PM FERRITIN-17
[**2197-1-2**] 12:50PM WBC-6.7 RBC-3.01* HGB-7.7* HCT-24.5* MCV-81*
MCH-25.6* MCHC-31.5 RDW-16.5*
[**2197-1-2**] 12:50PM PLT COUNT-219
CT Chest IMPRESSION: No evidence of metastastic disease within
the thorax
CT Abd/Pelvis: No evidence for metastatic disease in the abdomen
or pelvis
Stable compression deformities at the T11, T12 and L3 vertebral
bodies are
noted. Post-kyphoplasty changes at T10 and L3. Tortuous,
calcified and slightly ectatic abdominal aorta, without frank
aneurysm.
GI Tissue Biopsy: Colon Adenocarcinoma
[**2197-1-9**] 06:52AM BLOOD WBC-5.6 RBC-3.76* Hgb-10.3* Hct-31.2*
MCV-83 MCH-27.4 MCHC-33.0 RDW-16.1* Plt Ct-204
[**2197-1-10**] 06:40AM BLOOD WBC-5.0 RBC-3.91* Hgb-10.4* Hct-32.5*
MCV-83 MCH-26.7* MCHC-32.1 RDW-16.3* Plt Ct-196
[**2197-1-11**] 07:10AM BLOOD WBC-11.2*# RBC-3.55* Hgb-9.6* Hct-28.8*
MCV-81* MCH-27.1 MCHC-33.5 RDW-15.9* Plt Ct-169
[**2197-1-12**] 06:19PM BLOOD WBC-4.5# RBC-2.59*# Hgb-7.1*# Hct-21.4*#
MCV-83 MCH-27.6 MCHC-33.3 RDW-16.3* Plt Ct-110*
[**2197-1-14**] 03:31AM BLOOD WBC-10.7# RBC-3.88* Hgb-10.8* Hct-32.6*
MCV-84 MCH-27.9 MCHC-33.2 RDW-15.8* Plt Ct-125*
[**2197-1-15**] 03:30AM BLOOD WBC-12.0* RBC-3.74* Hgb-10.3* Hct-31.9*
MCV-85 MCH-27.6 MCHC-32.4 RDW-15.7* Plt Ct-123*
[**2197-1-12**] 03:25AM BLOOD Plt Ct-160
[**2197-1-13**] 03:00AM BLOOD Plt Smr-LOW Plt Ct-126*
[**2197-1-15**] 03:30AM BLOOD PT-13.7* PTT-40.5* INR(PT)-1.2*
[**2197-1-13**] 03:00AM BLOOD ALT-8 AST-24 LD(LDH)-165 CK(CPK)-131
AlkPhos-64 TotBili-1.1
[**2197-1-14**] 03:31AM BLOOD ALT-9 AST-25 LD(LDH)-160 CK(CPK)-120
AlkPhos-73 TotBili-0.6
[**2197-1-13**] 03:00AM BLOOD CK-MB-6 cTropnT-0.06*
[**2197-1-13**] 10:24AM BLOOD CK-MB-5 cTropnT-0.05*
[**2197-1-14**] 03:31AM BLOOD CK-MB-3 cTropnT-0.05*
Brief Hospital Course:
84F with slow GIB, presented for admission after seeing her
gastroenterologist, Dr. [**First Name (STitle) 452**] due to concerns of progressive
anemia. Pt was transfused 2 units PRBC on admission. Pt had
previously been declining colonoscopy as an output, however, pt
consented here, and is now s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] which found a mass
concerning for malignancy.
.
Colon mass, probable malignancy:
Surgery was consulted, and CT Chest, abd/pelvis was obtained for
staging purposes. CEA was drawn, and was low (3.3). [**Name (NI) 1094**] son
came in to town to assist patient with decision making process.
- CEA 3.3
.
Chronic blood loss anemia:
Probable colon cancer on [**Last Name (un) **].
-s/p transfusion 2 units
-consulted surgery for probable colon cancer
.
CAD, NATIVE VESSEL
Pt denies any cardiac symptoms on history for perioperative
cardiac risk stratification. Pt was not on aspirin as an
outpatient due to concern of her chronic GI bleed. This has not
been restarted due to ongoing source of GI bleed, and in
anticipation of possible surgical intervention.
-unclear why not on statin
.
Secondary Diagnosis: 427.31 ATRIAL FIBRILLATION
-continued amio at home dose
.
Secondary Diagnosis: 530.11 GASTROESOPHAGEAL REFLUX DISEASE
(GERD)
-ppi
.
Secondary Diagnosis: 244.9 HYPOTHYROIDISM
-continued home thyroid meds
.
Secondary Diagnosis: 311 DEPRESSION, NOS
-no longer on SSRI
.
Lower extremity edema:
Pt showed me her prescription for Torsemide 60 mg po q day, and
she requested that this be restarted for her chronic LE edema.
This remained held in the setting of CT with contrast for
staging purposes, to minimize the risk for contrast nephropathy.
.
.
The perioperative rate of cardiac death, nonfatal myocardial
infarction, and nonfatal cardiac arrest is approximately:
.
This Patient:
Probable proposed surgery is a moderate risk procedure
(colectomy).
Pt likely has a history of ischemic heart disease with Hx of
LBBB, but does not endorse any ischemic symptoms, and has had a
negative MIBI 2/[**2195**]. Thus, active ischemic heart disease is not
likely.
There is no known history of CHF or CVA.
Glucose has been well controlled without insulin.
Creatinine is <2.
This patient has 0 risk factors, and hence has a 0.4% risk of
perioperative cardiac complications. Age is not generally
regarded an independent risk factor, although these guidelines
have not been well studied in the geriatric population.
FEN: regular diet
PIV
DVT ppx: Heparin SQ, as at risk for DVT with probable CA.
Monitor for bleed.
DNR/DNI
On [**2197-1-12**] , the patient underwent open ileo cecectomy, takedown
splenic flexure and partial left colectomy with stapled #28
colocolostomy, which went well without complication. The patient
was admitted to the General Surgical Service. After surgery
patient was transferred to [**Hospital Unit Name 153**], she was intubated, received 2
units of blood for hematocrit of 21.4. She was on IV fluids and
in pressors initially.
On POD1: patient was extubated, off of pressors. She was doing
fine, we started sips diet which she tolerated very well. Lasix
IV was given to help her diuresis fluids received during
resuscitation.
On POD2: Physical therapy started working with her. Early
ambulation and incentive spirometer. She was advance to clears.
On POD3: Central line discontinued. Patient with vital signs
stable, doing fine.
On POD 4: She was transferred to the floor.
On POD 6: Continue awaiting return bowel function. She was
given, Senna, Colace and Dulcolax suppository.
On POD 7: Return of bowel function, diet was advanced to
Regular, which she tolerated very well.
Neuro: The patient received *****with good effect and adequate
pain control. When tolerating oral intake, the patient was
transitioned to oral pain medications.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
Electrolytes were routinely followed, and repleted when
necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection.
Hematology: The patient's complete blood count was examined
routinely.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, having bowel movements, ambulating with assistance,
voiding without assistance, and pain was well controlled.
Medications on Admission:
Discharge Medications from last admission. Patient does not know
her meds. Note there were a number of meds that were stopped on
the last admission. Not sure if this was intentional. Needs
confirmation.
1. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Medications:
1. Levothyroxine 25 mcg 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. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
5. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain for 2 weeks.
Disp:*85 Tablet(s)* Refills:*0*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-10**] Sprays Nasal
QID (4 times a day) as needed for nasal congestion.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain for 2 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
1. Colon Adenocarcinoma
2. Anemia, chronic blood loss
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 with anemia due to a slow gastrointestinal
bleed. You were found to have a mass in your colon which was
found to be adenocarcimnoma. Surgery was consulted and
recommended partial left colectomy and ileocecectomy. Your
surgery went well without complications.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-17**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7937**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2197-5-3**] 11:30
Dr. [**Last Name (STitle) 1120**]
Please call to schedule an appointment in 1 week.
([**Telephone/Fax (1) 3378**]
Completed by:[**2197-1-20**]
|
[
"427.31",
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icd9cm
|
[
[
[]
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[
"45.25",
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icd9pcs
|
[
[
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13317, 13411
|
6941, 8086
|
274, 457
|
13509, 13509
|
4219, 6918
|
15971, 16268
|
3633, 3651
|
12272, 13294
|
13432, 13488
|
11757, 12249
|
13686, 15560
|
15576, 15948
|
3666, 4200
|
227, 236
|
485, 2213
|
8333, 11731
|
13523, 13662
|
2235, 3198
|
3214, 3617
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,223
| 175,380
|
6975
|
Discharge summary
|
report
|
Admission Date: [**2107-7-24**] Discharge Date: [**2107-7-28**]
Date of Birth: [**2028-3-14**] Sex: F
Service: SURGERY
Allergies:
Iodine
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
sp cardiac arrest/colitis
Major Surgical or Invasive Procedure:
sp Left subclavian CVL placement
sp Right femoral CVL placement
History of Present Illness:
79F Pmhx CHF,COPD, found down at home, pulseless- CPR initiated
w/conciousness regained on scene. At OSH ABG 7.19/94/110, BiPAP
started. Pt found to be hypothermic w/ WBC 17 (pt on steroids)
pnuemobilia and thickening of sigmoid. Currently on Nasal
cannula 02 + hemodymamically stable.
Past Medical History:
CHF (EF 25%, mod AS,AR, mod MR, CAD,PAF, angina, COPD (O2
dependent-2 L) PVD, recurrent UTI's, Chronic bronchitis, ?h/o
DM,
sp L ax-bifem, L fem-[**Doctor Last Name **], ERCP '[**04**], T+A, Appy, CEA, L4-L5
laminectomy.
Social History:
ex tobacco
denies [**Hospital **]
nursing home resident
Family History:
NC
Physical Exam:
thin, A&O X 1
IRRR
Decreased BS bilaterally
soft, mild tenderness R and L lower quadrants-not reproducible
visible fem-fem graft
ext warm, + 1 edema
Pertinent Results:
[**2107-7-24**] 04:20AM BLOOD WBC-13.8* RBC-3.17* Hgb-8.9* Hct-28.4*
MCV-90 MCH-28.2 MCHC-31.4 RDW-15.0 Plt Ct-185
[**2107-7-26**] 03:15AM BLOOD WBC-6.8 RBC-2.86* Hgb-7.7* Hct-25.9*
MCV-91 MCH-27.0 MCHC-29.9* RDW-15.1 Plt Ct-178
[**2107-7-27**] 02:41AM BLOOD WBC-5.3 RBC-2.94* Hgb-8.2* Hct-27.4*
MCV-93 MCH-27.9 MCHC-29.9* RDW-15.0 Plt Ct-194
[**2107-7-25**] 03:07AM BLOOD PT-14.0* PTT-30.1 INR(PT)-1.2*
[**2107-7-24**] 04:20AM BLOOD Glucose-86 UreaN-18 Creat-0.8 Na-144
K-3.7 Cl-101 HCO3-40* AnGap-7*
[**2107-7-26**] 09:36AM BLOOD Glucose-202* UreaN-25* Creat-1.1 Na-139
K-3.9 Cl-100 HCO3-37* AnGap-6*
[**2107-7-27**] 02:41AM BLOOD Glucose-122* UreaN-31* Creat-1.3* Na-139
K-4.1 Cl-99 HCO3-35* AnGap-9
[**2107-7-24**] 04:20AM BLOOD ALT-51* AST-86* CK(CPK)-638* AlkPhos-65
Amylase-120* TotBili-0.4
[**2107-7-24**] 12:38PM BLOOD CK(CPK)-1086*
[**2107-7-24**] 09:45PM BLOOD CK(CPK)-972*
[**2107-7-27**] 02:41AM BLOOD CK(CPK)-218*
[**2107-7-24**] 04:20AM BLOOD cTropnT-0.18*
[**2107-7-24**] 12:38PM BLOOD CK-MB-18* MB Indx-1.7 cTropnT-0.17*
[**2107-7-24**] 09:45PM BLOOD CK-MB-14* MB Indx-1.4
[**2107-7-25**] 04:26AM BLOOD CK-MB-10 MB Indx-1.4 cTropnT-0.12*
[**2107-7-27**] 02:41AM BLOOD CK-MB-5 cTropnT-0.10*
[**2107-7-24**] 04:20AM BLOOD Calcium-8.1* Phos-3.2 Mg-2.0
[**2107-7-27**] 02:41AM BLOOD Calcium-8.2* Phos-5.3* Mg-1.9
[**2107-7-25**] 07:36AM BLOOD Vanco-16.2*
[**2107-7-26**] 10:26AM BLOOD Type-ART pO2-105 pCO2-95* pH-7.19*
calTCO2-38* Base XS-4
[**2107-7-26**] 11:05AM BLOOD Type-[**Last Name (un) **] pO2-35* pCO2-107* pH-7.17*
calTCO2-41* Base XS-5
[**2107-7-26**] 11:31AM BLOOD Type-ART pO2-144* pCO2-80* pH-7.23*
calTCO2-35* Base XS-3
[**2107-7-26**] 07:42PM BLOOD Type-ART pO2-127* pCO2-105* pH-7.16*
calTCO2-40* Base XS-4
[**2107-7-26**] 09:19PM BLOOD Type-ART pO2-76* pCO2-85* pH-7.26*
calTCO2-40* Base XS-7
[**2107-7-27**] 01:50AM BLOOD Type-ART pO2-47* pCO2-105* pH-7.15*
calTCO2-39* Base XS-3
[**2107-7-27**] 02:54AM BLOOD Type-ART pO2-64* pCO2-91* pH-7.23*
calTCO2-40* Base XS-6
CT CSpine: No evidence of cervical spine fracture. Cervical
spondylosis as described above.
CXR post CVL placement [**7-25**]:
A left subclavian vascular catheter terminates in the superior
vena cava. Several skin folds are present in the left hemithorax
but there is no pneumothorax. There are bilateral moderate
pleural effusions, both of which have increased in size since
the previous study. New perihilar and basilar opacities may
reflect pulmonary edema sparing the upper lobes in the setting
of emphysema, but it is difficult to exclude underlying
aspiration or infectious pneumonia in the lung bases. Surgical
clips are present in the left axilla.
[**7-27**] CXR: Interval development of large left pneumothorax with
almost complete collapse of the left lung.
Brief Hospital Course:
79F w/ a multiple medical problems including CHF (EF20%), COPD
(on home O2), found down at home, pulseless- CPR initiated
w/conciousness regained on scene. At OSH ABG 7.19/94/110, BiPAP
started. Pt found to be hypothermic w/ WBC 17 (pt on steroids)
pnuemobilia and thickening of sigmoid. Pt was transferred to
[**Hospital1 18**] for further management with wishes from the pt and family
to reverse DNR/DNI status if surgery was indicated. On
transfer, the pt had VSS with a mildly tender abdomen without
peritoneal signs. It was decided to treat her conservatively
with bowel and IV antibiotics. She improved and was tolerating
PO's without difficulty after passing a swallow study. Her
Cpine was clearly with both a negative CT Cspine and clinical
exam. Her groin CVL was DC'd after a L SC SVL was palced. CXR
confirmed good position and no PTx.
Overnight on HD 3, pt became mildly agitated and an ABG was
drawn which showed a severe resp acidosis and BiPAP was
initiated. The pt subsequently developed severe hypoxia with
hypotension. A CXR was obtained which showed complete collapse
of the L lung thought to be a result of bursting a bleb
associated with her severe COPD. Family did not want a chest
tube placed and decided to make the pt [**Name (NI) 3225**] measures.
On HD 4 pt continued to show a severe respiratory acidosis, was
continued on a morphine drip, and was difficult to arouse. At
6pm pt's respiratory status worsened and she died.
Medications on Admission:
coreg 6.25", captopril 12.5", effexor 150', colace 100" prn,
calcium ", lasix 40', KCL 20', Pred 5', opscal', protonix 40',
diamoxx 250', albuterol prn, darvocet prn, senekot, trazadone
25'
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
respiratory failure
Discharge Condition:
NA
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2107-7-29**]
|
[
"428.30",
"V46.2",
"512.8",
"584.9",
"557.9",
"414.00",
"518.81",
"428.0",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
5719, 5728
|
3989, 5452
|
292, 357
|
5791, 5795
|
1194, 3966
|
5846, 5879
|
1006, 1010
|
5692, 5696
|
5749, 5770
|
5478, 5669
|
5819, 5823
|
1025, 1175
|
227, 254
|
385, 672
|
694, 917
|
933, 990
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,132
| 114,932
|
48705
|
Discharge summary
|
report
|
Admission Date: [**2145-12-28**] Discharge Date: [**2146-1-14**]
Date of Birth: [**2064-8-10**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2145-12-30**] Coronary Artery Bypass Graft x 4 (Left internal mammary
artery to left anterior descending, Saphenous vein graft to
Diagonal, Saphenous vein graft to Ramus, Saphenous vein graft to
Obtuse Marginal)
[**2145-12-29**] Cardiac cath
History of Present Illness:
Ms. [**Known lastname 102405**] is a 81 female with multiple coronary artery
disease risk factors and previous strokes with dementia who
presented with acute onset chest pain. ED initially was not
concerned as patient had negative MIBI [**4-17**] and was originally
going to be ruled out and scheduled for a stress test. However
her troponin returned elevated at 0.21 so patient was started on
a heparin drip, got Aspirin 325mg, and was transferred to the
floor without plavix load.
Past Medical History:
Stroke w/ residual left sided weakness, Hypertension,
Hyperlipidemia, Diabetes Mellitus, Dementia, Gastroesophageal
Reflux Disease, Recurrent urinary tract infections, Iron
defiency anemia, Recurrent falls, s/p Hysterectomy
Social History:
Lives at [**Hospital3 **]- Country Club Heights in [**Location (un) 246**]. Has
daughter lives close by in [**Name (NI) 2436**]. She needs assitance with
showers. She is independent in ambulating with a walker, eating
and toileting
IADLS: Need assitance with shopping, bills, daughter does meds,
food preparation. She is independent with telephone use
Quit smoking 30 to 40 years ago. Occasional ETOH.
She has pre-existent home care services
+ H/o fall within 3 months
+ Unsteady gait?
+ Visual aides
Family History:
father had afib and CVA in 70s.
Two cousins with [**Name2 (NI) 499**] cancer.
Physical Exam:
Admission
VS - 97.0 162/77 86 18 100% on RA
Gen: elderly F in NAD.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 3 cm at 45' angle.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: slight crackles at the bases.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: wwp, no edema. slight brawny stasis dermatitis.
Discharge
VS T 97.4 HR 72SR BP 130/75 RR 18 O2sat 96%-RA
Gen NAD
Neuro A&Ox3, residual left sided weakness. Able to ambulate with
walker.
Pulm CTA-bilat
CV RRR, no M/R/G. Sternum stable, incision CDI
Abdm soft, NT/+BS
Ext warm well perfused. 1+ pedal edema bilat. Small rt arm
phlebitis- improving over last few days
Pertinent Results:
[**2145-12-28**] 09:30PM CK(CPK)-78
[**2145-12-28**] 09:30PM PT-12.4 PTT-32.8 INR(PT)-1.0
[**2145-12-28**] 01:00PM GLUCOSE-135* UREA N-19 CREAT-0.9 SODIUM-138
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15
[**2145-12-28**] 01:00PM cTropnT-0.21*
[**2145-12-28**] 01:00PM WBC-9.9 RBC-3.98* HGB-11.8* HCT-34.6* MCV-87
MCH-29.7 MCHC-34.2 RDW-13.6
[**2145-12-28**] 01:00PM PLT COUNT-336
[**2145-12-28**] 01:00PM PT-11.7 PTT-22.2 INR(PT)-1.0
[**2146-1-14**] 05:06AM BLOOD WBC-11.5* RBC-3.48* Hgb-10.8* Hct-31.1*
MCV-89 MCH-31.1 MCHC-34.8 RDW-15.0 Plt Ct-688*
[**2146-1-14**] 05:06AM BLOOD Plt Ct-688*
[**2146-1-7**] 12:08PM BLOOD PT-12.6 PTT-28.6 INR(PT)-1.1
[**2146-1-14**] 05:06AM BLOOD Glucose-141* UreaN-25* Creat-1.3* Na-137
K-4.4 Cl-100 HCO3-28 AnGap-13
[**2145-12-29**] 10:10AM BLOOD %HbA1c-7.2*
[**2145-12-29**] Cardiac Cath: 1- Selective coronary anguiography of
this left-dominant system demonstrated severe diffuse three
vessel coronary artery disease with markedly calcific vessels.
The distal LMCA/ostial LCX had 80% stenosis and the mid and
distal LCX had each 70% stenosis serially. The LAD had 70%
diffuse bifurcation stenosis at mid vessel with 60% stenosis in
the ostial major diagonal brancg. There was a small high
diagonal vessel(RI) with 30% stenosis. The RCA was a diminutive
vessel with 40% diffuse stenosis throughout. 2- Limited resting
hemodynamic assessment revealed normal systemic arterial
pressure (121/60 mmHg). The left-sided filling pressures were
normal at baseline (LVEDP 11 mmHg, increased to 16 mmHg after LV
gram). 3- Left ventriculography revealed normal LVEF (60-65%)
without regional wall motion abnormalities or mitral
regurgitation.
[**2145-12-29**] Carotid U/S: Less than 40% stenosis of the internal
carotid arteries bilaterally.
[**12-30**] Head CT:1. No significant interval change from prior MR
examination from [**2142-5-20**] with no acute infarction or hemorrhage
identified. 2. Multiple old lacunar infarctions of the bilateral
cerebellar hemispheres and pons, and changes consistent with
chronic small vessel ischemic disease.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 102406**] (Complete)
Done [**2145-12-30**] at 10:02:05 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2064-8-10**]
Age (years): 81 F Hgt (in):
BP (mm Hg): 108/65 Wgt (lb):
HR (bpm): 75 BSA (m2):
Indication: intraoperative management of CABG.
ICD-9 Codes: 440.0, 424.1, 424.0
Test Information
Date/Time: [**2145-12-30**] at 10:02 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW2-: Machine: 2
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.2 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 5.0 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.7 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.8 cm
Left Ventricle - Fractional Shortening: *0.24 >= 0.29
Left Ventricle - Ejection Fraction: 60% >= 55%
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.5 cm <= 3.0 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aorta - Arch: 2.5 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm
Aortic Valve - LVOT diam: 1.8 cm
Aortic Valve - Valve Area: *1.4 cm2 >= 3.0 cm2
Aortic Valve - Pressure Half Time: 738 ms
Mitral Valve - Pressure Half Time: 77 ms
Mitral Valve - MVA (P [**2-10**] T): 2.8 cm2
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A ratio: 1.11
Findings
LEFT ATRIUM: Moderate LA enlargement. Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels. Complex (>4mm) atheroma in the aortic arch. Normal
descending aorta diameter. Complex (>4mm) atheroma in the
descending thoracic aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral annular calcification. No MS. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. Results were
Conclusions
PREBYPASS
1. The left atrium is moderately dilated. The left atrium is
elongated. No atrial septal defect or PFO is seen by 2D or color
Doppler.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size 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 complex (>4mm) atheroma in the aortic arch. There
are complex (>4mm) atheroma in the descending thoracic aorta.
5. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis. There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
7. There is no pericardial effusion.
8. Dr.[**Last Name (STitle) 914**] was notified in person of the results in the OR at
the time of surgery
POSTBYPASS
1. Patient is on XX infusions.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2146-1-3**] 14:46
Radiology Report CHEST (PA & LAT) Study Date of [**2146-1-12**] 9:13 AM
[**Hospital 93**] MEDICAL CONDITION: 81 year old woman with s/p cabg
REASON FOR THIS EXAMINATION:
EVALUATE EFFUSIONS
Provisional Findings Impression: MLKb WED [**2146-1-12**] 10:50 AM
Decrease in amount of pleural effusion.
Final Report
HISTORY: 81-year-old female, status post CABG. Evaluate
effusions.
COMPARISON: Prior study, [**2146-1-10**].
FINDINGS: Status post sternotomy with surgical clips post-CABG.
There is
decreasing amount of pleural effusion seen on the lateral views.
Right-sided PICC line is again seen with the tip in the SVC.
Unchanged appearance of the cardiomegaly and bilateral bibasal
atelectasis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 75229**] [**Name (STitle) **]
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: WED [**2146-1-12**] 12:20 PM
Brief Hospital Course:
As mentioned in the HPI, Mrs. [**Known lastname 102405**] was admitted from the
emergency room after she was found to have a non-ST segment
elevation myocardial infarction. She was appropriately medically
managed and worked up for cardiac surgery. On [**12-30**] she was
brought to the operating room where she underwent a coronary
artery bypass graft x 4. The procedure was performed by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**]. Please see operative report for surgical
details. In summary she had CABG x4 with LIMA-LAD, SVG-Diag,
SVG-Ramus, SVG-OM. She tolerated the operation well and
following surgery she was transferred to the CVICU for invasive
monitoring in stable condition. She remained intubated for three
days after surgery secondary to a difficult airway and fluid
overload. She was weaned from her pressors and her chest tubes
were removed. She was fed via a dobhoff tube after surgery
secondary to somnolence. She was noted to be confused after the
surgery, but also has a baseline history of dementia. Her beta
blockade was titrated up as tolerated. On post-operative day
seven she was transferred to the surgical step down floor. She
had intermitant episodes of atrial fibrillation with hypotension
and was returned to the surgical intensive care unit, where she
converted to sinus rhythm after adjustment of Bblockers and
initiation of amiodarone. Her mediastinal incision was noted to
have some purulent drainage and she was started on Vancomycin
and ciprofloxacin. She was transferred back to the step down
floor on post-operative day nine. Sternal drainage subsided and
her sternum remained stable. As discussed with Dr.[**Last Name (STitle) 914**], Cipro
was discontinued and upon discharge, Vancomycin will be
continued for 7 days. She was seen by phyisical therapy. On
post-operative day 15 she was discharged to rehabilitation at
[**Hospital6 **].
Medications on Admission:
Alendronate 70 mg PO qweekly, Imipramine 20 mg PO QHS,
Lisinopril 10 mg PO qAM, Metoprolol XL 50 mg PO QHS, MVI (noon),
Nitrofurantoin 100 mg PO 3x/week MOWFri, Prilosec 20 mg PO
[**Hospital6 **], Simvastatin 20 mg PO [**Last Name (LF) **], [**First Name3 (LF) **] 81 mg PO daily, Calcium
Carbonate 750 mg PO TID, Vitamin D3 800 PO [**First Name3 (LF) **], Ferrous
Sulfate 325 mg PO [**First Name3 (LF) **], Aggrenox 200-25 mg PO BID, Simethicone
80 mg PO QID, Glyburide 1.25 mg PO QAM, Metformin 500 mg PO QAM,
Glucovance 5-500 PO BID before breakfast and supper)
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed.
Disp:*60 Tablet(s)* Refills:*0*
2. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
4. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr
Sig: One (1) Cap PO BID (2 times a day).
Disp:*60 Cap(s)* Refills:*0*
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TIDAC (3 times a day (before meals)).
Disp:*90 Tablet, Chewable(s)* Refills:*0*
6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Glyburide Micronized-Metformin 5-500 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for
5 days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
11. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
once a day for 7 days.
12. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
15. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
16. Sodium Chloride 0.65 % Aerosol, Spray Sig: Two (2) Spray
Nasal Q6H (every 6 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
Myocardial Infarction, Postop atrial fibrillation
PMH: Stroke w/residual left sided weakness, Hypertension,
Hyperlipidemia, Diabetes Mellitus, Dementia, Gastroesophageal
Reflux Disease, Recurrent urinary tract infections, Iron
defiency anemia, Recurrent falls, s/p Hysterectomy
Discharge Condition:
Stable
Discharge Instructions:
Please shower daily , no baths or swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 100.5
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for one month and off [**Doctor Last Name **] narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns: [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks
Dr. [**Last Name (STitle) **] in [**3-14**] weeks
Dr. [**Last Name (STitle) **] in [**2-10**] weeks
Completed by:[**2146-1-14**]
|
[
"250.00",
"V15.88",
"997.1",
"410.71",
"998.59",
"280.9",
"414.01",
"276.6",
"331.0",
"368.16",
"729.89",
"E878.2",
"285.1",
"458.29",
"438.89",
"427.31",
"294.10",
"272.4",
"401.9",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"99.04",
"88.53",
"37.22",
"96.71",
"88.57",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
14711, 14790
|
10355, 12271
|
332, 578
|
15173, 15182
|
2860, 4663
|
15697, 15871
|
1875, 1955
|
12886, 14688
|
9462, 9495
|
14811, 15152
|
12297, 12863
|
15206, 15674
|
1970, 2841
|
282, 294
|
9524, 10332
|
606, 1090
|
4671, 9422
|
1112, 1337
|
1353, 1859
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,058
| 121,601
|
5750
|
Discharge summary
|
report
|
Admission Date: [**2142-12-8**] Discharge Date: [**2142-12-22**]
Date of Birth: [**2101-3-31**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Oxygen
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
Skin lesions and SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 41-year-old man with Hodgkin's Disease s/p
autologous hematopoetic stem cell transplant (HSCT) [**2-11**] and two
prior episodes of varicella zoster virus (VZV) infection
(dermatomal vs. disseminated [**9-12**]; disseminated [**11-11**]) who noted
the onset new lesions along his anterior right torso at 1600
yesterday. The patient's lesions are erythematous, but unlike
classic VZV vesicles, these lesions are maculopapular and not
fluid-filled and not viscular. They are painful and slightly
pruritic, and there is some tingling associated with them as
well. Associated with the eruption of these lesions, he also had
shooting, burning pains along the right side of his torso.
In the ED, he was given acyclovir 900 mg IV x1 for presumed
disseminated VZV infection. He was also given two liters of
normal saline and hydromorphone 4 mg IV for pain control. While
there, the patient's wife noted the evolution of similar,
erythematous, maculopapular lesions along the patient's right
nasolabial fold; he also manifested a few lesions on the left
side of his torso as well. A fluorscein examination was
performed in the ED; there was no uptake or dendritic lesions
bilaterally. Following this eye examination, he was transferred
to 7 [**Hospital Ward Name 1950**].
.
The patient denies antecedent fever or malaise. He denies
ocular, forehead, or scalp pain or hypesthesia. He denies
changes in vision, blurred vision, trouble closing either eye,
or excess or insufficient lacrimation. He denies ear pain,
difficulty hearing, or changes in hearing (tinnitus,
hyperacusis). He denies facial weakness, difficulty speaking, or
change in ability to taste. He denies sense of imbalance or
dysequilibrium. Denies headache, neck stiffness, nausea,
vomiting, or confusion, although he does feel a bit more
sensitive to bright lights than normal. Other than the one dose
of acyclovir he took at home yesterday, he has not taken any
acyclovir in over two months.
.
Of note, 11 days prior to admission, the patient phoned the
oncology clinic and reported a hacking cough productive of
clear/yellow sputum and associated dyspnea. He had a mild sore
throat but had no fevers, coryza, myalgias, or arthralgias at
the time. He was empirically prescribed azithromycin for ten
days; he completed this course of antibiotics yesterday. His
cough and dyspnea have resolved completely.
Past Medical History:
1. Stage 1B Hodgkin's Disease (nodular sclerosis type) diagnosed
in [**2136**] (large anterior mediastinal mass). Treated with six
cycles of ABVD and XRT at that time. In remission until [**8-10**],
when he was treated with CEPP x2. Ultimately received autologous
SCT [**2-11**].
2. VZV infection [**11-11**] and [**9-12**] as per HPI
3. Line-related venous thrombus treated with line removal, lytic
therapy, and thrombectomy followed by six weeks of enoxaparin
[**11-10**]
4. Presumed community-acquired pneumonia [**8-12**]
5. Anxiety
6. Depression
7. Radiation-induced pleuropericarditis
8. Bleomycin-induced lung toxicity
9. Chronic lower extremity pain
10. Myocarditis [**5-8**]
Social History:
The patient lives at home with his wife and two children (an
eleven-year-old son and a nine-year-old daughter). His son was
just diagnosed with the chicken pox yesterday. His daughter has
never had the chicken pox; both children have had the VZV
vaccine. The patient works as a heating contractor (pipe
fitter). He has a 20-pack-year smoking history; he is currently
smoking [**4-11**] cigarettes daily. He drinks [**1-8**] glasses of wine per
week. He denies illicit drug use or abuse. He traveled to
[**State 622**] in [**6-12**]. He has no pets.
Family History:
The patient's niece has leukemia. His mother has hypertension,
diabetes mellitus, and a history of rheumatic heart disease.
Physical Exam:
Temp 97.1, BP 130/90, HR 79, RR 16, SpO2 97% RA
Gen: Pleasant, vigorous-appearing, non-toxic, comfortable man
who appears his stated age.
HEENT: No frontal sinus tenderness. Mild maxillary sinus
tenderness. Pupils pinpoint (2 mm) and equal bilaterally. No
conjunctival hyperemia or lid droop; conjunctivae clear. No
lesions in the auditory canal. Whitish coating on tongue. Dry
oral mucosae. No pharyngeal, buccal, or sublingual lesions.
Neck: Soft, supple, full range of motion.
Nodes: No cervical adenopathy.
CV: RRR, normal S1 and S2, no m/r/g.
Pulm: Symmetric bibasilar crackles, otherwise clear to
auscultation posteriorly bilaterally.
Abd: Soft, non-tender, non-distended, active bowel sounds. No
[**Doctor Last Name 515**] sign or hepatosplenomegaly.
Back: No spinal tenderness.
GU: Mild right CVA tenderness, none on left.
Ext: No LE edema, 2+ DP pulses.
Neuro: CN II-XII intact. 5/5 strength (grip, biceps, triceps,
deltoids, iliopsoas, hamstrings, quads, and dorsi- and plantar
flexion) bilaterally. Sensation to light touch intact.
Skin: Numerous (20-30) erythematous, maculopapular,
non-blanching, slightly tender rounded lesions over the right
side of the torso from the nipple line to the waist line; the
lesions measure 5-10 mm in diameter. There are a handful of
similar lesions on the left side of the torso, and there are
patches of smaller, coalesced lesions over both nasolabial
folds. All of these lesions are similar in appearance. There are
no lower extremity or genital lesions. There are some
erythematous lesions over the upper back that appear more
chronic and are dissimilar in appearance; there are no other
lesions over the back. None of the lesions are fluid-filled. Non
vescular and atypical for varicella.
Pertinent Results:
[**2142-12-8**] 09:00AM UREA N-18 CREAT-1.0 SODIUM-136 POTASSIUM-4.3
CHLORIDE-104 TOTAL CO2-24 ANION GAP-12
[**2142-12-8**] 09:00AM ALT(SGPT)-40 AST(SGOT)-31
[**2142-12-8**] 09:00AM CALCIUM-8.3* PHOSPHATE-3.8 MAGNESIUM-1.9
[**2142-12-8**] 09:00AM WBC-5.3 RBC-3.32* HGB-12.0* HCT-35.1*
MCV-106* MCH-36.1* MCHC-34.2 RDW-13.5
[**2142-12-8**] 09:00AM PLT COUNT-255
[**2142-12-8**] 12:24AM LACTATE-1.2
[**2142-12-7**] 10:28PM GLUCOSE-84 UREA N-22* CREAT-0.9 SODIUM-136
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-23 ANION GAP-16
[**2142-12-7**] 10:28PM estGFR-Using this
[**2142-12-7**] 10:28PM ALT(SGPT)-45* AST(SGOT)-38 ALK PHOS-68
AMYLASE-50 TOT BILI-0.2
[**2142-12-7**] 10:28PM ALBUMIN-4.4
[**2142-12-7**] 10:28PM LIPASE-40
[**2142-12-7**] 10:28PM WBC-6.0 RBC-3.60* HGB-13.4* HCT-38.8*
MCV-108* MCH-37.3* MCHC-34.6 RDW-13.5
[**2142-12-7**] 10:28PM NEUTS-54.1 LYMPHS-37.0 MONOS-4.7 EOS-2.2
BASOS-1.9
[**2142-12-7**] 10:28PM MACROCYT-3+
[**2142-12-7**] 10:28PM PLT COUNT-261
.
CT Chest:
New diffuse bilateral ground glass opacification with associated
reticulation, highly concerning for an acute infectious process,
but the absence of nodules is atypical for varicella pneumonia.
PCP should be considered as well as [**Month/Day/Year 1074**]/other viral pneumonias.
Non-infectious etiologies including pulmonary hemorrhage, acute
intersititial pneumonia, hydrostatic edema, and drug reaction
are also possible in the appropriate clinical setting.
.
[**12-15**] Rapid Resp Antigen Negative
Viral Respiratory Culture Pending
[**12-15**] Urine Legionella Antigen Negative
[**12-15**] Acid Fast Culture: Pending
Acid Fast Smear: Negative
[**12-14**] Sputum expectorated
Legionella culture: Prelim: No legionella isolated
Acid Fast Smear: None seen on direct/concentrated smear
Acid Fast Culture: Pending
[**12-14**] Immunology ([**Month/Year (2) 1074**]) [**Month/Year (2) 1074**] Viral Load Negative
[**12-14**] Blood Culture: Final, No growth
[**12-14**] Mycolitic Blood Culture, No AFB or Fungal culture so far
[**12-12**] Brochoalveolar lavage:
Gram Stain PMNs, no microorganisms seen
Respiratory Viral Culture
Fungal Culture: Preliminarily Yeast of 2 Colonial Morphologies
PCP: [**Name10 (NameIs) 22902**] Negative
Legionella Culture: Negative
[**12-12**] Bronchoalveolar lavage:
Gram Stain: PMNs, no microorganisms
Respiratory Culture: No growth
Legionella Culture: Negative
PCP: [**Name10 (NameIs) 22902**] Negative
Fungal Culture: Yeast, 2 colonial morphologies
Acid Fast Smear: No AFB seen on concentrated smear
Acid Fast Culture: Pending
Viral Culture: Prelim, No Virus Isolated so far
Viral culture: r/o [**Name10 (NameIs) 1074**], negative
[**12-11**] Induced Sputum
PCP: [**Name10 (NameIs) **] by [**Name10 (NameIs) **]
.
Acid Fast Smear: 3 AFB seen on concentrated smear
.
Acid Fast Culture: Pending
Amplified MTB direct test: Negative, Culture pending
Brief Hospital Course:
Impression: 41-year-old man with Hodgkin's Disease status-post
autologous HSCT [**2-11**] now with recurrent disseminated Varicella
Zoster infection.
.
1. Zoster: Lesions on trunk and face were atypical for
disseminated cutaneous disease. He never developed vesicles,
and thus he was never cultured. He was started on 850mg IV q8h
of acyclovir (10mg/kg) given his presentation, however, his
creatinine increased to 2.0. This was renally dose adjusted and
he completed a 14 day course of IV acyclovir. His pain was
controlled with Dilaudid PCA at first, then he developed
confusion. Ultimately, he was placed on a lidocaine patch,
fentanyl patch, Lyrica [**Hospital1 **], as well as Dilaudid PO prn for
control. He was discharged with two weeks worth of pain
medication as this is how long his post-herpetic neuralgia
usually lasts for. ID was involved for the duration of his
care, and he will follow up with them in early [**Month (only) 404**]. He was
discharged on valcyclovir, which he should continue to take for
prophylaxis indefinitely.
.
2. Acute renal failure: Likely secondary to acyclovir. He had
been on IVF at 100cc/h with an increase to 250cc/hr during
acyclovir infusions. His frequency of treatment with acyclovir
was decreased from q8h to q12h and his fluids were increased to
150cc/h. His creatinine steadily improved with hydration and
decreased dose of acyclovir.
.
3. Hypoxia/Pneumonia: While his CXR on admission was unchanged
from one a few months ago, he had a recent productive cough, and
an [**11-16**] PET scan showed new, mild FDG uptake associated with
new air-space disease in the left lung base; this was associated
with a mostly ground-glass appearance with a more solid
component on an accompanying chest CT. He was subsequently
treated empirically with ten days of azithromycin for a
productive cough (last dose was on the day of admission). Pt
spiked temp to 100.5 on [**2142-12-10**]. Routine BCx, UCx and CXR were
done. CXR showed new RUL infiltrate. Patient desatted to 83%
overnight, corrected with oxygen to 90%. He was started on
azithromycin/ceftriaxone. On [**12-11**] AM, got CT chest which showed
new diffuse bilateral ground glass opacification with associated
reticulation. The features are most concerning for an
infectious process, but the absence of nodules was atypical for
varicella pneumonia. Ddx included PCP, [**Name10 (NameIs) 1074**], other viral
infection, pulm hemorrhage, edema, or drug reaction. Because
patient has history of bleomycin induced lung toxicity he
received o2 cautiously His lowest sat was 83% ambulating on
[**12-11**]. ABG showed pH 7.46 pCO2 33 pO2 59 HCO3 24 with an O2 sat
of 89%. He was transferred to the MICU, where bronchoscopy was
performed as well as broncheoalveolar lavage. He was
transferred back to the floor the next morning, and overnight,
desaturated to 66% on RA with ambulation and was transferred
back to the MICU. In the MICU, his oxygen saturations were
maintained at a goal 80-85% with as much as a 50% high flow face
mask. Over the course of his second MICU stay, his oxygenation
worsened and then subsequently improved with the addition of 40
mg of prednisone a day, with improvement of his chest X-ray. On
[**12-20**], he was transferred back to the floor for further
management. Broncheoalveolar lavage and induced sputum results
were essentially negative for PCP, [**Name10 (NameIs) 3019**], but a concentrated
smear for AFB was positive on [**12-11**], and he was placed in a
negative pressure room (but the AFB was not treated). MTB probe
was negative, and patient was removed from precautions.
Cytology from bronchial washings was indeterminate.
.
3. Hodgkin's Disease: No evidence of recurrent FDG-avid disease
on [**11-16**] PET scan. Mild FDG uptake associated with a portacaval
lymph node is unchanged.
.
4. Depression: Continue citalopram. Per wife, has a history of
worsening depression/anxiety.
.
5. Transaminitis: Chronic, stable. HCV Ab negative [**12-10**], HBsAb,
HBsAg, and HBcAb negative [**12-10**]. Doubt medication side effect
given outpatient medication list.
.
6. Altered Mental Status: While in the [**Hospital Unit Name 153**] with low oxygen
saturations, he developed an altered mental status, marked by
hallucinations and irrational thought processes. Medications,
ICU delerium, hypoxia, sleep deprivation, high steroids were
thought to be possibly contributing. The PCA was stopped, his
hypoxia improved, and the altered mental status resolved.
Patient does not remember several days of his hospital stay.
.
7. Hyponatremia/SIADH - likely secondary to a pulmonary process
vs. medication. He was free water restricted and his medications
were concentrated, and the hyponatremia improved.
Medications on Admission:
1. citalopram 40 mg by mouth once daily
2. Multivitamin
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: Two (2) 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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO twice a day:
For shingles pain.
Disp:*60 Capsule(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QMONWEDFRI ().
Disp:*13 Tablet(s)* Refills:*2*
6. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours) for 1 weeks: Use the 50mcg
dose 1 week, then 25 mcg dose for 1 week.
Disp:*3 3 patches* Refills:*0*
7. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) patch Transdermal
every seventy-two (72) hours for 1 weeks.
Disp:*3 patches* Refills:*0*
8. Valacyclovir 500 mg Tablet Sig: One (1) Tablet PO tid () for
TID for 7 days, then qdaily thereafter days.
Disp:*68 Tablet(s)* Refills:*2*
9. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
10. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3-4H
(Every 3 to 4 Hours) as needed for 2 weeks.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Herpes zoster recurrence
Bilateral pneumonia/pneumonitis steriod responsive,
Discharge Condition:
Good
Discharge Instructions:
You were admitted with shingles as well as a severe pneumonia,
which has now improved. You will be discharged on a
prophylactic dose of medicine to prevent shingles recurrence.
Please continue to take this medication for an indefinite period
of time. You will also be discharged on a prophylactic dose of
Bactrim.
.
If you feel at all short of [**Last Name (LF) 1440**], [**First Name3 (LF) 691**] chest pain, notice any
new rashes, nausea, vomiting, abdominal pain, fever > 100.5,
please contact your oncologist's office.
.
Please take all medications as presribed.
Followup Instructions:
You should call Dr.[**Name (NI) 6168**] office on Monday for a follow-up
appointment. Please call his office at: ([**Telephone/Fax (1) 3936**]
.
Please [**1-8**] @ 9:30am to see [**First Name8 (NamePattern2) **] [**Doctor Last Name 3394**] at the Infectious
Disease building ([**Hospital Ward Name **]) in the basement.
|
[
"V58.65",
"486",
"428.0",
"584.9",
"305.1",
"799.02",
"293.0",
"201.50",
"253.6",
"V42.82",
"053.9",
"518.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
14985, 14991
|
8812, 12940
|
300, 306
|
15131, 15138
|
5904, 8789
|
15755, 16080
|
4004, 4129
|
13669, 14962
|
15012, 15012
|
13589, 13646
|
15162, 15732
|
4144, 5885
|
240, 262
|
334, 2715
|
15031, 15110
|
12955, 13563
|
2737, 3422
|
3438, 3988
|
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