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Discharge summary
|
report
|
Admission Date: [**2184-12-22**] Discharge Date: [**2185-1-6**]
Date of Birth: [**2104-11-3**] Sex: M
Service: MEDICINE
Allergies:
Biaxin
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Hypoxia and hypotension
Major Surgical or Invasive Procedure:
femoral line placement
midline placement
subclavian line placement
bronch x2
intuabtion
History of Present Illness:
80 y/o M with PMH significant for presumed lung CA metastatic to
colon, COPD, and CAD admitted to [**Hospital1 18**] on [**12-22**] with fever and
SOB. Of note, pt was recently admitted to [**Hospital1 18**] from [**12-16**]
thorugh [**12-21**] on the OMed service for neutropenic fever due to
Klebsiela bacteremia sensitive to cefepime (it was resistant to
levofloxacin and gentamycin). Pt was also treated with stress
dose steroids during this admission. Pt was discharged to the
[**First Name4 (NamePattern1) 1785**] [**Last Name (NamePattern1) **] on the evening of [**2184-12-21**]. Pt had a difficult
night once arriving at the [**Hospital1 1501**] where he reports having
subjective fevers, chills, rigors, diaphoresis, and SOB. Pt also
developed a cough over the course of the night. He denies any
chest pain, wheezing, abdominal pain, palpitations, dysuria,
diarrhea, or n/v following his discharge. On evaluation at the
[**First Name4 (NamePattern1) 1785**] [**Last Name (NamePattern1) **], the pt's VS were 100/60 120s-130s 42 85% 2L NC.
He was noted to have significant bilateral LE edema and edema of
the back. Pt was given 0.4 mg of morphine and 0.5 mg of ativan
then transferred to [**Hospital1 18**] for further care.
In the ED, the pt's VS were 97.6 124/61 120s 48 80% RA. His
BP subsequencly decreased to 80/63. Pt was placed on a NRB for
his decreased sat and 3L of NS was infused with an increase in
his SBP into the 90s. Labs whoed a WBC count of 15/9, troponin
of 0.35, CK of 176, and a CK MB of 8. CXR was significant for a
new LLL infiltrate suggestive for a PNA. Pt was given
levofloxacin, ceftriaxone, and vancomycin. He was also treated
with continuous nebs and solumedrol 125 mg x1. A cardiology
consult was obtained and they felt the pt's elevated troponins
were secondary to demand ischemia from ongoing sepsis. Of note,
a right femoral CL was placed after two failed attempts at an IJ
bilaterally.
He then was admitted to the [**Hospital Unit Name 153**].
Past Medical History:
1. Presumed lung CA metastatic to the colon- Pt was found to
have mutiple polyps on colonoscopy in 01/[**2182**]. Repeat
colonoscopy on [**2183-9-2**] whoed high grade dysplasia and CIS.
Follow up PET scan demostrated abnormal FDG activity in a lung
nodule and the transverse colon. Right upper lobe nodule biopsy
on [**2184-7-2**] was significant for undifferentiated carcinoma
which was positive for CK 7, negative for CK 20, negative for
TTF-1, and negative for LCA. This pattern is compatible with a
primary pulmonary CA. Pt was started on Nevelbine for treatment
(pt is now day 25 of cycle 2 of Nevelbinie).
2. COPD- PFTs on [**2183-9-18**] were significant for a FEV1/FVC of
60%; FEV1 of 17%; and FVC of 28%. Pt is on 2L of oxygen at
baseline.
3. CAD- ETT MIBI on [**1-/2181**] was significant for a moderate
partially reversible inferior defect. Medical management was
initiated. Echo on [**9-/2184**] was significant for a LVEF of >55%.
4. Hypercholesterolemia
5. Type 2 diabetes mellitus
6. Chronic kidney disease- Baseline creatinine is between 1 and
1.3.
7. H/O DVT
8. S/P pelvic fracture and liver laceration from a MVA
9. Anemia
10. Depression
11. ETOH abuse
Social History:
Pt was previously lving at an [**Hospital3 **] facility but was
sent to the [**First Name4 (NamePattern1) 1785**] [**Last Name (NamePattern1) **] following discharge on [**12-21**]. He is a
former construction worker. The pt never married and does not
have any children. He has a 60 pack year smoking history but
quit one month ago. He used to drink ETOH heavily but quit one
year ago. No drug use. He has one sister, but does not engage
her in medical decisions.
Family History:
[**Name (NI) 1094**] father died at age 85. He had DM. His mother died from
"natural causes" at age 85. His brother died in an accident at
age 19. He is estranged from his sister.
Physical Exam:
Exam on initial admission to [**Hospital Unit Name 153**]:
96.4 110/45 67 21 99% 2L NC
Gen- Very pleasant elderly man resting in bed. Alert and
oriented. NAD. Able to speak in full sentences without any SOB.
HEENT- NC AT. EOMI. Anicteric sclera. Dry mucous membranes with
cracks around the lips.
Cardiac- Distant heart sounds. Tachycardic. Regular rhythem. No
appreciable murmurs, rubs, or gallops.
Pulm- Very faint air movement on the right lung. Rales in the
upper portion of the left lung.
Abdomen- Soft. NT. ND. Positive bowel sounds.
Extremities- 3+ pitting edema to the knees bilaterally.
Exam on readmission to the [**Hospital Unit Name 153**] after a mucus plug on the floor:
VS: 153/87 108 34 87% NRB
Gen: diaphoretic, appears uncomfortable, no audible wheezing;
respiratory distress with subcostal retraction
HEENT: PERRL, EOMI
Skin: bruising on neck, particularly L side
Neck: shoddy LAD, could not assess JVD as pt refuses to be
supine
CV: tachycardic, regular, nl S1/S2, no murmurs appreciated
Pulm: wheezes bilaterally, fair air movement; symmetric breath
sounds
Abd: soft, +BS, could not assess further as pt refuses to be
supine
Ext: compression stockings in place, [**1-29**]+ pitting edema, hands
cool, but 2+ radial pulses, could not palpate PT or DP pulses
[**12-30**] edema
Neuro: answers questions appropriately, minimal conversation
Exam on day discharge:
VS-82 kgs, T 97.5, HR 59-83, BP 100-130/50-60, RR 32-37, sats
98%/4LNC with humidified shovel mask
Gen- Elderly man sitting in bed with HOB at 30 degrees. Alert
and oriented. Mild resp distress. Appeared to be breathing
laborously, with accessory muscle usage and pursued lips.
HEENT- NC/AT. EOMI. Anicteric sclera. Dry mucous membranes with
cracks around the lips.
Cardiac- RRR, s1 s2 distant. No appreciable murmurs, rubs, or
gallops.
Pulm- Poor air movement, long I/E ratio; no w/r/r.
Abdomen- Soft. NT. ND. Positive bowel sounds.
Extremities- 2+ pitting edema to the knees bilaterally.
Pertinent Results:
Labs on admission:
[**2184-12-21**] 05:45AM BLOOD WBC-7.7 RBC-3.95* Hgb-9.8* Hct-30.6*
MCV-77* MCH-24.9* MCHC-32.1 RDW-20.0* Plt Ct-551*
[**2184-12-21**] 05:45AM BLOOD Neuts-52 Bands-5 Lymphs-16* Monos-1*
Eos-0 Baso-1 Atyps-0 Metas-17* Myelos-7* Promyel-1* NRBC-7*
[**2184-12-21**] 05:45AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-NORMAL Microcy-3+ Polychr-NORMAL Ovalocy-1+
[**2184-12-21**] 05:45AM BLOOD Plt Smr-HIGH Plt Ct-551*
[**2184-12-21**] 05:45AM BLOOD PT-25.8* PTT-42.2* INR(PT)-4.9
[**2184-12-21**] 05:45AM BLOOD Glucose-181* UreaN-14 Creat-0.9 Na-132*
K-3.6 Cl-98 HCO3-30 AnGap-8
[**2184-12-21**] 05:45AM BLOOD Calcium-7.8* Phos-2.8 Mg-2.1
.
Labs on discharge:
[**2185-1-6**] 06:00AM BLOOD WBC-12.1* RBC-3.52* Hgb-8.8* Hct-28.2*
MCV-80* MCH-25.0* MCHC-31.3 RDW-19.7* Plt Ct-413
[**2185-1-4**] 12:00PM BLOOD LMWH-0.21
[**2185-1-6**] 06:00AM BLOOD Glucose-97 UreaN-19 Creat-0.8 Na-137
K-4.4 Cl-96 HCO3-36* AnGap-9
[**2185-1-6**] 06:00AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.0
.
Micro: multiple negative sputum, blood and urine cultures this
admission.
.
Studies:
.
CXR ([**12-22**])- Shows stable cardiac and mediastinal and hilar
contours. Again seen is a rounded mass in the superior right
mediastinum that appears unchanged from prior study. There
appears to be some increased opacity in the left lung,
concerning for aspiration or developing pneumonia. No pleural
effusions are seen. Again seen is evidence of old rib fractures
on the right side.
IMPRESSION: Interval development of increased opacity in the
left lung concerning for aspiration or developing pneumonia.
.
CXR on [**12-28**] after mucus plug and sudden resp decompensation:
HISTORY: COPD. Hypotension and hypoxia.
IMPRESSION: AP chest compared to [**12-25**] and 30:
The right upper lobe is newly collapsed. Increase in marked
leftward
mediastinal shift. Right lung demonstrates emphysema.
Diaphragmatic pleural calcification probably asbestos related is
noted. [**Month (only) 116**] be a small left pleural effusion. Heart size is
indeterminate but probably unchanged since previous studies.
Mass at the medial aspect of the right upper lobe is now
projected over the thoracic spine.
.
CXR on discharge: [**1-2**]
COMMENTS: Portable erect AP radiograph of the chest is
reviewed, and compared with the previous study of yesterday.
The left subclavian IV catheter remains in place. No
pneumothorax is
identified. Again note is made of lung cancer in the right
upper lobe. There is continued left lower lobe opacity
indicating pneumonia versus atelectasis. The heart is normal in
size. Note is made of underlying emphysema and bilateral
calcified pleural plaques indicating asbestos related pleural
disease.
.
Brief Hospital Course:
80 y/o M with PMH significant for presumed lung CA
metastatic to colon, COPD, and CAD admitted to [**Hospital1 18**] on [**12-22**]
with fever and SOB. He was initially admitted to the [**Hospital Unit Name 153**] on
[**12-22**]. In the [**Hospital Unit Name 153**], multiple etiologies were considered for the
pt's symptoms but it was felt that he was most likely septic.
His cefepime was changed to meropenem and vancomycin since he
had a recent history of ESBL pseudomonas in his sputum. The pt's
hypotension resolved with treatment on the antibiotics, stress
dose steroids (on steroids at baseline for COPD), and some IV
fluids. His sepsis was most likely due to PNA but blood, urine,
and sputum cultures wewre all negative. On [**12-24**], pt was started
on PO diltiazem for rate control in the setting of atrial
flutter. His oxygen has been weaned down to 2L NC with stable
sats.
He was then transferred to the floor on [**12-25**] and was
initially stable. However, on [**12-28**] he became hypoxic due to a
mucus plug and subsequent LUL collapse. He was transferred back
to the [**Hospital Unit Name 153**] for CPAP, then required intubation. He recieved 2
bronchosopies which removed mucus plugs and relieved his LUL
collapse. He was hypotensive requiring dopamine for a short
time. Hydralazine was added for BP control. Lovenox was stopped
due to dropping Hct and hematuriaa nd elevated factor 10A
levels. On [**2185-1-1**], pt had respiratory distress with desats in
70's on exertion. Vanc, Meropenem were d/c'd on [**1-1**], Lovenox
restarted as hematuria resolved and Epo increased on [**2185-1-1**].
Patient requires intermittent BiPAP, as recently as the evening
of [**2185-1-3**] for ongoing respiratory distress. Patient was
transfused 1 unit of PRBCs for Hct of 24 on [**2185-1-4**],
post-transfusion Hct 26.
Ongoing family discussions with [**Hospital Unit Name 153**] team and PCP regarding
code status secondary to his poor prognosis; however, patient
wants to be full code as he is afraid of dying. Patient prefers
to be intubated again if needed, but if intubation not able to
change respiratory status in the short term, wants to be
terminally extubated. Does not want to have his sister involved
with medical care.
By Problem:
1. [**Name (NI) 15305**] Pt's presentation on admission was most consistent
with sepsis in the setting of PNA and immune reconstution (he
initially was admitted in [**Month (only) 404**] for Klebesilla PNA/sepsis in
the setting of neutropenia). All cultures were negative. He
finished an emperic 10 day course of meropenem and vancomycin
for presumed aspiration pneumonia and additionally a ten day
course of levaquin for double coverage. He received stress dose
steroids and was transitioned to 60mg prednisone will be slowly
tapered over two weeks.
2. Hypoxia/COPD- He had significant hypoxia on admission. For a
short time, he was back on 2L NC after his initial [**Hospital Unit Name 153**]
admission. However, after his mucus plug, he has been requiring
4L NC for sats of 95%. His hypoxia is most likely multifactorial
in origin: PNA, severe COPD, and lung CA. The diagnosis of PE
was entertained, but a workup for PE could not be easily
undertaken as a VQ scan would not be helpful in the setting of
the pt's baseline lung disease and a CTA was avoided given a
recent episode of ARF. He developed acute hypoxia during his
hospital stay, and was transferred to the intensive care unit.
On the AM of transfer, pt was tachypneic into 30s but was
sleeping comfortably. Pt had been satting 93-95% on 3-5L O2.
Pt was then noted to be hypoxic into mid-80s, requiring a
nonrebreather. Chest xray revealed LUL collapse, and on
bronchoscopy likely due to mucous plugging. Rapidity of
developement of L-sided lung collapse and white-out suggested
mucous plugging as etiology of hypoxia. Repeat bronch showed
secretions in LLL. He was intubated breifly then extubated
successfully and maintained on coolneb facemask with an oxygen
requirement which was slowly weaned to 4L. He finished his ten
day course of meropenem and vancomycin for a presumed pneumonia,
and was to finish a ten day course of levaquin started later for
double coverage of a presumed pneumonia.
His new poor baseline is thought to be due to his end stage
COPD and lung cancer. The patient remains very tachypnic to 25 -
30 resting. He requires 4L NC for his O2 sats to be 95% resting.
He has desatureated to the 70's with exertion, therefore, his O2
needs to be increased when he is transferred or with exertion.
He will be on a slow steroid taper to end at a maintence dose of
20 daily. He should be maintained on BIPAP at night with the
settings of [**10-31**]. This helps him sleep. He should be given
humidified O2 to keep secretions hydrated to avoid mucus
plugging. He will continue with aggressive tx of COPD with
albuterol, atrovent, advair, and prednisone to decrease
inflammation in airways. The levofloxacin will stop on [**1-7**]. The
paitent has been getting IV morphine and ativan prn for
tachypnea and anxiety which helps him greatly.
.
3. Lung cancer: He had chemotherpy last in the beginning of
[**Month (only) 404**]. There are no other options currently for chemo or
radiation according to his [**Month (only) 5564**].
4. Chronic iron def anemia: His iron studies in [**11-1**] c/w iron
deficiency anemia. His stool is guiac positive with a stable
hct. He has known colonic malignant lesions. His Epo and Fe
supplements were increased. Basline HCT was 24 - 31. He was
transfused 2 units for a HCT of 24 to assist with O2 delivery.
5. Diabetes Mellitus: He was continued on NPH and ISS.
6. h/o DVT in [**2183**] - [**Hospital Unit Name 153**] team started holding lovenox on [**12-31**]
due to decreasing HCT. No DVT seen on f/u LENIs [**12-23**]. He was on
lovenox 150mg sc daily on discharge from last hospitalization
for DVT in [**10-2**] His lovenox was restarted [**2185-1-1**] as Hct stable
at very low dose 50 mg SC daily. The level was 0.21 on this
dose, therefore will increase Lovenox to 60 SC daily on
discharge.
7. Atrial flutter - He was started on diltiazem for rate control
- no intervention indicated at this time, unless patient goes
into CHF from rapid atrial flutter.
.
8. hematuria - He had a breif episode of hematuria possibly [**12-30**]
to supratherapeutic lovenox. Hematuria new on this admission,
present on UAs since [**2184-12-22**]. + RBCs (not myoglobinuria), urine
sediment w/o acanthocytes, casts. Hematuria resolved with lower
lovenox dose.
.
9. H/o CAD - He had a troponin leak on admission, thought to be
in setting of hypotension per cardiology consult. He cannot have
a BB [**12-30**] to severe COPD. cont on statin and rate control.
.
10. Depression - The patient is extremly depressed about his
prognosis and social isolation. He is on venlafaxine. This
should be increased to treat his depression as needed.
.
11. Access - He is very difficult to get IV access. He had a
central line placed on [**12-29**] mainly for blood draws. His midline
that will flush, but not draw blood. He will remain with the
midline for IV access. Flush per protocol. subclavian was
removed on [**1-6**].
.
12. Code: The patient was initially DNR/DNI. However, in his
acute respiratory distress with the mucus plug, he decided to be
intubated. FOllowing extubation, he maintained that he wasnted
to be full code once more. It was explained multiple times that
he has a very dismal prognosis and given his end stage COPD,
that he has a very high liklihood of being vent dependant if he
is intuabted again. This was explained to him by his PCP,
[**Name10 (NameIs) 5564**], ICU team, and pallative care nurse. His sister was
also brought in, whom he then decided he did not want involved.
He repeatedly expressed feelings of fear and isolation about
dying. He inderstands that he has a terminal diagnosis, but
would want to be intubated for a short time again if needed.
.
#. Communication - sister [**Name (NI) 17**] [**Name (NI) **] is his HCP. [**Name (NI) **] phone
number is [**Telephone/Fax (1) 32122**]. note - must ask paitent before speaking
with sister. they are estranged.
.
At the time of discharge, pt reports that he is feeling much
better than on admission. His breathing is more comfortable. He
denies any pain including CP and abdominal pain. His appetite is
poor but he is trying to eat. He is able to drink fluids without
difficulty. He has been moving his bowels.
Medications on Admission:
1. Navelbine
2. Cefepime 2 gm IV Q8H- Pt was to complete five more days at
the time of his admission.
3. Prednisone 60 mg daily- Part of a prednisone taper.
4. Fluticasone-Salmeterol 250-50 mcg inhaled [**Hospital1 **]
5. Tiotropium bromide 18 mcg inhaled daily
6. Albuterol Q4H and PRN
7. Ipratropium bromide 0.02% Q6H PRN
8. Atrovastatin 20 mg daily
9. Venlafaxine 75 mg daily
10. NPH insulin 10 units at breakfast and 8 units QHS
11. RISS
12. Lovenox 15 mg SQ daily
13. Trazodone 150 mg QHS PRN
14. Ferrous sulfate 325 mg [**Hospital1 **]
15. Tylenol PRN
16. Epoetin alfa [**Numeric Identifier 961**] units Mon-Wed-Fri
17. Pantoprazole 40 mg daily
18. Docusate 100 mg [**Hospital1 **]
19. Senna 8.6 mg [**Hospital1 **]
20. Zydis 5 mg QHS PRN
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) inhalation Inhalation [**Hospital1 **] (2 times a day).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
twice a day.
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q2H (every 2 hours) as needed.
6. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO DAILY (Daily).
7. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed: Hold for sedation or RR <12. Thanks.
8. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
14. Enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) mg
Subcutaneous DAILY (Daily).
15. Epoetin Alfa 20,000 unit/mL Solution Sig: [**Numeric Identifier 389**] ([**Numeric Identifier 389**]) unit
Injection QMOWEFR (Monday -Wednesday-Friday).
16. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day): Hold for SBP <100 or HR <60. .
17. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): hold for sbp less than 100 .
18. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for constipation.
19. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
20. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Per
scale Subcutaneous twice a day.
21. Humalog 100 unit/mL Cartridge Sig: as per sliding scale
Subcutaneous four times a day.
22. Prednisone 20 mg Tablet Sig: One (1) Tablet PO QD ().
23. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours) as needed for anxiety.
24. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 1 days.
25. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
26. Morphine 10 mg/5 mL Solution Sig: 3-4 mg PO every four (4)
hours as needed for anxiety, pain, SOB: Hold if RR < 18.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
Primary diagnosis:
Sepsis
Secondary diagnosis:
COPD
Respiratory distress
Hypotension
Type 2 diabetes mellitus
Hypercholesterolemia
Presumed lung to colon CA
Discharge Condition:
Stable
Discharge Instructions:
1. Please keep all follow up appointments.
2. Please take all medications as prescribed.
3. Seek medical attention for fevers, chills, chest pain,
shortness of breath, abdominal pain, or any other concerning
symptoms.
Followup Instructions:
Please make an appointment with Dr. [**Last Name (STitle) **] once he is discharged
to the [**Location (un) 550**].
|
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"518.0",
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"507.0",
"276.52",
"V58.67",
"276.2",
"995.92",
"250.00",
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"519.1",
"427.32",
"285.29",
"599.7",
"300.4",
"162.3",
"E912",
"491.21",
"V15.82",
"038.9",
"197.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"38.93",
"93.90",
"99.04",
"33.24",
"96.04",
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icd9pcs
|
[
[
[]
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] |
20914, 20987
|
9021, 17481
|
290, 380
|
21189, 21198
|
6289, 6294
|
21466, 21584
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4098, 4279
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18277, 20891
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21008, 21008
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17507, 18254
|
21222, 21443
|
4294, 6270
|
8483, 8994
|
227, 252
|
6967, 8469
|
408, 2405
|
21056, 21168
|
21027, 21035
|
6308, 6948
|
2427, 3600
|
3616, 4082
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,671
| 109,832
|
37157+58127
|
Discharge summary
|
report+addendum
|
Admission Date: [**2174-1-13**] Discharge Date: [**2174-1-28**]
Date of Birth: [**2093-5-21**] Sex: F
Service: NEUROLOGY
Allergies:
Codeine / Amoxicillin / Penicillins
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
aphasia and right sided weakness
Major Surgical or Invasive Procedure:
IVtPA at OSH, IAtPA, MERCI and PENUMBRA device applications at
[**Hospital1 18**].
History of Present Illness:
per admitting resident:
The patient is an 80 year old woman with a history of atrial
fibrillation s/p PPM not on Coumadin due to fall risk,
hypertension, and perforated diverticulitis s/p ex lap and
sigmoidectomy [**2173-9-6**] who was last seen normal at 12:00 pm who
presented to an OSH with stuttering symptoms of aphasia and
right
sided weakness who received IV tPA at 2:13 pm and was
transferred
to [**Hospital1 18**] for possible further intervention, called as a CODE
STROKE. She is accompanied by her daughter and son.
Per the patient's daughter, the patient was last seen normal at
12:00 pm when she left the house to walk to the post-office to
drop off her [**Holiday **] cards. Apparently, a woman had found her
mother down and called EMS. Approximately 30 minutes later, EMS
knocked on the daughter's door (as the patient was able to say
her address at that time). After that, the patient had decreased
conversation, and was awake but "like a drunk." En route to
hospital had an episode of right sided flaccidity that lasted
1-2
minutes. At [**Hospital3 **], her daughter says that she became more
aware, and was talking for an approximately 3 minute period
(asking for her coat) before receiving tPA, but then became
aphasic again.
She was initially taken to [**Hospital3 **]. On initial arrival to ED
at 1:17 am she was talking, answering questions, and had an
intact neuro exam. Within about 5 minutes her clinical status
deteriorated and she developed aphasia, dysarthria, right facial
droop, and right sided weakness UE>LE. On exam, she had left
gaze
preference, right facial droop, right sided neglect, aphasia,
dysarthria, unable to hold RUE against gravity, RLE [**5-9**]. NIHSS
16. Labs showed INR 1.0, WBC 8.1, Hct 37.6, plt 277, Na 138, K
3.9, Cl 100, glucose 133, BUN 21, Cr 1.0, Ca 9.6, Mg 1.4, Phos
3.8, alk phos 310, ALT 39, AST 32, CK 47, CKMB 1.8. Neurology
was
consulted, and head CT/CTA showed prelim no acute bleed,
proximal
left ICA occlusion with slow flow to M1 and M2 branches, likely
occlusion of left MCA. tPA was bolused at 2:13 pm, with no
significant improvement in her symptoms after tPA bolus. She was
transferred to [**Hospital1 18**] for possible IA tPA or embolectomy.
A CODE STROKE was called at 16:36 pm, and Neurology was
immediately at the bedside. Per the ED, the EKG also showed some
T-wave inversions.
NIHSS Score:
1a. LOC: 0
1b. LOC Questions: 2
1c. Commands: 1 (squeezes left hand, but does not close eyes)
2. Best Gaze: 0
3. Visual Fields: 2 (does not blink to threat on the right)
4. Facial Palsy: 2 (right)
5. Motor Arm: 3 (right)
6. Motor Leg: 2 (right)
7. Limb Ataxia: X
8. Sensory: X
9. Best Language: 2 (almost completely globally aphasic, but
does
try to make a few vocal utterances: no, I don't know)
10. Dysarthria: 2
11. Extinction/Neglect: X
NIHSS Score Total: 16
Past Medical History:
Hypertension
Atrial fibrillation s/p PPM not on Coumadin due to fall risk
RA
Sigmoid diverticulitis and perforated diverticulitis s/p ex lap
and sigmoidectomy [**2173-9-6**] c/b peritonitis
h/o PNA
Syncope s/p right arm and wrist fracture 5 years ago
Osteoporosis
Anxiety
Kidney disease
Pulmonary nodules
Social History:
She lives at home with her daughter, and does not
use a cane or walker at baseline. She is a former seamstress,
but
had to stop working after her right arm/wrist fracture 5 years
ago. She works part-time as a lunch monitor at an elementary
school. She does not use cigarettes, EtOH, or illicit drugs.
Family History:
There is no family history of strokes.
Physical Exam:
Physical Examination:
VS: temp 97.4, bp 138/85, HR 67, RR 22, SaO2 94% on RA
Genl: Awake, alert
HEENT: Sclerae anicteric, no conjunctival injection, oropharynx
clear
CV: Irregularly irregular rate, Nl S1, S2, no murmurs, rubs, or
gallops
Chest: CTA bilaterally anteriorly and laterally, no wheezes,
rhonchi, rales
Abd: +BS, soft, NTND abdomen, surgical scar on abdomen
Neurologic examination:
Mental status: Awake and alert, occasionally follows commands
(squeezes hand on the left and breathes in and out for chest
auscultation, however she will not protrude her tongue or close
her eyes). Unable to name. Unable to read (but does say "I don't
know"). Intermittently says "no" and makes rare other vocal
utterances. Unable to say her age or the month. No dysarthria
when she does speak.
Cranial Nerves: Pupils equally round and reactive to light, 4 to
2 mm bilaterally. Blinks to threat on the left but not the
right.
Extraocular movements intact bilaterally with limited upgaze.
Flat right NLF. Will not phonate to elevate palate. Will not
follow command to protrude tongue.
Motor: Normal tone bilaterally in UE and LE. No observed
myoclonus, asterixis, or tremor. She is able to keep her left
arm
against gravity for 10 seconds and her left leg against gravity
for 5 seconds (at least). Upon initialy exam, she has minimal
movement of her right arm when asked to lift it above gravity,
but does not sustain against gravity. Of note, when this
examiner
lifts her right arm against gravity she actively tries to push
it
down. However, 15 minutes later on repeat exam she is able to
briefly keep her right arm extended against gravity. However, 1+
hour after that she is again unable to lift her right arm
against
gravity and is more sleepy. She lifts her right leg against
gravity, but it drifts back to the bed in <5 seconds.
Sensation: She cannot cooperate with pinprick testing.
Reflexes: 3+ in right biceps/brachioradialis, 2+ on the left. 3+
and symmetirc in triceps and knees. Toes upgoing bilaterally
(but
more so on the right then left).
Gait: Deferred
Exam at time of discharge:
Pertinent Results:
Labs on admission:
[**2174-1-13**] 04:50PM BLOOD WBC-11.2* RBC-3.87* Hgb-11.4* Hct-34.4*
MCV-89 MCH-29.4 MCHC-33.1 RDW-13.9 Plt Ct-283
[**2174-1-16**] 01:27AM BLOOD WBC-13.5* RBC-3.56* Hgb-10.7* Hct-30.7*
MCV-86 MCH-30.0 MCHC-34.8 RDW-13.5 Plt Ct-245
[**2174-1-13**] 04:50PM BLOOD Neuts-87.3* Lymphs-10.3* Monos-1.8*
Eos-0.4 Baso-0.2
[**2174-1-13**] 04:50PM BLOOD PT-12.9 PTT-26.4 INR(PT)-1.1
[**2174-1-13**] 04:50PM BLOOD Glucose-114* UreaN-20 Creat-1.0 Na-138
K-4.2 Cl-102 HCO3-27 AnGap-13
[**2174-1-16**] 01:27AM BLOOD Glucose-105 UreaN-19 Creat-0.9 Na-138
K-3.8 Cl-102 HCO3-26 AnGap-14
[**2174-1-13**] 04:50PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2174-1-14**] 02:50AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2174-1-13**] 04:50PM BLOOD CK(CPK)-48
[**2174-1-14**] 02:50AM BLOOD CK(CPK)-34
[**2174-1-13**] 04:50PM BLOOD Calcium-9.6 Phos-3.6 Mg-2.0
[**2174-1-14**] 02:50AM BLOOD Calcium-8.1* Phos-3.5 Mg-1.7 Cholest-147
[**2174-1-14**] 02:50AM BLOOD Triglyc-254* HDL-30 CHOL/HD-4.9
LDLcalc-66
[**2174-1-14**] 02:50AM BLOOD %HbA1c-5.7
[**2174-1-14**] 09:30PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.0 Leuks-NEG
labs during course of hospital stay
[**2174-1-15**] 02:12AM BLOOD WBC-10.4 RBC-3.51* Hgb-10.5* Hct-31.2*
MCV-89 MCH-29.9 MCHC-33.6 RDW-14.1 Plt Ct-219
[**2174-1-18**] 05:10AM BLOOD WBC-9.5 RBC-3.60* Hgb-10.6* Hct-31.9*
MCV-89 MCH-29.4 MCHC-33.1 RDW-14.0 Plt Ct-265
[**2174-1-21**] 05:30PM BLOOD WBC-12.1* RBC-3.99* Hgb-11.5* Hct-34.8*
MCV-87 MCH-28.8 MCHC-33.1 RDW-13.2 Plt Ct-377
[**2174-1-25**] 04:15AM BLOOD WBC-13.0* RBC-4.10* Hgb-11.8* Hct-35.6*
MCV-87 MCH-28.8 MCHC-33.1 RDW-13.4 Plt Ct-444*
[**2174-1-27**] 04:20AM BLOOD WBC-11.6* RBC-3.84* Hgb-11.2* Hct-34.5*
MCV-90 MCH-29.3 MCHC-32.6 RDW-13.9 Plt Ct-516*
[**2174-1-21**] 03:45PM BLOOD Plt Ct-354
[**2174-1-24**] 05:35AM BLOOD PT-13.0 PTT-26.2 INR(PT)-1.1
[**2174-1-26**] 05:19AM BLOOD PT-12.6 PTT-28.2 INR(PT)-1.1
[**2174-1-17**] 02:42AM BLOOD Glucose-126* UreaN-23* Creat-0.9 Na-141
K-3.9 Cl-105 HCO3-27 AnGap-13
[**2174-1-19**] 05:05AM BLOOD Glucose-119* UreaN-27* Creat-0.7 Na-140
K-3.4 Cl-102 HCO3-27 AnGap-14
[**2174-1-21**] 05:30PM BLOOD Glucose-120* UreaN-31* Creat-0.7 Na-138
K-3.9 Cl-101 HCO3-27 AnGap-14
[**2174-1-23**] 06:45AM BLOOD Glucose-109* UreaN-32* Creat-0.7 Na-140
K-4.1 Cl-103 HCO3-27 AnGap-14
[**2174-1-24**] 05:35AM BLOOD Glucose-109* UreaN-34* Creat-0.7 Na-142
K-4.3 Cl-105 HCO3-26 AnGap-15
[**2174-1-25**] 04:15AM BLOOD Glucose-99 UreaN-31* Creat-0.8 Na-141
K-4.5 Cl-102 HCO3-31 AnGap-13
[**2174-1-27**] 04:20AM BLOOD Glucose-94 UreaN-28* Creat-0.8 Na-142
K-4.6 Cl-105 HCO3-25 AnGap-17
[**2174-1-13**] 04:50PM BLOOD CK(CPK)-48
[**2174-1-14**] 02:50AM BLOOD CK(CPK)-34
[**2174-1-13**] 04:50PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2174-1-14**] 02:50AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2174-1-15**] 03:23PM BLOOD Calcium-9.0 Phos-3.4 Mg-2.5
[**2174-1-17**] 02:42AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.1
[**2174-1-19**] 05:05AM BLOOD Calcium-9.1 Phos-2.6* Mg-2.1
[**2174-1-21**] 05:30PM BLOOD Calcium-9.3 Phos-4.0 Mg-2.1
[**2174-1-24**] 05:35AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.2
[**2174-1-26**] 05:19AM BLOOD Calcium-9.9 Phos-4.4 Mg-2.4
[**2174-1-14**] 02:50AM BLOOD %HbA1c-5.7
[**2174-1-14**] 02:50AM BLOOD Triglyc-254* HDL-30 CHOL/HD-4.9
LDLcalc-66
[**2174-1-14**] 02:50AM BLOOD Digoxin-0.2*
Microbiolgy
urine culture [**1-14**]- negative
Blod culture [**1-15**]- negative
sputum culture [**1-16**]- normal flora
Urine studies
[**1-14**], [**1-26**], [**1-27**]- negative for infection
Imaging
CTP/CT head [**1-13**]:
IMPRESSION:
1. Decreased perfusion in the left MCA distribution concerning
for a large
acute infarct, with possible mismatch between the cerebral blood
volume and
cerebral blood flow.
2. Hypodensity of the left basal ganglia on CT likely reflects
an area of
acute infarct.
3. White matter hypodensities are a nonspecific finding, but
likely
represents the sequela of chronic microangiopathy given the
patient's age
ECHO [**1-14**]
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal global and regional biventricular systolic function. Mild
aortic regurgitation. Mild mitral regurgitation. Moderate
tricuspid regurgitation. Moderate pulmonary hypertension.
[**1-13**] CXR - no acute process
CT head [**1-14**]:
IMPRESSION:
1. Evolving left MCA territory infarct with mild local mass
effect and shift of midline structures to the right. No
intracranial hemorrhage identified. A wet read was provided by
Dr. [**Last Name (STitle) **].
CXR [**1-15**]:
IMPRESSION: No evidence of pneumonia
CXR [**1-19**]
FINDINGS: As compared to the previous examination, the
nasogastric tube and
the left-sided pacemaker are in unchanged position. The
pre-existing
retrocardiac opacity has completely resolved. There is no
evidence of focal
parenchymal opacity, notably no evidence of pneumonia. Unchanged
moderate
cardiomegaly without signs of overhydration or pulmonary edema.
No pleural
effusions. No hilar or mediastinal adenopathies.
CXR [**1-25**]
IMPRESSION:
Stable chest findings with cardiac enlargement including left
atrial contour
prominence. No evidence of new infiltrates.
Video swallow test [**1-20**]
IMPRESSION: Profound delay in transporting bolus through the
oral phase of
swallow. Penetration with thin and nectar barium. Small residue
in the
pyriform sinuses.
Duplex Doppler Kidneys [**1-24**]
IMPRESSION:
1. Decreased left main renal artery peak systolic flow with
absent diastolic
flow within the interpolar arteries. These findings suggest
stenosis on the
left side, however, not matched by the size discrepancy between
the right and
left kidneys. Therefore, at this time, an MRA of the kidneys may
be warranted
for further evaluation
USG kidneys [**1-24**]
The right kidney measures 8 cm in size. The main renal vein is
patent. The
main renal artery demonstrates brisk upstroke with a peak
systolic velocity of
81 cm/sec. The interpolar arteries are patent without evidence
of parvus
tardus. There is mild decreased diastolic flow.
The left kidney measures 9.2 cm in size. The main renal vein is
patent. The
main renal artery is patent without evidence of parvus tardus
and a peak
systolic velocity of approximately 38 cm/sec. The interpolar
arteries on the
left side do not demonstrate parvus tardus, however, demonstrate
absent
diastolic flow. The constellation of these findings suggests
left renal
artery stenosis.
Brief Hospital Course:
80 year old woman with atrial fibrillation s/p PPM not on
Coumadin due to
prior fall and HX of syncope, HTN who presented to an OSH with
stuttering symptoms of aphasia and right sided weakness,
received IV tPA and was transferred to [**Hospital1 18**] for possible
further intervention. On arrival her NIH SS was still 16, while
her exam briefly improved in the ED (able to lift her right arm
off the bed) she then again deteriorated.
CTA head from the OSH showed a T Left ICA occlusion and a CT at
[**Hospital1 **] showed loss of the left insular ribbon with initial read of
CTP showing increased MTT in left MCA territory, CBV is
generally preserved indicating penumbra to be saved.
Patient was treated with IA tPA, PENUMBRA and MERCI clot
retrieval by IR and was admitted to NEURO ICU for further
monitoring and treatment.
NEURO. On admission to ICU, patient was intubated, had global
aphasia, withdrew flexor to noxious on left and no movement on
the right. BP was allowed to auto regulate with a goal of
140-160 maintained as best as possible (BP range of 100 - 180).
Normoglycemia and normothermia were maintained. Repeat CT head
showed
increased hypo density and size of the left middle cerebral
artery territory infarction and a 4-mm shift of midline
structures to the RIGHT. Etiology of stroke was felt to be of
embolic origin in pt. w/ fib off anticoagulation.
Patient was extubated on HD#1. Her exam at that time was notable
for arousal to voice, open eyes with left [**Hospital1 **] deviation,
inability to follow commands, motor and comprehension aphasia
and AG strength on L with extensor withdrawal to noxious on the
right.
She was transferred to floor for further care. she was
evaluated by PT/OT who recommended that she would require long
term support and acute rehab level of care on discharge. She was
seen and evaluated by speech and swallow therapy team . She was
on tube feeds during her hospital stay and attempts were made to
try PO feeds as tolerated but it was felt that she would require
[**Hospital1 282**] tube for long term feeding measures which was discussed with
her daughter who is also her health care proxy and [**Name2 (NI) 282**] tube was
placed on [**1-27**].
CV. Atrial fibrillation. She was continued on digoxin, Isordil
and Toprol XL was changed to an equivalent 1/2 dose of
metoprolol. ROMI was completed, EKG showed no evidence of
ischemia. TTE showed mild symmetric left ventricular
hypertrophy with nl EF, mild AR/MR, moderate TR and PAH. She
was noted to have worsening hypoxemia on HD#2 and evidence of
pulmonary congestion on CXR. Her Lasix was increased to daily
dosing. After transfer to floor she was continued on Lasix PO,
however she was noted to be dehydrated and her BUN /CR ratio was
high hence Lasix was stopped. Other outpatient meds including
digoxin were continued. Her Blood pressure was on the higher
side and her renal USG showed renal art stenosis for which she
was seen by renal who did not recommend stenting. MRI was not
possible owing to pacer. For blood pressure , hydralazine was
increased with moderate response and calcium channel blocker
amlodipine was added. she was stared on Coumadin after [**Month/Year (2) 282**] tube
and ASA as well as SC heparin ( for DVT Prophy) should be
stopped after her INR becomes therapeutic.
PU LM. Extubated on HD#1. Hypoxemia and volume overload were
treated with increasing PO Lasix to 40 mg daily. she was
transferred to floor and was maintaining good saturations on
room air. she underwent repeat chest xray which did not show any
new infiltrates.
PPX. Heparin SC was started on HD#2, maintained on Protonix.
ID- she underwent work up for excluding infections such as UA,
chest xray on periodic basis which were negative.
The goals of care were discussed with her daughter ,[**Name (NI) 2270**] who is
also her HCP and prognosis was explained from time to time.
Her neuro exam at the time of discharge was notable for - she
spontaneously opens her eyes, no verbalization, has hemi neglect
towards right side but does track slightly past midline, facial
droop on right side, R sided hemiplegia with upgoing toe, left
side is normal strength.
Suggested plan of care at DC
1. Frequent checks on her neuro status. aggressive physical
therapy and occupational therapy to prevent contracture and to
possible gain some function. Evaluation by speech and swallow
therapist for language function and swallow tests.
2. continuation of tube feed now with adequate calorie intake.
3. Adjustments of blood pressure meds for goal of 120-140
systolic. use of prn IV hydralazine for SBP more than 180. we
have held her Lasix as she was dehydrated with high BUN/Cr
ratio. if clinically indicated, she can be started again on
Lasix
4. prevention of bedsores, and stomach ulcers and treatment of
fungal rash over buttocks
5. watch over closely for any clinical signs of infection such
as development of UTI or pneumonia
6. Continue aspirin till she becomes therapeutic on Coumadin
with frequent INR checks. Aspirin should be stopped once her INR
becomes [**3-9**]. ( For A fib, to prevent further strokes. She is on
heparin SC for DVT prophylaxis which should be stopped once her
INR is therapeutic. we avoided heparin bridge given large stroke
and possible hemorrhagic conversion.
7. Medical management as felt appropriate by the team for blood
sugars, pain control, Electrolyte balance and other medical
issues.
Medications on Admission:
ASA 325 mg daily
Omeprazole 20mg daily
Digoxin 125mcg every other day
Toprol XL 100mg [**Hospital1 **]
Ambien 5mg QHS prn
Hydralazine 10mg [**Hospital1 **]
Isordil 5mg [**Hospital1 **]
Hydroxychloroquine 200mg every other day
Lasix 20mg every other day
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
3. Isosorbide Dinitrate 5 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
5. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for thick secretions.
6. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash.
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing, shortness of breath.
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
13. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
14. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO
EVERY OTHER DAY (Every Other Day).
16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
17. Hydralazine 20 mg/mL Solution Sig: Ten (10) mg Injection Q6H
(every 6 hours) as needed for bp control: FOR SBP MORE THAN 160.
18. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day:
Please Stop the aspirin when the INR is therapeutic (between
[**3-9**]).
Discharge Disposition:
Extended Care
Facility:
Bear [**Doctor Last Name **] Nursing Center - [**Location (un) 2199**]
Discharge Diagnosis:
Left MCA infarct
s/p t PA and MERCI, PENUMBRA
Discharge Condition:
Mental Status:Confused - always
Level of Consciousness:Lethargic but arousable
Activity Status:Bedbound
Discharge Instructions:
You were admitted for evaluation of stroke. You were found to
have left MCA stroke and underwent thromolytic and endovascular
therapy for the stroke.
Please take your medicines as prescribed, please call 911 or
your doctor if you develop any concerning symptoms.
Followup Instructions:
Please follow up in neurology clinic -
Scheduled Appointments :
Provider [**First Name8 (NamePattern2) **] [**Name9 (PRE) 162**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2174-3-4**]
10:30
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Name: [**Known lastname 13306**],[**Known firstname 647**] Unit No: [**Numeric Identifier 13307**]
Admission Date: [**2174-1-13**] Discharge Date: [**2174-1-28**]
Date of Birth: [**2093-5-21**] Sex: F
Service: NEUROLOGY
Allergies:
Codeine / Amoxicillin / Penicillins
Attending:[**First Name3 (LF) 1886**]
Addendum:
Ms. [**Known lastname **] had intermittent discomfort this morningand is
associated with her attempting to pass gas. Her abdominal exam
is benign with soft, non-tender abdomen and normal bowel sounds.
There is slight typany but no rebound or guarding. She has
remained afebrile. Given her PEG placement yesterday, this
finding is consistent with mild abdominal distention secondary
to encephlation for the procedure and will improve as the
patient continues to pass gas. We are going to give her a dose
of simethicone to see if her symptoms may improve and this can
be used PRN if her symptoms persist.
Chief Complaint:
.
Major Surgical or Invasive Procedure:
.
History of Present Illness:
.
Past Medical History:
.
Social History:
.
Family History:
.
Physical Exam:
.
Pertinent Results:
.
Brief Hospital Course:
.
Medications on Admission:
.
Discharge Medications:
.
Discharge Disposition:
Extended Care
Facility:
Bear [**Doctor Last Name **] Nursing Center - [**Location (un) 654**]
Discharge Diagnosis:
.
Discharge Condition:
.
Discharge Instructions:
.
Followup Instructions:
.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1887**] MD, [**MD Number(3) 1888**]
Completed by:[**2174-1-28**]
|
[
"434.11",
"V45.88",
"342.00",
"733.00",
"V15.88",
"486",
"787.21",
"518.89",
"300.00",
"784.3",
"427.31",
"276.6",
"V45.01",
"401.9",
"440.1",
"348.4",
"110.8",
"562.10",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"88.41",
"96.6",
"00.40",
"96.71",
"39.74",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
22289, 22385
|
22208, 22211
|
22048, 22051
|
22430, 22433
|
22182, 22185
|
22483, 22626
|
22142, 22145
|
22263, 22266
|
22406, 22409
|
22237, 22240
|
22457, 22460
|
22160, 22163
|
4021, 4369
|
22007, 22010
|
22079, 22082
|
4805, 6097
|
6136, 12549
|
20298, 20390
|
4393, 4393
|
22104, 22107
|
22123, 22126
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,201
| 166,954
|
3506
|
Discharge summary
|
report
|
Admission Date: [**2135-7-11**] Discharge Date: [**2135-7-20**]
Date of Birth: [**2090-2-14**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
Tingling in the left hand.
Major Surgical or Invasive Procedure:
MRI of the head
intravenous dopamine and neosynephrine administration
History of Present Illness:
45 yo RH woman who was recently discharged from our service with
right carotid dissection, presents today with left hand tingling
and heaviness and exacerbated gait (feels unsteady). She says
after DC from hospital her headache improved but she still has
dull headache on the right retroorbital region. She was doing
well but about 130pm today, she had a sudden onset of tingling
in
the left hand (tip of her fingers felt "weired") and she had
some pain over the left deltoid region. She felt she could not
sense the napkin in her left hand. She feels her symptoms
resembled the initial symptoms she had before her last admission
(e.g., heaviness feeling in her left arm), but she feels the
tingling and gait problem is new. She used to be a runner and in
previous exam she had normal tandem gait. Pt says the tingling
and heaviness of the left arm lasted about 10minutes and are
gone
(see below for the recurrence of her symptoms while she was in
the ED)
REVIEW OF SYSTEMS
Negative for nausea, vomiting, syncope, weakness, problems with
swallowing, bladder, bowel, fevers/chills, chest pain, or
shortness of breath.
Past Medical History:
ptosis right eye since eye surgery as a child
Social History:
going thru a separation, 2 kids, construction manager, runs
15 miles a week, no tob/etoh/drugs.
Family History:
Dad with CAD and high cholesterol, Mom with high chol,
no h/o strokes, brother has "bad" headaches.
Physical Exam:
Vitals: 98, 130/80, 16, 98%
Gen: seems in NAD.
HEENT: supple neck. No carotid bruits.
Pulmonary: CTA
Cardiovascular: RRR
Abdomen: soft, NT and ND
Skin: No rash, cyanosis, or trauma.
MENTAL STATUS
Alert, and oriented to place, date, and person. Attention intact
w MOYB and DOWB. Language and memory intact. No apraxia. No
alexia or agraphia. No visuospatial deficit. No propagnosia. No
neglect. Copying a cube is intact. [**Last Name **] problem with line
bisection. Prosody of speech intact.
CRANIAL NERVES:
Visual fields full. Dipolpia not present. Fundoscopic exam
reveal
no papilledema. Pupils are unequal (right 3mm) and left 2mm.
Both
reactive. Gaze with exotropia at rest. Fixes with left eye and
the right eye is laterally positioned. Cover test positive.
Ptosis on the right eye. EOMs intact. No nystagmus. Facial
sensation intact for fine touch, pinprick and temperature. No
facial droop. Palate elevates symmetrically. Shrug [**6-2**]. Head
version in all directions [**6-2**]. Tongue movement strong, and
protrudes at midline.
MOTOR:
No atrophies or fasciculations. Normal tonus. Pronator drift not
present. Strength normal in all limbs.
COORDINATION:
No asterixis. No tremor. Finger to nose normal. Heel-to-shin
normal. [**Doctor First Name **] normal. Problem with the left hand in
ddysdiadocokinesia.
REFLEXES:
Normal and symmetric in UE and LE. No clonus. Plantar reflexes
with withdrawal/
SENSATION:
Fine touch, pin prick and temperature intact in all limbs. Can
recognize objects with the left hand. Can read numbers on the
left hand. Vibration intact in distal extremities. Joint
position
intact. Romberg: slightly positive.
GAIT:
Patient can rise from bed without assistance or difficulties.
The
initiation of the gait is fast. Ha wide based gait and falls to
the sides on turning fast. Tandem is very abnormal.
Pertinent Results:
[**2135-7-11**] 06:15AM GLUCOSE-92 UREA N-13 CREAT-0.8 SODIUM-142
POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-27 ANION GAP-12
[**2135-7-11**] 06:15AM CALCIUM-9.3 PHOSPHATE-4.9* MAGNESIUM-2.0
[**2135-7-11**] 06:15AM WBC-7.1 RBC-4.07* HGB-12.8 HCT-37.0 MCV-91
MCH-31.3 MCHC-34.5 RDW-12.5
[**2135-7-11**] 06:15AM PLT COUNT-192
[**2135-7-11**] 06:15AM PT-17.1* PTT-39.7* INR(PT)-1.9
[**2135-7-11**] 06:15AM FIBRINOGE-330
[**2135-7-10**] 04:25PM PT-16.3* PTT-34.4 INR(PT)-1.8
[**2135-7-10**] 02:15PM GLUCOSE-92 UREA N-7 CREAT-0.7 SODIUM-143
POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-27 ANION GAP-15
[**2135-7-10**] 02:15PM WBC-8.7# RBC-4.32 HGB-13.4 HCT-38.1 MCV-88
MCH-31.1 MCHC-35.3* RDW-12.4
[**2135-7-10**] 02:15PM NEUTS-75.9* LYMPHS-19.1 MONOS-4.3 EOS-0.4
BASOS-0.3
[**2135-7-10**] 02:15PM PLT COUNT-212
[**2135-7-11**] 06:15AM BLOOD WBC-7.1 RBC-4.07* Hgb-12.8 Hct-37.0
MCV-91 MCH-31.3 MCHC-34.5 RDW-12.5 Plt Ct-192
[**2135-7-11**] 06:15AM BLOOD PT-17.1* PTT-39.7* INR(PT)-1.9
[**2135-7-11**] 06:15AM BLOOD Plt Ct-192
[**2135-7-11**] 06:15AM BLOOD Fibrino-330
[**2135-7-11**] 06:15AM BLOOD Glucose-92 UreaN-13 Creat-0.8 Na-142
K-3.7 Cl-107 HCO3-27 AnGap-12
[**2135-7-11**] 06:15AM BLOOD Calcium-9.3 Phos-4.9* Mg-2.0
[**2135-7-12**] 06:45AM BLOOD WBC-7.6 RBC-4.13* Hgb-13.0 Hct-36.5
MCV-88 MCH-31.4 MCHC-35.5* RDW-12.2 Plt Ct-186
[**2135-7-12**] 06:45AM BLOOD Plt Ct-186
[**2135-7-12**] 06:45AM BLOOD PT-15.7* PTT-37.6* INR(PT)-1.6
[**2135-7-12**] 06:45AM BLOOD Glucose-78 UreaN-10 Creat-0.7 Na-140
K-4.0 Cl-107 HCO3-25 AnGap-12
[**2135-7-13**] 05:50AM BLOOD PT-17.0* PTT-43.0* INR(PT)-1.9
MRA Brain:
1) Right internal carotid artery dissection, involving the
distal cervical internal carotid artery. In the interval since
the previous examination dated [**2135-7-4**], the flow at the
level of the dissection has not improved and may possibly be
less robust.
2) No evidence of acute infarct on diffusion-weighted imaging.
Slight asymmetry in signal between the right and left
hemispheric cortical regions on FLAIR imaging is of uncertain
significance, particularly in view of the negative findings on
diffusion. No hydrocephalus.
MRA CAROTID/VERTEBRAL W&W/O CONTRAST:
IMPRESSION: Right internal carotid artery dissection with
suggestion of slight decrease in flow proximal and distal to the
dissection in comparison with the examination dated [**2135-7-5**]. These findings were discussed with Dr. [**Last Name (STitle) **] at 12:15 p.m.
on [**2135-7-11**].
CT Head:
IMPRESSION: No significant interval change. No acute
intracranial pathology identified.
ECG:
Sinus bradycardia. Occasional atrial ectopy. No other diagnostic
abnormalities.
Compared to the previous tracing of [**2135-7-4**] no significant
diagnostic change.
Brief Hospital Course:
Ms. [**Known lastname 16117**] is a 45y/o female with history of right ICA
dissection admitted last week now presented with intermittent
left arm sensory changes. MRI showed no new stroke but her
known, right ICA dissection appeared slightly larger. Her exam
showed old right Horner's but otherwise she was neurologically
intact. On admission her INR was 1.9 and she was on Lovenox
alone.
She was admitted to Neurology service where she was started on
Coumadin and continued on Lovenox. She was aggressively
hydrated with IVG and she was kept on bed rest with the head of
the bed flat.
Despite these measures, she continued to have left arm sensory
changes and limb-shaking TIAs. She was therefore started on
Florinef in an attempt to keep her blood pressure elevated. This
was not successful and she was given one dose of albumin which
made her short of breath but did not increase her blood
pressure. Because of continued limb shaking events, she was
transferred to the neuro ICU for pressors including dopamine and
neo. She had no TIAs for two days while in the ICU and was
transferred back to the stepdown unit. She had no further TIAs
and will be discharged on Coumadin and Lovenox until her INR is
between 2 and 3.
Medications on Admission:
Lovenox
Coumadin
Discharge Medications:
1. Acetaminophen-Caff-Butalbital [**Medical Record Number 3668**] mg Tablet Sig: [**1-30**]
Tablets PO Q8H (every 8 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
2. Warfarin Sodium 2.5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*90 Tablet(s)* Refills:*2*
3. Enoxaparin Sodium 60 mg/0.6mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours).
Disp:*20 syringe* Refills:*0*
4. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for for breakthrough headache.
Disp:*60 Tablet(s)* Refills:*0*
5. Outpatient Lab Work
Please check PT, PTT, INR, CBC on Friday.
Discharge Disposition:
Home
Discharge Diagnosis:
right carotid artery dissection
Discharge Condition:
no longer having TIAs
Discharge Instructions:
Please take all medications. Follow up with all appointments.
Please have your INR checked in 3 days. Dr. [**Last Name (STitle) **] should
follow your INR and adjust the dose for a goal INR of 2.0-3.0
Followup Instructions:
1. NEUROLOGY : [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], M.D. Where: [**Hospital 273**] NEUROLOGY Phone:[**Telephone/Fax (1) 1694**] Date/Time:[**2135-9-27**] 4:00
2. F/U with Dr. [**Last Name (STitle) **] this week to follow up INR results
|
[
"443.21",
"435.9",
"276.6",
"349.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8435, 8441
|
6507, 7736
|
344, 416
|
8517, 8541
|
3741, 6213
|
8791, 9098
|
1765, 1867
|
7804, 8412
|
8462, 8496
|
7762, 7781
|
8565, 8768
|
1882, 2376
|
277, 306
|
444, 1565
|
2392, 3722
|
6222, 6484
|
1587, 1635
|
1651, 1749
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,446
| 150,201
|
284
|
Discharge summary
|
report
|
Admission Date: [**2124-6-12**] Discharge Date: [**2124-7-8**]
Date of Birth: [**2083-3-21**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
GERD and small hiatal hernia
Major Surgical or Invasive Procedure:
[**2124-6-12**]
Laparoscopic converted to open, redo Nissen
fundoplication, and repair of hiatal hernia.
[**2124-6-16**]
Esophagogastroduodenoscopy.
[**2124-6-19**]
1. Reopening of abdomen and washout of intraperitoneal
hematoma.
2. Endoscopy
[**2124-6-27**]
CT guided pigtail placement left pleural space
[**2124-6-27**]
CT guided drain placed in perisplenic fluid collection
History of Present Illness:
41-year-old black gentleman status post Nissen
fundoplication five years ago. He did great during this time
with no reflux or difficulty swallowing at all. He had
previously undergone endoscopic approaches to relieve his
heartburn, which had failed. However, for the last two months,
he has had difficulty with some reflux as well as swallowing
water. Endoscopy revealed a small hiatal hernia and gastritis.
A barium swallow showed a small herniation of the GE junction
possibly above the diaphragm. He complains of these problems
with swallowing and also notes more frequent burping.
Past Medical History:
Episcleritis bilaterally: Followed by Dr. [**Last Name (STitle) **].
GERD s/p Nissen Fundoplication
Obesity
Hypercholesterolemia: Borderline in the past.
Chronically elevated liver function tests: Normal evaluation in
the past.
Chronic low back pain
Hypertension.
s/p distal biceps tear and repair on [**2119-9-8**] by Dr. [**Last Name (STitle) 2719**].
Social History:
The patient states that he drinks beer occasionally on the
weekends. He smokes occasional cigars, but is exposed to
secondhand smoke at home. The patient smoked while he was in
military but quit over 10 years ago.
Family History:
Mother has a history of migraine headaches. His mother has a
history of diabetes. Uncle has a history of lung cancer. He has
four children who are all healthy.
Physical Exam:
Vital signs
Temperature of 97.2, blood pressure 143/92, O2 sat 99%, pulse
84, Resp 20, weight 236 pounds.
Breathing comfortably.
Abdomen is soft. Incision is well healed.
Moving all extremities well.
Pertinent Results:
[**2124-6-14**] UGI : No evidence of leak. Slow passage of contrast
from the esophagus into the stomach, likely from edema, with
residual barium within the distal esophagus.
[**2124-6-16**] CT Abd/pelvis/CTA chest :
1. Dense right lower lobe consolidation consistent with
pneumonia. Large
left pleural effusion with pleural enhancement; infection cannot
be excluded. Small right effusion. Patchy consolidation at lung
apices suggests aspiration or infection.
2. Fluid collection in the surgical bed, extending along the
stomach and
pancreatic tail, with marked stranding in left upper quadrant.
Extraluminal hyperdense material at the GE junction may
represent surgical pledgets or extravasated contrast. Cannot
exclude anastomotic leak. Notably, however, there is no
intraperitoneal free air (endoscopy with insufflation was
performed prior to this examination to assess for leak).
3. Limited evaluation for pulmonary embolus due to timing of
contrast, but no evidence of large pulmonary embolus.
4. Peripancreatic fluid may be tracking from surgical bed, but
recommend
obtaining pancreatic enzymes for clinical correlation to exclude
pancreatitis as a cause of left upper quadrant inflammatory
change.
5. ETT terminates 1.4 cm above the carina. Consider
repositioning.
[**2124-6-17**] TTE :
Mild symmetric left ventricular hypertrophy with normal systolic
function. Right ventricular dilation, hypertrophy, mild
hypokinesis, and severe estimated pulmonary artery systolic
hypertension. These findings are consistent with a primary
chronic pulmonary process.
[**2124-6-17**] Esophagus :
No evidence of leak at the gastric fundus to correlate with the
findings on previous CT. While it remains possible that the
density at the GE junction seen on the previous CT represents
leaked barium, given the inability to demonstrate leak on the
present examination, these densities are felt more likely to
represent hyperdense pledgets which were reportedly used in the
surgery.
[**2124-6-19**] CT Abd/pelvis : 1. Stable size and configuration of
peri-GE junction low-density fluid. No new intraabdominal
collection. Unchanged extraluminal hyperdense material, may
represent extraluminal contrast versus surgical pledgets.
2. New small-bowel obstruction with transition point in the mid
abdomen (2, 66), most likely due to adhesion.
3. Improved bilateral pleural effusions status post left chest
tube
placement. Improved but persistent bibasilar atelectasis.
4. Trace pneumomediastinum, likely expected post-surgical
change.
[**2124-6-26**] CT Abd/pelvis : 1. Interval placement of multiple
intra-abdominal drains, with persistent multiple low-density
collections within the lesser sac and peripancreatic location,
gastrohepatic space, and perisplenic regions. Though one of the
drains situated in the gastrohepatic space appears centered
within a fluid collection, the remainder of the drains do not.
2. Moderate left pleural effusion, larger in size, that is
slightly
hyperattenuating, may contain hemorrhagic or proteinacious
components.
3. Left subclavian line tip not central in location and should
be adjusted.
4. Trace free fluid in the pelvis, nonspecific, and may reflect
sequela of
recent surgery.
[**2124-7-2**] CT Abd/pelvis : 1. Interval decrease in size of
perisplenic fluid collection which contains a pigtail catheter;
decreased although persistent smaller loculations including
lesser sac, peripancreatic and gastrohepatic collection.
2. Near-resolution of a left pleural effusion which contains a
pigtail
catheter.
3. Stranding and low density within the abdominal wall
musculature,
developing collection not entirely excluded. Correlation with
physical
examination and consideration of ultrasound is suggested if an
infection is suspected in the area. The CT findings are
non-specific and may be
post-operative or due to serous or infected fluid.
4. Few subtle wedge-shaped hypodensities within the renal
parenchyma. main
differential considerations include infarction versus infection,
other
etiologies are considered less likely. Correlation with
urinalysis and other clinical factors is suggested. The areas of
relative hypoperfusion are in the upper poles only, so possibly
the appearance is secondary to nearby peripancreatic
inflammation and might not be significant in itself.
[**2124-6-18**]
Blood Culture, Routine (Final [**2124-6-24**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
SENSITIVITIES PERFORMED ON REQUEST..
[**2124-6-19**] Peritoneal fluid
GRAM STAIN (Final [**2124-6-19**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2124-6-21**]):
A swab is not the optimal specimen collection to evaluate
body
fluids.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
ANAEROBIC CULTURE (Final [**2124-6-23**]): NO ANAEROBES ISOLATED.
Brief Hospital Course:
Mr. [**Known lastname **] presented to [**Hospital1 18**] on [**2124-6-12**] for a laparoscopic Redo
Nissen which was converted to open Nissen redo and hiatal hernia
repair. Postoperatively, he was transferred from the PACU to the
floor where over the next few days experienced an increase in
oxygen requirements with saturations in the 90s% despite
vigorous pulmonary toilet. His chest xray revealed a new large
left pleural effusion and a small right pleural effusion. This
prompted an upper GI which ruled out a leak. His pain was
controlled with an epidural and PCA and his stomach remained
decompressed with a nasogastric tube.
On [**2124-6-16**] he was transferred to the SICU as he had more
respiratory distress and was electively intubated for airway
control and subsequent imaging. He had a CT scan of the chest,
abdomen and pelvis. This imaging study showed a large left
pleural effusion and RLL consolidation c/w pneumonia, peri-GE
junction fluid. His WBC 25K at that time and vancomycin was
started. The thoracic surgery service was consulted for left
chest tube placement and subsequent endoscopy which revealed
normal mucosa, an intact wrap and no leaks. His chest tube
drained about 850 cc and his PO2 gradually improved. His sputum
culture was MSSA positive, BAL were both negative. He also
developed rapid atrial fibrillation and was seen by the
Cardiology service. Part of their work up included an ECHO which
showed moderate-severe RV dysfunction demonstrated by PASP 62.
His EF was 60%. his atrial fibrillation converted to NSR with
amiodarone.
On [**6-18**], he was trialed for extubation, but reintubated for
increased work of breathing.
On [**6-19**] he had a follow up CT scan which showed fluid at GE
junction. Due to an increasing WBC and no significant
improvement he had an exploratory lap and washout of
intraperitoneal hematoma which showed no evidence of leak. He
was started Zosyn and continued on vancomycin empirically. His
left chest tube was removed without difficulty.
From [**Date range (1) 2720**], Mr. [**Known lastname **] continued to be intubated with a mucus
plug removed by bronchoscopy on [**6-21**], and a failed trial of
extubation on [**6-25**]. He had a follow up CT torso on [**6-26**] which a
large L pleural effusion and subdiaphragmatic/perisplenic
collection. Both the left pleural effusion and perisplenic
abscess were drained by IR on [**6-27**] with pig tail catheters.
These collections both drained dark fluid which were culture
negative. Mr. [**Known lastname 2721**] WBC count began trending down from 17 to 12
following drainage.
Additionally, after the IR guided drainage of the left pleural
effusion and perisplenic fluid, Mr. [**Known lastname 2721**] respiratory status
improved and he was extubated on [**2124-6-28**]. After extubation, he
improved rapidly and on [**2124-6-29**] his tube feeds, nasogastric tube,
foley, and central venous line were all discontinued and his
diet was advanced to full liquids. He was transferred to the
floor on [**2124-6-30**].
On the floor, Mr. [**Known lastname **] continued to improve dramatically while
his WBC decreased to 10.3. He was seen by physical therapy for
deconditioning but after a few treatments he was up and walking
independently. A followup CT scan on [**2124-7-2**] showed that the
left pleural effusion had mostly resolved and the perisplenic
collection had decreased to 13 mm. His drains were then
sequentially discontinued. On [**2124-7-7**] the last drain was removed,
his WBC was 6K and his antibiotics were discontinued.
His abdominal wound drained some serosanguinous fluid from the
lower 1/3rd and was partially opened on [**2124-7-5**]. There was no
cellulitis and the base of the wound was clean. He underwent
[**Hospital1 **] dressing changes with saline moist to dry gauze. He did have
some minor skin tears which were treated with non adherent
dressings. His appetite was slowly improving and he was also
started on Ensure for supplementation.
After a long, protracted hospital course he was discharged to
home on [**2124-7-8**] and will follow up with Dr. [**Last Name (STitle) **] in 2 weeks.
Medications on Admission:
1. ECONAZOLE - 1 % Cream - apply to groin and bottom and sides
of
feet twice a day Use for at least 3 months, then once a week
thereafter.
IBUPROFEN - 800 mg Tablet - 1 Tablet(s) by mouth three times a
day. Take with food.
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth twice a day
Discharge Medications:
1. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
2. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
take this if you are requiring Percocet to prevent constipation.
Disp:*60 Capsule(s)* Refills:*2*
4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation four times a day as needed for wheezes.
5. 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:
[**Location (un) 86**] VNA
Discharge Diagnosis:
1. Gastroesophageal reflux.
2. Recurrent hiatal hernia.
3. Abdominal fluid collection
4. Pneumonia
5. Parapneumonic effusion
6. Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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 [**5-8**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
* Your abdominal wound needs to be packed twice daily with
saline moistened gauze and covered with a dry dressing. The VNA
will helpou with that.
*Please call Dr. [**Last Name (STitle) **] if you have increased pain, swelling,
redness, or drainage from the incision site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
Followup Instructions:
Please have followup CT scan in 6 mo for evaluation of
peripancreatic fluid which has the potential to develop into a
pseudocyst.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2722**], MD Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2124-7-21**] 8:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 2723**]
Date/Time:[**2124-7-21**] 1:00
call Dr.[**Last Name (STitle) **] for a follow up appointment in [**2-2**] weeks.
|
[
"379.00",
"278.00",
"401.9",
"567.22",
"518.0",
"482.41",
"V85.36",
"038.9",
"272.0",
"511.9",
"427.31",
"997.4",
"276.3",
"518.5",
"553.3",
"998.59",
"V64.41",
"530.81",
"E878.8",
"288.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"99.15",
"33.24",
"34.04",
"54.91",
"54.12",
"38.93",
"96.72",
"45.13",
"44.66"
] |
icd9pcs
|
[
[
[]
]
] |
12468, 12525
|
7309, 11457
|
341, 724
|
12717, 12717
|
2369, 7286
|
14787, 15305
|
1969, 2131
|
11818, 12445
|
12546, 12696
|
11483, 11795
|
12868, 14312
|
14327, 14764
|
2146, 2350
|
273, 303
|
752, 1344
|
12732, 12844
|
1366, 1721
|
1737, 1953
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,423
| 104,699
|
14540
|
Discharge summary
|
report
|
Admission Date: [**2119-10-26**] Discharge Date: [**2119-11-2**]
Date of Birth: [**2093-8-8**] Sex: M
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: A 25-year-old male status post
motor vehicle accident in [**2119-6-22**]. Injuries sustained
included an intracranial hemorrhage, subarachnoid hemorrhage,
left temporal contusion, C2 ring fracture, as well as splenic
and hepatic lacerations, pneumothorax. The patient was
admitted on the 5th for a cervical fusion.
PAST MEDICAL HISTORY:
1. Only significant for the injuries related to the motor
vehicle accident in [**2119-6-22**].
2. Splenic rupture status post splenectomy.
3. Pneumothorax.
4. Aspiration pneumonia.
5. Subdural and subarachnoid hemorrhages status post
ventriculostomy.
6. Pelvic fracture.
7. C2 fracture.
8. Multiple rib fractures.
9. Vertebral artery trauma.
10. Tracheostomy.
11. PEG tube.
PHYSICAL EXAMINATION UPON ADMISSION: Alert and oriented,
follows commands. Poor verbal ability. The patient has left
hemiparesis. Is able to wiggle toes on the left side. Does
have a left facial droop. Strength is [**2-24**] right upper
extremity, [**3-26**] right lower extremity, 0/5 left upper
extremity, 0/5 left lower extremity. Reflexes 3+ on the
left, knees, biceps, triceps, and wrist, and normal on the
right. Patient presents a Foley, PEG tube, and a trache
tube.
LABORATORIES: Laboratories are within normal limits.
HOSPITAL COURSE: On [**10-27**], he was taken to the
operating room for a cervical fusion. Postoperative course
was only significant for spiking temperatures. Cultures were
sent and they are still pending. Temperatures resolved on
their own. The patient has been afebrile for the last 24
hours prior to discharge. Neurologically, he remains
unchanged and is stable. He will be discharged to
rehabilitation.
DISCHARGE MEDICATIONS:
1. Dilantin 100 mg po tid.
2. Percocet [**3-31**] mL po q4-6 prn.
3. Docusate 100 mg po bid.
4. Lactulose 30 mL q8 prn.
5. Albuterol 1-2 puffs inhaled q6 prn.
6. Tylenol 325-650 mg nasogastric q4-6 prn.
7. Profenicin 15 mL nasogastric q day.
8. Scopolamine patch one patch q72h.
FOLLOWUP: Followup after discharge will be in [**11-23**] weeks with
Dr. [**Last Name (STitle) 1327**].
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2119-11-1**] 11:49
T: [**2119-11-1**] 12:16
JOB#: [**Job Number 38891**]
|
[
"V44.1",
"805.02",
"V45.79",
"E819.9",
"V44.0",
"723.8",
"780.6",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.03",
"81.01",
"03.53",
"81.02",
"77.79",
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
1865, 2515
|
1445, 1842
|
174, 492
|
927, 1427
|
514, 912
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,600
| 183,892
|
45641
|
Discharge summary
|
report
|
Admission Date: [**2163-1-10**] Discharge Date: [**2163-1-19**]
Date of Birth: [**2090-4-20**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
N/V
Major Surgical or Invasive Procedure:
None
History of Present Illness:
72 M who is 1 week s/p R. colectomy for colon cancer, presents
with increasing nausea and emesis for the past 2 days. He was
discharged 3 days ago, and has had increasing abdominal
distention since. He denies any fever or chills, and reports
continuing to pass flatus.
Past Medical History:
HTN, BPH, GERD, arthritis, monoclonal gammopathy
Social History:
Lives with wife
Family History:
Mother passed away from breast cancer
Physical Exam:
At time of admission:
97.4 108 95/45 25 94%RA
A&O X 3, conversant
PERRL, EOMI, feculent breath
Heart irregularly irregular
Lungs CTAB
Abd distended, hypertympanic, tender to deep palpation in
epigastrium
Incision C/D/I
Rectal guiac negative
Ext without c/c/e
NGT with 2L feculent output
Pertinent Results:
[**2163-1-10**]: PT-12.4 PTT-20.4* INR(PT)-1.0
PLT COUNT-416# WBC-8.1 RBC-3.94* HGB-11.4* HCT-32.7* MCV-83
MCH-28.8 MCHC-34.8 RDW-13.3
ALBUMIN-3.5 CALCIUM-9.1 PHOSPHATE-6.1*# MAGNESIUM-4.2*
CK-MB-7 cTropnT-<0.01
ALT(SGPT)-53* AST(SGOT)-80* CK(CPK)-377* ALK PHOS-203*
AMYLASE-108* TOT BILI-0.6
LIPASE-148*
Brief Hospital Course:
On [**2163-1-10**] Mr. [**Known lastname 63015**] was admitted to the surgery service under
the care of Dr. [**Last Name (STitle) **]. He had been discharged 3 days prior
after having a right colectomy for colon cancer. He was
readmitted with a partial SBO, ARF, and new onset of a. fib. He
was initially admitted to the ICU for volume resuscitation and
heart rate control. An NG tube was place and initally put out
over 2 liters of feculent material. After converting in and out
of atrial fibrillation, Mr. [**Known lastname 63015**] was started on amiodarone
and heparin. By HD 3 he remained in sinus rhythm. He was
transferred out of the ICU on HD 6 when is renal status had
improved and his HR and BP were stable. His diet was slowly
advanced after his NGT was removed. During this time he was
treated for a UTI with cipro. He was also started on Zosyn when
an abdominal CT revealed a small fluid collection in the RUQ. He
was transitioned to po Levo and Flagyl. By HD 10, Mr. [**Known lastname 63015**]
was tolerating a regular diet, ambulating with minimal
assistance, and therapeutic on his coumadin. He was discharged
home with instructions to follow-up with his PCP for INR checks,
cardiology, and Dr. [**Last Name (STitle) **].
Medications on Admission:
atenolol 50', doxazosin 4', amlodipine 5', lisinopril 10',
nexium 40, colace, percocet, klonapin
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
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. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Please take 2 pills twice a day for 3 days, then 2 pills
once a day for 7 days, and then 1 pill once a day from then on.
Disp:*120 Tablet(s)* Refills:*2*
4. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
Disp:*qs 1* Refills:*2*
7. Coumadin 1 mg Tablet Sig: Three (3) Tablet PO at bedtime:
Adjust dose based on INR.
Disp:*90 Tablet(s)* Refills:*2*
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
10. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every [**5-12**]
hours.
Disp:*50 Tablet(s)* Refills:*0*
11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Partial small bowel obstruction s/p R. colectomy
New onset A. fib.
Acute renal failure
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor or go to the ER if you experience any of
the following: high fevers >101.5, severe pain, increasing
shortness of breath, chest pain, palpitations, or worsening
nausea/emesis. Please follow-up with your primary care doctor
regarding your coumadin dose. Also please follow-up with
cardiology.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 2981**] Follow-up
appointment should be in 2 weeks
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 275**] [**Name Initial (NameIs) **]. (CARDIOLOGY) [**Telephone/Fax (1) 2934**] Call to
schedule appointment
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. (PCP) [**Telephone/Fax (1) 2660**] Call to schedule
appointment
|
[
"427.31",
"600.00",
"560.9",
"530.81",
"276.51",
"273.1",
"599.0",
"584.9",
"401.9",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4173, 4179
|
1445, 2684
|
318, 325
|
4310, 4317
|
1116, 1422
|
4680, 5157
|
745, 784
|
2831, 4150
|
4200, 4289
|
2710, 2808
|
4341, 4657
|
799, 1097
|
275, 280
|
353, 623
|
645, 695
|
711, 729
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,183
| 182,296
|
33521
|
Discharge summary
|
report
|
Admission Date: [**2151-1-20**] Discharge Date: [**2151-2-3**]
Date of Birth: [**2128-9-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Cellulitis, found down
Major Surgical or Invasive Procedure:
S/P Intubation and Extubation
S/P Central line placement
S/P PICC line
History of Present Illness:
Mr. [**Known lastname 77719**] is a 22 yo M with morbid obesity with hx of recent
RLE cellulitis. He was being treated for his cellulitis at
[**Hospital3 7571**]Hospital when he was found down in his urine and
stool, and had a temp of 106. Per OSH's report he was
"non-verbal" and had a witnessed aspiration event. His father
recalled that a few days prior to this incident, [**Known firstname **] had
mentioned not feeling well and complaining of a HA. After being
found down, he was intubated for airway protection and
prevention of further aspiration. An LP showed 300 RBC, no WBC.
He was started on ceftriaxone, ampicillin, vanc, and acyclovir,
and given 8L of NS and dexamethasone empirically. His SBPs
persisted in the 90's and his HR remained in the 130's, thus he
was transferred to [**Hospital1 18**] and admitted to the MICU on [**2151-1-20**].
Once in the MICU, his pet scan showed RUL infiltrate,
splenomegaly and mesenteric retroperitoneal LAD. An EEG was
performed (read still pending). Blood cultures at OSH grew [**12-19**] +
GPC (staph epidermidis), and he was therefore switched to
vanco/zosyn on [**1-20**]. OSH cultures were negative for CSF growth
from LP, HSV PCR was negative. HIV viral load was negative,
EBV/CMV IgG +, IgM -. DFA flu was neg. He had several episodes
of hyperglycemia requiring large doses of insulin. He also had
elevated Cr and ARF, which improved with IVF. His fevers and
leukocytosis resolved on antibiotics. He self extubated on
[**2151-1-23**] and was weaned off 02. He had poor memory of preceding
events, but was A&Ox3 post-extubation. He also had diarrhea, and
stool studies were sent. So far they have been negative,
including for C. diff, and pt reports that his diarrhea has
improved. At this time, he denies CP, HA, fevers, chills, SOB,
N/V, or abdominal pain.
Past Medical History:
Morbid obesity
Hx of cellulitis in [**9-24**], requiring hospitalization
Social History:
From [**State 5887**], works at Job Corp as electrician, drinks
alcohol socially, denies tobacco and drugs. Is currently
attending [**Company 31653**] school at Ft. [**Last Name (un) 77720**] in [**Location (un) **].
Family History:
Strong family Hx of DM (paternal grandmother, father), mother
has alcoholism.
Physical Exam:
Tc: 97.1, Tm: 98.7, BP: 120/80 (120-126/70-80), P: 68 (68-74),
RR: 18, O2 sats: 98% RA, FS 111-132
Gen: Morbidly obese, alert, talkative, NAD
HEENT: PERRL, EOMI, MMM, anicteric sclera
Neck: thick, difficult anatomy, RIJ intact
CV: RRR, nl S1 S1 no M/G/R
Resp: CTAB
Abd: + BS, obese, soft, NT
Ext: RLE with diffuse erythema, swelling, mild skin breakdown,
however looks improved from original line drawing of borders on
skin. 2+ pitting edema at ankles B/L.
Neuro: Awake, alert, oriented, appropriate responses to
questions.
Pertinent Results:
IMAGING
CT Chest/Abd/Pelvis [**2151-1-20**]: The consolidation noted in the
posterior segment of the right upper lobe does not have the
typical appearance of atelectasis and might represent
superimposed aspiration/pneumonia. Fatty liver and splenomegaly
with the spleen measuring 15.9 cm. Multiple nonspecific enlarged
nodes are noted within the mesentery within the retroperitoneum
and along the both external iliac arteries/pelvic walls.
LENIS [**2151-1-20**]: Neg for DVT
EEG [**2151-1-21**]: Markedly abnormal portable EEG due to the marked
suppression of the background with bursts of generalized slowing
and
prominent beta activity. These findings indicate a widespread
encephalopathy. The Propofol noted on the requisition is the
most
likely explanation, and the widespread beta rhythm suggests
medication effect. There were no areas of persistent focal
slowing, but encephalopathies may obscure focal findings. There
were no epileptiform features.
CXR [**2151-1-23**]: Has been placement of a right IJ central venous
catheter with its lead tip in the mid to distal SVC. No
pneumothoraces are seen. Lungs are clear. Cardiac silhouette is
within normal limits.
CXR [**2151-1-25**]: The right internal jugular line was removed. The
right PICC line tip terminates at the junction of the right
brachiocephalic vein and SVC. The cardiomediastinal silhouette
is stable and the lungs are clear. There is no pleural effusion
or pneumothorax.
ECHO [**2151-1-25**]: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and global systolic function (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion. IMPRESSION: Suboptimal image
quality. No valvular pathology or pathologic flow identified.
Mild symmetric left ventricular hypertrophy with preserved
global biventricular systolic function.
CXR Portable AP [**2151-2-1**]: The right PICC line tip is at the
junction of the right brachiocephalic vein and SVC. The
cardiomediastinal silhouette is unremarkable. There is a faint
opacity in the right lower lung which appears new compared to
the prior study and may represent developing pneumonia, although
note is made that the technique of the exam is suboptimal, thus
reevaluation with PA and lateral radiograph is recommended for
precise evaluation of this area. No appreciable
pleural effusion is demonstrated.
CXR AP and Lateral [**2151-2-1**]: In comparison with the study of
[**2-1**], there is no change. No evidence of acute cardiopulmonary
disease. Central catheter again extends to the upper portion of
the SVC.
Brief Hospital Course:
A/P: 22 obese M found down in setting of RLE cellulitis, found
down with loss of urinary/bowel continence, fever of 106, and
GPC bacteremia.
# Altered mental status: Likely toxic-metabolic in setting of
coag neg staph bacteremia/sepsis from RLE cellulitis. Initially
he received antibiotics for suspected meningitis (ceftriaxone,
vanc, ampicillin, acyclovir), however the CSF from the OSH
showed WBC=0, cultures negative including negative HSV PCR of
the CSF. His antibiotics were then changed to vancomycin & zosyn
on [**1-20**], with resolution of his leukocytosis and clinical
improvement - his mental status quickly returned to baseline and
his fever resolved after the abx were started. Blood cultures
at OSH grew [**12-19**] + GPC (staph epidermidis). His hypotension
resolved with IVF administration. His EEG showed no signs of
epileptic activity. He was given a full 14 day course of
vancomycin, and a 7 day course of zosyn (both were started on
[**2151-1-20**]). There was no further growth from blood cultures. An IR
guided PICC line was placed for long-term abx given until [**2-2**],
when the PICC was removed. A TTE Echo was done and no valvular
vegetations suggestive of endocarditis were seen (results
above).
# Fever: The patient was febrile on admission but improved
following treatment with antibiotics. Unfortunately, on [**2151-1-31**]
he again begame spiking fevers (day [**10-31**] of vancomycin). He
continued to spike fevers over the next few days. No localizing
symptoms. LFTs were recheked on [**2-1**] and were normal, aside
from an elevated ALT of 48. A CXR (PA & LAT) showed no evidence
of PNA. His blood cx remained NGTD, and were sampled from both
his PICC and his peripheral IV. A UA on [**2-1**] showed moderate
blood, 38 RBCs, trace protein, and no evidence of infection (no
elevated WBC, no bacteria/yeast). This will need to be followed
by his PCP in [**Name9 (PRE) **]. His Ucx was negative. A rectal exam was done
[**2-1**] to r/o prostatitis, and his prostate was not tender on
exam. His previous TTE on [**1-25**] had showed no valvular pathology,
mild symmetric LVH. He was febrile for 24 hours prior to
discharge.
# Aspiration PNA: Patient reportedly had a witnessed aspiration
even during initial incident, and completed 7 days of zosyn and
vancomycin as above. He was breathing comfortably on room air
after extubation. Follow-up CXRs showed no signs of pneumonia.
# RLE Cellulitis/Bacteremia: Blood cultures from [**Hospital 11373**] grew Staph epidermidis; its most likely source was his
RLE cellulitis. His cellulitis continued to improve and he
completed a 14 day course of vancomycin in the hospital, as
insurance would not cover outpatient iv antibiotics.
# Hyperglycemia: During the patient's stay in the ICU, his blood
glucose was very difficult to control, likely due to the
steroids he initially received, his bacteremia, and underlying
insulin resistance. Initially he required up to 18 units/hour
on an insulin drip to maintain his blood sugars. Once his
infection improved, he remained off insulin with well-controlled
blood sugars < 150. Nutrition and social work were consulted to
discuss eating habits in the setting of morbid obesity.
Outpatient f/u was arranged with his PCP in [**Name9 (PRE) **].
# Guaiac positive stools: He had a low Hemotocrit on admission
but this remained stable. He was started on PPI [**Hospital1 **] for 30 days,
as it was felt that he likely had stress gastritis in the
setting of sepsis.
# ARF: Pt had an elevated Cr on admission, likely secondary to
sepsis/pre-renal etiology. This normalized with resolution of
infection.
# Hypertension: After his initial hypotension, he became
hypertensive with SBPs in the 150's-160's. Pt refused starting
HCTZ 25 mg QD, and will instead have his BPs followed by his PCP
in [**Name9 (PRE) **].
# Access: PICC line was placed for 14 day course of iv
antibiotics.
# Lymphadenopathy/splenomegaly: Splenomegaly &
mesenteric/retroperitoneal lymphadenopathy were noted on pt's
initial CT scan. A peripheral blood smear reviewed by
hematopathology showed mature PMNs and normal lymphocytes, with
no immature forms. This finding was not felt to be consistent
with a viral infection. His EBV & CMV serologies were c/w a
prior infection, however his IgM was negative for both & his CMV
VL was negative. Both his HIV antibody/viral load were negative.
Follow-up was arranged for pt to see his PCP and consider
repeat CT in [**2-21**] weeks as an outpatient.
# Transaminitis: CT scan showed fatty liver. Viral hepatitis
serologies were negative. Pt had outpatient f/u arranged for
evaluation of ?NASH with his PCP in [**State 5887**].
# Dispo: Patient completed a 14 day course of iv antibiotics for
coag neg staph bacteremia in the hospital as he did not have
insurance that covered outpatient iv antibiotics. He was
discharged to home in [**State 5887**] with outpatient PCP
[**Last Name (NamePattern4) 702**].
Medications on Admission:
None
Discharge Medications:
1. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (twice a day) for 30 days.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis
coag neg staph bacteremia and sepsis
Secondary
hyperglycemia
Morbid obesity
Discharge Condition:
Stable, ambulating, eating PO
Discharge Instructions:
You were admitted with cellulitis of your leg which caused a
bacterial bloodstream infection with a bacteria called Staph.
You were admitted to the intensive care unit on a ventilator.
You completed a course of antibiotics.
Please call your primary care physician or seek immediate
medical attention if you notice any of the following: loss of
consciousness, loss of bladder/bowel control, dizziness, fever,
nausea, vomiting, chills, chest pain/pressure, palpitations,
confusion, abdominal pain, weakness, or any other concerning
symptoms.
Medication changes:
You completed a 14 day course of vancomycin and a 7 day course
of zosyn antibiotics for the infection. You were started on a
new medication called protonix to help decrease the
inflammation/irritation in your stomach - please take this twice
a day as instructed.
Followup Instructions:
Please be sure to follow-up with your [**State 5887**] primary care
doctor, Dr. [**First Name8 (NamePattern2) 1787**] [**Last Name (NamePattern1) 16008**], on Friday, [**2-5**], at 2:45 pm
(office number [**Telephone/Fax (1) 77721**]). You will need to follow-up the
following problems with her:
------
1. Impaired glucose tolerance
2. Elevated liver function tests and fatty liver seen on CT scan
3. Follow-up outpatient CT scan of abdomen to re-evaluate
lymphadenopathy in [**2-21**] weeks
4. Follow-up on your blood pressure, which was elevated during
your hospitalization (consider starting a medication for this)
5. Guaiac positive stools
6. Hematuria (microscopic amounts of blood in your urine)
|
[
"584.9",
"349.82",
"518.81",
"682.6",
"599.7",
"038.11",
"995.92",
"535.51",
"507.0",
"276.2",
"278.01",
"250.00",
"571.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11522, 11528
|
6300, 6452
|
337, 410
|
11660, 11692
|
3241, 6277
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12565, 13270
|
2603, 2682
|
11314, 11499
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11549, 11639
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11285, 11291
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11716, 12258
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2697, 3222
|
12278, 12542
|
275, 299
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438, 2255
|
6467, 11259
|
2277, 2353
|
2369, 2587
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,631
| 140,516
|
10527
|
Discharge summary
|
report
|
Admission Date: [**2199-9-13**] Discharge Date: [**2199-9-18**]
Date of Birth: [**2141-10-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Right lower lobe lung cancer.
Major Surgical or Invasive Procedure:
Flexible bronchoscopy.
Thoracoscopic right lower lobe wedge resection.
VATS, right lower lobectomy.
Mediastinal lymph node dissection.
History of Present Illness:
Mr. [**Known lastname 4300**] is a 57-year-old gentleman who is referred to me at
the thoracic multidisciplinary clinic by Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 410**] for
evaluation of an incidentally
noted right lower lobe mass. Mr. [**Known lastname 4300**] has a history of
polysubstance abuse and has had multiple admissions for
pancreatitis and trauma. In a preoperative x-ray for ankle
surgery, he was noted to have a nodule back in [**2198-10-12**].
This was followed on a CT of the chest on [**2199-5-6**]. This
showed the right lower lobe had a 2.1 cm suspicious nodule.
There were enlarged lymph nodes in the subcarinal station and
right peribronchial lymph node station. There were also
prominent though non-pathologically enlarged nodes in the right
peribronchial region, left hilus, and left paratracheal
stations. In addition, there was a 5-mm nodule in the right
upper lobe and a 4-mm nodule in the right lower lobe of
indeterminate significance. On [**2199-8-2**] he had a CT of the chest
which showed a right middle lobe mass suspicious for malignancy
that had increased in size. On [**2199-8-21**] he underwent a
flexible bronchoscopy with alveolar lavage of the superior
segment of the right lower lobe, cervical mediastinoscopy which
was negative. He is admitted for a right lower lobectomy.
Past Medical History:
1.Right lower lobe mass
2.ETOH abuse
3.HCV
4.Frequent episodes of pancreatitis related to etoh abuse
5.CAD with [**2195**] MIBI showing mod partially reversible defect in
LAD region
6.Osteoarthritis
7.s/p colectomy for ?SBO/bowel perforation, done at [**Hospital1 112**]
Social History:
He is married lives with his wife and has grown children. He
currently drinks 1-2 beers daily but states he has been drug
free since [**2198-12-12**] after an arrest for possession of
cocaine. He is currently on probation. He is on social
security disability.
Family History:
Dad with ETOH cirrhosis, uncle with Diabetes, Mom with MI at 72.
Physical Exam:
GENERAL: Well-appearing middle-aged African-American man in no
acute distress.
HEENT: No scleral icterus. Oropharynx clear.
LUNGS: Right decreased lungs with faint crackles inferiorly,
Left breath sounds clear
HEART: Regular rate and rhythm, normal S1 and S2, no murmurs,
rubs or gallops appreciated.
ABDOMEN: Soft, nontender, nondistended. No masses or
hepatosplenomegaly appreciated.
Wound: Right incision clean, dry intact, chest tube site clean
EXTREMITIES: warm no edema
Neuro: non-focal
Pertinent Results:
Studies:
CXR:
[**2199-9-17**] Interval removal of two chest tubes with linear lucency
at right base suggestive of a right basilar pneumothorax.
Persistent right lower lung airspace opacification.
Cultures:
[**9-15**] BCx - Pending
[**9-15**] Ucx - Neg
[**2199-9-17**] Chemistry BS: 113 BUN: 25; Cre: 1.2 Na: 138; K+ 4.8;
[**2199-9-17**] CBC: WBC: 7.9, Hct 33/ Hgb: 11.1; Plts 271
Brief Hospital Course:
The patient was admitted to Thoracic Surgery and underwent
successful flexible bronchoscopy, thoracoscopic right lower lobe
wedge resection, and mediastinal lymph node dissection. The
patient tolerated the procedure well and was transferred to the
PACU in stable condition then later to the floor. On POD#2 the
patient spiked a fever to 101.4. A chest x-ray was done. His
urine culture was negative the blood cultures x 2 are still
pending. The patient also had serial chest X-rays showing a RLL
opacity. On POD#4 the patient's chest tubes were removed
without complication. The patients oxygen saturation was 86% on
room air at rest and 83% with activity. On postoperative day 5
he was discharged to home on oxygen 2 liters via nasal cannula
to maintain saturations greater than 90%. He was
hemodynamically stable, tolerating po feeds, pain controlled on
po pain meds, and ambulating well. He will follow-up with Dr.
[**Last Name (STitle) **] as an outpatient.
Medications on Admission:
ASA 325 mg once daily
Atenolol 25 once daily
Lisinopril 10 mg once daily
Omeprazole 40 mg once daily
Sildenafil PRN
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*80 Tablet(s)* Refills:*0*
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
3 days.
Disp:*3 Tablet(s)* Refills:*0*
9. Oxygen @ 2 LPM continuous Via nasal Cannula to maintain Sats
> 90%
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Right lower lobe lung cancer s/p right lobe lobectomy
Hypertension
Alcoholic cardiomyopathy (EF 25-30%),
EtOH abuse
Alcoholic pancreatitis
Hepatitis C
Discharge Condition:
Good
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office if experience any of the
following:
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
-Chest pain
Dressing: remove chest tube dressing on Friday. Cover with a
clean bandaid. Should site start to drain cover with a clean
dressing and change as needed. Keep site clean and dry.
After showering cover chest to site with bandaid.
Monitor incision site for increased warmth or purulent
discharge.
No swimming or bathing for 6 weeks
No driving while taking narcotics.
Take stool softners while taking narcotics. i.e. colace, senna
Resume regular diet.
Continue to walk throughout day.
Continue to use incentive spirometer.
Take lasix 20 mg once daily for 3 days. Eat a banana or drink
[**Location (un) 2452**] juice daily while taking lasix
Oxygen 2 liters to maintain sats: > 90%
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] on [**10-1**] at 1:30 on the
[**Hospital Ward Name 517**], [**Location (un) **] [**Hospital Ward Name 23**] Clinical Center.
Report to the [**Location (un) **] radiology department for a chest x-ray
45 minutes before your schedule appointment.
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
Completed by:[**2199-9-18**]
|
[
"401.9",
"162.8",
"070.54",
"425.5",
"303.91",
"577.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.21",
"32.29",
"40.3",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
5463, 5520
|
3478, 4451
|
353, 490
|
5715, 5722
|
3069, 3455
|
6617, 7020
|
2467, 2534
|
4617, 5440
|
5541, 5694
|
4477, 4594
|
5746, 6594
|
2549, 3050
|
283, 315
|
518, 1872
|
1894, 2167
|
2183, 2451
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,203
| 147,462
|
51477
|
Discharge summary
|
report
|
Admission Date: [**2186-4-5**] [**Year/Month/Day **] Date: [**2186-4-11**]
Date of Birth: [**2126-2-25**] Sex: F
Service: MEDICINE
Allergies:
Urecholine / Iodine; Iodine Containing / Zanaflex / Tigan
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
unresponsive secondary to oversedation from ketamine infusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 60 yo F with a history of chronic pelvic and rectal
pain, s/p multiple pelvic surgeries who was seen in pain clinic
today for her second ketamine infusion for chronic pain. She
received a 57mg IV infusion over a course of 4 hours in a
recliner chair. She reports with limited speech feeling well
until 3 hours into the procedure when she felt a dream like
sensation, then as if she had no control of her body. She could
hear all discussion around her but was unable to move. To the
staff she reportedly became "unresponsive" Vitals were all
stable, with normal O2 sats, RR, BP during the infusion and
thereafter. She was found "slow to emerge" and was sent to the
ED for further evaluation. She states this has occured in the
past after anesthesia for ob/gyn surgery and [**First Name3 (LF) **], with
resolution of sx within several hours. She had no loss of bowel
or bladder function, no chest pain, diaphoresis, sob, fever,
clonic/tonic movements. She took one ambien the night prior.
Denies illicit drug use, alcohol or other meds other than
prescribed medications which include fentanyl and lyrica.
.
In the ED, initial vs were: T 98.9 P 86 BP 160/99 R 15 O2 sat
100% on RA. At that time she was not responding to sternal rub.
Patient was given Narcan x2 with no response. She states she
knew this was given, and felt an overwhelming sense of
agitation, nausea, "inner warmth" but could not relay this to
the staff. Toxicology was consulted, who did not recommend any
intervention. Neurology was also consulted but deferred
evaluation until on the floor.
.
In the MICU, patient is awake and able to nod appropriately to
questions, though with limited speech. She confirms that she has
abdominal pain, though no difficulty breathing or chest pain.
Past Medical History:
1. A rectocele s/p revision in [**9-6**]
2. History of cholelithiasis with cholecystectomy in [**2178**].
3. Cystocele status post repair in [**2182-10-1**] with a
sling.
4. Bladder dysfunction.
5. History of bowel obstruction.
6. History of urinary retention.
7. History of Clostridium difficile associated diarrhea.
8. History of total abdominal hysterectomy, oophorectomy, and
rectocele in [**2179-1-29**].
9. Hypothyroidism.
10. Raynaud's phenomenon.
11. Hypertension.
12. Squamous cell cancer.
13. Esophageal spasm.
14. Lumbosacral plexopathy secondary to positioning during
TAH-BSO.
15. VRE UTI in the past
16. Genitofemoral neuralgia/LE neuropathic pain
17. LE edema
Social History:
Lives at home by herself, does not work due to chronic pain. No
tobacco/EtOH/illicits.
Family History:
Mother died age 82 of ovarian CA, father died 31 with MI
Physical Exam:
Vitals: T: BP:140/81 P:77 R: 16 O2: 97% on RA
General: Alert, no acute distress
HEENT: Sclera anicteric, EOMI, PEERLA, MMM, oropharynx clear.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, tenderness in the lower quadrant, non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Cooperative, follows commands. CN 2-12 intact and
symmetric. Unable to assess strength due to lack of cooperation.
Tone normal. Reflexes 1+ symmetric patellar and brachioradialis.
Patient does not move extremities to command, though witnessed
lifting of right arm to find remote. Toes downgoing bilaterally
Pertinent Results:
[**2186-4-5**] 04:10PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2186-4-5**] 03:50PM GLUCOSE-91 UREA N-26* CREAT-0.9 SODIUM-136
POTASSIUM-4.8 CHLORIDE-103 TOTAL CO2-25 ANION GAP-13
[**2186-4-5**] 03:50PM CALCIUM-9.4 PHOSPHATE-2.9 MAGNESIUM-2.4
[**2186-4-5**] 03:50PM WBC-7.2 RBC-5.10 HGB-15.9 HCT-46.1 MCV-90
MCH-31.1 MCHC-34.4 RDW-12.4
[**2186-4-5**] 03:50PM NEUTS-55.7 LYMPHS-36.6 MONOS-5.8 EOS-1.0
BASOS-0.8
[**2186-4-5**] 03:50PM PLT COUNT-271
[**2186-4-5**] 03:50PM PT-12.7 PTT-25.8 INR(PT)-1.1
[**2186-4-8**] 07:00AM BLOOD WBC-6.3 RBC-4.46 Hgb-13.7 Hct-40.5 MCV-91
MCH-30.8 MCHC-33.9 RDW-12.3 Plt Ct-228
[**2186-4-8**] 07:00AM BLOOD Plt Ct-228
[**2186-4-9**] 07:35AM BLOOD Glucose-84 UreaN-20 Creat-1.0 Na-140
K-4.0 Cl-105 HCO3-27 AnGap-12
[**2186-4-6**] 03:48AM BLOOD ALT-20 AST-26 LD(LDH)-189 AlkPhos-99
TotBili-0.7
[**2186-4-9**] 07:35AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.3
[**2186-4-10**] 12:15AM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.006
[**2186-4-10**] 12:15AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
[**2186-4-10**] 12:15AM URINE Mucous-RARE
UCx: Pending
CT HEAD W/O CONTRAST Study Date of [**2186-4-5**] 4:52 PM:
IMPRESSION: No acute intracranial pathology including no
hemorrhage.
Brief Hospital Course:
60 year-old female with chronic pain admitted with altered
mental status s/p ketamine infusion.
MICU COURSE
===========
# Altered mental status: Secondary to ketamine infusion for pain
control this afternoon. Potential hallucinations,
depersonalization related to ketamine. Patient has had similar
sx in the setting of anesthesia. CT head negative for acute
pathology. CBC, chem 7 within normal limits. Urine and serum tox
negative. Toxicology and neurology consulted in ED who
recommended no further interventions, just close monitoring.
Narcan x2 administered in ED without effect. Patient alert,
awake, though unable to converse. Unclear whether depression,
psychiatric issues at play but concern for this arises. Psych
consulted, wish to start her back on her home medications,
including cymbalta (which they wish to taper off).
# Chronic pelvic and rectal pain: Patient on complicated
outpatient pain regimen. Initially held, pain consult
recommended starting patient on methadone. Floor team to
consider restarting Wellbutrin, Celexa, Nortryptilline, and
Lyrica depending on mental status
# h/o hypothyroidism: Continued outpatient synthroid 125mcg po
daily
# h/o Raynaud's syndrome: Continued ASA 325mg po daily
# h/o HTN: Patient on Amlodipine 5mg po daily. held as BP
normotensive on admission.
MEDICINE COURSE
===============
Patient was transferred to medicine service after brief MICU
stay. Remained of hospital course was as follows.
#. Altered mental status: Resolved prior to transfer from MICU.
Patient alert, oriented, and without confusion. Interactive,
appropriate. Will avoid ketamine in the future.
#. Suicidality: On medicine service, patient denied comments of
harming herself on leaving hospital. She reported she would take
pain medications "until my pain stops." Denied suicidal
ideations. Stated that quality of life was very poor due to
uncontrolled pain. Per psychiatry, patient being titrated off of
duloxetine. Per pain, being uptitrated on nortriptyline. Plan to
is to also add venlafaxine once off of duloxetine. Patient
prefers to be on a combination of citalopram and bupropion - to
be discussed with psychiatry
.
#. Chronic pelvic and rectal pain: Pt was followed by the pain
service. She was continued Lyrica 150mg PO BID. Additionally,
she will be continued on methadone 5mg PO daily, which was down
titrated from [**Hospital1 **] per pain service. The patient should follow-up
as an outpatient at Pain Clinic when discharged.
.
#. UTI: Pt with complaints of dysuria on [**4-9**]. A UA was grossly
positive, but likely contaminated given epi. Will plan to
empirically treat for 3 days given patient is symptomatic.
Continue bactrim DS 1 tab [**Hospital1 **] for 3 days. (last dose is evening
of [**4-12**]). Her urine culutre was still pending and should be
followed up.
.
#. Hypothyroidism: TSH 2.5 this hospital course. Continued
levothyroxine 125mcg PO daily per home regimen
.
#. Raynaud's syndrome: Pt continued ASA 325mg PO daily per home
regimen
Her Amlodipine held given low blood pressure and discontinued
so as to not cause orthostasis.
.
#. Hypertension: Normotensive. Amlodipine discontinued as above.
**FULL CODE, confirmed with health care proxy
**Contact: [**Name (NI) **] [**Name (NI) 88153**] (son, health care proxy), ([**Telephone/Fax (1) 106740**]
Medications on Admission:
1. Lyrica 150 mg po bid
2. Levothyroxine 125 mcg po daily
3. Aspirin 325 mg po daily
4. Fentanyl 25 mcg/hr patch q 72 hours
5. Amlodipine 5 mg po daily
6. Folic Acid 800 mcg po daily
7. Docusate 200 mg po bid
8. Estradiol Climara patch weekly 0.075mg/24 hours
10. Lidocaine patch 5% 700mg patch daily
11. Wellbutrin 300mg po daily
12. Celexa 60mg po daily
13. Nortryptilline
Vitamin E
Omega 3
Lactulose
Miralax
[**Telephone/Fax (1) **] Medications:
1. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Three
(3) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily).
8. Nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 6 doses: last day [**4-12**].
10. Methadone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Month/Year (2) **] Disposition:
Home
[**Month/Year (2) **] Diagnosis:
Change in mental status
[**Month/Year (2) **] Condition:
stable, pt with abdominal pain at baseline, ambulating,
tolerating po
[**Month/Year (2) **] Instructions:
You were admitted for altered mental status. It was likely
secondary to your ketamine. You will be transferred to Psych
Service for further evaluation.
Please follow the medications below.
Please follow-up with the appointments below.
Please call PCP or go to the ED if you have worsening mental
status, confusion, loss of conciousness, fever, chills, nausea,
vomiting, chest pain, or other concerning symptoms.
Followup Instructions:
Please follow-up with your PCP [**Last Name (NamePattern4) **] [**12-2**] weeks.
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 133**]
Provider: [**Name10 (NameIs) 4338**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2186-4-14**] 8:20
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 3688**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2186-4-19**] 2:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2186-4-27**] 10:45
Pt should follow-up with Pain Clinic 1 week after [**Month/Day/Year **]
Completed by:[**2186-4-12**]
|
[
"338.29",
"599.0",
"E938.3",
"780.97",
"569.42",
"E849.8",
"443.0",
"625.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5298, 5429
|
390, 396
|
3939, 5275
|
10614, 11327
|
3005, 3063
|
8647, 10591
|
3078, 3920
|
289, 352
|
424, 2187
|
6780, 8621
|
2209, 2884
|
2900, 2989
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,575
| 194,369
|
2614
|
Discharge summary
|
report
|
Admission Date: [**2159-11-3**] Discharge Date: [**2159-11-18**]
Date of Birth: [**2077-2-25**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
send to Ed py PCP for to work up a HCT of 21.9
Major Surgical or Invasive Procedure:
Colonoscopy
EGD
History of Present Illness:
Mr [**Known lastname 13162**] is a 82 yo M with hx significant for recent MI and GI
bleed [**2-16**] anticoagulation sent in by PCP for HCT of 21 on
routine labs the day of admission. Pt had a STEMI in [**Month (only) 216**] and
is on anticoagulation with plavix and aspirin since then. Past
hospital course complicated by upper GI bleed with EGD showing
gastritis and erosions but no active bleed. Pt denies any
lightheadedness, CP, SOB, black stools, diarrhea, or nausea or
vomiting. No abdominal pain.
ROS: pt complains of leg and calfe pain when walking over one
hour and also complains of toe discoloration
In ED r/p hct of 21.9 showing no change over the past 24hr. IV
access, I unit of RBC
Past Medical History:
- anterior myocardial infarction [**8-21**], proximal LAD occlusion,
cypher stent placed. His stay was complicated by a low
hematocrit subsequent to melanotic stools as well as formation
of a AV fistula in the right external iliac artery s/p
catheterization.
- s/p Left Inginal hernia repair [**2156**]
- Dyslipidemia
- Hypertension
- Gastritis/gastric erosions
Social History:
Social history is significant for the absence of tobacco use.
There is no history of alcohol abuse. Work for Shaws / physical
work. lives with daughter
Family History:
There is no family history of premature coronary artery disease
or sudden death
Physical Exam:
PE: T: 96.6 BP: 120/102 HR: 64 RR: 20 O2Sat: 100%
General: comfortable, pleasant male in NAD
Neck: JVD >15 cm
Lung: CTA bilaterally
Heart: s1, s2, RRR
Abdome: soft, NT, ND, +BS
Extremities: 1+ pitting edema up to the knees, patchy
erythematous and cyanotic discoloration of all toes bilaterally.
TP pulses unable to palpate due to edema but dopplerable
triphasic, DP pulses symmetric, monophasic.
Rectal exam: brown tool, no melena, guaiac positiv
Pertinent Results:
[**2159-11-3**] 11:30AM CK(CPK)-100
[**2159-11-3**] 11:30AM CK-MB-5 cTropnT-0.02*
[**2159-11-3**] 11:30AM WBC-5.2 RBC-2.35* HGB-7.3* HCT-21.9* MCV-93
MCH-31.1 MCHC-33.4 RDW-16.5*
[**2159-11-3**] 11:30AM NEUTS-63.6 LYMPHS-21.9 MONOS-4.8 EOS-9.3*
BASOS-0.4
[**2159-11-3**] 11:30AM PLT COUNT-207
[**2159-11-3**] 11:30AM PT-14.8* PTT-29.9 INR(PT)-1.3*
[**2159-11-2**] 04:25PM FERRITIN-41
[**2159-11-2**] 04:25PM WBC-6.3 RBC-2.36*# HGB-7.3*# HCT-21.9*#
MCV-93 MCH-30.8 MCHC-33.2 RDW-15.7*
[**2159-11-2**] 04:25PM PLT COUNT-206
Brief Hospital Course:
A/P: 82 yo M with significant GI bleed in the past [**2-16**]
anticoagulation for past STEMI. PCP found pt to be anemic and
arranged for admission.
# Blood loss Colon Cancer: This is most consistent with GI
bleed, most likely chronic since past admission as HCT stable
over the past 24 hours, no melena, and pt asymptomatic. Patient
received 2 units of RBC, and IV PPi was initiated. GI was
consulted and pt underwent EGD + colonoscop. Colonoscopy showed
partially obstructing mass consistent with colon cancer. Before
doing to the OR, he was transitioned off plavix with a heparin
drip. The day of surgery, he had some BRBPR and was transfused
an additional one unit of blood. He was taken to the OR by
surgery.
.
# Chronic Systolic CHF: secondary to MI. Stable although signs
of volume overload. since pt is receiveing significant volume
with blood he also received low dose lasix givent his poor renal
function. He tolerated this well. Patient was also hydrated
Pre operatively and did not show any signs of volume overload.
ACE I was held due to patients bump in Cr.
# CAD: s/p stent placement. Patient was initially continued on
all his outpatient medications, including ASA and plavix because
of his recent stent placement. After the colon mass was
discovered, cardiology was consulted regarding his
anticoagulation and surgery. His aspirin was continued. Plavix
was stopped three days prior to surgery and he was started on a
heparin drip during the plavix washout. The drip was stopped
the morning of surgery.
.
# Chronic renal failure: Cr was initially stable, but bumped
during his hospitalization. Lisinopril was stopped the patient
was given fluids to protect his kidneys during the dye load of
CT scan. Cr was back to baseline at the time of surgery.
# Vascular: Patient had symptoms of claudication on admission;
however, vascular studies completed in house do not show any
arterial insufficiency
Medications on Admission:
1. Clopidogrel 75 mg
2. Atorvastatin 80 mg
3. Toprol XL 50 mg
4. Lisinopril 5 mg
5. Aspirin 325 mg
6. Pantoprazole 40 mg [**Hospital1 **]
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Lisinopril 5 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 once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed.
Disp:*30 Tablet(s)* Refills:*0*
8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 doses.
Disp:*1 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Gastrointestinal bleed
Secondary:
Chronic Systolic CHF
Myocardial infarction
Dyslipidemia
Hypertension
Renal failure
Peripheral vascular disease
Discharge Condition:
Good
Discharge Instructions:
Incision Care: Keep clean and dry.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Please call your doctor, call 911 or return to the ER for any of
the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
Followup Instructions:
[**Last Name (un) 6267**] follow up with your primary care [**First Name8 (NamePattern2) **] [**Last Name (Titles) **],[**First Name3 (LF) 132**] C.
Tel: [**Numeric Identifier 13163**] within the next two weeks
.
Please follow up with your cardiologist, [**First Name8 (NamePattern2) **] [**Last Name (Titles) **], [**First Name3 (LF) 487**]
within the next two weeks tel: [**Numeric Identifier 13164**]
.
Please follow up with your surgeon, Dr. [**Last Name (STitle) **] in [**1-16**]
weeks. ([**Telephone/Fax (1) 9011**]
Completed by:[**2159-11-20**]
|
[
"560.9",
"428.22",
"585.9",
"599.0",
"414.01",
"272.4",
"412",
"578.9",
"428.0",
"403.90",
"V45.82",
"280.0",
"153.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.25",
"45.75",
"45.13",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5701, 5707
|
2811, 4738
|
359, 376
|
5905, 5912
|
2247, 2788
|
7264, 7820
|
1675, 1756
|
4926, 5678
|
5728, 5884
|
4764, 4903
|
5936, 5936
|
5952, 7241
|
1771, 2228
|
273, 321
|
404, 1105
|
1127, 1490
|
1506, 1659
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,697
| 129,988
|
6738
|
Discharge summary
|
report
|
Admission Date: [**2179-7-13**] Discharge Date: [**2179-7-13**]
Date of Birth: [**2105-5-17**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Ciprofloxacin / Zosyn / vancomycin
Attending:[**Last Name (un) 2888**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2179-7-13**] cardiac catheterization
[**2179-7-13**] intubation
[**2179-7-13**] Tandem Heart placement
History of Present Illness:
Mr [**Known lastname 25586**] is a 74yo male with history HTN, DMII, CKD on PD,
CAD, ischemic systolic and diastolic CHF (EF 15%), VT s/p ICD
[**8-29**], recently hospitalized for NSTEMI s/p BMS to RCA for 99%
occlusion of old stents([**5-1**]), and history of chest pain not
relieved with recent stenting now presenting with chest pain.
Per patient pain started abruptly at 7pm on the night of
presentation. Pain, described as a pressure, is substernally
located with occassional radiation to bilateral upper
extremities and lower jaw. Denies associated n/v/dyspnea. Pain
is exacerbation when supine; no correlation with exertion. Took
3 SL nitro prior to presentation which helped to alleviate pain.
Overall, pain very similar to pain that promted [**Month/Year (2) 12876**]
in [**Month (only) 116**] when he got the BMS, and also similar to pain that
promted ED presentation on [**2179-6-25**]. Pharmacologic stress test on
[**2179-6-25**] demonstrated severe extensive fixed myocardial perfusion
defect, similar in extent compared to [**2172**], with markedly
increased left ventricular enlargement and decreased LVEF of
15%. Pacermaker was also interrogated yesterday ([**2179-7-12**]) and
found to be functioning normally.
Also of note, has had intermittent othostatic symptoms and low
BPs as an outpatient so has been off and on beta-blockers and
ACE-I since stenting. BP runs in 80-90s systolic.
In arrival to the [**Hospital1 18**] ED, initial vitals were 6 97.8 96 96/55
18 100%. Labs with troponin/CKMB on presentation uptrending
while in ED: Trop 0.27 -> 0.86, CKMB: 7 -> 22, CK 55 -> 207. CT
with contrast without dissection. Bedside US with small
pericardial effusion, EKG: no change, no obvious ischemia, L
bundle branch block. Patient then triggered for hypotension with
systolic nadir in the 60s. A triple lume central line was placed
without complications. Started on levophed 0.09mcg/kg/min.
Decision initially made to forego heparin ggt in the ED but
cardiology fellow was contact[**Name (NI) **] for [**Name (NI) **] ECHO. ECHO showed new
mod-severe mitral regurg and new posterior wall hypokinesis
compared to recent ECHOs. Decision was made to take the patient
straight to cath [**Name (NI) **] for likely RCA stent re-occlusion.
.
.
On arrival to CCU patient was stable but quickly transfered to
cath [**Name (NI) **] for intervention. In cath [**Name (NI) **] occlusion found between
left main and circ and stent was depolyed there, and coded with
PEA shortly thereafter. Concern that either LAD jailed or that
plaque was disrupted into ALD. CPR started and balloon pump
placed. Unable to obtain good cardiac output so tandem heart
placed and pressors started. Further PCI with stent placement in
areas of occlusion. Poor-no circulation somewhere between
10-30min. Discussions were had with family during code to update
them of proceedings. While in [**Name (NI) **] received 3 units of PRBC, 4
amps of bicarb with no change in pH.
.
REVIEW OF SYSTEMS: unable to obtain as patient intubated and
sedated
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +
Hypertension
(also with hypotension issues with baseline BPs low in the
80-90s)
2. CARDIAC HISTORY:
-prior MI in [**2153**]
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS:
-> PTCA of the LAD and RCA,
-> BMS to RCA in [**5-1**] for 99% occlusion of proximal RCA
-PACING/ICD:
-> s/p ICD in [**2175**] for VT
3. OTHER PAST MEDICAL HISTORY:
- Crohns Disease
- Bladder cancer rx s/p TURBT [**2174-1-11**]
- Lung adenocarcinoma T1 N0 s/p R VATS RLL lobectomy [**12-28**] for
3cm lesion. Last Heme/Onc f/u [**8-/2178**] noted to have RUL
ground-glass opacity persisting and growing in size. Was 11 x 20
mm from 11 x 17 mm in [**Month (only) 116**]. Referred to thoracic [**Doctor First Name **] and
underwent cyberknife in 11/[**2177**]. Last f/u with thoracics [**2179-5-20**]
thought that PET with pulmonary mass and the paratracheal
lymphadenopathy could be post radiation and inflammatory in the
setting of fairly recent PNA. Pt too frail to undergo pretty
much any therapy (RT or chemo) even if these areas/masses are
malignant. Plan to bring back in several months with a CT chest
to re-evaluate any progression (if malignant and need to obtain
tissue) or perhaps, regression (if inflammatory).
- CVA [**1-28**] w/ residual L arm paresis, imbalance
- Barrett's esophagus w/ HG dysplasia [**2175-10-11**] >> EUS w/ no CA
- Hip fracture [**2178-10-20**]
.
PSH:
[**2178-8-6**] - Laparoscopic repositioning of peritoneal dialysis cath
[**2176-1-31**] - Right VATS lower lobe superior segmentectomy,
mediastinoscopy
[**2174-12-23**] - Laparoscopic peritoneal dialysis catheter placement
[**2173-11-9**] - Transurethral resection of bladder tumor
[**2169-4-7**] - Bilateral repair of inguinal hernia
Social History:
Pt is a retired church decorator. Lives in [**Location 4310**] with his wife.
[**Name (NI) **] quit smoking in [**2153**], but has ~75 pack-yr history. Rare
Social EtOH. He does not use drugs.
Family History:
-Mother had adult-onset polycystic kidney disease, died at age
78 of intestinal perforation.
- Father died of oral/laryngeal cancer. Paternal cousin and
paternal uncle both died of lung cancer.
- His sister has Breast cancer.
- No family history of early MI, arrhythmia, cardiomyopathies,
or suddencardiac death; otherwise non-contributory
Physical Exam:
PHYSICAL EXAMINATION (post arrest):
GENERAL: Intubated and sedated, unresponsive to sternal rub
HEENT: ET tube in place, pinpoint pupils, sclera anicteric
NECK: supple, unable to assess JVP due to lines and tubes
CARDIAC: Regular rate from tandemheart
LUNGS: difficult to assess posterior, anterior fields with
diffuse rales
ABDOMEN: distened greater than baseline, no HSM, unable to
assess tenderness
EXTREMITIES: cold and clammy, Femoral bruit from tandem, tandem
heart catheters in both groins
NEURO: unresponsive and sedated, no spontaneous movements, some
dysynchrony in breathing with vent
Pertinent Results:
LABS:
On admission:
[**2179-7-13**] 12:15AM BLOOD WBC-6.3 RBC-2.80* Hgb-9.9* Hct-28.0*
MCV-100* MCH-35.5* MCHC-35.4* RDW-14.3 Plt Ct-200
[**2179-7-13**] 12:15AM BLOOD Neuts-74.6* Lymphs-13.5* Monos-5.6
Eos-5.6* Baso-0.7
[**2179-7-13**] 03:56AM BLOOD PT-10.4 PTT-27.5 INR(PT)-1.0
[**2179-7-13**] 12:15AM BLOOD Glucose-286* UreaN-68* Creat-8.7* Na-139
K-4.2 Cl-96 HCO3-27 AnGap-20
[**2179-7-13**] 12:15AM BLOOD ALT-11 AST-18 CK(CPK)-55 AlkPhos-64
TotBili-0.1
[**2179-7-13**] 12:15AM BLOOD Albumin-3.5 Calcium-9.5 Phos-5.4* Mg-2.0
[**2179-7-13**] 12:15AM BLOOD CK-MB-7
[**2179-7-13**] 12:15AM BLOOD cTropnT-0.27*
[**2179-7-13**] 04:22AM BLOOD Lactate-3.2*
[**2179-7-13**] 06:05AM BLOOD CK-MB-22* MB Indx-10.6* cTropnT-0.86*
Post-cardiac arrest:
[**2179-7-13**] 04:00PM BLOOD WBC-9.8# RBC-2.25* Hgb-7.3*# Hct-24.1*
MCV-107*# MCH-32.4* MCHC-30.2*# RDW-15.1 Plt Ct-151
[**2179-7-13**] 04:00PM BLOOD Neuts-87.7* Lymphs-6.3* Monos-4.9 Eos-0.9
Baso-0.2
[**2179-7-13**] 04:17PM BLOOD PT-17.8* PTT-127.2* INR(PT)-1.7*
[**2179-7-13**] 04:17PM BLOOD Glucose-651* UreaN-53* Creat-6.4*#
Na-125* K-4.3 Cl-95* HCO3-16* AnGap-18
[**2179-7-13**] 04:17PM BLOOD ALT-199* AST-296* LD(LDH)-755*
AlkPhos-36* TotBili-0.1
[**2179-7-13**] 02:02PM BLOOD Type-ART FiO2-100 pO2-202* pCO2-52*
pH-6.84* calTCO2-10* Base XS--27 AADO2-450 REQ O2-78
Intubat-INTUBATED
[**2179-7-13**] 02:19PM BLOOD Type-ART FiO2-100 pO2-270* pCO2-40
pH-6.89* calTCO2-8* Base XS--26 AADO2-394 REQ O2-70
Intubat-INTUBATED
MICRO:
[**2179-7-13**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2179-7-13**] BLOOD CULTURE Blood Culture, Routine-PENDING
STUDIES/IMAGING:
[**2179-7-13**] Echo:
The left atrium is mildly dilated. The left ventricular cavity
is moderately dilated. Overall left ventricular systolic
function is severely depressed (LVEF = 20 %) secondary to
akinesis of the inferior free wall, posterior wall, lateral
wall, and apex. The inferior septum is hypokinetic. [Intrinsic
left ventricular systolic function is likely more depressed
given the severity of valvular regurgitation.] The right
ventricular free wall thickness is normal. Right ventricular
chamber size is normal with depressed free wall contractility.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Moderate to severe (3+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Tricuspid regurgitation is present but cannot be
quantified. There is no pericardial effusion. There is an
anterior space which most likely represents a prominent fat pad.
Compared with the prior study (images reviewed) of [**2179-5-7**],
extensive posterior wall and lateral wall akinesis are now
present (contractile function of these walls was relatively
preserved in the prior study), associated with a marked increase
in the mitral regurgitation (previously mild).
[**2179-7-13**] CTA Chest:
IMPRESSION:
1. No evidence of dissection or other acute aortic abnormality.
2. Similar appearance of the dominant spiculated right
suprahilar mass, with interval resolution of the right apical
nodular opacity.
3. Chronic small left pleural effusion with left lower lobe
consolidation
suggestive of "rounded atelectasis."
4. Stable-to-progressive lower lobe peribronchial cuffing,
suggests ongoing inflammatory airways disease.
5. Small perihepatic ascites.
6. Atrophic polycystic kidneys.
7. Tiny perifalciform liver hypodensity, too small to fully
characterize.
8. Hiatal hernia.
[**2179-7-13**] Cath:
COMMENTS:
1. Selective coronary angiography demonstrated two-vessel
coronary
artery disease. The LMCA had a distal 50% stenosis. The LAD
had a 50%
stenosis at the origin and a mid 50% stenosis. The LCx had an
ostial
90% stenosisand a mid 70% stenosis. The RCA had a proximal 60%
stenosis.
2. Resting hemodynamics revealed elevated right and left sided
filling
pressures with a RA mean of 34 mmHg, RVEDP of 33 mmHg and a PCWP
of 28
mmHg. There was pulmonary arterial hypertension with a mean PA
pressure
of 37 mmHg. The pulmonary vascular resistance was 155
dynes-sec/cm2. The
cardiac index was significantly decreased at 1.89 L/min/m2.
There was
systemic arterial hypotension with a central aortic pressure of
90/56
mmHg on levophed.
3.
4. PTCA and stenting of the proximal LCx with overlapping
2.5x12mm and
2.5x8mm BMS.
5. PTCA of the thrombotically occluded distal LCx.
6. PTCA and stenting of the mid and proximal LAD with 2.5x8mm
and
2.5x12mm BMS, respectively.
7. Cardiogenic shock requiring multiple vasopressors and IABP
followed
by exchange for TandemHeart.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Severe right and likely left ventricular diastolic failure.
3. Severe left ventricular systolic failure.
4. PCI of the LCx and LAD with BMS (see Interventional
comments).
5. Cardiogenic shock treated with PCI as he was not an operative
candidate.
6. Successful post-arrest TandemHeart LV support device
placement.
Brief Hospital Course:
Mr [**Name13 (STitle) 25641**] is a 74yo male with history DMII, CKD on PD,
CAD, ischemic systolic/diastolic CHF (EF 15%), VT s/p ICD [**8-29**],
recently hospitalized for NSTEMI s/p BMS to RCA for 99%
occlusion of old stents([**5-1**]), and recurrent lung cancer with
possible metastatic disease who presented with chest pain
concerning for ACS due to new CK, MB, and trop elevations, new
severe MR, and new akinesis of posterior wall and lateral wall
on ECHO
Given concern for ACS and occlusion of recent BMS RCA stent (in
the area of wall akinesis), the patient was started on heparin
and plavix and sent for urgent cardiac catheterization. Cath
showed distal 50% LMCA stenosis with 90% ostial origin LCx and
mid LCx 70% with layering thrombus. Two overlapping BMS were
then placed to the occluded LCx, which "jailed" the LAD but
still showed good flow. He then complained of chest pain,
became hypotensive, and subsequently experienced PEA cardiac
arrest. CPR and epinephrine were given, with initiation of IABP
for hemodynamic support. He was also intubated at this time.
Repeat coronary films showed patent proximal LCx
stents, thrombotic occlusion of the distal LCx and thrombus in
the proximal LAD with slow flow, so these areas were then POBA'd
and stented. When he remained hypotensive despite maximal
pressor support and IABP, the decision was made to place a
TandemHeart. He was then transferred to the CCU. Family was
updated at that time on his poor clinical status, and the
decision was made to continue with full support.
On arrival to the CCU, the patient remained hypotensive despite
LVAD and maximal doses of 4 pressors. His hct had dropped to 14
while in the [**Last Name (LF) **], [**First Name3 (LF) **] he was given 2 units PRBCs and multiple
fluid boluses still without any change in BP. Bleeding was
suspected, either in the retroperitoneum, peritoneal cavity, or
possibly in the chest, however he never became stable enough to
investigate these sources. Neurological status appeared poor,
with fixed and dilated pupils and no withdrawl to pain.
Subsequent labs showed rising lactate, worsening acidosis (only
transient improvements with bicarb boluses), and further
metabolic derrangements. Another meeting was held to update the
patient's family on his status, and a realistic discussion was
had about potential outcomes. The family then decided that
[**Known firstname **] would have preferred to die peacefully at this time, so
he was transitioned to comfort focused care. He was given
morphine to make him comfortably, and his LVAD, pressors, and
ventillator support were stopped. He died comfortably at 20:18
on [**2179-7-13**] with his wife, 3 sons, and other family members at
bedside.
Medications on Admission:
- Aspirin 325 mg Tab, Delayed Release 1 Tablet(s) daily
- Atorvastatin 80 mg Tab 1 Tablet(s) by mouth once a day chol
- Glipizide 10 mg Tab 1 Tablet(s) by mouth twice a day dm
- Humalog 30 units once a day as needed for sq injection into
peritoneal dialysis bag 1 [**12-21**] solution 48 units 2 [**12-21**] solution
- Nephrocaps 1 mg Cap Capsule(s) by mouth
- Calcitriol 0.25 mcg Cap 1 Capsule(s) by mouth three days per
week
- Sevelamer 800 mg Tab 2 Tablet(s) by mouth three times a day
- Esomeprazole 40 mg Cap 1 Capsule(s) by mouth twice a day
- Tessalon Perles 100 mg Cap 1 Capsule(s) by mouth TID PRN
- Vitamin B-12 50 mcg Tab 1 Tablet(s) by mouth once a day
- Vitamin C 500 mg Tab Tablet(s) by mouth once a day
- Vitamin E 400 unit Tab 1 Tablet(s) by mouth once a day
- Colace 100 mg Cap 4 Capsule(s) by mouth once a day
- Folic Acid 400 mcg Tab 1 Tablet(s) by mouth once a day
- Gabapentin 100 mg Cap 1 Capsule(s) by mouth at bedtime
- Finasteride 5 mg Tab 1 Tablet(s) by mouth once a day
- Tamsulosin ER 0.4 mg 24 hr Cap 1 Capsule(s) by mouth once a
day
- Terbinafine 1 % Topical Cream Apply to affected area twice
daily
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary diagnoses:
Acute myocardial infarction
Cardiac arrest
Acute blood loss anemia
Cardiogenic shock
Secondary diagnoses:
End stage renal disease
Diabetes mellitus type II
Lung cancer
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"424.0",
"250.00",
"162.9",
"285.1",
"410.91",
"414.2",
"585.6",
"785.51",
"428.42",
"438.20",
"276.2",
"V10.51",
"530.81",
"403.91",
"459.0",
"V45.02",
"414.01",
"V12.79",
"427.5",
"V45.11",
"414.8",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.41",
"89.64",
"36.06",
"99.20",
"00.48",
"89.68",
"88.56",
"96.71",
"37.61",
"96.04",
"00.66",
"37.62",
"37.21",
"38.93",
"99.60"
] |
icd9pcs
|
[
[
[]
]
] |
15519, 15528
|
11571, 14306
|
318, 426
|
15759, 15768
|
6458, 6465
|
15824, 15834
|
5486, 5827
|
15487, 15496
|
15549, 15654
|
14332, 15464
|
11188, 11548
|
15792, 15801
|
5842, 6439
|
15675, 15738
|
3662, 3870
|
3436, 3487
|
268, 280
|
454, 3417
|
6479, 11171
|
3901, 5260
|
3509, 3642
|
5276, 5470
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,048
| 145,205
|
4993
|
Discharge summary
|
report
|
Admission Date: [**2193-1-31**] Discharge Date: [**2193-2-7**]
Date of Birth: [**2117-8-31**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Fall, unresponsiveness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 75 year old man with hx of Afib on Coumadin,
ESRD on dialysis, HTN, hyperlipidemia who had an unwitnessed
fall
while at home today and transported to [**Hospital3 417**] where he
was intubated for airway protection and found to have large
5X4cm
L ICH with extension into both lateral ventricles and 4th
ventricle. He was transferred here for further evaluation and
care. He was initially seen per NSURG who did not recommend
surgical intervention currently hence neurology was consulted.
Patient is intubated and sedated and unable to give own hx.
Spoke to daughter who is next of [**Doctor First Name **] who reports that she has
not
seen him for a few weeks but is aware that he was told per PCP
(Dr. [**First Name (STitle) **] [**Name (STitle) 9404**]) that he is bound to fall given his overall
weakness from co-morbidities including ESRD for which he is
getting 3x/week dialysis for the past 1.5 years.
There is no report of recent illness or infection but the
details
are unclear. [**Name2 (NI) **] does live alone and independently but
girlfriend lives in an apartment a few units down per daughter.
Patient's INR was 2.5 at OSH hence he received FFP and Vitamin
K.
His INR was 2.3 here on arrival hence he received more FFP,
Vitamin K and Profiline. He remains intubated and sedated with
repeat head CT showing no enlargement of the head bleed.
Past Medical History:
1. Afib on Coumadin
2. ESRD - on dialysis 3x/week
3. CAD
4. HTN
5. Hyperlipidemia
6. hx of EtOH abuse - been sober for several years
7. s/p both knee replacements
8. CHF
Social History:
Lives alone but girlfriend lives nearby. Independently
ambulatory although was told that falls are inevitable per PCP.
[**Name10 (NameIs) **] smoker of 1 PPD since adolescence. Hx of EtOH abuse but
sober for several years. Retired police officer.
Family History:
EtoH abuse
Physical Exam:
BP 164/93 HR 91 RR 20 O2Sat 100% on AC mode FiO2 40%
Gen: Lying in the ED stretcher, intubated and sedated.
HEENT: Hard cervical collar in place with R eye ecchymotic and
small blood.
Ext: No edema
Neurologic examination:
Mental status: Does not respond to verbal or sternal rub.
Cranial Nerves:
Both pupils small (~2mm) but reactive although minimally.
Positive corneals bilaterally but more brisk on L. Flickering
facial movement to nasal tickles but no gag, no OCR and no
blinking to visual threats.
Motor:
No increased tone or asymmetry. Does not withdraw to noxious
stim on both UEs but triple flexes on LEs. Occ myoclonic jerks
of both LEs where he extends his legs and dorsiflexes feet.
Sensation: Intact to nox stim in LEs.
Reflexes:
2s and symmetric on biceps and brachioradialis but none for
patellar given hx of knee replacements bilaterally - has well
healed scars. Toes upgoing bilaterally.
Pertinent Results:
[**2193-2-6**] 03:35AM BLOOD WBC-11.7* RBC-3.59* Hgb-11.1* Hct-33.3*
MCV-93 MCH-30.9 MCHC-33.3 RDW-16.2* Plt Ct-270
[**2193-1-31**] 12:00AM BLOOD WBC-12.1* RBC-3.75* Hgb-11.7* Hct-34.8*
MCV-93 MCH-31.1 MCHC-33.5 RDW-16.6* Plt Ct-210
[**2193-2-3**] 01:29AM BLOOD Neuts-83.1* Lymphs-10.4* Monos-5.3
Eos-1.0 Baso-0.2
[**2193-1-31**] 12:00AM BLOOD Neuts-82.4* Lymphs-10.4* Monos-4.4
Eos-2.4 Baso-0.4
[**2193-2-3**] 01:29AM BLOOD WBC-10.1 RBC-3.59* Hgb-11.2* Hct-33.2*
MCV-93 MCH-31.2 MCHC-33.8 RDW-16.4* Plt Ct-206
[**2193-2-6**] 03:35AM BLOOD PT-14.9* PTT-34.9 INR(PT)-1.3*
[**2193-1-31**] 12:00AM BLOOD PT-20.8* PTT-35.6* INR(PT)-2.0*
[**2193-2-6**] 03:35AM BLOOD Glucose-138* UreaN-102* Creat-7.9*#
Na-137 K-4.8 Cl-96 HCO3-22 AnGap-24*
[**2193-1-31**] 12:00AM BLOOD Glucose-139* UreaN-43* Creat-6.1*# Na-136
K-4.2 Cl-97 HCO3-26 AnGap-17
[**2193-1-31**] 05:53AM BLOOD ALT-14 AST-11 LD(LDH)-223 CK(CPK)-98
AlkPhos-113 TotBili-0.4
[**2193-1-31**] 05:53AM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2193-1-31**] 12:00AM BLOOD cTropnT-0.07*
[**2193-2-6**] 03:35AM BLOOD Calcium-9.4 Phos-5.3* Mg-2.4
[**2193-1-31**] 05:53AM BLOOD Albumin-3.6 Calcium-9.4 Phos-4.4 Mg-2.7*
[**2193-2-6**] 03:35AM BLOOD Vanco-18.4
[**2193-2-4**] 06:09PM BLOOD Vanco-11.3
[**2193-1-31**] 12:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2193-2-5**] 10:59AM BLOOD Type-ART pO2-162* pCO2-31* pH-7.49*
calTCO2-24 Base XS-2
[**2193-1-31**] 12:06AM BLOOD Type-ART Rates-16/23 Tidal V-500 PEEP-5
FiO2-50 pO2-112* pCO2-45 pH-7.41 calTCO2-30 Base XS-3
-ASSIST/CON Intubat-INTUBATED
[**2193-1-31**] 11:45AM BLOOD Lactate-0.7 Na-137 K-3.8
[**2193-1-31**] 12:06AM BLOOD Glucose-132* Lactate-0.8 Na-136 K-4.1
Cl-95*
[**2193-1-31**] 12:06AM BLOOD Hgb-12.0* calcHCT-36 O2 Sat-96 COHgb-3
NCHCT [**2193-1-31**]:
IMPRESSION:
1. Large left intraparenchymal hemorrhage centered about left
thalamus, but
involving left temporal lobe and intraventricular system.
2. Mass effect, 4-mm right shift of midline structures
indicative of
subfalcine herniation, and surrounding edema.
3. No evidence of transtentorial herniation.
NCHCT [**2193-2-4**]:
IMPRESSION: No significant interval change in extensive left
thalamic and
temporal lobe intraparenchymal hemorrhage with associated edema
and mass
effect.
Brief Hospital Course:
75 M w/ hx AF, previously on coumadin and ESRD on HD, presented
with a large Left ICH with intraventricular extension as
outlined in the HPI. Neurosx felt no intervention was necessary.
He remained intubated with little in the way of neuro exam save
initially some movement of all but his RUE to noxious. Over days
he developed a PNA for which he was treated with Abx and he was
ultimately completely non-responsive to noxious stimulation.
After one week in the ICU, his family decided that they did not
want to proceed with trach/PEG, noting that he would never have
wanted to have been kept alive connected to tubes. He was made
CMO on [**2-6**] and expired on [**2-7**].
Medications on Admission:
1. Coumadin
2. Lipitor
3. Phoslo
4. Coreg
5. Nifedipine
6. Lasix
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Intracerebral Hemorrhage
Discharge Condition:
deceased
Discharge Instructions:
none
Followup Instructions:
none
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2193-3-14**]
|
[
"428.0",
"V45.11",
"431",
"285.9",
"427.31",
"790.92",
"585.6",
"305.1",
"780.01",
"E934.2",
"348.30",
"518.81",
"348.5",
"303.93",
"414.01",
"997.31",
"041.09",
"272.4",
"403.91",
"V43.65"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.95",
"96.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
6315, 6324
|
5495, 6170
|
338, 344
|
6392, 6402
|
3186, 5472
|
6455, 6601
|
2225, 2237
|
6286, 6292
|
6345, 6371
|
6196, 6263
|
6426, 6432
|
2252, 2451
|
276, 300
|
372, 1748
|
2550, 3167
|
2490, 2534
|
2475, 2475
|
1770, 1942
|
1958, 2209
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,400
| 111,651
|
368
|
Discharge summary
|
report
|
Admission Date: [**2167-11-5**] Discharge Date: [**2167-11-9**]
Date of Birth: [**2087-3-14**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
urosepsis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
80 Russian female with h/o CAD, AF s/p PPM, HTN, CHF (EF
45-50%), CRI (Cr 1.5), lung CA s/p resection in [**2153**], chronic
pain who presents to the ED with complaints of progressive LE
pain and weakness over the past several days to weeks. She also
c/o incresing DOE at home, now limited to [**1-30**] steps. She has
been sleeping in a recliner recently with her husband helping
her with most ADLs.
.
She also complained difficulty urinating recently, as well as
some constipation. The constipation is not new, and it can be 4
days between bowel movements. The urinary difficulties include
both getting to the bathroom in time (due to pain and DOE), as
well as the sensation that she does not completely void. She has
no dysuria. The swelling in her legs is associated with mild
increase in pain and redness, as well as itching. Her back pain
has been worse.
.
She was recently admitted to [**Hospital1 18**] cardiology service and d/c on
[**2167-10-12**]. She was dx with CHF and her medication regimen was
adjusted.
.
Cardiac ROS: She describes intermittent chest pain with
activity, marked DOE with minimal activity, positive orthopnea
and PND, and has a h/o claudication, though pain is different
now. She would intermittently hold her BP meds (ie metoprolol)
b/c "my blood pressure was too low" - she was getting systolic
BPs in the 70's over the past few weeks.
.
ED COURSE: In ER, she was found to be hypotensive to 70s/40s,
have a positive UA, lactate 2.1, acute renal failure. She was
started on levophed, gentle IVF given CHF, and levo/flagyl.
.
ROS: No HA, visual changes, hearing changes, trouble speaking,
swallowing, numbness/weakness elsewhere, vertigo. No head, neck
or back trauma recently. No F/C/NS, no cough, no sick contacts.
[**Name (NI) **] diarrhea or dysuria.
Past Medical History:
# Atrial fibrillation s/p pacemaker placement [**2167-6-25**], nodal
ablation [**2167-7-1**].
# Hypertension
# Coronary artery disease: status post bypass grafting [**2153**] (Dr.
[**Doctor Last Name **]). Cath [**2154-6-14**] prior to CABG. EF ">40" on [**2157**]
echocardiogram. Sees Dr. [**Last Name (STitle) 3302**] q 6
months.
# Hyperlipidemia
# Peripheral Vascular Disease status post stenting of the SFA
[**11/2165**] and [**12/2165**]- stents in bilateral SFA. (Dr. [**First Name (STitle) **]
# Lung cancer status post left lower lobe lobectomy and right
upper lobectomy. Adenocarinoma (Dr. [**Last Name (STitle) 175**]
# Rheumatoid arthritis- On plaquenil (Dr. [**Last Name (STitle) 3303**])
# Chronic renal insufficiency (baseline Cr 1.4-1.6)
# Lumbar spinal stenosis status post laminectomy, osteoporosis
# Intermittent Ashtmatic bronchitis
# Zoster ophthalmicus-resolved without sequela.
# s/p bilateral cataract surgery,
# left breast biopsy-negative pathology
# pneumococcal vaccine-[**2156-12-8**]
# Thalasemmia Trait
# History of severe epistaxis requiring hospitalization
# Gout
Social History:
Lives with her devoted husband, son lives nearby. No
tobacco-distant smoking past, no alcohol, minimal walking given
right hip and knee pain and spinal stenosis.
Family History:
NC
Physical Exam:
VS- 96.3 122/76 (on levophed) 75 (paced) 18 94% 2Lnc
GEN- Elderly, ill-appearing female lying in bed in NAD
HEENT- MMdry, anicteric, full dentures, NCAT
NECK- supple, though limited ROM due to CVL in R jugular vein;
no LAD, JVP flat
CV- RRR, II/VI SEM at LLSB, nl S1S2
CHEST- Relatively clear to auscultation anteriorlly
ABD- obese, soft, NT, ND, pos BS, no HSM
EXT- 3+ pitting edema with weeping of skin, mild erythema L>R
without warmth, no clubbing or cyanosis
NEURO- AAOx3, speaking fluently without difficulty, CN intact,
strength in UE [**5-1**] and equal; strength in LE [**4-1**] bilaterally (?
due to pain or massive swelling). Unable to get reflexes in LE.
Normal sensory exam to light touch throughout. Gait not
assessed.
SKIN- Weeping venous stasis changes of LEs.
MSK- Limited ROM at neck
Pertinent Results:
.
ECG: Paced at 75 without obvious change from prior.
.
STUDIES:
.
*CXR [**2167-11-5**]: The central venous line on the right crosses the
midline and presumably terminates within the left
brachiocephalic vein. The cardiac and mediastinal contours are
stable. Marked elevation of the left hemidiaphragm with
underlying bowel-containing air is again seen. There is adjacent
compressive atelectasis at the left lung base. The right lung
appears grossly clear. No evidence of pneumothorax. IMPRESSION:
Suboptimal position of the central venous line crossing the
midline and terminating presumably in the left brachiocephalic
vein.
.
*PMIBI [**2167-10-12**]: Moderate, predominantly fixed basilar inferior
wall perfusion defect. In comparison to the report from the
prior study, there has been no interval change. LVEF=49%.
.
*TTE [**2167-10-8**]: The left atrium is moderately dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function cannot be reliably assessed, but appears to be at least
mildly reduced, with inferior-posterior hypokinesis. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
([**12-29**]+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2167-7-1**], no major change is evident, but the technically
suboptimal nature of the present study precludes definitive
comparison.
.
*Renal US [**2167-3-16**]: No hydronephrosis, could not tolerate study
to eval renal arteries.
.
*Arterial study [**2167-1-30**]: 1. Heterogeneous bilateral ICA calcific
plaque, however, no associated ICA or CCA stenosis (graded as
less than 40% ICA stenosis bilaterally). 2. Lower extremity
arterial hemodynamics unchanged compared to the [**2-1**], i.e.,
minimal right-sided tibial disease, left-sided aortoiliac
disease.
.
[**2167-11-8**] 03:47AM BLOOD Glucose-56* UreaN-135* Creat-4.2* Na-137
K-5.4* Cl-93* HCO3-27 AnGap-22*
[**2167-11-8**] 03:47AM BLOOD WBC-14.2* RBC-4.12* Hgb-8.9* Hct-28.7*
MCV-70* MCH-21.5* MCHC-30.9* RDW-19.5* Plt Ct-301
[**2167-11-8**] 03:47AM BLOOD PT-72.7* PTT-51.6* INR(PT)-9.4*
[**2167-11-8**] 03:47AM BLOOD ALT-40 AST-77* LD(LDH)-460* AlkPhos-156*
TotBili-1.0
Brief Hospital Course:
Patient presented after a progressive decline in health over the
past few months. She presented with complaints of weakness and
hypotension and most likely cause was infection (UTI/urosepsis
and cellulitis given leg findings.) Initially, CVL placed in ED
and CVP >20 in ED. Fluids and levophed used to improve BP with
minimal effect. Her infections were initially covered by vanco,
levo, flagyl to broaden GP as well as possible MRSA from recent
hospitalizations. Then, this was changed to vancomycin and
cefepime. Urine cultures grew enterococus and e.coli. However,
during the course of treatment, patient developed acute renal
failure/oliguria, worsening CHF, and persistent hypotension.
Likely multifactorial on top of chronic renal insuffiency. She
has had poor PO intake, as well as episodes of hypotension over
the past few weeks. She was given fluid boluses with minimal
effect and decreased urine output ultimately to 5cc/hr.
Furthermore, her INR rose steadily and was felt also to be
multifactorial from poor PO intake, worsening liver synthetic
capabilities.
.
Her Primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3306**], saw the patient and
her husband. Ultimately, it was decided to make her comfort
measures only as she was rapidly developing multi-organ failure
resistant to treatment. Her husband and family were at bedside
when she passed away at 3:15 AM [**2167-11-9**].
Medications on Admission:
Atorvastatin 10 mg
Metoprolol Tartrate 25 mg [**Hospital1 **]
Isosorbide Mononitrate 30 mg
Furosemide 80 mg qpm
Furosemide 1000 mg qqm
Docusate Sodium 100 mg [**Hospital1 **]
Warfarin 2 mg qhs
Pantoprazole 40 mg
Aspirin 81 mg
Camphor-Menthol 0.5-0.5 % Lotion prn itching
Oxygen-Air Delivery Systems
Plaquenil 200 mg [**Hospital1 **]
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient passed away on [**2167-11-9**] at 3:15 AM from urosepsis,
cardiac arrest, acute renal failure and CHF
Discharge Condition:
deceased
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"V10.11",
"599.0",
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icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
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8622, 8631
|
6817, 8238
|
332, 338
|
8784, 8931
|
4314, 6794
|
3472, 3476
|
8652, 8763
|
8264, 8599
|
3491, 4295
|
283, 294
|
366, 2155
|
2177, 3276
|
3292, 3456
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,766
| 108,626
|
16404
|
Discharge summary
|
report
|
Admission Date: [**2151-12-25**] Discharge Date: [**2152-1-19**]
Date of Birth: [**2123-4-10**] Sex: M
Service: Orthopaedic Surgery
HISTORY OF PRESENT ILLNESS: This is a 25-year-old gentleman
was involved in a high-speed motor vehicle collision on
[**2151-12-25**], complicated by loss of consciousness at the
scene.
HOSPITAL COURSE: The patient was transported intubated to
the [**Hospital1 69**] where he was worked
up and resuscitated by the Trauma Surgery Service. The
Orthopaedic Service was consulted regarding the patient's
clear bilateral ankle deformity as well as right arm
ecchymosis. Roentgenographic examination of these areas
revealed a left talus fracture, a left tibial plafond and
lateral malleolus fracture, a right distal tibia/fibula
fracture, and a right scapular fracture.
A computed tomography scan of the pelvis also revealed
bilateral superior and inferior pubic rami fractures as well
as bilateral anterior wall acetabular fractures. The initial
[**Location (un) 1131**] of the pelvic computed tomography was that the
sacroiliac joints were intact bilaterally.
A computed tomography scan of the left ankle was obtained
which showed a severely comminuted fracture of the talus as
well as a fracture of the calcaneous.
On [**2151-12-26**] the patient continued to be vigorously
fluid resuscitated, and other airway management procedures
were performed. Upon discussion with the Orthopaedic
attending, the patient was made nonweightbearing on his
bilateral lower extremities, and on hospital day three, the
patient was taken to the operating room for external fixation
of his bilateral lower extremity fractures.
Following this procedure, the patient continued his stay in
the Surgical Intensive Care Unit secondary to other medical
issues including a workup for a small left frontal
intraparenchymal contusion; for which Neurosurgery was
consulted, as well as assessment and treatment of a deep
peroneal wound sustained during the patient's motor vehicle
collision.
As the patient's condition stabilized, he was transferred to
the floor; where, on [**2152-1-2**], a significant amount
of bilateral erythema was noted around the sites of the
external fixators on the patient's bilateral lower
extremities, and a small amount fluid collection was palpated
on the patient's left ankle. To follow up on these findings,
a computed tomography of the patient's left foot was obtained
which showed a 1-cm stable left ankle fluid collection that
was unchanged from the prior computed tomography obtained
during the patient's initial trauma workup.
For treatment of the patient's lower extremity pin site
erythema, the patient was placed on vancomycin and Zosyn.
The Zosyn was discontinued on [**2152-1-3**]; however, the
vancomycin was continued. On this antibiotic regimen, the
patient's physical examination steadily improved. As the
patient remained nonweightbearing on his bilateral lower
extremities, the patient was placed on Lovenox for deep
venous thrombosis prophylaxis.
On [**2152-1-5**], the patient underwent a bedside Speech
and Swallow evaluation in light of the patient's relatively
long period of intubation, his altered mental status due to
presumed axial injury. So, there were no observed episodes
of overt aspiration. Pursuant to this consultation, the
patient was placed on a diet of honey-thickened liquids and
soft solids; as no clear signs of aspiration were appreciated
by the Speech and Swallow Service.
On [**2152-1-5**], the patient underwent a Physical Therapy
evaluation. As part of this evaluation, Physical Therapy
deferred on assessing the patient's discharge potential as
that service wished to await optimization of the patient's
neurologic abilities prior to discharge decision making.
In order to more fully assess the patient's mental status,
oral sedation medications were minimized. Over the next
three to four days, the patient's mental status improved
appreciably.
On [**2152-1-10**] (which was hospital day seventeen for
this patient), Dr. [**First Name (STitle) 4304**] [**Name (STitle) 284**] was asked to evaluate this
patient in light of the patient's complicated bilateral ankle
injury.
On [**2152-1-13**]; pursuant to this consultation, the
patient was taken to the operating room for removal of the
bilateral external fixators, a left talar fracture
dislocation open reduction/internal fixation, and a right
pilon fracture open reduction/internal fixation. Estimated
blood loss was for this procedure was 50 cc, and this
procedure was performed by Dr. [**Last Name (STitle) 284**] with no
complications.
The patient tolerated the procedure well and was transferred
to the Postanesthesia Care Unit where the patient was again
placed on Lovenox for prophylactic anticoagulation. The
patient was maintained nonweightbearing on his bilateral
lower extremities, and the postoperative neurologic
examination was reassuring.
Notably, the patient remained in an external fixator on the
left side while a clam shell brace was fitted to the patient
for his right ankle.
On [**2152-1-17**]; after being fully assessed by Physical
Therapy, and with reassuring wound appearance, and pin site
appearance on examination, the patient was considered to be
in stable condition for discharge to a rehabilitation center.
DISCHARGE INSTRUCTIONS/FOLLOWUP: (His discharge instructions
included)
1. Follow up at the Orthopaedic Trauma Clinic (telephone
number [**Telephone/Fax (1) 5499**]).
2. Wound care; including dry sterile dressings to the right
ankle to be changed once per day.
DISCHARGE DISPOSITION: As the patient's family was eager to
take care of the patient at home instead of sending the
patient to a rehabilitation center, the patient was assessed
to be safe to return home to the care of his family; and this
discharge was affected on [**2152-1-19**].
CONDITION AT DISCHARGE: The patient's condition at the time
of discharge was fair.
DISCHARGE DISPOSITION: Discharge was approved.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) 46661**]
MEDQUIST36
D: [**2152-1-19**] 08:28
T: [**2152-1-19**] 08:37
JOB#: [**Job Number 46662**]
|
[
"824.0",
"860.2",
"707.0",
"877.0",
"851.44",
"304.20",
"E812.0",
"825.21",
"808.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.22",
"38.93",
"79.17",
"34.04",
"96.72",
"78.18",
"79.37",
"96.6",
"78.68",
"48.23",
"79.36"
] |
icd9pcs
|
[
[
[]
]
] |
5972, 6253
|
354, 5314
|
5348, 5578
|
5887, 5947
|
178, 336
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
249
| 158,975
|
48760
|
Discharge summary
|
report
|
Admission Date: [**2156-4-27**] Discharge Date: [**2156-5-14**]
Date of Birth: [**2075-3-13**] Sex: F
Service: SURGERY
Allergies:
Altace / Bactrim / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
Occult positive stools, h/o stroke while off of anticoagulation
for GIB.
Major Surgical or Invasive Procedure:
Laparoscopy and open right ileocolectomy, [**2156-4-30**]
History of Present Illness:
81 yo F with pmh of CVA, stage III CKD, CAD s/p LIMA to LAD,
Afib on dabigatran who presents for a colonoscopy planned for
guiaic positive stools and a recent admission for GIB. The
patient denies any current complaints and has not noted any
recent bloody stools. She does complain of some right upper
quadrant "heaviness" that does not radiate. It is [**4-25**] in
intensity. Denies any relieving or exacerbating factors. She
notices it most at night time when she is trying to fall asleep.
She denies any change with diet. She denies any n/v, diarrhea,
constipation. She otherwise feels at her baseline with respect
to her health.
.
Review of Systems: Pain assessment on arrival to the floor: 0/10
(no pain). No recent illnesses. No fevers, chills, or night
sweats. Appetite is good and weight is stable. No SOB, new
cough. She has chronic angina that typically occurs when she
wakes up or sometimes at night time after a busy day, relieved
with 1 SLNG, this is stable but frequent (sometimes takes SLNG
daily). No PND or orthopnea. No urinary symptoms. No LE edema.
No skin changes. No arthralgias or joint swelling. Other systems
reviewed in detail and all otherwise negative.
Past Medical History:
- Coronary artery disease, s/p 3V CABG EF 50%
- Left subclavian stent [**51**]/[**2146**].
- Atrial fibrillation.
- Hypertension.
- Hyperlipidemia.
- COPD (FEV1/FVC 53, FEV1 0.63)
- GERD
- Anemia.
- Hypothyroidism
- Stage III CKD
- CVA
- fractured pelvis in fall several months ago
Social History:
She lives alone. She has extensive support from her daughters.
She denies tobacco, ETOH, or drugs
Family History:
Mother with myocardial infarction in her 60s. No diabetes
mellitus. Grandfather with chronic obstructive pulmonary
disease.
Physical Exam:
Vital Signs:
T 97.9 BP 101/66 P 77 RR 18 SpO2 100% on 2L
Physical examination:
- Gen: Well-appearing in NAD.
- HEENT: Conj/sclera/lids normal, left surgical pupil, right
pupil reactive. EOM full, and no nystagmus. Oropharynx clear
w/out lesions.
- Neck: Supple with no thyromegaly or lymphadenopathy.
- Chest: Normal respirations and breathing comfortably on room
air. Lungs clear to auscultation bilaterally.
- CV: Irregularly irregular. Normal S1, S2. II/VI systolic
murmur at left sternal border. JVP <5 cm.
- Abdomen: Normal bowel sounds. Soft, nontender, nondistended.
Liver not enlarged. Neg [**Doctor Last Name 515**] sign.
- Extremities: No ankle edema.
- Skin: No lesions, bruises, rashes with exception of stasis
dermatitis bilateral shins
- Neuro: Alert, oriented x3. Good fund of knowledge. Able to
discuss current events and memory is intact. CN 2-12 intact.
Speech and language are normal. No involuntary movements or
muscle atrophy. Normal tone in all extremities. Motor [**5-20**] in
upper and lower extremities bilaterally. Sensation to light
touch intact in upper and lower extremities bilaterally.
- Psych: Appearance, behavior, and affect all normal. No
suicidal or homicidal ideations.
Pertinent Results:
[**2156-4-27**] 04:40PM WBC-8.3 RBC-3.44* HGB-9.5* HCT-29.5* MCV-86
MCH-27.5 MCHC-32.1 RDW-16.5*
[**2156-4-27**] 04:40PM NEUTS-74.6* LYMPHS-13.7* MONOS-8.9 EOS-2.4
BASOS-0.4
[**2156-4-27**] 04:40PM PT-20.0* PTT-47.3* INR(PT)-1.8*
[**2156-4-27**] 04:40PM GLUCOSE-72 UREA N-27* CREAT-1.4* SODIUM-134
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-27 ANION GAP-12
[**2156-4-27**] 04:40PM CALCIUM-9.5 PHOSPHATE-3.8 MAGNESIUM-1.7
.
EKG - AFib, LAD, unchanged c/w prior with exception that TW is
upright in I instead of inverted. No acute ST/TW changes.
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the medical service and started on
a colonoscopy preparation, her pradexa was held and she was
started on a heparin drip. She was taken to the GI suite on
[**2156-4-28**] for endoscopy which showed an "ulcerated mass with
necrotic base highly suggestive of carcinoma" in the cecum. She
had a CT scan of the chest/abdomen/pelvis to assess for
metastasis and further define the tumor. It confirmed
colonoscopy findings and did not show evidence of metastasis.
She was taken to the operating room for a right colectomy with
Dr. [**Last Name (STitle) 1120**] of colorectal surgery on [**2156-4-30**]. There was 500 cc of
estimated blood loss.Please refer to Dr.[**Name (NI) 3377**] operative note
for further details. She was started on cipro/flagyl
prophylactically after the procedure. After a brief stay in the
PACU she was transferred to the floor but over the course of the
night had low urine output, her blood pressure dropped to the
systolic 80s/40s and her atrial fibrillation frequently took her
heart rate to the 120s-130s. She was transferred to the ICU
given her extensive cardiac history and unclear etiology of her
hypotension -- cardiogenic vs. septic. She was continued on
antibiotic coverage and the plan was for volume resuscitation
with close monitoring of other aspects of her clinical picture.
She was asymptomatic and felt well throughout the process,
though somewhat tired.
She was transfused one unit of PRBCs, volume resuscitated with
crystalloid and albumin and eventually her systolic pressures
returned to the 90s-100s systolic. She was deemed stable for
transfer to the floor. On POD 5 she reported passing flatus,
she was advanced in diet progressive to a low-residue regular
diet on POD 8.
Remaining aspects of her hospitalization, by systems:
Neuro: No issues. Pain controlled on a regimen of IV and PO
medications when tolerating. Mental status appropriate
throughout hospitalization.
Cardiac: Multiple cardiac issues assessed by cardiology service
preoperatively and which recommended continuing current care.
Multiple episodes of anginal chest pain relieved with sublingual
nitroglycerin. No EKG changes until POD 7 when chest pain was
accompanied by questionable ischemic changes on EKG. Cardiology
recommended nitroglycerin PRN as well as cycling enzymes which
returned at 0.05->0.05->0.04. Her afib was monitored on
telemetry and she was treated with 5 mg IV lopressor q6 hours
when NPO and transitioned to 25 mg PO BID.
Respiratory: Baseline used oxygen at home was kept on 2L oxygen
in the hospital and maintained good saturations in the high 90
percents. She did have some respiratory difficulty and
increased oxygen requirement while in the ICU but this resolved
after effective diuresis. At time of discharge satting 90s on
room air.
Heme: Once the patient's hematocrit was stable, a heparin drip
was started to bridge her to coumadin therapy. However, patient
developed melenic stools and hematuria when heparin drip
restarted. All anticoagulation except aspirin was held and no
further episodes of bleeding occured. Patient's coumadin will
need to be restarted when her nutritional status is more
improved.
ID: Cipro/Flagyl initially post-operatively and dc'd on POD 7.
Afebrile throughout course. Complained of vaginal itching, given
single dose of oral diflucan.
[**Name (NI) 153**] Course
Pt was transferred to the [**Hospital Unit Name 153**] on [**5-1**] for management of
hypotension and low urine output in setting of recent colectomy.
.
# Hypotension: Noted to be progressively hypotensive through
today (POD1) with concern for hypovolemia however could also be
related to evolving sepsis picture she is currently on
cipro/flagyl since last night. Given extensive cards history
could also be cardiogenic shock related to missed event given
her 500cc blood loss intraoperatively and prior hx of ischemic
event in setting of blood loss in 01/[**2155**]. Lower concern for
this given current clinical and exam status. Given hx of
recurrent UTIs (on home macrobid suppressive tx) could also be
related to urosepsis. Currently mentating at baseline. Plan to
volume resuscitate until increase in O2 requirement. She
received 1u pRBC on arrival to floor with 500cc LR IVF boluses x
2. Her BP improved to 90-110 wo pressors. She did not require a
CVL and declined this on her ICU consent form as well. NICOM was
placed which showed 33% change in CI, indicating likely fluid
responsiveness. Her UO improved to 20cc/hr but remained there
with crystalloid boluses. Per surgery recs, she was changed to
albumin 5% IVF hydration. She was given lasix for volume
overload XXXX.
She was broadened to vancomycin, zosyn and ciprofloxacin for
double GNR coverage overnight given higher likelihood of GI
etiology related to recent surgery and instrumentation. Given
her remarkable hemodynamic improvement overnight she was changed
back to cipro/flagyl. She was recultured for urine and blood.
Her EKG was checked and at baseline. Cardiac enzymes were cycled
and mildly elevated trop attributed to underlying CKD and
possible demand ischemia [**2-18**] tachycardia on presentation.
.
# CAD: Extensive cardiac hx including recent NSTEMI [**1-/2156**] in
setting of GIB and CVA at same time. Has been on home
dabigatran. Follows as outpt w Dr. [**Last Name (STitle) 120**]. Increasing NSL use
for her anginal equivalent altho per cards notes, outpt cards is
not concerned for ischemic etiology. Last TTE 8/[**2156**]. She was
continued on Heparin SQ, 81mg asa and pneumoboots. Her
transfusion goals were for Hct<30 per cardiology recs
pre-operatively. EKG in the ICU was rechecked and at baseline.
Cardiac enzymes were cycled (see above).
.
# Afib: On dabigatran at home for other comorbidities, CHADS2
score is 6. Currently in afib. Her home betablocker was held for
hemodynamic monitoring. She was noted to be in 100-130s afib
with mild SOB but otherwise comfortable. Her betablocker was
restarted on [**5-2**] and XXXX.
.
# CHF: Systolic EF 35% on TTE [**8-/2155**] and global LV hypokinesis.
Cards consulted pre-op w recommendation to gently diurese for
vol overload on presentation - last given 20mg IV lasix [**4-29**].
Pleural effusion on AM chest xray and crackles on exam on
transfer to the ICU. Home diuretic was held on admission to the
ICU for BP stabilization and restarted XXX.
.
# Cecal Mass: necrotic appearance on colonoscopy concerning for
malignancy. S/p colectomy [**4-30**]. Pathology is pending.
.
# CKD: unclear baseline but likely 0.9-1.1. On outpt procrit.
Creatinine elevated on admission. FENA this AM 1%, concern for
possible ATN related to hypovolemia. Repeat urine lytes notable
for FeNA = 0.1% indicating prerenal hypovolemic picture. Urine
output was monitored and responded to IVF boluses w increase to
20cc/hour.
.
# COPD/ASthma: On home O2 via nasal cannula at baseline. Unclear
pulmonary disease hx. She was continued on home dose
fluticasone, and spiriva. Albuterol held for tachycardia and
restarted on XXX.
.
# HTN: on home ace, and bblocker. Holding now for hemodynamic
monitoring.
.
# HL: cont home lipitor
.
# Hypothyroidism: continued on home dose levothyroxine
.
# DM: on home glipizide. Holding oral meds, cont ISS.
.
FEN: IVF to MAP>60, replete electrolytes, NPO for now
Prophylaxis: Subcutaneous heparin, pantoprazole IV q24
Access: peripherals
Code: DNR, ok to intubate, no CVL
Communication: Patient, HCP [**Name (NI) 16883**] [**Name (NI) **] [**Telephone/Fax (1) 102489**]
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA four times daily PRN
ASPIRIN - 81MG Tablet - ONE EVERY DAY
Pradexa 75 mg [**Hospital1 **]
FLUTICASONE [FLOVENT HFA] - 220 mcg Aerosol twice daily
GLIPIZIDE - 1.25 mg Tablet daily
LEVOXYL - 75MCG Tablet - ONE EVERY DAY; 150 mcg on Sunday
LIPITOR - 40MG Tablet - ONE EVERY DAY
LISINOPRIL - 2.5 mg Tablet - 1 Tablet(s) by mouth daily
NITROFURANTOIN [MACROBID] - 50 mg nightly
PROTONIX - 40MG Tablet, Delayed Release (E.C.) - ONE EVERY DAY
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg daily
TOPROL XL - 25 mg daily
OTC:
CALCIUM CARBONATE-VITAMIN D3 600 mg-400 unit Tablet - twice a
day
COENZYME Q10 - 100 mg Capsule by mouth daily
MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - 1 Tablet(s) by
mouth daily
Discharge Medications:
1. levothyroxine 75 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
2. fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
4. guaifenesin 100 mg/5 mL Syrup [**Hospital1 **]: Ten (10) ML PO BID (2
times a day).
5. atorvastatin 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
6. hydromorphone 2 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
7. docusate sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day): hold for loose stool.
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
10. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette [**Hospital1 **]: [**1-18**]
Drops Ophthalmic PRN (as needed) as needed for dryness.
11. ipratropium bromide 0.02 % Solution [**Month/Day (2) **]: One (1) neb
Inhalation Q6H (every 6 hours).
12. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization [**Month/Day (2) **]:
One (1) neb Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
13. nitroglycerin 0.3 mg Tablet, Sublingual [**Month/Day (2) **]: One (1) Tablet,
Sublingual Sublingual PRN as needed for chest pain.
14. metoclopramide 10 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO every
eight (8) hours for 3 doses: For three doses only once patient
is at rehab. Afterwards, this medication should be
discontinued.
Disp:*3 Tablet(s)* Refills:*0*
15. Blood Draw [**Month/Day (2) **]: One (1) blood draw once, [**2156-5-10**]: Please
check INR value for coumadin dosing.
Disp:*1 blood draw* Refills:*0*
16. metoprolol tartrate 25 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO
twice a day.
17. fluticasone 110 mcg/Actuation Aerosol [**Month/Day/Year **]: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
18. pramoxine-mineral oil-zinc 1-12.5 % Ointment [**Hospital1 **]: One (1)
Appl Rectal [**Hospital1 **] (2 times a day) as needed for anal itching.
19. camphor-menthol 0.5-0.5 % Lotion [**Hospital1 **]: One (1) Appl Topical
TID (3 times a day) as needed for puritis r/t dry skin on back.
20. insulin lispro 100 unit/mL Solution [**Hospital1 **]: One (1)
Subcutaneous ASDIR (AS DIRECTED).
21. lisinopril 5 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
Renaisance gardens
Discharge Diagnosis:
cecal adenocarcinoma
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 of a bleed from your
gastrointestinal tract. It was discovered that you had a
colonic mass upon further investigation and you then had a
surgical procedure called a right colectomy.
Regarding your anticoagulation, you have been very mal nourished
and when our surgical team attempted to anticoagulate you you
developed further GI bleeding and some blood in your urine. Your
anticoagulation has been on hold for the time being. The
rehabilitation facility should restart this anticoagulation at a
time they see as appropriate when you nutrtional status has
improved some.
In the coming days as you continue to recover, please keep in
mind the following:
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-25**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
While taking narcotic pain medication, please emember to take
colace (to avoid constipation) and please do not drive or
operate heavy machinery.
Please follow-up with your primary care physician (in addition
to your surgeon) in the coming weeks to reconcile all of your
medications and to touch base regarding other medical issues or
concerns after the surgery.
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.
Please call your doctor 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.
Followup Instructions:
Patient needs to have her INR checked on Monday, [**2156-5-10**], and
have her coumadin dosing readjusted per results. Primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3315**] at [**Location (un) **], [**Apartment Address(1) 8308**], [**Location (un) **],[**Numeric Identifier 1700**] and phone [**Telephone/Fax (1) 37171**] to arrange for appointment
on Monday.
Please follow-up with Dr. [**Last Name (STitle) **] in [**1-18**] weeks. Call ([**Telephone/Fax (1) 6316**] to schedule the appointment. Please call on Monday,
[**5-10**].
Completed by:[**2156-5-14**]
|
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icd9cm
|
[
[
[]
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[
"45.93",
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icd9pcs
|
[
[
[]
]
] |
14969, 15014
|
4041, 11566
|
382, 442
|
15079, 15079
|
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2318, 3450
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1132, 1662
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470, 1113
|
15094, 15206
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1684, 1967
|
1983, 2083
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,186
| 164,063
|
20492+57168
|
Discharge summary
|
report+addendum
|
Admission Date: [**2120-9-10**] Discharge Date: [**2120-10-1**]
Date of Birth: [**2070-3-5**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1032**]
Chief Complaint:
Headache, fever, worsening gait x 1 d
Major Surgical or Invasive Procedure:
Fluoroscopy-guided lumbar puncture
History of Present Illness:
Mrs [**Last Name (STitle) 54844**] is a 50 y/o right handed woman with h/o
encephalitis
of unknown etiology (currently on empiric anti-Tb therapy) who
presents with headache, fever, and worsening gait x 1 d. She is
a
patient well-known to the Neurology service, and is followed by
Drs [**Last Name (STitle) 1968**] and [**Name5 (PTitle) 1206**]. Pt reports gradual development of dull,
bifrontal headache yesterday. She took Tylenol which made
headache better, but it later returned. She stated headache was
better sitting up and worse lying down. She also had associated
photophobia and worsening of baseline blurry vision. She said
vision was blurry in all directions and specifically denied
seeing double. She also described falling more to the L and
overall unsteadiness, which she attributed to blurry vision. She
felt nauseous and vomited x 2. Pt also endorsed feeling more
sleepy than usual. She took a temperature at home which was
100.5. She denied any sick contacts. As a result of these
symptoms, she decided to come to the ER.
Of note, pt was recently admitted from [**2120-7-5**] - [**2120-7-24**] for
encephalitis of unknown etiology. She initially presented with
fever, altered mental status, headache, and nystagmus. LP showed
a marked neutrophil-predominant leukocytosis. MRI showed FLAIR
hyperintensity and contrast enhancement in the R thalamus,
midbrain, corpus callosum splenium, temporal lobe, and
cerebellum
as well as leptomeningeal enhancement. Extensive neurologic and
infectious work-up was negative aside from a mildly elevated
adenosine deaminase level. Given borderline positive PPD and
known exposure to Tb in her native country of [**Country 4574**], empiric
anti-Tb therapy was started with RIPE. She also received a
course
of high dose steroids for possible inflammatory etiology of her
symptoms. Pt was also started on moxifloxacin for Tb and
Mycoplasma coverage. During her rehab course, she developed
pneumonia and moxifloxacin was changed to levofloxacin. This
resolved, but pt had elevated LFT's. Levofloxacin was changed
back to moxifloxacin, but this was course completed 3 weeks ago.
Of not, pt did have episode of fever and headache about 1 month
ago which resolved.
Per most recent ID ([**2120-8-12**]) and neurology ([**2120-8-21**]) outpatient
notes, pt was stable and improved from earlier admission. She
continued to have dizziness on standing and unsteadiness as well
as fluctuating diplopia. On exam she had a L facial droop and
diplopia on L gaze (probable VI palsy). Strength on L was a
little better at that time. Also had L dysmetria.
General ROS:
Reports sharp LUE pain which has been present for 1 wk, but
denies trauma. Denies chills, weight loss, chest pain,
palpitations, abdominal pain, diarrhea, constipation, dysuria,
hematuria, easy bruising/bleeding.
Neurological ROS:
Reports L side weakness which is attributed to pain. Denies
headache, dysarthria, dysphagia, bowel/bladder incontinence,
numbness or tingling.
Past Medical History:
Hyperlipidemia
Anemia (borderline microcytic on CBC)
H/o positive PPD
Social History:
Originally from [**Country 4574**], but has been in US for 16 years.
Employed as NP. Married to husband with 1 child. Dnies alcohol,
tobacco, or recreational drug use.
Family History:
Father died in accident. Mother and siblings are alive and
healthy.
Physical Exam:
Physical exam:
Vitals: Tmax 99.6, BP 132-138/80-86, RR 91-104, RR 16, O2
98-100%
RA
General: Obese female appearing stated age, NAD
Head/neck: NC, AT, moist mucous membranes
Breast: Palpable L axillary lymph nodes
Heart: RRR, S1, S2, no murmur/rub/gallop
Lungs: CTA, good air movement, no wheeze/rhonchi/crackle
Abdomen: Positive BS, soft, NT, ND, distended bladder in the
suprapubic region with palpable uterus on R lower side of
abdomen
Extremities: Radial pulses 2+ b/l, dorsalis pedis pulses 2+ b/l
Neurological exam:
Mental status: Awake, alert, cooperative, abulic
Orientation: Oriented x 3 ("[**Known firstname **] [**Known lastname 54845**]", "[**Hospital3 **]",
"[**2120-9-11**]")
Attention: Able to name [**Doctor Last Name 1841**] backwards
Speech/language: Fluent with a paucity of speech (answers in [**12-25**]
words), intact naming, follows simple and midline-crossing
commands, intact [**Location (un) 1131**], pt deferred writing
Memory: Registers [**2-21**], recalls [**2-21**] at 5 min
Calculation: $1.25 = 5 quarters
Praxis/neglect: Can demonstrate use of hammer, no evidence of
neglect
CN: Vision 20/30 L and 20/20 R, pupils round nonreactive at 2
mm,
partial R VI palsy, horizontal/torsional nystagmus on upward and
lateral gaze,she keeps moving her eyes, so there may be an
apparent field cut. She did not tolerate fundoscopy. Her facial
sensation is intact to light touch, L facial droop in peripheral
distribution, palate elevation midline, tongue midline,
sternocleidomastoid and trapezius grossly intact
Motor: Normal bulk and tone, no pronator drift, no adventitious
movements
D B T WE WF FE FF IP Q HS DF [**Last Name (un) 938**] PF
L 3 4+ 4 4 4 3 4 4 5 4 4 4 5
Pt may have limited effort in LUE due to pain
R 5 5 5 5- 5 5 5 5 5 5 4 5 5
DTR: B T Br P A Babinski
L 1+ 0 0 0 1+ Withdrawal
R 2+ 1+ 1+ 1+ 1+ Withdrawal
Sensory: Intact to light touch, temperature, vibration in all 4
extremities, diminished to joint proprioception in toes
Coordination: Possible L dysmetria (difficult to assess given
weakness/pain), [**Doctor First Name **] intact, HTS deferred
Gait: Deferred
Pertinent Results:
[**2120-9-10**] 06:00PM WBC-7.4 RBC-4.43 HGB-11.5* HCT-36.1 MCV-81*
MCH-25.9* MCHC-31.8 RDW-15.1
[**2120-9-10**] 06:00PM NEUTS-74.6* LYMPHS-19.1 MONOS-4.8 EOS-1.0
BASOS-0.5
[**2120-9-10**] 06:00PM PLT COUNT-323
[**2120-9-10**] 06:00PM GLUCOSE-103* UREA N-7 CREAT-0.4 SODIUM-139
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-24 ANION GAP-13
[**2120-9-10**] 06:00PM ALT(SGPT)-39 AST(SGOT)-19 ALK PHOS-58 TOT
BILI-0.4
[**2120-9-10**] 06:02PM LACTATE-1.0
TSH 0.74
HIV Ab negative
CSF:
[**2120-9-12**]: Tube 1 WBC 100 RBC [**2024**] Polys 78 Lymphs 9 Monos 13
Tube 4 WBC 90 RBC 512 Polys 82 Lymphs 13 Monos 5
Protein 152 Glucose 42
[**2120-9-24**]: Tube 1 WBC 32 RBC 3 Polys 0 Lymphs 95 Monos 5
Tube 4 WBC 23 RBC 0 Polys 1 Lymphs 92 Monos 7
Protein 63 Glucose 45
ACE 6
CBC at discharge: WBC 5.5 Hb 9.9 HCT 23.9 Plt 355
Chem profile at discharge: Na 138 K 3.9 Cl 105 HCO3 26 BUN 7 Cr
0.6 Glu 79
ALT 20 AST 15 AP 56 T.bili 0.3 Ca 8.9 P 4.2
Mg 2.2
Repeat CSF cultures and [**Male First Name (un) 2326**] virus and CSF/serum parasite and
viral cultures pending
IMAGING:
MRI head ([**2120-9-11**]): Interval progression and recurrence of the
previously seen
enhancing lesions in the right thalamus, right mesial temporal
lobe, and right cerebellum with further smaller enhancing areas
in the right mid brain. Increased mass effect and 4-mm midline
shift to the left. Post-contrast images are incomplete due to
motion artifact. Appearances are in keeping with lymphoma or
less likely infection. MR spectroscopy is planned for further
management as discussed in the neurology case conference.
MR Spec ([**2120-9-13**]): Unchanged size and enhancement of the right
cerebellar and thalamic lesions with unchanged mass effect on
fourth and third ventricles from the lesions in the cerebellum
and thalamus respectively; increased size of the ventricles
since the previous study with increased
size of the temporal horns indicating developing hydrocephalus;
MR spectroscopy is suggestive but not definitive of a neoplastic
lesion in
the right thalamus. The cerebellar spectroscopy is limited for
evaluation.
MRI head ([**2120-9-19**]): Post-biopsy changes from the recent right
cerebellar biopsy with associated hemorrhagic components and
mild worsening of the perilesional edema with slight increase in
the upward transtentorial herniation, effacement of fourth
ventricle and related mild worsening of enlargement of the
occipital [**Doctor Last Name 534**] of right lateral ventricle; marked improvement in
the enhancing component of both right cerebellar and
right thalamic lesion; No new lesions.
2D ECHO: Normal biventricular cavity sizes with preserved global
and regional biventricular systolic function.No valvular
pathology or pathologic flow identified.
CT HEAD ([**2120-9-24**]): Stable right supratentorial hyperdensity;
Increased distribution of right cerebellar hypodensity, likely
due to
worsening post-biopsy edema. No increased mass effect associated
with edema; Mildly decreased hydrocephalus.
Brain biopsy: active encephalitis
Brief Hospital Course:
Ms. [**Known lastname 54845**] is a 50 year old woman with a known brain lesion,
previously believed to be TB encephalitis and was treated as
such with initial improvement during previous admission, but who
presented with headache and worsening of blurry vision.
Initially, her Tb medications (RIPE therapy) were continued and
a repeat MRI was performed which showed interval progression in
and recurrence of the previously seen enhancing lesions in the
right thalamus, right mesial temporal lobe, and right cerebellum
with further smaller enhancing areas in the right mid brain as
well as increased mass effect and 4-mm midline shift to the
left. This imaging was thought to be more compatible with a
neoplastic process such as CNS lymphoma rather than an
infectious process. Given her worsening at this point, ID was
consulted and anti-Tb medications were stopped. There was a
thought that this may also be CNS sarcoid; to further evaluate
optho was consulted to evaluate and serum/CSF ACE levels were
checked. There was no opthamologic evidence of sarcoid and ACE
levels were normal. Neurosurgery and neuro-oncology consults
were requested. An emergent biopsy of the lesion was performed
by Neurosurgery. While the biopsy results were pending, she was
started on dexamethasone 4 mg q6h, but this was changed to q8h
after she began to have hallucinations; she was only noted to
have minimal clinical improvement on steroids. In fact, a repeat
head CT performed after increased lethargy was noted, showed
enlarging ventricles and the possibility of a drain for
hydrocephalus was discussed, though not placed as her mental
status improed without intervention.
The biopsy results then returned as active encephalitis
(likely bacterial or parasitic), but still no causative
organisms were identified. As per ID, she was started on empiric
Ampicillin (for Listeria), Rifampin and Moxifloxacin. She
actually has since clinically improved while on the antibiotics.
Her energy levels and mood have improved, and her cranial nerve
palsies (which include a right 6th nerve palsy, left 3rd nerve
palsy, and peripheral 7th nerve palsy), though still remain
appear to have slightly improved as well. Her steroids have also
begun to be tapered; she will be decreased to Dexamethasone 1 mg
daily on [**2120-10-1**] and the steroids will then be stopped 1 week
later. A repeat MRI will then be performed 2 weeks after the
steroids have been discontinued to evaluate for changes in
lesions size and monitor effectiveness of antibiotics. Of note,
two LPs were performed this admission, in addition to the LPs
she had during her prior admission, and the most recent CSF
results show improvement while on the antibiotics, including
lower WBC and protein counts (please see results section for
full comparison of CSF results). Given that no organisms have
grown yet, multiple new cultures were sent including those for
rare parasites. These are currently still pending, as is CSF [**Male First Name (un) 2326**]
virus.
Ms. [**Known lastname 54845**] also had left shoulder pain throughout this
admission. She has left sided weakness and it was unclear if her
weakness stemmed from her CNS lesion or from her shoulder pain.
An X-ray was done and showed Mild OA of the left AC and
glenohumeral joints. No improvements were noted during
[**Last Name (LF) 54846**], [**First Name3 (LF) **] the Orthoepdics service was called to
evaluate. They believe the pain and weakness are of a neurogenic
etiology, with no evidence of frozen shoulder/cuff related
symptoms and recommended conservative treatment with pain
control and physical therapy. She was started on Neurontin 100
mg tid for the pain; this dose can be titrated up if needed for
improved pain control.
Of note, Ms. [**Known lastname 54847**] current neurologic exam shows an
awake, alert, oriented, attentive woman. She still has a left
third nerve palsy and right sixth nerve palsy, thoough these are
less pronounced currently. She also has a left peripheral
seventh nerve palsy. Also as mentioned above, she has left upper
extremity pain and weakness (deltoid [**2-23**], triceps 4-/5, biceps
4+/5, finger extensors 4-/5 and finger flexors [**3-25**]). Her hip
flexors are also weak bilaterally, left greater than right (left
[**2-23**], right [**3-25**]); some of this weakness is likely due to
deconditioning. Her reflexes have not been able to be elicited.
It is important to note that when her condition worsens; she
becomes more lethatrgic and her cranial nerve palsies become
more pronounced.
Medications on Admission:
Ethambutol 800 mg daily
Isoniazid 300 mg daily
Pyrazinamide 1000 mg daily
Rifampicin 600 mg daily
Pyridoxine 50 mg daily
Discharge Medications:
1. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. ampicillin sodium 2 gram Recon Soln Sig: One (1) Recon Soln
Injection Q4H (every 4 hours).
5. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for constipation.
6. dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO once a day
for 1 weeks: Please stop steroids after dose on [**2120-10-8**]. .
7. moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO q24hrs ()
as needed for mycoplasma.
8. rifampin 300 mg Capsule Sig: Two (2) Capsule PO Q24H (every
24 hours).
9. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
12. Acetaminophen Extra Strength 500 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for pain: NOT TO EXCEED
4g daily.
13. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
14. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
15. medication
Please use insuling sliding scale while on steroids
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
active encephalitis
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 came to the hospital with blurry vision and unsteadiness.
You have known history of a lesion in your brain and was being
treated for Tuberculosis encephalitis. During this admission, it
was determined that this was not the result of your symptoms as
you were getting worse despite the treatments. While you were
here, the swelling in your brain was getting worse and so a
brain biopsy was done urgently to try to figure out what the
pathology of the brain lesion. After the biopsy, you were
started on steroids to help with the swelling in the brain. The
biopsy results returned as active encephalitis, likely from a
bacterial or parasitic origin. Multiple blood and CSF studies
were sent and have either returned as negative or are still
pending. For the encephalitis, while we don't know the causative
organism, you were started on empiric antibiotic treatment with
Ampicillin, Rifampin and Moxifloxacin. You have improved
clinically while on the antibiotics and the number of
inflammatory cells in your CSF also decreased since they were
started. The steroids are also currently being tapered and will
then be discontinued. A repeat MRI will be done 2 weeks after
the steroids are off to see if the size of the lesion in your
brain has changed.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2120-10-21**]
9:50
Provider: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], MD (infectious disease)
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2120-11-11**] 10:00
Provider: [**Name10 (NameIs) 2341**] [**Last Name (NamePattern4) 2342**], M.D. (Neuroinfectious
disease)Phone:[**Telephone/Fax (1) 2343**] Date/Time:[**2120-11-27**] 1:00
MRI on [**2120-11-5**]
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD, [**MD Number(3) 1041**]
Completed by:[**2120-10-1**] Name: [**Known lastname 10266**],[**Known firstname 5494**] Unit No: [**Numeric Identifier 10267**]
Admission Date: [**2120-9-10**] Discharge Date: [**2120-10-1**]
Date of Birth: [**2070-3-5**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10122**]
Addendum:
It is important to note that the following antibiotics and lab
work needs to be completed as requested by Infectious Disease.
OUTPATIENT ANTIBIOTIC REGIMEN AND PROJECTED DURATION:
[**Doctor Last Name **] and DOSE:
Ampicillin 2g Q4h
Start date: [**2120-9-25**]
Stop date: [**2120-10-23**]
Rifampin 600mg Qdaily
Moxifloxacin 400mg Qdaily
Start date: [**2120-9-25**]
Stop date: 6 months
REQUIRED LABORATORY MONITORING:
While on Ampicillin
LAB TESTS: CBC, Bun, Crea, LFTs
FREQUENCY: Qweekly
While on Rifampin/ Moxifloxacin
LAB TESTS: CBC, LFTs
FREQUENCY: Qmonthly
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 3790**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 95**]
([**Hospital3 96**] Center)
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD, [**MD Number(3) 10124**]
Completed by:[**2120-10-1**]
|
[
"795.5",
"285.9",
"378.54",
"323.9",
"272.4",
"V85.39",
"342.90",
"378.51",
"278.00",
"351.9",
"324.0",
"719.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.59",
"38.97",
"01.13",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
18672, 18957
|
9153, 13698
|
353, 389
|
15494, 15494
|
5997, 6836
|
16946, 18649
|
3692, 3761
|
13870, 15271
|
15451, 15473
|
13724, 13847
|
15670, 16923
|
3791, 4280
|
6909, 9128
|
4299, 4299
|
276, 315
|
417, 3398
|
15509, 15646
|
3420, 3491
|
3507, 3676
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,467
| 163,935
|
5458
|
Discharge summary
|
report
|
Admission Date: [**2149-7-1**] Discharge Date: [**2149-7-9**]
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
male with a history of a abdominal aortic aneurysm rupture,
coronary artery bypass graft, diverticulosis, deep venous
thrombosis, and aspiration pneumonia who presents with
progressive weakness.
He has had progressive weakness of his lower extremities over
the past several months. On the morning of admission, the
patient was getting out of bed. At that time, he felt weak. He
denied lightheadedness, dizziness, shortness of breath, or chest
pain. He went to urinate, but when he got up he fell to the
ground. He denies any loss of consciousness. Again, he denies
lightheadedness, chest pain, and palpitations. He was unable to
get up, however, because he simply felt too weak. He was not
sure how long he was on the ground, but ultimately was able to
get back to bed. About three to four hours later he got out of
bed again. At that time, he suddenly felt weak and collapsed
into a chair. He called 911 and was brought to the Emergency
Room.
He still denies lightheadedness, no chest pain, no shortness
of breath, but he felt that his entire body was weak. Of
note, he has a history of hemoptysis and guaiac-positive stool.
He had been seen by the Gastroenterology Service and had a
negative colonoscopy as well as a negative
esophagogastroduodenoscopy.
In the Emergency Room, his initial vital signs were a temperature
of 96.7, a heart rate of 103, and a blood pressure of 118/59. His
oxygen saturation was 98%. He had a hematocrit of 21.2. They
were unable to clear the blood by nasogastric lavage. He was
seen by the Gastroenterology Service and taken to urgent
esophagogastroduodenoscopy. His INR was found to be 5.2, so he
was given 4 units of fresh frozen plasma, 3 units of packed red
blood cells, and 5 mg of intravenous vitamin K, and 40 mg of
Protonix. Of note, he had not checked his INR in several months
because "I don't like having the blood drawn."
He returned from esophagogastroduodenoscopy intubated due to
hematemesis and was admitted to the Medical Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Coronary artery bypass graft times six in [**2134**].
2. Abdominal aortic aneurysm rupture repair in [**2144**].
3. Deep venous thrombosis in [**2144**].
4. Aspiration pneumonia in [**2144**].
5. Hypertension.
6. Diverticulosis.
7. Hypercholesterolemia.
8. Question of benign prostatic hypertrophy.
9. Inferior vena cava filter placement due to recurrent deep
venous thrombosis.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Metoprolol 25 mg p.o. b.i.d.
2. Coumadin 7.5 mg p.o. q.o.d.
3. Lipitor 10 mg p.o. q.d.
4. Iron supplements.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination on admission to the Medical Intensive Care Unit
his blood pressure was 143/59, his heart rate was 84, he was
afebrile, his oxygen saturation was 98%. Generally, he
seemed to be in no acute distress. His head, eyes, ears,
nose, and throat examination showed sclerae were anicteric
and constricted pupils. He was intubated. On neck
examination, no lymphadenopathy was appreciated. His chest
was clear bilaterally with occasional rhonchi. His
cardiovascular examination revealed a regular rate and
rhythm. Normal first heart sound and second heart sound. On
abdominal examination, he was obese and mildly distended with
active bowel sounds. He was guaiac-positive in the Emergency
Department. His extremities were nonedematous, and his
pulses were 2+ and symmetric.
PERTINENT LABORATORY DATA ON PRESENTATION: His blood counts
were a white blood cell count of 10.3, hematocrit of 21.2,
and platelets were 215. His PT was 27.4 with an INR of 5.2.
His sodium was 143, potassium was 3.9, chloride was 111,
bicarbonate was 19, blood urea nitrogen was 64, creatinine
was 0.7, and blood glucose was 156.
RADIOLOGY/IMAGING: Initial laboratory study revealed an
electrocardiogram with no acute ST-T wave changes.
A chest x-ray showed no consolidations or effusions.
HOSPITAL COURSE BY SYSTEM: (While in the Medical Intensive
Care Unit)
1. GASTROENTEROLOGY: The patient has had repeated episodes
of hematemesis and was taken to urgent
esophagogastroduodenoscopy. He was intubated for airway
protection prior to this procedure.
On esophagogastroduodenoscopy, he was found to have two ulcers in
his esophagus 40 cm from the incisors which were injected with
epinephrine for hemostasis. A large amount of red blood was
found and suctioned from the stomach. His duodenum was normal. A
rectal tube was placed, and he was started on pantoprazole 40 mg
b.i.d.
Three days later, after his hematocrit had stabilized and the
bleeding was considered to have stopped, a repeat
esophagogastroduodenoscopy was performed which noted diffuse
erythematous mucosa in the lower third of the esophagus with
changes consistent with [**Doctor Last Name 15532**] esophagus. A few nonbleeding 7-
mm ulcers with clean bases were found in the lower third of the
esophagus. A single 6-mm nonbleeding polyp was found in the
stomach body; a cold forceps biopsy was performed for histology.
The duodenum was normal. He also had an esophageal biopsy.
The pathology on the esophageal biopsy was returned as cardia-
type mucosa with focal goblet cells, metaplasia, and chronic
inflammation, but no squamous epithelium or dysplasia. The
pathology on the gastric polyp showed foveolar hyperplasia
consistent with hyperplastic polyp.
2. HEMATOLOGY: The patient's initial hematocrit was 21.2.
He required multiple transfusions. By [**7-2**] he had
received 4 units of packed red blood cells, 5 units of fresh
frozen plasma, and 2 units of platelet concentrate. He
required several more units of packed red blood cells over
the next day, to a total of fifteen units, but has not had a
transfusion for the past six days.
3. PULMONARY: He was intubated on [**7-1**] at
esophagogastroduodenoscopy. On [**7-3**], he had a temperature
spike to 102.2. He was started on ceftriaxone and clindamycin
for presumed aspiration pneumonia. After several attempts to
wean him off his intubation, he was successfully extubated on
[**7-5**].
4. CARDIOVASCULAR: He had two episodes of atrial fibrillation
on [**7-4**] but converted spontaneously. No further therapy was
initiated.
He was transferred from the Medical Intensive Care Unit to
the Medicine floor on [**2149-7-6**]. On the Medicine Service
his hematocrit remained stable in the 35 range, and he required
no further transfusions. His metoprolol was increased to 37.5 mg
b.i.d. for improved blood pressure control. He was continued on
his course of ceftriaxone and clindamycin for a total of 10 days
but has remained afebrile on the Medicine Floor. He was not
restarted on any anticoagulation given the history of the bleed
and medical noncompliance with heparin, in light of the fact
there was an inferior vena cava filter in place.
DISCHARGE DISPOSITION: He will be discharged in stable
condition on [**7-9**] to [**Hospital6 85**].
DISCHARGE FOLLOWUP: He will be followed by the Gastroenterology
Service by Dr. [**First Name (STitle) **] [**Name (STitle) **]. He will also follow-up with his
primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 22104**] [**Telephone/Fax (1) **].
CONDITION AT DISCHARGE: Condition on discharge was stable.
MEDICATIONS ON DISCHARGE:
1. Metoprolol 37.5 mg p.o. b.i.d.
2. Pantoprazole 40 mg p.o. b.i.d.
3. Colace 100 mg p.o. b.i.d. as needed.
4. Atorvastatin 20 mg p.o. q.d.
5. Clindamycin 600 mg intravenously q.8h. (last day on
[**2149-7-11**]).
6. Ceftriaxone 1 g intravenously q.24h. (last day on
[**2149-7-11**]).
DISCHARGE DIAGNOSES:
1. Upper gastrointestinal bleed; likely from esophageal ulcers.
2. Hypertension.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern1) 423**]
MEDQUIST36
D: [**2149-7-8**] 20:24
T: [**2149-7-8**] 20:34
JOB#: [**Job Number 22105**]
cc:[**Hospital6 22106**]
|
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"401.9",
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"530.82",
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"V45.81",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"45.16",
"42.33",
"38.93",
"45.13"
] |
icd9pcs
|
[
[
[]
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] |
7023, 7102
|
7819, 8168
|
7507, 7798
|
2640, 4091
|
4119, 6999
|
7445, 7481
|
7124, 7430
|
120, 2162
|
2184, 2614
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,659
| 125,400
|
19285+19286+19518+19519+57038
|
Discharge summary
|
report+report+report+report+addendum
|
Admission Date: [**2182-3-18**] Discharge Date: [**2182-4-12**]
Date of Birth: [**2107-4-11**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 74-year-old female who
was transferred from [**Hospital 1562**] Hospital with hemoptysis status
post bronchoscopy. The patient is a former smoker of 60-pack
years that presented to outside hospital with a two- to
four-week history of persistent cough and weight loss. Chest
CT obtained on [**2182-3-12**] showed a left lower lobe clot with
an abnormal soft tissue density over the left infrahilar
area. She underwent a bronchoscopy and was noted to have an
obstruction of the distal portion of the left main stem at
the level of the secondary carina. Biopsies were obtained as
well as washings, but everything was negative for malignancy
so far. The patient presented to the emergency department
with hemoptysis, dyspnea on exertion, and mild shortness of
breath.
The patient was transferred to [**Hospital6 2018**] from [**Hospital 1562**] Hospital for further management and for
definitive diagnosis.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Osteoporosis.
3. History of left carotid occlusion.
PAST SURGICAL HISTORY: Status post appendectomy 50 years
ago.
ALLERGIES: Question of Penicillin to which she reports
swelling.
MEDICATIONS ON ADMISSION:
1. Norvasc.
2. Fosamax.
SOCIAL HISTORY: Patient is married. She lives at home.
They have one daughter. She is retired. She quit smoking
over four years ago. She has a history of 60-pack years.
She drinks occasional alcohol.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 97, blood
pressure 156/58, heart rate 99, respiratory rate 22, oxygen
saturation 90% on 15 liter nasal cannula. In general, she is
in moderate distress complaining of shortness of breath and
back pain. HEENT: Normocephalic, atraumatic; pupils equal,
round, reactive to light; sclerae anicteric. Her neck is
supple; no lymphadenopathy; she does have a right carotid
bruit. Her cardiovascular exam is regular rate and rhythm;
normal S1, S2; a III/VI systolic ejection murmur heard into
the carotid as well as the apex. Her lung exam is clear to
auscultation bilaterally with decreased breath sounds
bibasilarly, left greater than right. Her abdomen is benign;
active bowel sounds; soft, nontender. Her extremities are
notable for no clubbing, cyanosis, or edema. Her
neurological exam is alert and oriented times three;
following commands.
LABORATORY DATA ON ADMISSION FROM OUTSIDE HOSPITAL: Her CBC:
Her white blood cell count was 10.3, hematocrit 28, platelets
543, INR was 1.0 with a PT of 11.4, PTT of 27.3. Chem-7 was
notable for sodium 127, potassium 4.5, chloride of 95,
bicarbonate 25, BUN 16, creatinine of 0.9, glucose of 119,
calcium of 9.2.
HOSPITAL COURSE: 74-year-old female transferred from
[**Hospital 1562**] Hospital for definitive diagnosis of soft tissue
mass occluding her left main stem bronchus. The patient was
admitted to the Surgical service under the care of Dr.
[**Last Name (STitle) 952**]. The patient immediately required a non-rebreather
mask on admission to the hospital.
On [**2182-3-19**] patient underwent bronchoscopy with
mediastinoscopy to further evaluate the soft tissue density.
The flexible bronchoscopy documented found enlarged lymph
nodes and a mass on a secondary carina of the left lung
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-367
Dictated By:[**Name8 (MD) 3482**]
MEDQUIST36
D: [**2182-4-12**] 12:30
T: [**2182-4-14**] 14:21
JOB#: [**Job Number 52535**]
Admission Date: [**2182-3-18**] Discharge Date: [**2182-4-12**]
Date of Birth: [**2107-4-11**] Sex: F
Service:
This is a continuation of the past dictation, #[**Numeric Identifier 52535**]. I was
accidentally disconnected. Please continue it together if
possible.
On [**2182-3-20**] Mrs. [**Known lastname **] underwent rigid and flexible
bronchoscopy with endobronchial biopsy of the left main stem
bronchus with Argon plasma coagulation of the bleeding mucosa
of the left main stem bronchus for further evaluation of the
left main stem occlusion with a tumor.
Over the next several days the patient continued to be short
of breath while requiring non-rebreather face mask to
maintain her oxygen saturation.
On [**2182-3-24**] Mrs. [**Known lastname **] [**Name (STitle) 52536**] significantly to the 70%
oxygen level and was transferred from the Surgical Floor to
the Critical Care Unit for closer monitoring.
On [**2182-3-25**] the patient underwent repeat bronchoscopy with
the goal being tumor destruction and dilation. She also
underwent therapeutic aspiration of retained secretions in
the left upper lobe.
Bronchoscopy found abnormal oropharynx with poor dentition
and abnormal areas with large amount of tumor in the left
main stem bronchus and main to the left lower lobe. The
procedure was complicated by tooth obstruction of the upper
incisor. During the procedure it was noted that the left
main stem tumor was very vascular and bled easily. Attention
was made to destroy to coagulate the tumor with argon plasma
coagulation. However, due to bleeding the procedure was cut
somewhat early. In addition, Dr. [**Last Name (STitle) 952**] was consulted during
the procedure about the feasibility of placing a left main
stem stent, but given that he planned for a possible
lobectomy or pneumonectomy, he felt that a stent in the
airway would not be appropriate. Therefore, a stent was not
placed at that time by Interventional Pulmonary.
Post procedure the patient had multiple bouts of hypotension
and hypoxemia as well as during the procedure. Therefore,
she was intubated at the termination of her procedure and
brought to the Surgical Intensive Care Unit. At this point
the Radiation Oncology resident was called for evaluation of
the role of radiation therapy for Mrs.[**Known lastname 52537**] left main stem
bronchus tumor.
Decision was made by Radiation Oncology in conjunction with
Dr. [**Last Name (STitle) 952**] for five radiation treatments while Mrs. [**Known lastname **] was
in hospital. In addition, Hematology/Oncology was consulted
for assistance in the treatment of her left main stem
bronchus and the possible role of chemotherapy. At the point
Oncology was consulted, Mrs. [**Known lastname **] was already intubated and
her performance score was quite low. The pathology from
[**2182-3-20**] showed non-small cell poorly differentiated lung
carcinoma. The oncologist felt that there was little role
for chemotherapy given her low performance score.
On [**2182-3-28**] Mrs. [**Known lastname **] was transferred to the [**Known lastname 52538**]
Intensive Care Unit to the Medical service from the Thoracic
service so that she would be able to go for her daily
radiation therapy treatments, which would begin on
[**2182-3-28**].
BRIEF HOSPITAL COURSE SUMMARY AT THE TIME OF TRANSFER TO THE
MEDICAL INTENSIVE CARE UNIT: At this point the pathology had
shown non-small cell lung cancer. Mrs. [**Known lastname **] had a head CT
which was negative for metastases. The CT scan on [**2182-3-19**]
had documented the enhancing soft tissue mass within 2 cm of
the carina and a question of an extrabronchial component of
the neoplastic mass in the left hilum. In addition, there
were multiple right lung nodules which were concerning for
metastases which were less than 5 mm.
Furthermore, there was an enlarged left adrenal gland which
was indeterminate for malignancy. The CT at that time
recommended correlative PET imaging for the further
evaluation of her metastases.
In addition, Mrs. [**Known lastname **] had had an echocardiogram which
showed left ventricular outflow track gradient of 37 and
moderate left ventricular outflow obstruction as well as
aortic stenosis. Blood pressure in the 60s with an ejection
fraction of 75%.
In the [**Known lastname 52538**] Intensive Care Unit Mrs.[**Known lastname 52537**] chief problem
was her respiratory failure, which was felt to be hypoxia
secondary to shunt from the large endobronchial tumor
obstructing her left main stem bronchi. Multiple attempts
were made to wean Mrs. [**Known lastname **] from assist control to the
pressure-support ventilation. She repeatedly did not
tolerate the pressure-support ventilation trials.
In addition, an attempt was made to wean her positive
end-expiratory pressure. When the PEEP was decreased below
8, Mrs.[**Known lastname 52537**] left upper lobe was noted to collapse in
addition to the persistent collapse of her left lower lobe.
During these occasions her oxygen saturation fell
significantly. The first occasion which her left upper lobe
collapsed was on [**2182-4-1**] after having her morning
radiation therapy.
An urgent bronchoscopy was performed which removed some mucus
plugging and some bloody secretions and documented the tumor
obstructing 75% of her left main stem bronchi.
Post procedure Mrs.[**Known lastname 52537**] aeration of the left upper lobe
did improve significantly. Her oxygen saturations improved,
as well. It was noted that the patient bled easily.
Continued efforts were made to wean her FIO2 and her PEEP.
It was felt that part of the difficulty weaning Mrs. [**Known lastname **] to
pressure-support ventilation was secondary to volume overload
given that she was significantly net positive and by chest
x-ray had evidence of congestive heart failure. Mrs. [**Known lastname **]
was diuresed very gingerly secondary to episodes of
hypotension and episodes of requiring pressors while in the
Intensive Care Unit.
With the difficulty weaning Mrs. [**Known lastname **] from the ventilator,
she was again reevaluated by Dr. [**Name (NI) **] of
Interventional Pulmonary for stent placement. Given that, at
the time the bronchoscopy was done on [**2182-4-6**], her left
upper lobe was aerated. He felt that there was little role
for a stent as the stent could not open up the obstruction in
the left lower lobe and was only useful if there was
persistent left upper lobe clots.
After significant progress was made in diuresing Mrs. [**Known lastname **],
and she was noted to be stable and comfortable and had
tolerated pressure-support ventilation trial for several
hours in the morning of [**2182-4-9**], an attempt was made to
wean her PEEP again to 0.5. Immediately Mrs. [**Known lastname **]
desaturated to the mid-80% range. Her PEEP was immediately
increased back and her FIO2 was increased; however, her
oxygen saturations did not improve. The PEEP was further
increased to 12, 100% FIO2, and her sats remained quite low.
A repeat urgent bronchoscopy was performed which showed that
the left main stem bronchus appeared to be about 85% occluded
by the tumor at this point. She had significant blood
secretions and adherent mucus secretions in her airway.
Again, post bronchoscopy, her left upper lobe opened up and
her oxygen saturation improved.
Given the difficulty weaning Mrs. [**Known lastname **] from the ventilator,
conversations were renewed in terms of what could be done to
stent open her left upper lobe airway in order to wean her
from the ventilator. A decision was made to repeat a chest
CT to evaluate if there was any progression of the multiple
right lung nodules as a PET scan could not be performed while
she was intubated. The team felt that if the nodules had
increased in size, that would be more suggestive that they
were metastases and people would be less likely to continue
forward in her treatment.
The repeat chest CT scan was unable to fully assess the right
lung field for the nodules which were again seen secondary to
motion artifact. On [**2182-4-12**], a chest CT scan did show
worsening bilateral pleural effusions and persistent left
lower lobe collapse and probable direct invasions of the mass
in the mediastinum posteriorly.
In further conversations with the Interventional Pulmonary
service and the Thoracic service, a decision was made to
stent open Mrs.[**Known lastname 52537**] left main stem bronchus to improve
aeration to the left upper lobe and hopefully decrease her
dependence on PEEP. The stent was placed successfully on
[**2182-4-12**] by Dr. [**Last Name (STitle) **].
Mrs. [**Known lastname **] was transferred back from the [**Hospital Ward Name 517**] to the
[**Hospital Ward Name 52538**] Intensive Care Unit for further observation and with
hopeful weaning from the ventilator with the stent in place.
Her other chief medical problems during her stay in the
[**Name (NI) 52538**] Intensive Care Unit from the date [**2182-3-28**] to
[**2182-4-10**] included episodes of hypotension requiring
intermittent pressure support with Neo-Synephrine as well as
congestive heart failure complicated by hypertrophic
obstructive cardiomyopathy requiring careful diuresis.
Throughout her stay in the [**Year (4 digits) 52538**] Intensive Care Unit, the
Intensive Care Unit team maintained close communication with
her husband, Mr. [**First Name4 (NamePattern1) 401**] [**Known lastname **]. The team had regular
conversations with Mr. [**Known lastname **] regarding Mrs.[**Known lastname 52537**] prognosis
and her code status which began on [**2182-4-3**] after the
difficulties weaning Mrs. [**Known lastname **] from the ventilator. Given
the possibility of chore by left pneumonectomy offered to the
family by Dr. [**Last Name (STitle) 952**], Mr. [**Known lastname **] said that Mrs. [**Known lastname **] should
remain Full Code. Mrs. [**Known lastname **] initially expressed a wish not
to be resuscitated if her heart were to stop. The team
attempted to clarify her code status through further
conversations with the patient and her husband. However,
Mrs.[**Known lastname 52537**] mental status began to wax and wane during her
Intensive Care Unit stay, so the team felt that it was
appropriate to continue Mrs. [**Known lastname **] as a Full Code in
accordance with her husband's wishes as she did not appear to
have the capacity to make the decision on her own.
On a regular basis the team attempted to reassess Mrs.[**Known lastname 52539**] wishes regarding her code status and, on occasion,
she was noted to say that she did wish to be brought back.
In addition, Social Work was consulted to offer Mr. [**Known lastname **]
support throughout this process. With Social Work's
assistance, Mr. [**Known lastname **] was able to understand the gravity of
Mrs.[**Known lastname 52537**] illness and to understand that, even though we
would do all we could to take care of, there may come a point
when we would not be able to bring her back. Nevertheless,
Mr. [**Known lastname **] did wish to continue with aggressive therapy in the
hopes of potential cure. He was in full agreement with the
decision to go ahead with the left upper lobe stent in the
hopes that Mrs. [**Known lastname **] might be able to be weaned from the
ventilator.
At the time of this dictation ends on [**2182-4-12**], Mrs. [**Known lastname **]
had undergone the stent successfully and the plan was still
in place for possible salvage/curative pneumonectomy of the
left lung in the event that we were unable to wean Mrs. [**Known lastname **]
over the next few days from the ventilator. Dr. [**Last Name (STitle) 952**] still
hoped that this tumor may be resectable.
Further hospital course will be dictated by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. Please see remainder of hospital course for further
events and discharge status.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Name8 (MD) 3482**]
MEDQUIST36
D: [**2182-4-12**] 22:14
T: [**2182-4-14**] 14:33
JOB#: [**Job Number 52540**]
Admission Date: [**2182-3-18**] Discharge Date: [**2154-3-25**]
Date of Birth: [**2107-4-11**] Sex: F
Service: Thoracic Surgery Service
ADDENDUM: There are prior discharge dictations. This will
be comprehensive from the date of thoracic surgery involving
the patient's care.
HISTORY OF PRESENT ILLNESS: This is a 74-year-old female
transferred from [**Hospital 1562**] Hospital with hemoptysis after
bronchoscopy.
The patient is a former smoker that presented to the outside
hospital with a 2-week to 3-week history of persistent cough
and weight loss. A computed tomography scan obtained on
[**2182-3-12**] showed a left lower lung collapse with
abnormal soft tissue density in the left intrahilar area.
She underwent a bronchoscopy and was noted to have an
obliteration of the distal portion of the left main stem at
the level of the secondary. Biopsies obtained were all
negative for malignancy so far.
The patient presented to the Emergency Department today with
hemoptysis, dyspnea on exertion, and mild shortness of
breath. The patient was transferred to [**Hospital1 190**] for further management and for a tentative
diagnosis.
PAST MEDICAL HISTORY: (Significant for)
1. Hypertension.
2. Osteoporosis.
3. History of left carotid occlusion.
PAST SURGICAL HISTORY: (Significant for)
1. Appendectomy 50 years ago.
2. Bronchoscopy.
ALLERGIES: Question to PENICILLIN.
MEDICATIONS AT HOME: The patient takes Norvasc and Fosamax.
SOCIAL HISTORY: She is a married woman. She lives at home
with one child who is 42 years old. She is retired. She
quit tobacco four years ago. She had a 60-pack-year history
of smoking.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, the patient's temperature was 97 degrees
Fahrenheit, her heart rate was 99, her blood pressure was
156/58, her respiratory rate was 22, and she was saturating
90% on 2 liters by nasal cannula. The patient was in no
acute distress. She was complaining of shortness of breath.
She was able to talk. The pupils were equal, round, and
reactive to light. Head was normocephalic and atraumatic.
She had no scleral icterus. The neck was supple with no
lymphadenopathy. She had a right carotid bruit.
Cardiovascular examination revealed a regular rate and
rhythm. Normal first heart sounds and second heart sounds.
There was a 3/6 systolic ejection murmur. The lungs were
clear to auscultation bilaterally with decreased bibasilar
breath sounds (left greater than right). The abdomen was
benign. The extremities were warm, and dry, and well
perfused. On neurologic examination, she followed commands.
Examination was grossly intact.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories at
the outside hospital showed a white blood cell count of 10.3,
her hematocrit was 28, and her platelet count was 543.
Chemistry-7 revealed sodium was 127, potassium was 4.5,
chloride was 95, bicarbonate was 25, blood urea nitrogen was
16, creatinine was 0.9, and her blood glucose was 119. The
patient's coagulations showed her INR was 1.
ASSESSMENT AND PLAN: This is a 74-year-old female
transferred from [**Hospital 1562**] Hospital with hemoptysis after
bronchoscopy and biopsy for an occluding lesion of the left
secondary main stem at the level of the secondary carina.
Limited pathologies from the biopsy. The patient is here for
further diagnosis, workup, and management. This was
discussed with Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**], and the patient's pulmonary
function tests were obtained with a question of repeat
computed tomography scan and a positron emission tomography
scan in preparation for potential surgery.
BRIEF SUMMARY OF HOSPITAL COURSE: On hospital day one, the
patient had preoperative pulmonary function tests which
showed forced vital capacity SaO2 of 84% on 4 liters. Lung
volumes were not obtained due to low oxygen saturations. For
further pulmonary function tests results, please follow up
with report in the patient's record.
On hospital day two, the patient was short of breath without
oxygen. She required oxygen 5 liters by nonrebreather. The
patient was afebrile with stable vital signs.
The patient was prepared for bronchoscopy, mediastinoscopy,
and video-assisted thoracic surgery by Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**]. The
patient was nothing by mouth. An electrocardiogram was
obtained which showed no ischemic changes. The patient was
typed and crossed. A urinalysis was sent which showed many
bacteria, 6 to 10 white blood cells, and no urinary tract
infection. A chest computed tomography showed calcifications
on the right lung and left lower lung collapse. A head
computed tomography showed calcifications in pons with no
metastasis. Anesthesia saw the patient, and the patient was
consented.
On hospital day three, the patient was brought to the
operating room for procedure. The patient underwent a
flexible bronchoscopy and mediastinoscopy with lymph node
biopsy, rigid bronchoscopy with lymph node biopsy, and argon
beam coagulation. There, they found enlarged lymph nodes and
a mass on the secondary carina of the left lung. For full
note of operative procedure, please see the operative
dictation.
On hospital day three, postoperative day one, after
mediastinoscopy and bronchoscopy, the patient complained of a
sore throat. Her temperature maximum was 99 degrees
Fahrenheit. Otherwise, her vital signs were stable. She was
saturating 100% on a nonrebreather. The plan for the patient
was to wean off oxygen for a positron emission tomography
scan. The patient was scheduled for a possible positron
emission tomography scan on an outpatient basis. The patient
was continued on aggressive chest physical therapy. The
patient was given Lasix, and a chest x-ray was obtained. The
patient continued to do well.
On postoperative day five, the house officer was called to
see the patient for an oxygen saturation of 76%. The patient
had decreased breath sounds bilaterally. Obtained a chest
x-ray which showed atelectasis, bilateral effusions, and
congestion. An arterial blood gas drawn showed a pH of 7.48,
PCO2 was 42, PO2 was 52, bicarbonate was 32, and a base
excess was 6. Nebulizer treatments and incentive spirometry
were attempted. Chest physical therapy was done, and the
patient's saturations ranged in the 80% to 90% range. The
patient was then at 84%. No complaints of shortness of
breath.
The patient was transferred to the Coronary Care Unit for
closer monitoring. The patient's laboratory values revealed
the patient had a white blood cell count of 9.4, her
hematocrit was 25.1, and her platelet count was 739.
Chemistries revealed sodium was 131, potassium was 5.2,
chloride was 93, bicarbonate was 29, blood urea nitrogen was
22, and her creatinine was 1.3. The patient's chest x-ray
showed a left lower lobe collapse which was similar to
previous.
On [**2182-3-25**], the patient went to the operating room
again for a rigid bronchoscopy. The patient tolerated the
procedure and was transferred back to the Intensive Care
Unit. The patient was hypoxic during surgery and required a
high positive end-expiratory pressure. There were bloody
secretions and clots in the endotracheal tube. The patient
was also placed on a Neo-Synephrine drip for low blood
pressures. The patient was also given normal saline boluses
when her blood pressure would drop.
On [**2182-3-26**], the patient was postoperative day seven
from mediastinoscopy and bronchoscopy and postoperative day
one from second bronchoscopy. The patient had experienced
hypotension and hypoxia after bronchoscopy and intubated. A
chest x-ray showed white out of the left lung. The patient's
hypoxia improved with increased positive end-expiratory
pressure. The patient was also given 2 units of packed red
blood cells and a central line was placed. The patient was
given fluid boluses. The Neo-Synephrine was weaned off for
blood pressure support.
On postoperative days eight and two, the patient failed to
wean from the ventilator; however, the patient was off the
Neo-Synephrine drip. The patient had experienced some labile
blood pressures. Radiology/Oncology was consulted for
possible radiation therapy while an inpatient. Please see
the full Oncology consultation note for specifics. Oncology
felt the patient had poorly differentiated non-small-cell
lung cancer with a very prominent left endobronchial lesion
and a high-grade obstruction. Oncology felt there was little
or no role for chemotherapy and felt that if anything she
would be more of a candidate for radiation therapy.
The patient was seen by the Nutrition Service for nutritional
consultation. Radiation/Oncology saw the patient. The
patient was transferred then from the Thoracic Surgery
Service to the Medicine Service for further treatment of her
left main stem bronchus mass. The patient had surgical tumor
ablation. She was unable to extubate. The plan was for
radiation treatment to decrease tumor burden. For additional
information on the [**Hospital 228**] medical course, please see the
Discharge Summary by medical house staff.
On[**4-23**], the patient was then transferred from the
[**Hospital Ward Name 332**] Intensive Care Unit from the Medicine Service to the
[**Hospital Ward Name **] Cardiothoracic Surgery Recovery Unit for thoracic
surgery. On [**2182-4-23**] the patient underwent sternotomy,
left pneumonectomy, omental flap of the left main bronchus by
Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**], and mediastinal lymph node dissection. The
attending surgeon was Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**], Dr. [**Last Name (Prefixes) **], Dr.
[**Last Name (STitle) 1537**]. The patient tolerated the procedure well and was
transported back to the Cardiothoracic Surgery Recovery Room.
On postoperative day one from left pneumonectomy, omental
flap, and percutaneous endoscopic gastrostomy tube placement
the patient was stable postoperatively. She was on a
Neo-Synephrine drip at 0.8 and receiving beta blockade. The
patient was also on an insulin drip. The patient was
continued on meropenem from her medical admission. The
patient was continued intubated and sedated.
On postoperative day one, the plan was to remove the left
chest tube, wean the ventilator, and start her tube feeds.
The patient was seen by the Nutrition Service for the
beginning of tube feeds. Tube feeds were resumed with a goal
of Impact with fiber at 60 cc per day. The patient was on an
insulin drip. Once tube feeds were at goal, consider
starting NPH.
On postoperative day two, the patient was still on a
Neo-Synephrine drip for labile blood pressures. The patient
was started on tube feeds at 50 cc per hour. The patient was
continued on meropenem. The patient's vital signs were
stable. The patient was on ventilator. Tube feeds were
advanced toward goal, and the Neo-Synephrine was weaned on
postoperative day three. The patient was continued on a
Neo-Synephrine drip. The patient was started on Haldol for
agitation. The patient continued to be intubate. Extubation
was attempted.
On postoperative day three, after extubation, the patient was
found again to be in respiratory failure. The patient was
intubated again and started on a propofol drip. The patient
had been weaned off pressors. The patient was continued on
meropenem, Haldol, and Lopressor. The patient was intubated
and sedated.
On postoperative day five, the patient was again weaned to
continuous positive airway pressure with a pressure support
of 5 and positive end-expiratory pressure of 5. The patient
tolerated this well; however, she was kept intubated.
On postoperative day six, the patient had been extubated
overnight. The patient tolerated extubation. The patient
was still on a Neo-Synephrine drip for labile blood
pressures. She was continued on Haldol, Lopressor, and
meropenem. The patient was otherwise afebrile with stable
vital signs.
On postoperative day seven from pneumonectomy, the patient
continued to do well extubated with oxygen saturations of 95%
or better on 2 liters by nasal cannula or 50% shovel mask.
The patient's labile blood pressures persisted on and off
Neo-Synephrine. Lasix was given, and tube feeds were
continued at 40 cc an hour. On postoperative day seven, the
patient had burst of supraventricular tachycardia or atrial
fibrillation to the 130s with labile blood pressures. The
patient had hypertension when awoken and was agitated;
however, was hypotensive when asleep. Thick yellow
secretions were suctioned from the airway but the patient
continued to do well extubated. The patient was continued
with aggressive chest physical therapy.
The patient was awaiting transfer to the floor on
postoperative day eight. The patient was seen by Speech and
Swallow for consultation. Their recommendations were that
the patient should be strictly nothing by mouth, and an
evaluation by Ear/Nose/Throat for vocal cord should be
obtained, and that the patient would need to demonstrate
improved strength and functioning before by mouth intake
could again started. The patient was working with Physical
Therapy and was continued on tube feeds at that time.
On postoperative day nine, the patient was working with
Physical Therapy. She was scheduled to see Ear/Nose/Throat.
The patient's Lopressor was increased to 100 mg twice per
day. The patient was afebrile and her vital signs were
stable. The patient was saturating 96% on 40% face mask.
The patient was transferred to the floor on postoperative day
nine. The Nutrition Service continued to see the patient.
On postoperative day ten, the patient required a Foley
placement for an inability to void. The patient was afebrile
with stable vital signs. The patient was continued on
meropenem (day 18). The patient had some episodes of
hypertension; however, she was asymptomatic. The patient was
saturating 94% on 4 liters by nasal cannula. The chest tube
was removed on postoperative day ten. The patient's
Lopressor was increased again to 100 mg twice per day. On
postoperative day ten, a repeat swallow evaluation was
obtained. Their recommendations were to upgrade diet to
puree and thickened liquids. The patient was encouraged to
tuck chin toward the chest before swallowing. The patient
was continued on her tube feeds.
On postoperative day eleven, the patient was comfortable.
The patient's vital signs were stable. The patient was
saturating 97% on 4 liters. The patient had some coarse lung
sounds, but tolerated the removal of chest tube. The patient
was working with Physical Therapy. Rehabilitation screening
was begun.
On postoperative day twelve, the patient was doing well. The
patient was out of bed with Physical Therapy. Rehabilitation
screening was obtained. The patient had been discontinued
from meropenem and was placed on ciprofloxacin. The patient
was day three of ciprofloxacin on postoperative day twelve.
The patient was tolerating the rest of her medications well.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern1) 10638**]
MEDQUIST36
D: [**2182-5-5**] 12:41
T: [**2182-5-8**] 09:31
JOB#: [**Job Number 52967**]
Admission Date: [**2182-3-18**] Discharge Date: [**2182-6-7**]
Date of Birth: [**2107-4-11**] Sex: F
Service: [**Last Name (un) 7081**]
HOSPITAL COURSE: This patient has had a very long,
complicated hospital course which has been written out in
multiple discharge summaries which are included in the packet
to the rehab center. To summarize, Ms. [**Known lastname **] is a 74-year-
old woman who presented with a 60-pack year smoking history
to an outside hospital with 3 weeks history of cough and
weight loss. Her work-up at that time included a CAT scan on
[**3-12**] at the outside hospital demonstrating left lower
lung collapse and a mass in the left hilum. She underwent
bronchoscopy with biopsy and was transferred to the [**Hospital6 1760**].
She underwent multiple bronchoscopies here, as well,
demonstrating left main stem obliteration with tumor, with
attempted but unsuccessful clearing of her airway to
reinflate her left lower lobe which occurred with multiple
bronchoscopies, attempts at ablation therapies, and stenting.
She had increased oxygen requirement, and needed to be
intubated for respiratory distress, and transferred to the
Medical ICU where she had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3928**] course on and off pressors
for a very long time on the ventilator. She was treated with
1-1/2 weeks of radiation therapy without significant
improvement as a last ditch effort to try to improve her
respiratory status. At that time, the patient wished to
proceed with treatment, and after 5 weeks in the hospital,
she underwent a left pneumonectomy and omental flap on [**2182-4-23**].
Her postoperative course was significant for ongoing pressor
requirement which eventually subsided, and she was extubated
on postoperative day six. She subsequently developed rapid
atrial fibrillation and Klebsiella pneumoniae with copious
secretions. She had to be reintubated, and developed a large
right pleural effusion. A tracheostomy was performed on
[**5-14**] to assist with her pulmonary toilet, and her chest
tube was placed around the same time to try to drain this
large pleural effusion around the only remaining lung. She
is currently on the floor with a Passy-Muir valve, on tube
feeds at goal, starting with POs with strict aspiration
precautions, and going to the rehabilitation facility.
In the time between late [**Month (only) 547**] where she was set to go to
rehab and the current time, she had an episode on the floor
which was responsible for the delay, where she was
tachycardic in SVT with decreased blood pressure and poor
oxygen saturations in the 80s. This was at a time where her
Lasix dose was cut back and was probably attributed to both
mucous plugging, the development of a UTI, and the lack of
ongoing diuresis. She went to the ICU, just received
pulmonary toilet, and was transferred back to the floor
within 48 hours. She was also treated with antibiotics for
gram-negative rod coverage, and eventually this was tailored
to the Enterococcus that grew in her urine which was
sensitive to ampicillin. However, she had a penicillin
allergy, so we treated her with vancomycin. The Enterococcus
was resistant to Levaquin, which was the antibiotic that she
was placed on when she was transferred to the ICU,
empirically. The chest tube was removed prior to this
episode because the output from her right chest went from
more than a liter to less than 200 per a 24-hour period over
the course of about 10 days to 14 days. Since her transfer
to and return from the ICU, she has been overall improved,
now tolerating Passy-Muir valve, and much more awake, alert
and out-of-bed with activity. Currently, she has no fluid,
but she is requesting it because of the decreased ability for
her to get herself to the toilet, giving her significantly
impaired stamina. So, the date of discharge is [**2182-6-7**].
DISCHARGE DIAGNOSES:
1. Lung cancer.
2. Respiratory failure.
3. Ventilatory dependence.
4. Hemodynamic instability.
5. Inotrope pressor requirements.
6. Multiple pneumonias.
7. Multiple bronchoscopies.
8. Prolonged intensive care unit requirement.
9. Hypertension history.
10.Osteoporosis history.
11.History of left carotid occlusion.
12.History of an appendectomy 50 years ago.
13.Multiple bronchoscopies in past, as well.
14.Supraventricular tachycardia.
15.Hypotension.
16.Anemia.
17.Hypoxia.
18.Status post radiation therapy for left hilar lung mass.
19.Klebsiella pneumoniae.
20.Enterococcus urinary tract infection.
21.Thrombocytopenia, resolving.
22.Status post multiple chest tubes, all removed.
23.Status post left pneumonectomy with omental flap, [**2182-4-23**].
24.Status post tracheostomy, [**2182-5-14**].
25.Status post chest tube drainage of pleural effusion, [**2182-5-16**].
DISCHARGE CONDITION: Improved.
DISCHARGE MEDICINES:
1. Albuterol prn.
2. Dulcolax prn.
3. Sertraline 50 mg po qd.
4. Percocet elixir prn.
5. Colace 100 mg po bid.
6. Prevacid to be given in her tube q 12 h.
7. Vancomycin 1 gm IV q 12 for 5 days to treat the
Enterococcus in the urine.
8. Lasix 40 mg po bid.
9. Lopressor 12.5 po bid.
10.Ipratropium inhaled q 6 h neb solution.
11.Subcu heparin 5,000 U q 8 h.
The patient obviously needs a tremendous amount of trach
care. She is going to rehabilitation and will need
respiratory therapy, pulmonary toilet, trach education,
frequent suctioning, frequent nebs, negative fluid balance,
antibiotics for a short time, physical therapy, occupational
therapy, nursing care to check wounds, cardiorespiratory
checks, evaluation for home services with social work given
her prolonged hospitalization and her elderly husband, speech
therapy, [**Name (NI) 36422**] valve ongoing, as well as strict
aspiration precautions, given that she has one lung, has
suffered a tremendous amount of respiratory compromise over
the past few months, and would find an aspiration event
absolutely devastating and probably life-threatening.
FOLLOW UP:
1. Dr. [**Last Name (STitle) 952**] is the follow-up surgeon in 1 month.
2. PCP [**Last Name (NamePattern4) **] [**1-25**] weeks as needed.
[**First Name11 (Name Pattern1) 951**] [**Last Name (NamePattern4) **], MD 2367
Dictated By:[**Last Name (NamePattern1) 11971**]
MEDQUIST36
D: [**2182-6-7**] 10:45:58
T: [**2182-6-7**] 12:15:53
Job#: [**Job Number **]
Name: [**Known lastname 9773**], [**Known firstname **] Unit No: [**Numeric Identifier 9774**]
Admission Date: [**2182-3-18**] Discharge Date: [**2182-4-23**]
Date of Birth: [**2107-4-11**] Sex: F
Service:
This is an addendum to her [**Hospital Unit Name 1863**] course. Please see further
addendum for patient's postoperative course beginning on
[**2182-4-23**].
ADDENDUM BY SYSTEMS:
1. Non-small cell lung cancer: Patient awaited complete left
pneumonectomy and tracheostomy until [**2182-4-23**].
Patient's course was complicated by thrombocytopenia and
fevers, please see below, and thus pneumonectomy was
postponed until that time. Patient will go to the Surgical
Intensive Care Unit following operative care.
2. Fevers: Patient began to spike fevers during her [**Hospital Unit Name 1863**]
admission. Her sputum grew Klebsiella that was somewhat
resistant to antibiotics. She was treated with seven days of
meropenem with resolution of her fevers. Her left internal
jugular line was also discontinued and a new right internal
jugular line was placed. Her A line was also discontinued
during her febrile episode. None of patient's blood cultures
or urine cultures had any growth except for contamination
with Staph epi. Patient's last fever was on [**4-17**], and
she remained afebrile since that time.
3. Thrombocytopenia: Patient developed an acute drop in her
platelets during her [**Hospital Unit Name 1863**] course. This occurred after
beginning Bactrim for initial sputum culture. Patient's
platelets trended downward with a minimum count of 30. She
received 1 unit of platelets after a bronchoscopy for minor
oozing, however, required no other transfusions. After
cessation of Bactrim, patient's platelet count began to
recover. A Hematology consult was also obtained to help
further evaluate the patient's thrombocytopenia. The
patient's heparin-induced thrombocytopenia antibody was
negative. A DIC panel was checked and was also negative. It
was thought that this was really medication related, and the
patient's count began to increase slowly after Bactrim
cessation.
4. Anemia: Patient had a slow trending downward of her blood
count. This is likely due to prolonged ICU course and
frequent blood draws. Patient's iron studies indicated
anemia of chronic disease as well. She received 2 units of
packed red blood cells during her [**Hospital Unit Name 1863**] course since the time
of last dictation.
5. Blood pressure control: Patient's blood pressure
continued to oscillate from hypertension to hypotension.
Patient's hypertension was managed with prn IV hydralazine
with good effect. She was also continued on her beta-blocker
therapy. For the patient's hypotension, she was given small
fluid boluses of 250 cc with good response in her blood
pressure. Patient did require Neo-Synephrine, however, was
weaned off of this within 24 hours and responded to simple
fluid boluses. Her MAT would go down to as low as high 30s,
but did respond with fluid.
6. FEN: The patient was continued on tube feeds through her
OG tube. She will likely have a PEG placed intraoperatively
or postoperatively for prolonged inability to eat. Patient
was transferred to the surgical team on [**4-22**] for
pneumonectomy procedure to be completed on [**2182-4-23**].
Please see addendum to this discharge summary for further
hospital course.
[**Name6 (MD) 9775**] [**Last Name (NamePattern4) 9776**], M.D.12.AFO
Dictated By:[**Last Name (NamePattern1) 1791**]
MEDQUIST36
D: [**2182-4-23**] 14:04
T: [**2182-4-24**] 10:19
JOB#: [**Job Number 9777**]
|
[
"518.0",
"997.3",
"196.1",
"427.31",
"482.0",
"162.5",
"478.32",
"287.4",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"32.01",
"33.91",
"32.5",
"33.48",
"33.22",
"33.23",
"33.93",
"40.3",
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] |
icd9pcs
|
[
[
[]
]
] |
36038, 37190
|
35142, 36016
|
1331, 1358
|
31389, 35121
|
17210, 17250
|
17083, 17188
|
37201, 41253
|
19512, 31371
|
16104, 16942
|
1600, 2776
|
16965, 17059
|
17267, 19482
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,013
| 185,178
|
1495
|
Discharge summary
|
report
|
Admission Date: [**2188-7-2**] Discharge Date: [**2188-7-14**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Diarrhea, hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
87 male with history of untreated colon cancer, PAF (not on
anticoagulation), recent hospitalization for hypoxia, weakness
and a UTI who presents with ongoing weakness and diarrhea. He
was noted to be weak at home, and a friend urged him to activate
his lifeline. He states that he has been having lots of
diarrhea, roughly every two hours, since his last discharge. He
has not been having any fevers, chills, abdominal pain, nausea,
vomiting, or bleeding.
.
His last hospitalization concluded that his weakness was due to
deconditioning, and his shortness of breath was due to fluid
overload. He was treated with flagyl for two days last
admission, and, and was discharged on Augmentin to complete a
course for a UTI. He had a positive c.dif toxin noted in the
computer last admission, but was not discharged on any
treatment.
Past Medical History:
Colonoscopy [**2184-3-25**]:
>Polyp in the transverse colon (polypectomy) - adenoma
>Polyps in the sigmoid colon (polypectomy)- Colonic mucosa with
focal hyperplastic features
>Polypoid, ulcerated mass in the hepatic flexure (biopsy) -
Superficial fragments of colonic mucosa with ulceration, marked
acute inflammation, and highly atypical glands, suspicious for
carcinoma.
Past history:
# Colon mass during colonoscopy for guaiac positive stools in
[**2184**]. Pathology was worrisome for carcinoma. Although the
patient was offered resection by Dr. [**Last Name (STitle) **], he declined
# hematuria/BPH - traumatic foley insertion and manipulation
[**3-16**] lead to urosepsis and subsequent urinary retention
# sick sinus syndrome and bifascicular block s/p pacemaker [**2184**]
# PAF - on amiodarone, not on coumadin d/t concern for
malignancy
# H/O SVT
# Atrial flutter status post ablation [**2-/2186**] - not on
anticoagulation d/t concern for malignancy
# Anemia - on arenesp and iron
# Echo [**2186**]: mild-to-moderate mitral regurgitation, RA and LA
# BPH s/p TURMP [**2187**]
# b/l edema with skin changes
# hard of hearing
# hx of guiaic positive stools/GI bleeding
# osteoarthritis
# osteoporosis
# subclinical hypothyroid state as per record
# [**Year (4 digits) **] insufficiency
# right pleural effusion - Found on CT on [**2188-2-25**] for increasing
DOE. [**3-6**] and [**3-18**] thoracentesis c/w transudative. Workup during
last admission revealed RV diastolic dysfunction. Concern was
for PE as etiology, but unable to get CTA d/w ARF and V/Q not
helpful. Not anticoagulated due to h/o GIB, pleurodesis not an
option d/t transudative.
# Tibial talar dislocation with comminuted distal tib fib
fracture status post surgery [**2181**]
# hx syncope in [**2181**], unclear etiology
Social History:
living at lone at home with VNA, Former smoker with 35-pk-yrs,
quit 50-55 yrs ago. Social ETOH.
Family History:
brother had [**Name2 (NI) 500**] marrow stem cell transplant at age 82
Sister died from heart attack. Also had an unknown cancer.
Mother died from an unknown cancer.
Neice has unknown cancer.
Physical Exam:
Vs- 99 88/41 70 20 90% 5L
Gen- Tired appearing elderly male, sleeping at 30 degrees HOB
elevation
Heent- MM dry, anicteric, poor dentition, no oral lesions
Neck- supple, JVP 8cm
Cor- regular, soft II/VI HSM along sternal border
Chest- Expiratory wheezes, bibasilar rales
Abd- soft, ttp RUQ and RLQ, no guarding or rebound tenderness.
Positive bowel sounds.
Ext- 3+ edema right leg, 2+ edema left leg. No clubbing or
cyanosis.
Neuro- AAO x 3. No focal findings.
Skin- Venous stasis changes L>R lower extremity.
Msk- moves all extremities. no obvious findings.
Pertinent Results:
ADMISSION LABS
[**2188-7-2**] 02:52AM BLOOD WBC-25.0*# RBC-3.81* Hgb-10.4* Hct-32.8*
MCV-86 MCH-27.2 MCHC-31.7 RDW-16.3* Plt Ct-251
[**2188-7-2**] 02:52AM BLOOD Neuts-72* Bands-23* Lymphs-2* Monos-2
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2188-7-2**] 02:52AM BLOOD PT-14.9* PTT-33.2 INR(PT)-1.3*
[**2188-7-2**] 02:52AM BLOOD Glucose-106* UreaN-33* Creat-1.2 Na-143
K-3.5 Cl-109* HCO3-25 AnGap-13
[**2188-7-2**] 02:52AM BLOOD ALT-34 AST-37 LD(LDH)-268* AlkPhos-189*
TotBili-0.5
[**2188-7-2**] 02:52AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.0
[**2188-7-2**] 03:04AM BLOOD Lactate-1.3
MICRO
[**7-2**] blood cultres-NGTD
[**7-2**] urine cultres-NGTD
[**7-2**]-c.diff positive
IMAGING
[**7-2**]-liver u/s-Gallbladder distension likely related to
patient's having been NPO for 48 hours, without evidence of
acute cholecystitis. These findings were posted to the ED
dashboard at 10:30 a.m. on [**2188-7-2**]
.
[**7-2**]-CT abdomen-1. New pancolitis with rectal involvement, with
"accordion"-like accentuated haustration, a marked change since
[**2188-3-5**], is highly suggestive of C. difficile colitis; given
the history of previous episode, this likely represents the
chronic "recurrent" form.
2. Infectious pancolitis (due to Campylobacter, CMV, parasitic
or staphylococcal infection) is a less likely consideration.
3. No evidence of bowel obstruction.
4. Congestive heart failure, with multi-chamber cardiac
enlargement and bilateral pleural effusions, right greater than
left.
.
[**7-2**]-CXR-Portable upright chest radiograph is reviewed and
compared to [**2188-6-22**]. Mildly enlarged cardiac silhouette is
unchanged, with left pacemaker and two intracardiac leads. Right
pleural effusion is little changed, but there is still right
basilar consolidative opacity. Left basilar atelectasis is
unchanged. There is no left pleural effusion. There is no
pneumothorax.
IMPRESSION: Little change in CHF, with slightly decreased right
pleural fluid. Unchanged right basilar atelectasis
[**7-5**]-CXR-Moderate-sized bilateral pleural effusions
[**7-9**]-CT abdomen/CT chest-1. Multisegmental bilateral pulmonary
emboli.
2. Atelectasis and aspiration/pneumonia of the lung bases
bilaterally, with aspirated barium seen within the left lung
base.
3. Fluid overload, with anasarca and moderate bilateral pleural
effusions.
4. Colonic wall thickening, also involving the rectum. Although
some of the wall thickening may be attributable to volume
overload, these findings are again compatible with a pancolitis
such as pseudomembranous colitis, improved from [**2188-7-2**].
5. Area of stricturing and narrowing of the hepatic flexure,
compatible with known colonic malignancy.
6. Perirectal abscess, measuring approximately 2.7 cm.
Brief Hospital Course:
87 male with history of colon cancer (untreated), atrial
fibrillation, recent UTI, and positive C.dif toxin assay who
presents with diarrhea, hypotension, and dehydration.
.
# Hypotension: On admission he was hypotensive to SBP 80's and
thus admitted to the MICU, this was likely in the setting of
profound dehydration from GI losses and poor PO intake. He was
fluid responsive thus far (a total of 5L of isotonic fluids).
Alternate etiologies, such as distributive or cardiogenic shock
at this point were considered less likely. He received a total
of 4-5L and his BP improved such that he was transferred to the
medical floor. His BP remained normal afterwards. Metoprolol
and terazosin were held throughout admission which patient
tolerated well.
.
# Diarrhea/C.dificile colitis. He has had several positive C
Diff toxin assays, and had one course of treatment after an
[**Month (only) 547**] admission. It is not clear that he was treated during his
past admission. He was C diff toxin positive again and he was
treated with IV flagyl and PO vancomycin as his diarrhea was
severe and there was concern about the vancomycin working in the
setting of a rapid transit time. Initially he did not have
abdominal pain, but began having lower abdominal pain and some
rebound tenderness on exam. A CT abdomen showed improvement in
the colitis and a new perirectal abscess but no other
abnormalities. At the time of discharge he was tolerating a
regular diet without difficulty and had improvement in his
abdominal pain and diarrhea. Antibiotics were started on [**7-2**]
with a plan to complete a 21 day course of flagyl and vanco as
an outpatient.
.
#Perirectal Abscess-Seen on CT, non-symptomatic but on exam he
had tender fluctuance in the posterior rectum. Gen [**Doctor First Name **] was
consulted and stated I&D at this time is not necessary as it
could not be performed bedside, because of the position of the
abscess they may have to use a percutaneous approach which would
raise concern about creating a colon-skin fistual tract. They
recommended added cipro for gram negative coverage but given
concern over exacerbating his c.diff which was already slow to
improve, it was not added and conservatively management was
pursued. He will be seen for follow-up by surgery as an
outpatient.
.
# Edema / CHF: He has bilateral pleural effusions, which have
recently been tapped and found to be transudative. He is
currently intravascularly dry but total body overloaded. He has
a normal LVEF, but has had recent issues with fluid
overload-likely [**2-23**] MR, TR. He was diuresed with IV lasix 4-5L,
now patient is lasix dose of 40mg daily.
.
# Hypoxia: Initially thought to be related to fluid overload /
cardiac cause. However he was suspected to have PEs in the
setting of untreated malignancy (colon cancer-he refused
surgery), he was on 4L O2 NC. Initially he was diuresed, and
his oxygenation slowly improved. He had a CTA with bilateral
subsegmental PEs, nonobstructive and an IVC filter was placed on
[**7-10**] given inability to anticoagulate due to known colon
malignancy. His oxygenation has improved to 94% on room air
prior to discharge.
# PE: Thought to be in setting of known malignancy. As above,
seen on recent CTA. Not anticoagulated due to colon malignancy,
permanent IVC filter placed.
.
# Sick Sinus: His pacer was interrogated by EP, and appears to
be working well.
He was continued on home amiodarone. As above, metoprolol was
held. He will follow-up with PCP and cardiology to discuss
restarting medication.
.
# [**Month/Year (2) 2793**] isufficiency: He appears to be at his baseline - but his
BUN was elevated on admission likely due to dehydration. [**Month/Year (2) 2793**]
function remained at baseline.
.
# Anemia: He had a recent transfusion - possibly due to
underlying malignancy.
Hct was monitored, there was no need for transfusion as he is
actually above recent baseline. Will continue iron supplements.
.
# Code status: Full, discussed with pateint.
# Communication: Daugher is HCP. [**Name (NI) 501**]
Medications on Admission:
1. Amiodarone 200 mg daily
2. Finasteride 5 mg daily
3. Furosemide 40 mg daily
4. Metoprolol Succinate 25 mg SR daily
5. Terazosin 5 mg daily
6. Aspirin 81 mg daily
7. Hexavitamin daily
8. Ferrous Sulfate 325 mg daily
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO once a day.
7. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 8 days.
8. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 8
days.
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
clostridium difficle diarrhea
pulmonary emboli
perirectal abscess
colon cancer untreated
[**Hospital6 **] insufficiency
sick sinus syndrome
Secondary:
hematuria/BPH - traumatic foley insertion and manipulation
[**3-16**] lead to urosepsis and subsequent urinary retention
sick sinus syndrome and bifascicular block s/p pacemaker [**2184**]
PAF - on amiodarone, not on coumadin d/t concern for
malignancy
H/O SVT
Atrial flutter status post ablation [**2-/2186**] - not on
anticoagulation d/t concern for malignancy
Anemia - was on arenesp and iron
BPH s/p TURMP [**2187**]
b/l edema with skin changes
hard of hearing
hx of guiaic positive stools/GI bleeding
osteoarthritis
osteoporosis
subclinical hypothyroid state as per record
right pleural effusion - Found on CT on [**2188-2-25**] for increasing
DOE. [**3-6**] and [**3-18**] thoracentesis c/w transudative. Workup during
last admission revealed RV diastolic dysfunction. Concern was
for PE as etiology, but unable to get CTA d/w ARF and V/Q not
helpful. Not anticoagulated due to h/o GIB, pleurodesis not an
option d/t transudative.
Tibial talar dislocation with comminuted distal tib fib
fracture status post surgery [**2181**]
Paget's disease of pelvis
Discharge Condition:
stable, afebrile, good po intake, diarrhea improved.
Discharge Instructions:
You were admitted with low blood pressure and were found to have
C.difficle diarrhea. You were in the medical ICU for 2 days,
your blood pressure improved after you received IV fluids and
antibiotics. You were transferred to a medical floor where your
diarrhea improved, you were found to have a perirectal abscess
which was not treated with medication due to your c.difficile
infection. You should follow up with outpatient surgery for
further treatment. Your oxygen level was low, you had a CT of
your chest that showed pulmonary emboli (blood clots in your
lungs) and an IVC filter was placed.
.
Please continue to take your medications as prescribed. You will
need to continue on the antibiotics flagyl and vancomycin as
prescribed for your c.difficile infection. Please note your
lasix dose has been increased to 40mg daily. Please note your
metoprolol and terazosin were stopped, please discuss restarting
these with your PCP.
.
You should follow up as outlined below.
.
You should seek medical attention if you have worsening
diarrhea, dizzyness, abdominal pain, chest pain ,shortness of
breath or any other concerning symptoms.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:2L
Followup Instructions:
please call your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 324**] [**Last Name (NamePattern1) 311**] [**Telephone/Fax (1) 1713**] and make an
appointment within the next two weeks
Provider: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD Phone:[**Telephone/Fax (1) 1579**]
Date/Time:[**2188-7-23**] 1:30
Provider: [**Name Initial (NameIs) 703**] (H3) GENERAL 2 RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2188-8-25**] 1:30
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2188-8-28**] 11:00
Provider: [**Last Name (NamePattern4) **].[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 8792**] on [**2188-8-14**] at
8:30am
Provider: [**Last Name (NamePattern4) **].[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2232**] Phone: ([**Telephone/Fax (1) 8793**] on [**2188-7-23**] at
11:20am
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
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"428.0",
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"715.90",
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"427.31",
"428.33",
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"276.51",
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] |
icd9cm
|
[
[
[]
]
] |
[
"89.45",
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
11954, 12020
|
6644, 10706
|
282, 288
|
13285, 13340
|
3893, 6621
|
14649, 15783
|
3104, 3298
|
10975, 11931
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12041, 13264
|
10732, 10952
|
13364, 14626
|
3313, 3874
|
221, 244
|
316, 1146
|
1168, 2974
|
2990, 3088
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,127
| 142,076
|
49109+49136
|
Discharge summary
|
report+report
|
Admission Date: [**2146-10-7**] Discharge Date: [**2146-10-11**]
Date of Birth: [**2074-10-7**] Sex: F
Service: ORTHOPEDIC
HISTORY OF PRESENT ILLNESS: This is a 71 year old female who
presented to the Emergency Department on [**2146-10-7**], with the
chief complaint status post fall. A 71 year old female with
a history of paroxysmal atrial fibrillation, pacemaker,
severe three vessel coronary artery disease, hypertension,
hyperlipidemia, type 2 diabetes mellitus, history of smoking
who presents status post mechanical fall. Overnight the
patient got up to go to the bathroom. When she ambulated to
the end of her bed on the way to the bathroom, she felt
dizzy. She then fell and hit her head and landed on her
right hip. She then dragged herself to the telephone to call
EMS. She denies vertigo, chest pain, shortness of breath,
loss of consciousness, nausea and vomiting, diaphoresis or
arm pain.
PAST MEDICAL HISTORY:
1. Atrial fibrillation.
2. Status post pacemaker.
3. Coronary artery disease.
4. Hypertension.
5. Hyperlipidemia.
6. Diabetes mellitus type 2.
7. Osteoarthritis.
8. lumbar degenerative joint disease.
9. Right foot drop.
PAST SURGICAL HISTORY:
1. Sinus surgery.
2. Umbilical herniorrhaphy.
3. Coronary artery bypass graft.
ALLERGIES: Contrast dye.
MEDICATIONS ON ADMISSION:
1. Lipitor.
2. Amiodarone.
3. Metoprolol.
4. Glyburide.
5. Accupril.
6. NPH.
7. Coumadin.
8. Diovan.
SOCIAL HISTORY: The patient lives alone, currently divorcing
husband.
PHYSICAL EXAMINATION: Blood pressure is 171/64, pulse 70,
respiratory rate 19, oxygen saturation 97% in room air. In
general, the patient was pleasant, conversant, elderly female
in bed in no acute distress. Cardiovascular is regular rate
and rhythm, normal S1 and S2. The lungs are clear to
auscultation anteriorly bilaterally. Extremities - No
cyanosis, clubbing or edema. Right lower extremity was
shortened, externally rotated.
LABORATORY DATA: On admission, white blood cell count was
9.4, hemoglobin 14.5, hematocrit 43.5, platelet count
199,000. Sodium 138, potassium 4.7, chloride 99, bicarbonate
25, blood urea nitrogen 14, creatinine 0.7.
Chest x-ray showed no pneumonia and no congestive heart
failure. CT of the cervical spine, wet read, no fracture,
giant osteophyte at C5-6 anterior and C7-T1 posterior. CT of
the head showed no intracranial hemorrhage. Right mastoid
sinus abnormalities. Loss of aeration, 3.0 millimeter soft
tissue density right tympanic cavity. Hip x-ray showed right
intertrochanteric fracture with shortening and fracture of
the lesser trochanter as well.
PLAN: At that time, the patient was preopped and made NPO
with intravenous fluids, type and cross screened two units
packed red blood cells.
HOSPITAL COURSE: The patient was brought to the operating
room on [**2146-10-8**], for open reduction and internal fixation
right intertrochanteric fracture. Surgery went without
complication. The patient was transferred on [**2146-10-9**], from
the SICU to the floor. The patient had no events. On
[**2146-10-10**], cardiology saw the patient with recommendations to
decrease intravenous fluids, give a small dose of Lasix
intravenously, continue her current insulin regimen and to
increase and encourage incentive spirometry. Postoperative
day two, the patient was without complaints, denied fevers,
chills, chest pain or shortness of breath. Hematocrit was
30.3 and INR was 1.4. Cardiovascular was regular rate and
rhythm. Lungs with slight rales in the right lower lobe.
Right lower extremity incision was clean, dry and intact.
Sensation and motor intact. Capillary refill less than two
seconds. Dorsalis pedis 1+. A 72 year old female status
post open reduction and internal fixation, right
intertrochanteric fracture. The patient was increased to
full weight-bearing right lower extremity. Physical therapy
was consulted to evaluate and treat incentive spirometer.
The patient was given intravenous Lasix 20 mg times one now
per cardiology recommendations. Foley was discontinued at
that time. Dressing was changed, and the patient was
screened for rehabilitation with tentative placement on
[**2146-10-11**]. The patient was also weaned off oxygen face mask
and currently is 94 to 95% in room air. The patient will be
discharged on [**2146-10-11**].
DISCHARGE INSTRUCTIONS: Full weight-bearing right lower
extremity. Coumadin 5 mg p.o. q.h.s. Please have house
officer adjust dose as needed for goal INR of 1.5 to 2.0.
The patient will need to be anticoagulated for a six week
course.
FINAL DIAGNOSIS: Right femur fracture.
FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) 9694**] in
two weeks of [**Location (un) 86**] Orthopedic Group, telephone [**Telephone/Fax (1) 42114**].
CONDITION ON DISCHARGE: Good.
MEDICATIONS ON DISCHARGE:
1. Tylenol 325 mg one to two tablets p.o. q4-6hours p.r.n.
2. Amiodarone 200 mg tablets, one tablet p.o. once daily.
3. Pantoprazole 40 mg tablet delayed release one tablet p.o.
Once daily.
4. Lisinopril 20 mg tablet, two tablets p.o. once daily.
5. Valsartan 160 mg tablets, one tablet p.o. once daily.
6. Metoprolol 50 mg tablets, one tablet p.o. twice a day.
7. Atorvastatin Calcium 10 mg tablets, one tablet p.o. once
daily.
8. Glyburide 5 mg tablets, one tablet p.o. twice a day.
9. Coumadin 5 mg tablets, one tablet p.o. once daily. Once
again, please have house officer adjust dose as needed for
goal INR of 1.5 to 2.0.
10. Insulin sliding scale with sliding scale add 6 doses of
Glyburide. The patient will be on diabetic consistent
carbohydrate diet.
11. The patient will need continued physical therapy and
should be out of bed with assistance, right lower extremity
full weight-bearing.
[**Name6 (MD) **] [**Last Name (NamePattern4) 9697**], M.D. [**MD Number(1) 9698**]
Dictated By:[**Last Name (NamePattern1) 20276**]
MEDQUIST36
D: [**2146-10-10**] 14:44
T: [**2146-10-10**] 17:59
JOB#: [**Job Number 103046**]
Admission Date: [**2146-10-7**] Discharge Date: [**2146-10-11**]
Date of Birth: [**2074-10-7**] Sex: F
Service:
ADDENDUM
The patient is a 71-year-old female scheduled to be
discharged to an acute rehabilitation facility on [**2146-10-11**]. Her postoperative course has been uneventful, and
she has had a good recovery.
However, on [**2146-10-10**], routine postoperative labs
showed a gradually decreased platelet count of 68,000. It
should be noted that preoperative platelet levels on [**2146-10-7**], were 199,000, and gradually trended downward with [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 12899**] at 62,000.
The trend downward in her platelets had been gradual from
199,000 to 100,000, which could be associated with platelet
loss due to intraoperative blood loss. Decrease following
that can be matched when she had received her first dose of
Heparin.
Given these findings, it was deemed appropriate to have
Hematology/Oncology Service consult. They indeed were kind
enough to come and evaluate her.
Per their suggestion, Heparin antibodies were sent, and
serotonin release assay was added. These results are pending
at the time of discharge. Upon further recommendation, all
Heparin has been stopped.
The patient is encouraged to follow-up on this issue with her
primary care physician and should [**Name9 (PRE) 702**] on this should
she ever need Heparin again.
[**Name6 (MD) **] [**Last Name (NamePattern4) 9697**], M.D. [**MD Number(1) 9698**]
Dictated By:[**Name6 (MD) 103095**]
MEDQUIST36
D: [**2146-10-11**] 11:24
T: [**2146-10-11**] 11:23
JOB#: [**Job Number 103096**]
|
[
"285.1",
"V45.01",
"E885.9",
"427.31",
"401.9",
"820.21",
"287.5",
"V45.81",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.35"
] |
icd9pcs
|
[
[
[]
]
] |
4867, 7743
|
1343, 1453
|
2794, 4351
|
4608, 4809
|
4376, 4590
|
1207, 1317
|
1548, 2776
|
173, 932
|
954, 1184
|
1470, 1525
|
4834, 4841
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,534
| 164,328
|
5863
|
Discharge summary
|
report
|
Admission Date: [**2162-7-8**] Discharge Date: [**2162-7-13**]
Date of Birth: [**2091-6-8**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Patient is a 71-year-old man
with history of metastatic carcinoid tumor of bronchial
origin (metastatic to bone and liver) status post multiple
chemotherapy treatments, resection of tumor from left upper
lobe of lung in [**2146**], chemoembolization of liver metastases
([**2152**], [**2153**]), and is currently on a clinical trial of an oral
tyrosine kinase inhibitor affecting VEGFR/PDGFR families,
SU011248, also known as Sugen and concurrently taking
Sandostatin. Over the years he has had multiple episodes of
flushing/diarrhea with carcinoid crises.
The patient was in his usual state of health until five days
prior to admission when he developed facial and upper
thoracic flushing, tachycardia, tachypnea, diaphoresis,
nausea, vomiting, and fatigue. Over the course of the few
days, the emesis became bloody and the patient developed
maroon-colored stools. When his fatigue became intolerable,
his wife brought him to an outside hospital, where he was
found to be hypotensive blood pressure 77/52, and
tachycardic, heart rate 122. He was given fluid boluses, had
a single episode of syncope with a blood pressure of 56
systolic/palp. He received 1 unit of packed red blood cells
and his vital signs stabilized. He was transferred to the
[**Hospital Ward Name 332**] Intensive Care Unit on [**7-8**] as he primarily
gets his care at the [**Hospital1 69**].
PAST MEDICAL HISTORY:
1. Carcinoid tumor.
2. Upper gastrointestinal bleed in [**2159**] found to be candidal
esophagitis.
3. Formally used alcohol, but quit in [**2159**].
MEDICATIONS ON ADMISSION:
1. Ibuprofen prn--increased use prior to admission
2. Sandostatin q month.
3. Sugen.
ALLERGIES: Horse serum - the patient develops a rash.
SOCIAL HISTORY: The patient is married with five children.
Lives with wife. Is a retired lawyer and formally drank [**1-26**]
drinks per day, but quit in [**2159**].
FAMILY HISTORY: Significant for a brother with hepatic and
pancreatic cancer. Father liver cancer. Mother abdominal
cancer and grandparents both died of cancer.
PHYSICAL EXAM ON ADMISSION: Temperature 98.0, blood pressure
100/60, heart rate 121, respirations 16, and oxygen
saturation 94% on room air. Generally, patient was pale,
pleasant, and lethargic gentleman in no apparent distress.
HEENT revealed no oral lesions, but dry oral mucosa. Neck
was supple with no jugular venous distention and no
lymphadenopathy. Lungs were clear bilaterally. Heart sounds
were regular, but tachycardic, no murmurs. Abdominal
examination was benign. Liver margin palpated 1 cm below
costal margin. Extremities showed no edema. Patient had no
rashes. Neurologic examination: Patient was alert and
oriented times three, full strength, 1+ deep tendon reflexes
at patella, but absent ankle jerk reflexes.
LABORATORIES ON ADMISSION: White count 11.3, hematocrit
23.7, platelets 125. INR 1.6, PT 15.4, PTT 25.4. Normal
electrolytes. BUN and creatinine 54 and 0.8. ALT 232, AST
688, alkaline phosphatase 159, total bilirubin 0.8. Lactate
dehydrogenase 1870, CK 1553.
SUMMARY OF HOSPITAL COURSE:
1. Atrial fibrillation: On admission to the [**Hospital Unit Name 153**], the
patient was found to be in atrial fibrillation and was
converted to normal sinus rhythm with 5 mg of IV Lopressor,
and he has remained in normal sinus rhythm ever since.
2. GI: An esophagogastroduodenoscopy was performed on the
morning of [**7-9**], and revealed severe esophagitis, mild
antral gastritis, but no site of active bleeding. The
patient was started on IV Protonix for 24 hours and then was
switched to Protonix 40 mg po bid, which he is to continue
for at least one month.
With regards to his maroon-colored stool, it was felt that
although this could be secondary to the upper GI bleed, a
lower source of bleeding should be ruled out and a
colonoscopy is recommended as an outpatient. As patient had
a history of candidal esophagitis, he was also started on an
empiric course of nystatin swish and swallow this admission,
however, no biopsies were obtained during the EGD to confirm
this diagnosis.
3. Elevated liver function tests: These were likely
secondary to shock liver from the hypotensive episode the
patient had the outside hospital. LFTs continued to trend
down throughout his admission as blood pressure remains
stable. On day of discharge, ALT was 50, AST 28, alkaline
phosphatase 151, and a total bilirubin of 1.4. No further
intervention was necessary at this time.
4. Anemia: Patient was found to have a very low hematocrit
of 23 on admission. He was transfused 4 units of packed red
blood cells in the Intensive Care Unit, and required another
2 units on the floor. His hematocrit remained above 30 a
few days prior to discharge. He was to followup closely
regarding need for a subsequent transfusion.
5. Infectious disease: Once transferred out of the unit onto
the floor, the patient complained of a chest pain across the
lower right aspect of his sternum and he developed a fever of
101.2. Although he was sating well on room air at rest, it
was noted that the patient had an ambulatory saturation in
the mid 80s. A chest x-ray was done, which initially was
negative for an infiltrate, however, clinical suspicion was
high. A CT scan was performed which showed left lower lobe
pneumonia. The patient was started on clindamycin and Levaquin.
He remained afebrile and by the day of discharge had an
ambulatory oxygen saturation greater than 95%.
6. Pneumothorax: On admission to the Intensive Care Unit, a
right sided triple lumen catheter was placed, which resulted
in a small pneumothorax, which was stable throughout his
hospital per serial chest x-rays and CT scans. No further
intervention was required.
7. Rule out myocardial infarction: When patient first
presented to the Intensive Care Unit, he had elevated CKs and
an electrocardiogram showing ST depressions in the
inferolateral leads. He proceeded to rule out for myocardial
infarction via serial enzymes and follow-up
electrocardiograms. This is most likely secondary to demand
ischemia from hypovolemia.
DISCHARGE DIAGNOSES:
1. Upper gastrointestinal bleed secondary to esophagitis.
2. Paroxysmal atrial fibrillation.
3. Left lower lobe pneumonia.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg po bid.
2. Lidocaine solution 5 mL swish and swallow tid.
3. Nystatin swish and swallow 5 mL po qid.
4. Clindamycin 300 mg po q8h for seven days.
5. Levaquin 500 mg po q day for seven days.
6. Colace 100 mg po bid.
7. Neutra-Phos one packet po bid.
The patient was instructed to continue taking Protonix twice
a day for at least one month and to followup with his primary
doctor regarding the plan for discontinuation of this
medication. He was also instructed to not take any aspirin,
ibuprofen, Naprosyn, or other nonsteroidal anti-inflammatory
medications. He was also instructed to avoid caffeine,
smoking, or any other stomach irritants. It was recommended
that he get a colonoscopy as an outpatient, as well as repeat EGD
with biopsy. He is to follow up with Dr. [**First Name (STitle) **] in
Hematology/[**Hospital **] Clinic on [**7-20**] at 9:30 in the morning
and also to followup with Dr. [**Last Name (STitle) 23206**], [**Hospital **] Clinic on [**7-30**]
at 11 in the morning.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 23207**]
Dictated By:[**Last Name (NamePattern1) 2543**]
MEDQUIST36
D: [**2162-7-14**] 17:49
T: [**2162-7-17**] 08:43
JOB#: [**Job Number 23208**]
|
[
"578.9",
"276.5",
"V10.11",
"530.10",
"198.5",
"486",
"427.31",
"197.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
2054, 2216
|
6263, 6387
|
6444, 7731
|
1726, 1868
|
3235, 6242
|
154, 1527
|
2969, 3207
|
2813, 2954
|
1549, 1700
|
1885, 2037
|
6412, 6421
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,068
| 105,351
|
51263
|
Discharge summary
|
report
|
Admission Date: [**2190-10-30**] Discharge Date: [**2190-11-23**]
Date of Birth: [**2120-11-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2972**]
Chief Complaint:
Right flank pain
Major Surgical or Invasive Procedure:
Invasive ventilation
History of Present Illness:
69 y/o male with CAD s/p CABG, atrial fibrillation s/p BIV pacer
and on warfarin, CHF (EF >55% in [**2188**]), DM type 2, p/w acute
onset of right flank pain this morning. Pain intermittently
radiates to groin. Reports increased abdominal pressure and
weight gain of eight lbs in recent weeks, and also endorses
headache and dyspnea on exertion (cannot climb single flight of
stairs without having to stop). Denies trauma, hematuria,
dysuria, dark stools, constipation, chest pain, palpitations,
fevers or chills. Reports history of kidney stone many years
ago.
.
In the ED, initial vs were: T98.6 60 150/61 18 94% RA. Abdominal
CT revealed markedly abnormal R kidney with evidence of
renal/perirenal hemorrhage. Patient was seen by Urology, who
recommended medical admission for reversal of INR, pain control,
and serial Hct checks and repeat CT in two days. Patient was
given morphine & dilaudid with good analgesic effect.
.
On the floor, patient appears comfortable, but requesting
further pain medications
Past Medical History:
- Hypertension
- Hyperlipidemia
- Systolic heart failure, history of low EF with improvement on
TTE [**12/2188**] (LVEF>55%)
- Hx of inducible VT, s/p upgrade to a BiV ICD [**2186**]
- CAD s/p CABG [**2163**]; s/p DES to LAD in [**2186**]; history of MI
- Atrial fibrillation/flutter
- Diabetes mellitus, diagnosed 7 years ago, HgA1c 8.5% in [**August 2190**]
- OSA on CPAP with 3 liters O2
- ? Reactive airway disease
- Chronic renal insufficiency, stage 3 disease, baseline Cr ~2.8
- history of Strep bovis bacteremia c/b acute renal failure [**2188**]
- Hypothyroidism
- Bronchitis
- s/p resection of benign colon polyps
-s/p cholecystectomy
- Gout
- GERD
Social History:
Patient is retired previously worked as a manager in a paint
factory. Remote 40 pack-year tobacco history. No EtOH use, no
illicit drug use. Lives with wife at home
Family History:
Brother also with CABG at age 60 doing well. Mother died during
childbirth, father died of cirrhosis that pt thinks was alcohol
related.
Physical Exam:
Vitals: T:97.3 BP:132/80 P:81 R:20 O2:95 on 2L FSG: 284
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, no conjunctival
pallor or injection
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, + wheezes with forced
expiration, no crackles
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Scattered erythematous spots at sites of insulin
administration. Tense, obese abdomen, distended, bowel sounds
present, tender to deep palpation on RLQ and R flank, abdominal
exam limited by habitus, no shifting dullness or fluid wave
appreciable, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No rashes or ulcers
Neuro: CNII-XII intact, no focal abnormalities
Motor: 5/5 strength in UE and LE
Sensation: intact bilaterally in LE and UE
DTR: 2+ bilaterally
Coordination: [**Doctor First Name **] intact
Gait: not assessed
Pertinent Results:
On admission:
[**2190-10-30**] 09:45AM BLOOD WBC-13.7*# RBC-4.49* Hgb-12.8* Hct-38.6*
MCV-86 MCH-28.6 MCHC-33.2 RDW-16.8* Plt Ct-175
[**2190-10-30**] 09:45AM BLOOD Neuts-86.1* Lymphs-7.9* Monos-4.3 Eos-1.1
Baso-0.6
[**2190-10-30**] 09:45AM BLOOD PT-25.7* PTT-27.1 INR(PT)-2.5*
[**2190-10-30**] 09:45AM BLOOD Glucose-215* UreaN-38* Creat-2.8* Na-146*
K-4.5 Cl-111* HCO3-24 AnGap-16
[**2190-10-30**] 09:45AM BLOOD ALT-14 AST-17 AlkPhos-115 Amylase-66
TotBili-0.3
[**2190-10-30**] 09:45AM BLOOD Lipase-33
CT: CT ABDOMEN WITHOUT IV CONTRAST: The patient is status post
median sternotomy with right atrial and left ventricular pacing
leads as well as right ventricular AICD lead; these are
incompletely visualized on the current study. There are new
moderate right and tiny left pleural effusions with adjacent
relaxation atelectasis. No nodules seen in the visualized lung
bases.
Assessment of the solid organs is limited due to lack of IV
contrast
administration. The non-enhanced liver demonstrates a tiny 5-mm
hypodensity along the left dome of the liver (2:10), too small
to accurately characterize. No gallbladder is seen probably due
to prior surgical removal. The nonenhancing spleen, pancreas,
adrenal glands, left kidney, and the non-opacified stomach and
small bowel appear unremarkable. Again note is made of extensive
colonic diverticulosis, without evidence of diverticulitis.
There is very abnormal appearance to the right kidney which is
expanded and demonstrates heterogeneous appearance with multiple
densities. Areas of high density likely represent subcapsular
and intraparenchymal acute hemorrhage. It is difficult to
discern the kidney margin, however, note is made that previously
seen indeterminate 12 mm lesion which is partially exophytic
arising from the upper pole of the right kidney currently
measures approximately 22 mm (300B:47) and is separate from the
current hemorrhagic process. There is also extracapsular
extension of the hemorrhage from the lower pole of the right
kidney into the perinephric space which is expanded and causes
mass effect on the adjacent IVC and duodenum. No nephrolithiasis
and no definite hydronephrosis is noted.
The abdominal aorta contains mural calcifications as well as
mural
calcifications along the origin of the major abdominal arteries,
without
aneurysmal dilatation. No lymph node enlargement is seen meeting
size
criteria for adenopathy.
CT PELVIS WITHOUT IV CONTRAST: The urinary bladder, prostate,
seminal
vesicles, and rectum appear unremarkable on this non-enhanced
study. There is sigmoid diverticulosis, without evidence of
diverticulitis. There are
bilateral fat-containing inguinal hernias. No pelvic fluid, free
air, or
adenopathy is noted.
OSSEOUS STRUCTURES: Degenerative changes are noted along the
visualized
thoracolumbar spine, particularly noted at the L2-3 and L5-S1
levels which
causes some narrowing of the spinal canal. No region of bony
destruction is seen concerning for malignancy. Degenerative
changes are also noted at the sacroiliac joints and the hips.
IMPRESSIONS:
1. Markedly abnormal right kidney, with likely subcapsular and
intraparenchymal acute hemorrhage. There is marked heterogeneous
appearance to the kidney, making delineation of the parenchyma
difficult. There is also extracapsular extension of hemorrhage
from the lower pole. No stone or hydronephrosis seen. Etiology
indeterminate; possibilities include trauma, underlying mass
(not previously seen in [**2188**]), or AV malformation. If cardiac
pacer is MRI compatible and patient's GFR allows administration
of IV gadolinium, MRI may be helpful. Preexisting small upper
pole mass (cf. Impression #2 ) likely not involved in this acute
process.
2. Increased size of right upper pole nodule from 12 to now 22
mm since
[**2188-6-19**].
3. Moderate right pleural effusion.
Brief Hospital Course:
This is a 69yo man with history of CABG, atrial fibrillation
with pacer/defibrillator on coumadin, systolic CHF, and DMII who
p/w acute onset of R-sided flank pain on [**2190-10-30**] found to have
retroperitoneal hemorrhage possibly from renal cyst, transferred
to ICU on day of admission for hypoxia, hypotension, oliguric
acute renal failure with ATN requiring HD, and concern for ACS.
.
(#) Hypoxia. On day 1 of admission the patient triggered for an
episode of guaic positive emesis and hypoxia to the 80's. This
was thought to be post-tussive emesis with aspiration. He was
started on an 8 day course of azithryomycin, vancomycin, and
ceftriaxone to cover for community acquired pneumonia and
culture positive Klebsiella pneumonia. By the time he arrived to
the ICU his CXR also showed signs of volume overload. Following
which, his Hct was noted to drop and he required aggressive
volume and blood product resuccitation. For volume overload,
caused by aggressive IVF and blood procduct resucitation,
diuresis was attempted, but he developed an oliguric renal
failure in the setting of his hypotension and was unable to
produce sufficient UOP for diuresis. He was started on CVVH
given his hypotension which was complicated by numerous filter
clottings. Blood pressure improved and HD was initated. His
kidneys showed some recovery and aggressive diuresis was
undertaken. Volume status improved and he was extubated. He
was weaned to nasal canula. Given improvement in his
respiratory state he was called out to the floor where with
continued diuresis he was weaned off nasal canula to room air.
(#) POSSIBLE UGIB: Pt had episode of guaiaic positive emesis in
context of severe cough and post-tussive emesis. Shortly
afterwards, his GI secretions cleared. He was started on [**Hospital1 **]
ppi and required no further intervention.
.
(#) Retroperitoneal bleed: Pt initially presented with R flank
pain, CT scan noted right retroperitoneal bleed possibly from
renal cyst rupture. Coumadin was reversed with FFP, but given
worsening renal failure repeat CT was obtained which showed
enlarging of the hematoma. Hct also noted to drop a nadir of
20.2 (38.6 on admission) He was given aggressive volume and
blood product resucitation. He was given 3 units of RBCs,
8units FFP, and 1 units plasma. Following which his Hct
remained generally stable although lower than baeline thought to
be precipitated by overphlebotomization and poor hematopoesis in
the setting of pneumonia and renal failure.
.
(#) Acute renal failure on Chronic Kidney Injury: He has history
of chronic renal funciton with baselin creatinine likely in mid
2s, which was abruptly worsened in the setting of hypotension
and he developed oliguric ATN. He required hemodialysis
throughout his hospitalization. With conversion of ATN to
non-oliguric variety, HD was held to observe return of renal
function. Renal function was slowly improving at the time of
discharge.
.
(#) Myocardial Ischemia: On transfer to the ICU, ST changes were
noted on ECG which were considered to be artifact by the cards
fellow. MI was ruled out. He was continued on statin. ASA was
held given the acute bleed.
.
(#) Fever/Leukocytosis - He was noted to have a Klebsiella
pneumonia (pansensitive) treated with ceftriaxone and pan
sensitive Enterococcus UTI treated with Vancomycin. All blood
cultures were negative, although he was noted to have a pyogenic
skin/line infection at the site of central LIJ.
.
# CHF (h/o systolic dysfunction, though normalized on [**2188**]
echo): Pt reports history of mild edema and recent weight gain.
Known systolic dysfunction although LVEF in [**2188**] >55%. ECHO was
repeated given concern of change in heart failure in setting of
possible MI, which showed EF of 35%. Another repeat ECHO was
performed to showed improvement with EF 45-50%.
.
#Atrial fibrillation: Pt had history of inducible VT, s/p
upgrade to a BiV ICD [**2186**] (defibrillated 1x). During this
hospitalization he had several episodes of wide complex afib
(confimred by EP). HR control with home dose of amiodarone was
continued. Metoprolol was started and uptitrated to maintain HR
<100.
.
# DMII: Pt's insulin regimen was changed throughout the course
of his hospitalization several times to maintain BG between
100-200. [**First Name8 (NamePattern2) **] [**Location (un) 805**] of [**Last Name (un) **] folows his DM, as pt is on a
study drug for kidney disease
.
#HTN: After hypotension was addressed, pt's became hypertensive.
Metoprolol was uptitrated. He was also started on nitrate.
Home diovan was held given his changing renal function.
.
#Hypothyroidism: He was continued on levothyroxine sodium 125
mcg
.
#Gout: The patient was continued on home dose of alloprunol,
adjusted dose given changing renal fucntion.
.
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
================================================================
Post discharge to do at rehab
Please draw Chem 7 and fax to Dr. [**Last Name (STitle) **] and Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**]
([**Last Name (un) **]) Phone number ([**Telephone/Fax (1) 817**].
Please follow finger stick blood sugars and adjust insulin
accordingly
Medications on Admission:
folic acid 800mg 1 tab daily
simvastatin 40 mg bedtime
warfarin 5mg a day
aspirin 81mg 1 tab daily
diovan 320 mg 1 tab daily
metoprolol tartrate 50mg 2 tabs daily
calcitriol 25 mg 1 tab daily
allopurinol 100mg 1 tab daily
amiodarone 200 mg 1 tab daily
furosemide 20 mg three times a week
levoxyl 125 mg daily
insulin lantus 44 units am
humalog sliding scale at meals 7-13 units
insulin novalog 46 units bedtime
symlin pen 120/units before lunch and dinner
Discharge Medications:
1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
5. Outpatient Lab Work
Please check HCT and chem-10 three times per week m/w/f for the
next two weeks and fax results to [**Telephone/Fax (1) 8474**] Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
6. humalog 100U/ml sliding scale up to 20units premeals as
directed
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours).
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. Lantus 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous once a day: Please take in the morning.
10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO three times a day.
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
14. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO three
times a day: With meals.
15. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
16. Epoetin Alfa 3,000 unit/mL Solution Sig: 3000 (3000) Units
Injection QMOWEFR (Monday -Wednesday-Friday).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Primary:
retroperitoneal hemorrhage
Aspiration pneumonia
Acute renal failure
Acute tubular necrosis
Acute systolic heart failure
Secondary:
Chronic renal insufficiency
Atrial fibrillation
Congestive heart failure
Diabetes Type II
CABG
Discharge Condition:
Stable, Afebrile
Discharge Instructions:
You were admitted to [**Hospital1 18**] on [**2190-10-30**] for sudden onset right
flank pain. A CT scan showed bleeding in the right kidney. You
developed a pneumonia and were treated with a course of
antibiotics. Your blood pressure was low resulting in kidney
injury that required temporary hemodialysis. There was a concern
that you may be having a heart attack although the blood tests
were negative for this.
Please continue your home medications with the following
changes:
1. CHANGE your dose of lasix to 20mg once a day
2. STOP taking valsartan (diovan)
3. STOP taking coumadin (Warfarin)
4. INCREASE metoprolol to 50mg three times per day
5. Decrease lantus to 40U every morning
6. Stop Symlin (discuss this with your primary care doctor)
Weight yourself each morning and if weight increases >3 pounds
contact MD.
You should have your blood drawn three times per week and the
results faxed to Dr. [**Last Name (STitle) **].
.
Please return to the emergency department for fever, chills,
shortness of breath, or worsening symptoms.
Followup Instructions:
Please have a potassium, Creatinine and BUN drawn three times
per week and faxed to Dr. [**Last Name (STitle) **].
.
1. [**First Name8 (NamePattern2) **] [**Location (un) 805**]
[**Hospital1 18**]-Division of Nephrology View Map
[**Last Name (NamePattern1) 439**], LMOB Suite #7
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 673**]
Thursday [**12-9**] 4:30PM
2. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location:CARDIOLOGY ASSOCIATES OF GREATER [**Location (un) **]
Address:[**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 809**]
Phone:[**0-0-**]
Please follow up with Dr. [**Last Name (STitle) **] in [**1-29**] weeks
3. [**Doctor First Name **] Das
[**Hospital1 69**] View Map
[**Location (un) 830**], [**Hospital Ward Name 23**] [**Location (un) **]
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 921**]
Please call to schedule a follow up appointment in 3 months. You
will need an order to get a CT scan done before this meeting -
please inform the secretary of this when you schedule an
appointment.
Completed by:[**2190-11-23**]
|
[
"428.0",
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"414.00",
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icd9cm
|
[
[
[]
]
] |
[
"93.90",
"96.72",
"96.6",
"96.04",
"38.95",
"38.91",
"99.15",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
14516, 14596
|
7283, 12495
|
335, 358
|
14876, 14895
|
3420, 3420
|
15988, 17176
|
2281, 2420
|
13002, 14493
|
14617, 14855
|
12521, 12979
|
14919, 15965
|
2435, 3401
|
279, 297
|
386, 1400
|
3434, 7260
|
1422, 2083
|
2099, 2265
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,142
| 137,726
|
18496
|
Discharge summary
|
report
|
Admission Date: [**2109-6-5**] Discharge Date: [**2109-7-5**]
Date of Birth: [**2071-4-30**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 1042**]
Chief Complaint:
DTs, Intubated. Transfer from outside hospital.
Major Surgical or Invasive Procedure:
1. Intubation
2. Tracheostomy
3. Video swallow study
4. Numerous temporary central venous catheters
5. EGD
History of Present Illness:
38 yo M h/o asthma, HTN, macrocytic anemia, erosive gastritis
admitted to OSH w/pancreatitis. Pt had and EGD 6 days prior to
initial admission due to "blood in stools" which found errosive
gastritis. He had been taking Immodium due to diarrhea, he
denied any hematemesis, melena or hematochezia. His wife denied
any h/o DTs, or hospitalizations for ETOH abuse/withdrawal,
seizure or pancreatitis. He presented to OSH on [**2109-5-29**] for
epigastric pain, N/V x2 days. Initial Lipase 3223, amylase 314
and Abd CTO c/w severe pancreatitis w/o any evidence of
pancreatic necrosis or abscess. He was agressively resuscitated
with IVF, pain control with dilaudid and kept NPO. On 1st night
of admission he was transferred to the ICU for increasing
agitation thought to be ETOH withdrawal, requiring high doses of
benzos, in which he was eventually started on an ativan drip. On
[**6-1**] he developed a fever 102.5 and started on imepenem. His HCT
also dropped from 26.5 to 23% and transfused PRBC.
.
On [**6-2**] his agitation increased and his ativan was increased,
placed in 4 point restraints due to severe agitation, he
developed acure respiratory distress concerning for pulm edema
in the setting IVF and PRBC transfusions (unclear number of IVF
and PRBC transfusions). Diuresis was initiated. Psychiatry also
evaluated the pt whom recommended ativan gtt + haldol 10mg q6hr
+ haldol prn for presumed DTs.
On [**6-3**] his restraints were removed, started a clear diet,
resumed his lisinopril for HTN, and imepenem d/c'd due to
negative cultures and CXR.
On [**6-4**] his haldol dose was increased, he was maintained on a
higher dose of ativan gtt, he had an acute episode of hypoxia at
10pm-acute respiratory distress and intubated. CTA was negative
for PE, no evidence of PNA.
On [**6-5**] he had another fever to 103, tachycardic, haldol use,
elevated CK 3800- Neuroleptic malignant syndrome was considered.
The pt was put back on ativan gtt at an increased dose to
20mg/hr and fentanyl gtt prior to transfer. Per family request
he was transferred to [**Hospital1 18**] for further care.
Past Medical History:
-Extensive ETOH abuse, drinks 1.5 pints Vodka per day may be 3
pints since the age of 18, no prior h/o DTs or ETOH withdrawal,
but admits to black outs and tremors.
-Erosive gastritis
-Asthma
-GERD/PUD
-HTN
-chronic diarrhea
-macrocytic anemia
-s/p MVA [**2095**] with R leg/foot skin grafts
-anxiety/agitation
-h/o physical abuse
Social History:
-Married w/4 children, works in construction, +TOB 1ppmonth
-Extensive alcohol abuse as noted above, no h/o DTs or
hospitalizations for ETOH w/drawal or abuse
-per wife, denies any other form of drug abuse
Family History:
Unable to obtain due to intubation
Physical Exam:
On arrival to MICU:
GEN: Intubated, sedated
HEENT: ETT in place, PERRL
RESP: CTABL anteriorly, diminished BS at bases b/l
CV: Reg Nml S1, S2, no M/R/G
ABD: Soft, ND, NT diminished BS
EXT: No peripheral edema, warm, 1+ DP pulses
NEURO: Sedated
Pertinent Results:
-CXR
The tip of the endotracheal tube is 7 cm above the carina.
There is a feeding tube whose distal tip is beyond the
gastroesophageal junction. There is mild cardiomegaly. There
is low lung volumes with crowding of the pulmonary vascular
markings at the lung bases. There is a left retrocardiac opacity
and blunting of bilateral costophrenic angles suggestive of
small pleural effusions. No overt pulmonary edema is seen.
.
OSH IMAGING:
-[**5-30**] Abd U/S
Mild hepatosplenomegaly. The liver shows increased echogenicity
suggesting fatty infiltration, spleen enlarged at 15.7 cm,
kidneys are normal in size
-[**5-30**] Abd CT
CT findings compatible with severe pancreatitis. The pancreas is
diffusely enlarged and has extensive high-attenuation stranding
and surounding fluid. No loculated drainable fluid collection is
identified.
.
CTA CHEST:
IMPRESSION:
1. Pulmonary embolus within the distal right main pulmonary
artery extending into the proximal upper and lower lobe
branches. Questionable filling defects within the left lower
lobe branches may be breathing/mixing artifact.
2. Mild amount of retained secretions within the distal trachea
and proximal main stem bronchi.
3. Splenomegaly and mild peripancreatic mesenteric stranding
consistent with known history of pancreatitis.
.
CT SINUS:
IMPRESSION: Sinus thickening in multiple paranasal sinuses with
features as described above. No air fluid levels
.
CTA ABDOMEN [**6-19**]:
IMPRESSION:
1. Resolving pancreatitis with mild fat stranding suggestive of
inflammation. No evidence of pancreatic necrosis. Fluid tracking
from the head of the pancreas and extending along the right
anterior pararenal and paracolic spaces has decreased since
prior examination. No organized fluid collections or abscesses.
2. Splenomegaly is unchanged since prior examination.
.
TEE:
No thrombus is seen in the left atrial appendage. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thickness, cavity size, and systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. No valvular vegetations or paravalvar abcesses
seen.
IMPRESSION: No echo evidence of endocarditis.
.
[**2109-6-22**] 3:27 am BLOOD CULTURE Source: Line-left SC.
**FINAL REPORT [**2109-6-26**]**
AEROBIC BOTTLE (Final [**2109-6-26**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL
SENSITIVITIES.
Please contact the Microbiology Laboratory ([**6-/2408**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 2ND COLONIAL
MORPHOLOGY.
FINAL SENSITIVITIES.
Please contact the Microbiology Laboratory ([**6-/2408**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance Oxacillin RESISTANT Staphylococci MUST be
reported as
also RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
ERYTHROMYCIN---------- =>8 R =>8 R
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- 0.25 S <=0.12 S
OXACILLIN-------------<=0.25 S =>4 R
PENICILLIN------------ =>0.5 R =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 2 S
ANAEROBIC BOTTLE (Final [**2109-6-26**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
SENSITIVITIES PERFORMED FROM AEROBIC BOTTLE.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 2ND COLONIAL
MORPHOLOGY.
SENSITIVITIES PERFORMED FROM AEROBIC BOTTLE.
Brief Hospital Course:
38 yo M with extensive ETOH abuse, p/w alcoholic pancreatitis
and ETOH withdrawal/DTs. Developed respiratory distress in the
setting of IV fluid resusitation, intubated [**6-2**], did not
tolerate extubation x 2. Persistent agitation along with course
c/b line infections & development of PE despite SQ heparin had
prevented extubation. Trached on [**6-27**], currently off the vent
and tolerating.
.
#. Agitation/sedation: 3+ weeks out from large volumes of ETOH,
course c/b DT's, also requiring seroquel, versed, fentanyl;
Propofol off . Previously on large doses of diazepam. Has
improved on seroquel. Successfully weaned off versed and
fentanyl this morning. Now mental status is much improved as
patient is awake/ alert/ interacting with team, and is requiring
less prn haldol. After transfer from ICU, all psychotropic
medications were discontinued the patient had no further
episodes of anxiety or agitation.
.
#. Respiratory failure: Initially intubated for ETOH withdrawl,
difficult to wean from vent secondary to agitation. Failed
extubation twice. Found to have PE on CTA of chest, started on
heparin drip and transitioned to warfarin. S/p tracheostomy
with 8f ETT by IP [**6-27**], on trach collar 40% FI02 with good sats.
Has been on multiple sedatives for agitation (seroquel, versed,
fentanyl, propofol), with improved mental status with seroquel &
haldol prn. The patient was maintained on respiratory toilet and
care and was cleared to use a Passy-Muir valve.
.
#. Asthma: the patient continued to have a significant amount of
wheezing and his asthma regimen was titrated to include
fluticasone inhaler, salmeterol diskus, montelukast, and
tiotropium. Albuterol was maintained for rescue breathing.
.
#. Infection: s. epi bacteremia from central line. currently
afebrile. TEE negative [**6-24**]. [**2030-6-24**] cultures negative to date.
Troughs show vanc levels appropriate 18.6([**6-27**]). Continue
vancomycin - for 2 week course to complete in 6 days after
discharge. Levels will need to monitored every 2-3 days with a
goal trough of [**9-21**] mcg/mL.
#. Pancreatitis: ETOH pancreatitis. Lipase, amylase have been
trending down; now wnl. Resolving fluid collection on abdominal
CT, negative abdominal exam, LFT's normalized now. The patient
was asymptomatic after transfer from the ICU.
.
#. Anemia: Negative workup for hemolysis, negative SPEP, no
iron/folate/B12 deficiency, near-appropriate retic count
suggests decent bone marrow response. Pattern suggests some
degree of chronic disease + ?intermittent acute bleeding. Pt
has h/o gastritis/gastric ulcer in [**Last Name (LF) **],[**First Name3 (LF) **] wife and has been
guaiac positive. Gross hematuria after starting heparin drip,
but negative UA's for past few days. Hct is stable. The patient
was maintained on a PPI after ICU transfer and his hematocrit
remained stable.
.
#. Pulmonary embolus: the patient was diagnosed with pulmonary
embolus and started on warfarin anticoagulation. On [**7-3**] he was
noted to be supratherapeutic with an INR of 6.7. His warfarin
has since been on hold and on discharge remained >5. His goal
INR is 2.5 (range 2-3) for a treatment of 6 months or longer.
Medications on Admission:
MEDS:
-Protonix 40mg daily
-Lisinopril daily-unknown dose
-Advair [**Hospital1 **], unknown dose
-FeSO4 [**Hospital1 **]
.
MEDS ON TRANSFER:
-Fentanyl gtt
-Ativan gtt 20mg/hr
-Pantoprazole 40mg IV daily
-Thiamine 100mg daily
-Lisinopril 5mg [**Hospital1 **]
-Heparin SC
-Advair [**Hospital1 **]
-Combiven nebs prn
-Albuterol prn
-Dilaudid
-Tube feeds
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
2. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: Ten (10) mL PO every
four (4) hours as needed for fever.
3. Hydrocortisone Acetate 1 % Ointment [**Hospital1 **]: One (1) Appl Rectal
DAILY (Daily).
4. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
HS (at bedtime) as needed.
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 2-4 Puffs Inhalation
Q2H (every 2 hours) as needed for rescue breathing for wheezing.
7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Last Name (STitle) **]:
One (1) Cap Inhalation DAILY (Daily).
8. Montelukast 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
9. Fluticasone 220 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2) puffs
Inhalation twice a day as needed for asthma.
10. Salmeterol 50 mcg/Dose Disk with Device [**Last Name (STitle) **]: One (1) puff
Inhalation Q12H (every 12 hours) as needed for asthma.
11. Vancomycin 500 mg Recon Soln [**Last Name (STitle) **]: 1500 (1500) mg Intravenous
Q 12H (Every 12 Hours) for 6 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. Alcoholic pancreatitis
2. Alcohol withdrawal
3. Coagulase negative Staphyloccocal bacteremia
4. Respiratory failure on mechanical ventilation complicated by
prolonged wean, status post tracheostomy
5. Pulmonary embolus
6. Agitation and anxiety, resolved
7. Asthma
8. GERD with erosive esophagitis
9. Hypertension
Discharge Condition:
Improving without fever
Discharge Instructions:
1. Continue your rehabilitation
2. Discuss with your rehabilitation physician about when to make
a follow up appointment with your primary care physician
3. You will need the enroll with an [**Hospital3 **] to
monitor your warfarin
4. You should discuss with your primary care physician about [**Name Initial (PRE) **]
referral to see a pulmonologist (lung doctor)
5. Please have an INR checked daily and restart your warfarin
when your INR is less than 3.
6. Please have your vancomycin level checked in [**1-5**] days time to
insure that it is still therapeutic.
Followup Instructions:
1. Discuss with your rehabilitation physician about when to make
an follow up appointment with your primary care physician
2. You will need the enroll with an [**Hospital3 **] to
monitor your warfarin
3. You should discuss with your primary care physician about [**Name Initial (PRE) **]
referral to see a pulmonologist (lung doctor)
|
[
"789.5",
"303.91",
"530.81",
"790.7",
"281.9",
"415.19",
"482.40",
"577.0",
"996.62",
"493.90",
"401.9",
"999.9",
"535.40",
"291.0",
"518.81",
"599.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"96.04",
"45.13",
"38.93",
"99.15",
"99.04",
"96.6",
"96.72",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
13306, 13376
|
8397, 11582
|
315, 424
|
13736, 13762
|
3457, 8374
|
14375, 14712
|
3142, 3178
|
11984, 13283
|
13397, 13715
|
11608, 11731
|
13786, 14352
|
3193, 3438
|
228, 277
|
452, 2547
|
2569, 2902
|
2918, 3126
|
11749, 11961
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,033
| 107,337
|
43046
|
Discharge summary
|
report
|
Admission Date: [**2187-7-30**] Discharge Date: [**2187-8-2**]
Date of Birth: [**2148-4-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
nausea, vomiting, abd pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 39 yo M with DM1 c/b ESRD and severe gastroparesis,
HTN, CAD s/p STEMI, and multiple line infections who presents
with nausea, vomiting, abdominal pain, and hypertensive urgency.
He was discharged from [**Hospital1 18**] on [**7-26**] for HTN urgency which
resolved after labetalol gtt and restarting his home BP meds. He
was feeling well until this am when he awoke and had abdominal
pain similar to his usual abdominal pain that subsequently
progressed to nausea and multiple episodes of non-bloody emesis.
He was unable to tolerate any of his medications and presented
to the ED.
Past Medical History:
1. Diabetes Mellitus Type I
- Gastroparesis with chronic hospitalizations
- ESRD on HD since [**2-/2184**]
- Autonomic dysfunction, frequent HTN emergency & orthostatic
hypotension
- Peripheral neuropathy
2. Coronary artery disease
- STEMI [**2186-12-17**] in setting of cocaine, s/p BMS to LAD
3. Aortic valve endocarditis ([**4-21**])
- In the context of coag neg staph bacteremia ([**Month (only) 404**] and
[**2187-3-16**]) and positive intravenous catheter tip [**2187-4-6**] had
his HD catheter changed over a wire. known MRSE bacteremia for
which he completed a course of vancomycin for possible
endocarditis on [**5-18**]
4. Hypertension
5. History of line sepsis with coag negative staph and
priors with klebsiella and enterobacteremia
6. Esophageal ulceration: H pylori neg, active esophagitis seen
on EGD [**2187-4-18**], h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear
7. History of substance abuse (cocaine, marijuana, alcohol)
9. History of thrombosed AV fistula in LUE [**4-20**], [**Doctor Last Name **]-tex in
place
10. Fungemia completed caspofungin IV on [**2187-7-12**]
11. GI bleed associated with hypotension-colonscopu showed
friable and inflammed ascending and transverse colon,suggestive
either of ischemia or infection [**2187-7-19**]
Social History:
Patient has a prior history of tobacco and marijauna use, but he
does not currently smoke. He has a prior history of alcohol
abuse and has been sober for 9 years. He has a past history of
cocaine use. He currently denies illicit drugs. Currently lives
with his mother and brothers.
Family History:
Father deceased of ESRD and DM. Mother aged 50's with
hypertension. Two sisters, one with diabetes. Six brothers, one
with diabetes. There is no family history of premature coronary
artery disease or sudden death.
Physical Exam:
VS: Temp 97.3 BP 100/62 HR 86 RR 20 O2 sat 98% RA
GEN: NAD
HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection,
anicteric, OP clear, slightly dry MM
Neck: supple, no LAD, no carotid bruits, JVP approximately 10 cm
above sternal notch
Chest: tunneled HD line over RSV, covered with bandage, NT to
palpation
CV: RRR, nl s1, s2, systolic murmur at RUSB
PULM: CTA b/l
ABD: soft, diffusely slightly tender to palpation but more so
over RLQ, + BS, no HSM
EXT: warm, dry, +1 distal pulses BL, no femoral bruits, R
femoral TLC in place
NEURO: alert & oriented x3
Pertinent Results:
ADMISSION LABS
[**2187-7-30**] 02:10PM BLOOD WBC-14.1*# RBC-3.95* Hgb-9.9* Hct-34.4*
MCV-87 MCH-25.0* MCHC-28.7* RDW-19.2* Plt Ct-285
[**2187-7-30**] 02:10PM BLOOD Neuts-84.2* Lymphs-10.1* Monos-2.1
Eos-3.1 Baso-0.5
[**2187-7-30**] 02:10PM BLOOD PT-11.6 PTT-27.2 INR(PT)-1.0
[**2187-7-30**] 02:10PM BLOOD Glucose-292* UreaN-70* Creat-10.8*#
Na-143 K-5.4* Cl-100 HCO3-27 AnGap-21*
[**2187-7-30**] 06:46PM BLOOD Calcium-9.7 Phos-5.8*# Mg-2.1
[**2187-7-30**] 02:10PM BLOOD CK(CPK)-139
[**2187-7-31**] 03:47AM BLOOD CK(CPK)-78
[**2187-7-30**] 02:10PM BLOOD cTropnT-0.28*
[**2187-7-30**] 02:10PM BLOOD CK-MB-7
[**2187-7-31**] 03:47AM BLOOD CK-MB-NotDone cTropnT-0.32*
DISCHARGE LABS
[**2187-8-1**] 11:37AM BLOOD WBC-7.0 RBC-4.09* Hgb-10.4* Hct-35.0*
MCV-85 MCH-25.4* MCHC-29.8* RDW-19.6* Plt Ct-213
[**2187-8-1**] 11:37AM BLOOD Plt Ct-213
[**2187-8-1**] 11:37AM BLOOD Glucose-202* UreaN-52* Creat-9.0*# Na-135
K-5.1 Cl-93* HCO3-28 AnGap-19
[**2187-7-31**] 03:47AM BLOOD Calcium-9.6 Phos-7.8*# Mg-2.1
IMAGING
CXR-Interval improvement in pulmonary vascular congestion.
Brief Hospital Course:
39 year old man with hx of DM1 c/b gastroparesis, autonomic
instability, ESRD on HD, CAD s/p MI presenting with hypertensive
urgency in the setting of nausea, vomiting, and abdominal pain.
.
# HTN urgency - Presents with pt's usual pattern of abdominal
pain, nausea, and vomiting which leads to hypertensive urgency.
Autonomic dysfunction also contributing. He had no focal
neurologic complaints or deficits on exam. BP better controlled
with labetolol gtt, now back on PO antihypertensives. He was
continued on his home dose labetolol PO and clonidine patch.
.
# Gastroparesis - His vomiting ceased and his nausea resolved.
He was able to tolerate a po diet, had minimal abd pain. He was
on standing metoclopramide PO, antiemetics prn and hydromorphone
prn.
.
# Leukocytosis -He had no bands on differential, afebrile since
presentation, denied fevers, chills, or any other localizing
symptoms other than abd pain, n/v on ROS. He is s/p treatment 2
weeks ago with vancomycin and caspofungin for coag negative
staph bacteremia and fungemia (sp. Trichosporon). Had HD line
resited and currently appears clean. Blood cultues had no growth
to date and his WBC decreased.
.
# DM1 with complications -
He was continued on his home dose lantus with insulin sliding
scale as well as his home regimen of gastroparesis meds: reglan,
dilaudid, ativan
.
# CAD s/p MI - With continued ST elevations on EKG, elevations
in V4-5 slightly more prominent than prior. No clinical symptoms
of active ischemia. Troponin elevated to 0.28 on presentation;
however, at baseline. CK flat, no chest pain or shortness of
breath. He was continued on [**Month/Day/Year **], [**Month/Day/Year 4532**], statin. He was not on
ACE-I given recent admission for transverse and ascending
colitis thought to be [**3-17**] ischemia.
.
# ESRD on HD: Renal aware of pt's admission, no needs for urgent
[**Month/Day (2) 2286**] on admission he had HD as scheduled.
.
#ACCESS: HD line, R femoral TLC, no peripheral IV access
#PPx - hep sq, ppi, bowel regimen prn given narcotics
#CODE: full, confirmed with pt
Medications on Admission:
Aspirin 325 mg daily
Clopidogrel 75 mg daily
Gabapentin 300 mg qTues, Thurs, Sat
Gabapentin 200 mg qSun, Mon, Wed, Fri
Lanthanum 1000 mg tid with meals
Pantoprazole 40 mg q12h
Labetalol 200 mg po tid
Simvastatin 80 mg daily
Metoclopramide 10 mg qidachs
Dilaudid 4 mg q4h prn
Lorazepam 1 mg q6h prn
Clonidine 0.3 mg/24 hr Patch qWed
Lantus 6 units SQ qhs
Nephrocaps 1 cap daily
HISS
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QTUTHSA
(TU,TH,SA).
4. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO 4X/WEEK
([**Doctor First Name **],MO,WE,FR).
5. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
11. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
12. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
13. Labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
14. Insulin Glargine 100 unit/mL Solution Sig: Six (6) units
Subcutaneous at bedtime.
15. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: as per
sliding scale units Subcutaneous qachs.
Discharge Disposition:
Home
Discharge Diagnosis:
hypertensive urgency
Diabetes Mellitus Type I
- Gastroparesis with chronic hospitalizations
- ESRD on HD since [**2-/2184**]
- Autonomic dysfunction, frequent HTN emergency & orthostatic
hypotension
- Peripheral neuropathy
-Coronary artery disease
- STEMI [**2186-12-17**] in setting of cocaine, s/p BMS to LAD
-Aortic valve endocarditis ([**4-21**])
- In the context of coag neg staph bacteremia ([**Month (only) 404**] and
[**2187-3-16**]) and positive intravenous catheter tip [**2187-4-6**] had
his HD catheter changed over a wire. known MRSE bacteremia for
which he completed a course of vancomycin for possible
endocarditis on [**5-18**]
-History of line sepsis with coag negative staph and
priors with klebsiella and enterobacteremia
-Esophageal ulceration: H pylori neg, active esophagitis seen
on EGD [**2187-4-18**], h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear
-History of substance abuse (cocaine, marijuana, alcohol)
-History of thrombosed AV fistula in LUE [**4-20**], [**Doctor Last Name **]-tex in
place
-Fungemia completed caspofungin IV on [**2187-7-12**]
-GI bleed associated with hypotension-colonscopu showed friable
and inflammed ascending and transverse colon,suggestive either
of ischemia or infection [**2187-7-19**]
Discharge Condition:
stable, afebrile, good po intake
Discharge Instructions:
You were admitted with abdominal pain, nausea, vomiting. Your
symptoms improved with blood pressure control. You were briefly
treated in the MICU (intensive care unit) then your care was
transferred to a medical floor. You continued to do well and
were able to tolerate food.
Please take your medications as prescribed. It is extremely
important that you take your medications to control your blood
pressure.
Please follow up as outlined below.
If you have any headaches, dizzyness, nausea, vomiting,
abdominal pain, chest pain, shortness of breath, bleeding from
the rectum or any other concerning symptoms please call your
doctor or go the emergency room
Followup Instructions:
please call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 92872**] at [**Telephone/Fax (1) 1247**] for a follow
up appointment within two weeks
continue on your regularly scheduled hemodialysis appointments
Completed by:[**2187-8-3**]
|
[
"337.1",
"585.6",
"250.61",
"412",
"250.41",
"403.01",
"414.01",
"536.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8397, 8403
|
4518, 6592
|
339, 346
|
9739, 9774
|
3425, 4495
|
10483, 10739
|
2617, 2832
|
7025, 8374
|
8424, 9718
|
6618, 7002
|
9798, 10460
|
2847, 3406
|
273, 301
|
374, 968
|
990, 2301
|
2317, 2601
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,417
| 123,828
|
24212
|
Discharge summary
|
report
|
Admission Date: [**2154-12-6**] Discharge Date: [**2154-12-24**]
Date of Birth: [**2114-4-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides)
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
severe epigastric pain after belching
and vomiting for roughly 30 minutes.
Major Surgical or Invasive Procedure:
1. Laparotomy, thoracotomy for esophageal repair.
2. Laparotomy and placement of gastric and jejunal
feeding tubes, placement of left groin central line.
Mid line LUE
History of Present Illness:
40M with signficant vascular and cardiac history was found
by EMS lying in bed with severe epigastric pain after belching
and vomiting for roughly 30 minutes. Pt. denied any radiating
pain, decreased breathing or diaphoresis. Sternum was tender to
the touch. Patient was then transferred to [**Hospital **] Hospital.
Upon
arrival to the [**Name (NI) **], pt underwent a CT C/A/P which demonstrated an
extensive pneumomediastinum surrounding a large hiatal hernia.
There is extensive extraluminal air and debris within the
mediastinum consistent with an esophageal rupture. The air
dissects superiorly to the thoracic inlet and under the
diaphragm.
Pt was then transferred to the [**Hospital1 18**]. On transport patient
maintained a 16-20 RR with 100% neb. with accessory muscle use.
He was speaking in short-full sentences. There was no palpable
abdominal mass. Pt received 2L NS and placed in the ambulance in
100% [**Hospital1 597**]. His vital signs remained stable although his lung
sounds began to diminish at the bases L>R. He became
increasingly
discomforted with 5/5 epigastric pain and nausea. Approximately
[**2-22**] mi. from [**Hospital1 18**], pt. developed respiratory difficulty with RR
28-30 and desaturations from 97%-91%. He noticed to have
increased Bilateral chest wall movements with subcutaneous
emphysema.
In the [**Last Name (LF) **], [**First Name3 (LF) 1092**] Surgery/Cardiac Surgery was consulted.
Patient was noticed to be in respiratory distress with a
distended abdomen at the time of my examination. He was
unresponsive to commands at this time and pressures fell to
60/5.
He was intubated in the trauma bay and 2 large bore IVs were
placed. Pt. received a total of 6L of IVF
Past Medical History:
Marfans Syndrome, History of Aortic Dissection s/p Aortic Valve
Replacement and Ascending Aorta Replacement in [**2153-5-20**], History
of Postop Deep Vein Thrombosis, History of Post-op Atrial
Fibrillation, Asthma, Gastroesophageal Reflux Disease, Hiatal
Hernia, s/p Hernia repair, s/p Foot surgery
Social History:
Denies tobacco. Admits to occasional ETOH. He is married and
lives with his wife. [**Name (NI) **] is an electrical engineer.
Family History:
Denies connective tissue disorders. No history of premature CAD.
Physical Exam:
PE: 124-65/5-26-86 100% [**Name (NI) 597**]
Pt. in distress with belching motions of abdomen and use of
accessory muscles to ventilate.
Heart sounds were distant and barely auscultated
Breath sounds were severely diminished and distant
Massive abdominal distention which worsened after intubation
Extremities were cold with poor capillary refill and nonpalpable
pulses x4
Pertinent Results:
COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2154-12-24**] 05:40AM 9.8 3.13* 8.6* 26.4* 84 27.5 32.6 18.7*
1852*1
PLT count [**2154-12-24**] 1852
[**2154-12-24**]: IMPRESSION: PA and lateral chest compared to [**12-20**]
through [**12-23**].
The large air and fluid collection at the base of the right
chest present since at least [**12-19**] is unchanged. A
moderate left pleural effusion or pleural thickening and the
postoperative mediastinum are stable in appearance. Heart is not
enlarged. Left lower lobe atelectasis is probably due to
persistent left pleural abnormality. Right basal atelectasis is
improving. Upper lungs are clear. Tip of the right PIC catheter
projects over the right clavicle, ending just outside the chest.
Tracheostomy tube is midline but the caliber appears small given
the diameter of the trachea. Aortic endoprosthesis is unchanged
in appearance running from the mid ascending to the proximal
descending aorta. No pneumothorax.
ULTRASOUND-GUIDED RIGHT THORACENTESIS.
HISTORY: 40-year-old male status post Boerhaave rupture with
air-containing fluid collection in the right lung base.
IMPRESSION:
1. 15 cc of serosanguineous fluid aspirated from the right
pleural cavity and sent to microbiology for Gram stain and
culture.
Brief Hospital Course:
Pt was admitted intubated, sedated, vol resusitated and on epi
and levo for hemodynamic stability .and taken emergently to the
OR for repair of ruptured esophagus and trach on [**2154-12-6**].
Started on empiric vanco/zosyn per infectious disease.
Immed post op period was notable for LUE mottled in the setting
of previous right ax-fem graft. Evaluated by vasc- circulation
intact w/ weak doppler signal.
Pt remained intubated, sedated, on pressor support w/ cont'd
cystalloid and colloid requirements. Pt had 4 left chest tubes
and 2 right chest tubes all w/ mod-large amount drainge.
POD#1: pt noted to have large right pleural effsuion on cxr
that was not being drained by the other 2 chest tubes on right
side - a 3th right chest tube was placed.
POD#2: Con't ventilated and on pressor support. Diuresis begun.
Chest tube drainage slowed.
POD#3 started on TPN for nutritional support. Doppler signals in
LUE much improved.
POD#4 pressors weaned. Vent support weaned to PSV. spiking
fevers on vanco/zosyn-fluc added to broaden coverage. LFT's
increasing (baseline elevated)-hepatology consulted and increase
thought to be benign.
POD# 5 G-J tube placed for enetral feeding.
POD#6 Hida scan- cholestasis. Liver US w/ sldge -no
cholecystitis.
POD#7 left chest tube d/c'd. Pt on trach collar.
POD#8 NGT d/c'd and trophic tube feed started.
POD#[**9-29**] TPN d/c'd. TF increased. Triple lumen d/c'd and mid
line placed in left upper extrem.
POD#11 Pt placed on passey muir valve intermittantly. Hematology
consulted for elevated platelet count. Cont on ASA and no role
for plavix at this time. Fluc d/c'd and ceftriaxone d/c'd and
cefepime started to decrease hepatotoxicity..
POD#12 2 right and 2 left chest tubes d/c'd. One remaining on
each side to sxn w/ minimal drainage.
POD#13 trach changed to #6 fenestrated cuffless. Passed swallow
eval and placed on clear liquid diet.
POD#14 Remaining chest tubes d/c'd. LFT's improving slowly.
working w/ PT/OT.
POD#15 -17 noted to have small right pleural fluid
collection-tapped under ultrasound guidance and culture
sent-pending at time of this d/c summary. Diet progressed to
full liquids-continues on tube feed. Cal counts done but not
able to take sufficient calories to wean tube feed at this time.
can progress to soft solids in one week and NOT advance until
follow up w/ Dr. [**Last Name (STitle) 952**].
Per ID will need to be on 3 weeks total of IVAB from date of
[**2154-12-19**]-ending [**2155-1-9**].
Medications on Admission:
none
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day/Year **]: One (1)
Injection TID (3 times a day).
2. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Day/Year **]: Four (4)
Puff Inhalation Q6H (every 6 hours).
3. Fluticasone 110 mcg/Actuation Aerosol [**Month/Day/Year **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day).
5. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: One (1) PO Q4-6H
(every 4 to 6 hours) as needed.
6. Quetiapine 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at
bedtime).
7. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: One (1)
Injection ASDIR (AS DIRECTED).
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. NPH insulin
4 units NPH insulin SQ qam and qpm
11. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device [**Last Name (STitle) **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
12. Vancomycin in Dextrose 1 g/200 mL Piggyback [**Hospital1 **]: One (1) gm
Intravenous Q 8H (Every 8 Hours) for 17 days: total 3
weeks-started [**2154-12-19**].
please check peak and trough serially.
13. Cefepime 1 g Recon Soln [**Month/Day/Year **]: One (1) Recon Soln Intravenous
Q12H (every 12 hours) for 17 days: total of 3 weeks started on
[**2154-12-19**].
14. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Date Range **]: Two
(2) ML Intravenous DAILY (Daily) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Boehaave's esophageal rupture/repair via left thoracotomy.
Discharge Condition:
deconditioned.
Discharge Instructions:
Call Dr.[**Name (NI) 1816**] office [**Telephone/Fax (1) 170**] if you have any chset
pain, problems swallowing, fever, chills, nausea, or vomitting.
Continue your tube feed and it may be cycled for convenience as
[**Last Name (un) 1815**]. Tube feed may be decreased as po intake increases.
continue full liquids until [**2154-12-30**] then increase to soft
solids.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 952**]. Please call his office, ([**Telephone/Fax (1) 4044**], to arrange the appointment upon d/c from rehab.
Completed by:[**2154-12-24**]
|
[
"576.8",
"518.81",
"512.0",
"553.3",
"518.1",
"V12.51",
"780.6",
"238.71",
"427.5",
"759.82",
"V43.3",
"530.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"43.19",
"96.04",
"99.07",
"53.80",
"31.1",
"96.6",
"96.72",
"99.15",
"00.17",
"34.04",
"89.64",
"99.04",
"42.87",
"46.39",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
8744, 8814
|
4528, 6996
|
371, 540
|
8916, 8933
|
3236, 4505
|
9348, 9540
|
2762, 2828
|
7051, 8721
|
8835, 8895
|
7022, 7028
|
8957, 9325
|
2843, 3217
|
257, 333
|
568, 2279
|
2301, 2602
|
2618, 2746
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,341
| 113,074
|
29281
|
Discharge summary
|
report
|
Admission Date: [**2138-6-9**] Discharge Date: [**2138-7-5**]
Date of Birth: [**2077-3-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Transfered from OSH in ARF s/p TIPS
Major Surgical or Invasive Procedure:
none
History of Present Illness:
61 yo M with HCV cirrhosis complicated by variceal bleeding,
refractory acites and edema who was admitted to OSH on [**2138-6-5**]
for TIPS procedure which was complicated by intraperitoneal
bleeding after hepatic puncture requiring transfusion of 3 units
PRBC. During the procedure systolic BP reached a low of 90 and
pt recieved iodinated contrast. Subsequent to the placement of
the TIPS pt's creatinine bumped from a basline of 1.4 to
1.8->2.1->2.7, and the pt was transfered to [**Hospital1 18**] for management
of acute renal failure.
Past Medical History:
1. End stage Liver Disease [**12-27**] HCV Cirrhosis on liver transplant
list.
2. DM Type 2
3. Hypertension
Social History:
Retired Construction worker, Currently Runs a small landscaping
company. Tobacco: Quit 15 years ago, ETOH: Last drink 1 year
Prior (drank heavily in past), no drugs
Family History:
Father=Alcoholic
Physical Exam:
VS: T:94.7 (oral) BP:165/81 P:67 R:20 O2:98%
General: Middle aged man sitting cmfortably in NAD
HEENT: NCAT PERRL EOMI OP clear
Neck: no thyromegally/bruit/LAD
CV: nml s1 s2 RRR, no m/r/g
Chest: Bilateral rales at bases, no wheeze
ABD: soft, +bs, nt, distended, peritoneal fluid draining into
ostomy bag taped to R side of abdomen
Rectal: Light brown stool in vault, guaiac negative
Ext: 3+ pitting edema of bil LE to mid thigh, and mid bil UE to
mid arm
Neuo: A+Ox3, nonfocal, no asterisix
Pertinent Results:
Labs from OSH [**2138-6-8**]:
10 13.6/39.3 129
131/105/76\ 208
5.5/17/3.9/
AsT 115, ALT 83, AP 70, bili 2.3, total protein 4.3, albumin
1.8, INR 1.4
Ca 7.8 Mg 1.8 Phos 5.9
Brief Hospital Course:
Mr [**Known lastname 70384**] had a prolonged, complicated hospital stay, with
several transfers to the ICU for decompensated hepatic failure
due to HCV (MELD=40), spontaneous bacterial peritonitis, and
multifactorial renal failure (hepato-renal syndrome). As I only
took care of him during his final ICU stay, I will attempt to
briefly summarize the events that happened earlier in his
course.
He was transferred to [**Hospital1 18**] after TIPS for variceal bleeding at
an outside hospital. His HCV cirrhosis was associated with
coagulopathy, mild ascites, thrombocytopenia, and
encephalopathy. He also had renal failure, likely a combination
of contrast-induced nephropathy and ATN, and a retroperitoneal
hematoma that occured as a complication of TIPS. He suffered
from respiratory distress from volume overload, which responded
to non invasive ventilation. He was additionally noted to have
candiduria. He initially improved somewhat with supportive
management of HCV cirrhosis, hemodialysis as needed, and
expectant management of the hematoma. He received fluconazole
for candiduria.
On [**6-25**], he developed fever, respiratory distress and decreased
sensorium, for which he was transferred to the ICU. He was
treated for SBP with broad spectrum antibiotics and his
respiratory distress again improved with noninvasive ventilation
and ultrafiltration for volume management. His mental status
improved somewhat, although not back to baseline, and he was
transferred to the transplant service [**Hospital1 **], where his overall
status remained tenuous, with marginal blood pressures,
leukocytosis despite antibiotics for SBP, and waxing and [**Doctor Last Name 688**]
delirium.
On [**7-3**], he became hypotensive and obtunded. He was transferred
to the ICU again. Antibiotics were broadened for presumed
sepsis, possibly from aspiration pneumonia or recurrence of SBP.
Noninvasive ventilation was inadequate to maintain oxygenation
and patient's encephalopathy was so severe that he could not
protect his airway; he was therefore intubated for ventilatory
support. Invasive hemodynamic monitoring, ie, pulmonary catheter
placement was discussed with the family, but since he was septic
from an unclear source, liver transplantation would not be an
option and his family decided to withdraw invasive measures and
focus on comfort measures. He subsequently expired.
Medications on Admission:
Nadolol 60 mg PO QD
Omeprazole 20 mg PO QD
Insulin: AM: NPH 30 Reg 10/PM:NPH 10 Reg 5
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
hepatitis C virus infection with cirrhosis, ascites, spontaneous
bacterial peritonitis
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"070.54",
"572.4",
"401.9",
"787.91",
"284.1",
"276.7",
"577.0",
"790.7",
"571.5",
"568.81",
"428.0",
"112.2",
"518.81",
"250.00",
"572.2",
"507.0",
"789.5",
"456.21",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"45.13",
"96.04",
"99.04",
"38.93",
"39.95",
"93.90",
"96.6",
"34.91",
"99.05",
"38.95",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
4548, 4557
|
2007, 4384
|
356, 362
|
4687, 4697
|
1808, 1984
|
4749, 4891
|
1264, 1282
|
4520, 4525
|
4578, 4666
|
4410, 4497
|
4721, 4726
|
1297, 1789
|
281, 318
|
390, 934
|
956, 1065
|
1081, 1248
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,303
| 115,721
|
16086
|
Discharge summary
|
report
|
Admission Date: [**2153-1-24**] Discharge Date: [**2153-2-1**]
Date of Birth: [**2108-3-6**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This gentleman had progressed to
shortness of breath and chest tightness over a 2-month period
with left arm numbness for which the patient visited his
cardiologist. He had a cardiac catheterization and
echocardiogram, and the patient was referred to Dr. [**First Name (STitle) **]
[**Last Name (Prefixes) **] for aortic valve replacement and coronary artery
bypass graft.
PAST MEDICAL HISTORY:
1. Hodgkin's disease at the age of 29.
2. Status post splenectomy with radiation therapy for
Hodgkin's disease in [**2135**] and [**2136**].
3. Left ankle injury with repair.
4. Question herniorrhaphy as a child.
MEDICATIONS ON ADMISSION: He was on no medications on
admission.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: On examination, his
heart was in a sinus rhythm at 108 and blood pressure was
133/89. He had no jugular venous distention or thyromegaly.
His neurologic examination was grossly intact with no motor
or sensory deficits. His lungs were clear bilaterally. No
wheezes or rhonchi. His heart was regular in rate and rhythm
with a grade 3/6 systolic ejection murmur radiating to both
carotids. He also had a well-healed midline scar. His
extremities were warm with no edema. He had some mild
varicosities bilaterally with left greater than right. He
had good femoral, dorsalis pedis, and posterior tibialis, and
radial pulses.
PERTINENT LABORATORY VALUES ON PRESENTATION: Preoperative
laboratory work revealed white blood cell count was 11.6 and
hematocrit was 40.1. Prothrombin time was 12.5, partial
thromboplastin time was 29, and platelet count was 371,000.
INR was 1. Sodium was 141, potassium was 4.1, chloride was
103, bicarbonate was 23, blood urea nitrogen was 17,
creatinine was 1, and blood glucose was 86. ALT was 18, AST
was 20, LDH was 211, alkaline phosphatase was 59, and total
bilirubin was 0.3.
PERTINENT RADIOLOGY/IMAGING: His preoperative chest x-ray
showed no evidence of pulmonary masses or nodules. No
consolidations or pneumothoraces or effusions. Please refer
to the chest x-ray report done on [**2153-1-11**].
His preoperative electrocardiogram from [**2153-1-11**] also
revealed a sinus rhythm with left ventricular hypertrophy and
secondary ST-T wave changes.
HOSPITAL COURSE: He was referred to Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **]
for aortic valve replacement.
On [**1-24**], he underwent a coronary artery bypass graft
times two with a right internal mammary artery to the
posterior descending artery a left radial artery to the
obtuse marginal. He had an aortic valve replacement with a
20-mm Homograft, and he had repair of his atrial septal
defect. Please refer to the Operative Report. He was
transferred to the Cardiothoracic Intensive Care Unit in
stable condition.
On postoperative day one, he was in a sinus rhythm with a
blood pressure of 94/54. He was on a propofol drip, and
nitroglycerin at 0.5 for his radial artery coverage,
Fentanyl, and Neo-Synephrine at 0.5. He remained intubated
with coarse breath sounds. He extremities had trace edema.
The plan was to wean his sedation.
His postoperative laboratories revealed white blood cell
count was 9.3, hematocrit was 27.1, and platelets were
242,000. Sodium was 141, potassium was 4, chloride was 107,
bicarbonate was 22, blood urea nitrogen was 11, creatinine
was 0.8, and blood glucose was 119. His chest x-ray showed
decreased lung volumes with no effusions of pneumothorax, and
no congestive heart failure.
An aggressive pulmonary toilet was started. The patient
remained stable on his perioperative antibiotics. He had a
bronchoscopy done; also done on [**1-25**], on postoperative
day one, which showed clean airways by Dr. [**Last Name (STitle) 952**]. He was
seen by Case Management and Physical Therapy when he was
transferred out to the floor. He also had an
Electrophysiology consultation on postoperative day two. He
had already been started on Lopressor and amiodarone for runs
of tachycardia. He also had some late night episodes which
were asymptomatic but responded to 5 mg of intravenous
Lopressor. Some were self-limiting. His tracing showed
atrial fibrillation. They recommended continuing his
Lopressor and amiodarone and starting him on a intravenous
heparin, off anticoagulation without a bolus if he could
tolerate that. This was confirmed and reviewed by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 73**]. A-wire tracing did confirm atrial fibrillation
and atrial flutter.
On postoperative day two, he was in a sinus rhythm in the 80s
with a blood pressure of 101/56. His oxygen saturations were
97% on face mask and nasal cannula. He was continued on
amiodarone, Imdur for his radial artery, albuterol, Colace,
Zantac, and aspirin, as well as Percocet for pain. His
hematocrit was stable at 28.7. Blood urea nitrogen was 11
and creatinine was 0.9. He was comfortable. His incision
was clean, dry, and intact. Amiodarone was increased to 400
mg three times per day as per recommendations, and he began
to auto diurese; putting out 3.5 liters of urine in a 24-hour
period. He was alert, awake, and oriented. He started his
rehabilitation with Physical Therapy on the floor on
postoperative day two. He continued to diurese on the floor.
He received an amiodarone bolus in addition to his routine
dosing for supraventricular tachycardia which converted him
back to a sinus rhythm.
On postoperative day three, his blood pressure was 107/70; in
a normal sinus rhythm at 67. His diet was advanced. He also
started his Zantac. His creatinine rose slightly to 0.9. On
postoperative day three, his chest tubes were removed. He
remained on Lopressor, amiodarone, and Imdur, as well as his
aspirin. He was comfortable. His lungs were clear
bilaterally. His hematocrit rose to 30.5, and his creatinine
dropped back down to 0.7. He had some trace peripheral edema
and was continued with a pulmonary toilet and diuresis. His
heparin drip continued. The decision was made to hold the
Coumadin for now, and the patient was transferred out to the
floor. He continued to receive Percocet for his incisional
pain. He was followed by Electrophysiology who suggested
possibly getting an Endocrine consultation given his
radiation therapy and elevated thyroid-stimulating hormone
with amiodarone. He was continued on his Lopressor and
insulin sliding-scale. His creatinine remained stable at
0.8.
He was started on 3 mg of Coumadin on postoperative day five
while he continued his baseline intravenous heparin for
anticoagulation for atrial fibrillation and atrial flutter,
in addition to amiodarone boluses. Endocrine recommended
starting him on Levoxyl 50 mcg p.o. once per day and
following up with Dr. [**First Name (STitle) 16901**] as an outpatient. They also
recommended that he get a yearly thyroid examination and to
recheck his thyroid function tests is approximately eight
weeks given his history of radiation therapy. He was seen
again by Case Management.
On postoperative day five, he continued with his
anticoagulation with heparin and Coumadin. His pacing wires
were discontinued. He remained in atrial flutter and atrial
fibrillation. His lungs were clear. His heart was regular
in rate and rhythm. He had trace peripheral edema. He was
in a sinus rhythm at 89 at the time of examination in the
morning with a blood pressure of 126/75.
On postoperative day six, he had some more bursts of atrial
fibrillation in the evening and rapid atrial fibrillation in
the morning which was rate controlled with Lopressor. The
patient was totally asymptomatic. He had a blood pressure of
134/81. Temperature maximum was 100.6. His lungs were
clear. He continued his anticoagulation and continued to
ambulate with Physical Therapy. Since all of the
recommendations had been followed, over the next day, the
patient continued to ambulate on the floor awaiting
therapeutic anticoagulation. His creatinine remained stable
at 0.9. His INR on postoperative day six rose to 1.2. He
continued to receive Percocet for pain and occasional Ambien
for sleep with good effect. The patient remained in house
awaiting a therapeutic INR.
On postoperative day seven, the patient had no events
overnight. He was in a sinus rhythm at a rate of 77. His
blood pressure was 94/53. Oxygen saturation was 94% on room
air. His heart was regular in rate and rhythm. His lungs
were clear. He had trace pedal edema. His INR was 1.3, and
he continued to ambulate.
On postoperative day eight, the patient went back into
intermittent atrial fibrillation and atrial flutter
alternating with his sinus rhythm but with no complaints.
His examination was unremarkable. On the day of discharge,
his INR rose to 1.6. His prothrombin time was 15.8, and his
partial thromboplastin time was 81.8 on heparin.
DISCHARGE STATUS: The patient was discharged to home.
DISCHARGE DIAGNOSES:
1. Status post aortic valve replacement with a 20-mm
Homograft, and coronary artery bypass graft times two, atrial
septal defect repair.
2. Status post Hodgkin's disease with splenectomy and
radiation therapy.
3. Status post left ankle surgery.
4. Status post herniorrhaphy as a child.
MEDICATIONS ON DISCHARGE: (Discharge medications were as
follows)
1. Lovenox 100 mg subcutaneously q.12h.
2. Coumadin 3 mg p.o. once per day (with instructions for
blood draws and dosing by the patient's cardiologist, Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 46008**] at [**Hospital3 1280**] Hospital).
3. Amiodarone 400 mg p.o. three times per day.
4. Isosorbide 60 mg p.o. once per day.
5. Lopressor 75 mg p.o. once per day.
6. Aspirin 325 mg p.o. every day.
7. Albuterol nebulizers as needed.
8. Percocet 5/325 one to two tablets p.o. q.4h. as needed.
9. Colace 100 mg p.o. twice per day.
10. Levothyroxine 50 mcg p.o. once per day.
DI[**Last Name (STitle) 408**]E INSTRUCTIONS/FOLLOWUP:
1. The patient was discharged with instructions to follow up
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 46008**] for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts Holter
monitor which was placed on [**2-1**] as well as blood
draws via the [**Hospital6 407**] with results called
in to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 46009**] office for dosing to get the
patient to a therapeutic INR for his atrial fibrillation.
2. The patient was also instructed to see Dr. [**Last Name (Prefixes) **] in
the office in approximately four weeks.
3. The patient was to follow up with his primary care
physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2153-4-10**] 08:54
T: [**2153-4-10**] 08:59
JOB#: [**Job Number 46010**]
|
[
"424.1",
"997.1",
"427.31",
"V10.72",
"414.01",
"745.5",
"244.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.71",
"36.11",
"33.23",
"35.21",
"88.72",
"36.15",
"42.23"
] |
icd9pcs
|
[
[
[]
]
] |
9116, 9407
|
9434, 11194
|
796, 2429
|
2448, 9095
|
154, 529
|
551, 769
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,635
| 108,376
|
3405
|
Discharge summary
|
report
|
Admission Date: [**2103-7-9**] Discharge Date: [**2103-8-3**]
Date of Birth: [**2024-12-10**] Sex: M
Service: MEDICINE
Allergies:
Allopurinol / Ciprofloxacin
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Severe Rash
Major Surgical or Invasive Procedure:
1. Debridement of scrotum under GETA.
2. Right Knee Arthrocentesis.
3. Suprapubic Catheter.
History of Present Illness:
78 yo M with ESRD, HTN, hyperlipidemia, MGUS who presents with
an approximately 7-day h/o desquamative rash that he states
began after taking an antibiotic prescribed in [**Country 3594**].
Mr. [**Known lastname **] presented to a [**Hospital 15762**] hospital [**6-29**] with complaint
of sore throat, 'heavy tongue' with difficulty talking, and
generalized weakness. He was reportedly diagnosed with a URI and
given an antibiotic (unsure of which) as well as tylenol. After
3 days of taking the antibiotic, he began to have a generalized,
desquamative rash, characterized by desquamation worst on the
scrotum and lips, with ulceration, oral bullae, and also
involving the trunk and to lesser extent on etremities. It was
pruritic. He discontinued taking the antibiotic approximately 1
week ago. At this point, he continues to experience some
pruritis, though states that is has improved somewhat, and does
not believe that he has had further ulcers appear over the past
few days. As a result of his oral involvement and some
dysphagia, he has had decreased PO intake over the past several
days. Of note, MR. [**Known lastname **] had diffuse skin flaking noted after
starting allopurinol [**2102**].
He denies any recent fevers or night sweats, shortness of
breath, chest pain, diarrhea or dysuria. He feels that the
'tongue-heaviness' and weakness have improved somewhat. He has
had frequent gouty flares in [**Country 3594**], typically involving his L
elbow and wrist.
ED course also notable for markedly elevated Cr of 6.7, which is
significanlty increased from prior measurement of 3.5 [**11-30**]. His
daughter reports a Cr of 5.6 last week in [**Country 3594**]. He was given
30cc of kayexalate for K=5.7, IV fluids for mild dehydration,
and a dermatology consultation was obtained.
Past Medical History:
-ESRD,followed by Dr. [**Last Name (STitle) 1860**]. Thought to be secondary to
nephrosclerosis. Cr 3.5 [**11-30**].
-anemia
-hypertension
-hyperlipidemia
-gout. Admitted [**8-30**] with polyarticular gout flare.
-MGUS
Social History:
Lives in [**Location 15763**] and United Sates
Former smoker
no drug use
occasional alchohol use
Family History:
non-contributory
Physical [**Location **]:
PE T102 HR 102 BP 134/76 RR 20 98% R/A
Gen: patient appears stated age, found lying flat in bed
surrounded by family, in mild discomfort
HEENT: Sclera anicteric, conjunctiva uninjected, +arcus senilis,
PERL (2mm -> 1mm with light), EOMI. Has significant ulceration
involving lips, with areas of crusting and hemorrhage. No oral
lesions appreciated currently (per family, had grayish bullae
earlier).
Neck: no JVD, no LAD, nl ROM
Cor: RRR nl S1 S2 no M/R/G
Chest: clear to percussion and asculation
Abd: soft, NT/ND, +BS. No HSM appreciated.
EXT: no calf tenderness. No edema
SKIN: crusting hemorrhagic perioral erosions, with superficial
desquamation involving primarily his trunk and to lesser extent
extremities, with both penile and more significnatly scrotal
ulceration, and ulcer involving lateral aspect of distal L lower
extremity.
Musculoskeletal: no synovitis currently.
Neuro: MS [**First Name (Titles) **] [**Last Name (Titles) **], CN II-XII in tact, UE/LE strength 5+
bilaterally ([**Last Name (Titles) **] limited by discomfort from rash)
Pertinent Results:
[**2103-7-8**] 11:15PM PLT COUNT-358#
[**2103-7-8**] 11:15PM NEUTS-70.0 LYMPHS-17.4* MONOS-5.0 EOS-7.5*
BASOS-0.1
[**2103-7-8**] 11:15PM WBC-8.7 RBC-3.98* HGB-11.8* HCT-35.8* MCV-90#
MCH-29.6 MCHC-33.0 RDW-17.3*
[**2103-7-8**] 11:15PM GLUCOSE-120* UREA N-64* CREAT-6.7*#
SODIUM-135 POTASSIUM-5.7* CHLORIDE-98 TOTAL CO2-21* ANION GAP-22
[**2103-7-8**] 11:20PM URINE [**Month/Day/Year 3143**]-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-7.0
LEUK-NEG
[**2103-7-8**] 11:20PM URINE RBC-0 WBC-0 BACTERIA-RARE YEAST-NONE
EPI-0
[**2103-7-8**] 11:20PM URINE COLOR-Yellow APPEAR-Clear SP
[**Last Name (un) 155**]-<=1.005
[**2103-7-8**] 11:27PM LACTATE-2.8*
[**2103-7-9**] 04:40AM WBC-6.7 RBC-3.53* HGB-10.5* HCT-31.6* MCV-90
MCH-29.7 MCHC-33.2 RDW-17.3*
[**2103-7-9**] 04:40AM calTIBC-246* FERRITIN-504* TRF-189*
[**2103-7-9**] 04:40AM ALBUMIN-3.6 CALCIUM-9.2 PHOSPHATE-5.1*
MAGNESIUM-2.1 IRON-18*
[**2103-7-9**] 04:40AM LIPASE-46
[**2103-7-9**] 04:40AM ALT(SGPT)-26 AST(SGOT)-26 ALK PHOS-75
AMYLASE-200* TOT BILI-0.5
.
Skin, left ankle, punch (A-B):
Subepidermal bullae with hyperkeratosis, parakeratosis,
scattered dyskeratotic keratinocytes, and a lichenoid
lymphohistiocytic inflammatory infiltrate (see note). Note: The
findings raise a differential diagnosis including erythema
multiforme/[**Doctor Last Name **]-[**Known lastname **] syndrome/toxic epidermal necrolysis
and bullous drug disorder. Clinical correlation is suggested.
.
Note: Sections show an epidermis with focal compact
hyperkeratosis, and an interface dermatitis characterized by
baso vacuolar degeneration, lymphocytes at the dermal-epidermal
junction and dyskeratotic keratinocytes. The lymphocytes do not
appear atypical. The differential diagnosis includes [**First Name8 (NamePattern2) **]
[**Known lastname **] syndrome/erythema multiforme spectrum of disorders or a
lichenoid/fixed drug eruption.
.
Negative Cultures:
[**2103-7-27**] JOINT FLUID
GRAM STAIN-FINAL; FLUID CULTURE-No Growth
[**2103-7-26**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING
[**2103-7-26**] URINE
URINE CULTURE-FINAL
[**2103-7-26**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING
[**2103-7-25**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING
[**2103-7-24**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING
[**2103-7-24**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING
[**2103-7-20**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
[**2103-7-19**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
[**2103-7-18**] DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS
DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS-FINAL; Direct
Antigen Test for Herpes Simplex Virus Types 1 & 2-FINAL
[**2103-7-19**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
[**2103-7-18**] SWAB
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS-FINAL; VARICELLA-ZOSTER
CULTURE-PRELIMINARY
[**2103-7-16**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
[**2103-7-15**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
[**2103-7-15**] STOOL
FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL; OVA +
PARASITES-FINAL; O&P MACROSCOPIC [**Month/Day/Year **] - WORM-FINAL; CLOSTRIDIUM
DIFFICILE TOXIN ASSAY-FINAL
[**2103-7-15**] SCOTCH TAPE PREP/PADDLE
SCOTCH TAPE PREP/PADDLE-FINAL
[**2103-7-14**] URINE
URINE CULTURE-FINAL
[**2103-7-14**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
[**2103-7-14**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
[**2103-7-13**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
[**2103-7-13**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
[**2103-7-12**] URINE
URINE CULTURE-FINAL
[**2103-7-12**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
[**2103-7-12**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
[**2103-7-9**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
[**2103-7-8**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
[**2103-7-8**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL
[**2103-7-8**] URINE
URINE CULTURE-FINAL
.
Cultures that grew bacteria:
[**2103-7-24**] CATHETER TIP-IV
WOUND CULTURE-FINAL {ACINETOBACTER BAUMANNII}
[**2103-7-15**] SWAB
GRAM STAIN-FINAL; WOUND CULTURE-FINAL {YEAST, PRESUMPTIVELY NOT
C. ALBICANS}; ANAEROBIC CULTURE-FINAL {PREVOTELLA SPECIES}
[**2103-7-16**] [**Month/Day/Year 3143**] CULTURE
AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS,
COAGULASE NEGATIVE}
.
IV catheter tip cx: acinetobacter baumannii ([**Last Name (un) 36**] to cefepime,
gent, zosyn and tobra. Resistant or indeterm to others.)
.
Joint aspirate.
[**2103-7-27**] 4:59P (2) FEW NEEDLE I/E
Intra/ExtraCellular NEG c/w monosodium urate crystals
(2) Source: Knee
[**2099-3-18**] 9:18P FEW NEEDLE I/E
Intra/ExtraCellular NEG c/w monosodium urate crystals
.
CT Pelvis ([**7-29**]) IMPRESSION:
1. No abscess or fluid collection identified.
2. Tiny bilateral pleural effusions.
3. Uncomplicated large right inguinal hernia containing multiple
small bowel
.
1. Skin, left lower leg (A-C):
Multiple fragments of stratum corneum.
2. Skin, scrotum (D-E):
Skin with ulceration, marked acute and chronic inflammation,
focal necrosis and granulation tissue formation (see note).
Note: No microorganisms are seen in PAS and gram stained
sections.
.
CXR: The heart, mediastinal and hilar contours are within normal
limits. The lungs demonstrate no focal areas of consolidation or
effusion. The osseous structures are within normal limits.
IMPRESSION: No evidence of CHF or pneumonia.
Renal Ultrasound: The right kidney measures 7.2 cm. The left
kidney measures approximately 8.0 cm. The kidneys are echogenic
bilaterally, somewhat limiting evaluation. There is no
hydronephrosis or stones. Note is made of a tiny hypodense
lesion in the upper pole of the left kidney measuring
approximately 9 mm, consistent with a simple cyst. The bladder
is partially distended with an apparent fold in the mid-portion
on the sagittal view. This could be due to Note is made of
bilateral ureteral jets. IMPRESSION:
1) No hydronephrosis.
2) Small echogenic kidneys.
3) Partially distended bladder with a possible fold, although a
diverticulum cannot be entirely excluded. This could be
reassessed with better distension of the bladder if indicated.
Echocardiogram [**2103-7-10**]
Left Ventricle - Ejection Fraction: >= 70% (nl >=55%)
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No ASD by 2D
or color
Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Overall
normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Normal ascending aorta
diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild
(1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets.
TRICUSPID VALVE: Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
Conclusions:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler (cannot exclude). Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
CT abd/pelvis [**2103-7-28**]:
IMPRESSION:
1. No abscess or fluid collection identified.
2. Tiny bilateral pleural effusions.
3. Uncomplicated large right inguinal hernia containing multiple
small bowel loops.
Brief Hospital Course:
Mr. [**Known lastname **] is a 78 year-old male with ESRD, HTN,
hyperlipidemia, MGUS who presented with Erythema
multiform/[**Doctor First Name **]-[**Known lastname **] syndrome after taking allopurinol
presumably. He had extensive desquamation of the skin with
recurrent fever. He was managed on the floor in a supportive
manner with fluids, empiric antibiotics, and wound care. He
developed PAF and was rate controlled. There was a question of
Fournier's gangrene of the scrotum which was debrided by urology
in the OR. He was transferred to the ICU during this time. He
was transferred back to the floor after 5 days in the MICU. On
the floor he had low grade feveres. His central line was pulled
and the tip grew out acinetobacter sensitive to cefepime. All
[**Known lastname **] cultures were negative. Patient was treated with 7 days of
cefepime for a line infection. Finally, he developed an acute
gouty flare treated with colchicine, oxycodone, and prednisone.
.
Hospital Course by Problem:
.
SJS: Derm was consulted for help with the diagnosis and
management of SJS. Two biopsies were taken. The 1st biopsy was
c/s SJS. 2nd biopsy from leg could also represent TEN or drug
reaction. Dermatology recommended constant skin hydration w/
multiple ointments and topical steroid. No IgG or steroids were
started as the patient presented past the window during which
time this is found to be a useful intervention. The inciting med
was allopurinol he recieved in [**Country **]. (NOTE: Cipro was also
started at the same time and should be suspected as well.) On
the floor insensible losses were tremendous and he recieved
aggressive IVF. Wound care was managed with xeroform and
bactroban. The ID service was consulted for persistent fevers
and a surveillance culture that showed GPC. ID service
recommended broad empiric antibiotics given travel hx and very
complicated patient. Pt was started on meropenem and
vancomycin. On [**7-15**], the urology service was consulted for
worsening pain and skin breakdown on the scrotum and penis.
Fournier's Gangrene was suspected and thus the patient was taken
to the OR for debridement. He was then tx to the SICU and then
the MICU for more aggressive management. He spent 5 days in the
ICU and was called out to the floors again. His rash continued
to improve. Skin care with bactroban and xeroform continued
throughout the hospitalization and the dry intact skin was
moistened with aquaphor.
Line infection: On callout from the MICU, patient was having low
grade fevers on the floor. Panculture including urine, [**Month/Year (2) **],
and CXR was negative. Patient's central line was d/c and tip
grew out cefepime sensitive acinetobacter. Subsequent [**Month/Year (2) **]
cultures remained negative. Thus, patient was treated with 7
days total of cefepime.
Scrotal lesion: It was minimally debrided for a concern of
Fournier's gangrene but it did not appear gangrenous and urology
OP note stated edematous but healthy tissue underneath. The
lesion did not appear gangrenous, and the patient remained
afebrile with normal WBC. Samples were also taken for HSV and
VXZ. These samples were negative.
.
A-fib: The patient was found to be in paroxysmal a-fib on [**7-10**].
He was well rate controlled with toprol XL 200. Echo showed no
clot. He converted to sinus on his own but has been in and out
of afib. Diltiazem 30 mg po qid was started [**2103-8-1**] for improved
rate control, as patient was running in the 90s. Since
initiation of this medication, patient is again back in sinus.
PR interval < 0.12 on BB + CCB. Coagulation was held initially
due to dysphagia and concern for mucosal involvement and bleed
risk. On [**7-24**], heparin and coumadin were intiated with a goal
of INR [**3-1**]. Currently, patient is supratherapeutic on coumadin.
His last INR was 4.2.
.
CRI: Pt has baseline renal failure with a Cr of 3.4 in [**2102-11-27**]
but presented w/ creatinine of 6. The renal svc was consulted
and he was volume repleted. His Cr trended down. He had eos in
his urine, so while hypovolemia was most likely the cause of
acute on chronic renal failure, could not rule out AIN.
Currently his creatinine is 2.1. He will follow-up with [**First Name8 (NamePattern2) 3122**]
[**Doctor Last Name 1860**] in 1 month. Continue IVFs prn to keep well hydrated.
Constipation: Patient w/ h/o hemorrhoids. No BM x 5 days but had
a good BM [**2103-8-2**] w/ assist of an enema. Plan to manage w/
colace, senna, and enema prn if no BM x 2 consecutive days.
Gout: Pt had a history of gout. On [**7-19**] he developed right knee
pain and a low grade fever. No ankle and wrist pain. On [**7-28**]
the pt's knee was tapped. This was notable for monosodium
nitrate, negative birefringent, needle-shaped crystals c/w gout.
Cx and gram stain were negative for any organisms. NSAIDs were
not an option given CRI. Thus, patient treated w/ renal dose of
colchicine. He continued to have pain, and thus po prednisone
and oxycontin/oxycodone were added. Currently, his pain is well
controlled.
Hyperglycemia: no h/o of [**Name (NI) 15764**] pt had high [**Name (NI) **] sugars early in
his hospitalization that resolved as his health improved. On
steroids, his sugars are again in the 200s. We are managing this
with a sliding scale of insulin.
Communication was with [**First Name8 (NamePattern2) **] [**Known lastname **] (daughter) cell
[**Telephone/Fax (1) 15765**], home [**Telephone/Fax (1) 15766**]; [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13662**] (daughter) cell
[**Telephone/Fax (1) 15767**]; [**Name (NI) **] [**Name (NI) **] (son) cell [**Telephone/Fax (1) 15768**]
.
The patient was discharged to [**Hospital3 672**] rehab in good
condition with improving skin lesions, rate controlled heart in
sinus rhythm, and well controlled pain.
Medications on Admission:
Meds on admission:
Atenolol 100
Amlodipine 10
Lipitor 20
Lasix 40
(was started on gout regimen including colchicine prior to going
to [**Country 3594**], which he discontinued shortly after leaving
[**Location (un) 86**]).
Discharge Medications:
1. Erythromycin 5 mg/g Ointment Sig: [**1-28**] gtt Ophthalmic QID (4
times a day).
Disp:*1 tube* Refills:*0*
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Mineral Oil-Hydrophil Petrolat Ointment Sig: One (1) Appl
Topical QD ().
Disp:*1 bottle* Refills:*0*
4. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*1 tube* Refills:*0*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical Q
6HRS () as needed for PRN pruritis.
Disp:*1 tube* Refills:*0*
7. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
8. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for knee pain.
9. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
10. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
11. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Epogen 10,000 unit/mL Solution Sig: One (1) injection
Injection qMon,Wed,Fri.
13. Prednisone 10 mg Tablet Sig: 1-2 Tablets PO once a day for 3
days: Taper as follows:
[**8-4**] = 20 mg po qd,
[**8-5**] = 10 mg po qd,
[**8-6**] = 10 mg po qd.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
15. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
injection Injection four times a day: please follow attached
sliding scale.
16. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Principal:
1. [**Doctor Last Name **]-[**Known lastname **] Syndrome.
2. Paroxysmal Atrial Fibrillation with rapid ventricular
response
3. Acute Gout Flare - Right Knee.
4. Dermal necrosis of the scrotum.
5. Acinetobacter catheter-related bloodstream infection.
6. Right Inguinal Hernia.
Secondary:
1. Gout.
2. MGUS.
3. Hypertension.
4. Hypercholesterolemia,.
5. ESRD - Hypertensive Nephrosclerosis.
6. Anemia of ESRD/Chronic Disease.
Discharge Condition:
afebrile (on steroids), skin healing, heart rate controlled,
gout pain controlled.
Discharge Instructions:
Monitor for fevers, chills, rashes, worsening knee pain, or
increased sedation (on narcotic).
NEVER TAKE ALLOPURINOL. Wear your new bracelet letting health
care professional know of this allergy. You should also NOT
take VANCOMYCIN or CIPROFLOXACIN, as these medications may also
have been involved in starting or worsening the rash.
You have been started on a medication called coumadin. Coumadin
thins your [**Last Name (LF) **], [**First Name3 (LF) **] it is important that you take precautions
to avoid bleeding. First, use an electric razor to shave.
Second, do not engage in activities in which you might fall and
bruise yourself. Finally, do not eat large amounts of leafy
green vegetables because this can interfere with your coumadin.
Followup Instructions:
Follow up with PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Call to set up an appointment
within 1-2 weeks of leaving rehab. [**Telephone/Fax (1) 7976**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D., PH.D.[**MD Number(3) **]: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2103-9-13**] 4:30
You will be contact[**Name (NI) **] regarding a follow-up appointment with an
ophthamologist. If you do not hear from anyone by Monday, please
call [**Telephone/Fax (1) 253**] to schedule an appointment within the next [**1-28**]
weeks.
Urology appointment: follow up with Dr. [**Last Name (STitle) 9125**], [**8-7**], 3:00pm,
[**Hospital1 **] [**Location (un) 453**]. If any questions, call [**Telephone/Fax (1) 6445**].
Follow up with Dermatology at [**Hospital1 **] in [**1-28**]
weeks. The department will call you to set up an appointment. If
you don't hear from them in one week, please call to set up an
appointment, [**Telephone/Fax (1) 1971**].
You should hear back regarding an appointment to follow-up with
a rheumatologist. If you do not hear about this by Monday,
please call [**Telephone/Fax (1) 2226**] to schedule this within 1-2 weeks.
|
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18077, 19832
|
19931, 20368
|
17830, 17835
|
20497, 21248
|
246, 260
|
12979, 17804
|
420, 2214
|
17849, 18054
|
2236, 2457
|
2473, 2572
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,129
| 133,150
|
49771
|
Discharge summary
|
report
|
Admission Date: [**2196-1-12**] Discharge Date: [**2196-1-26**]
Date of Birth: [**2143-9-8**] Sex: M
Service: MEDICINE
Allergies:
Ilosone / Dicloxacillin
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Cough.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known firstname 3510**] [**Known lastname 15352**] is a very nice 52 year-old gentleman with
history of HTN, HL, CVA in [**2184**] with residual L-side weakness,
HIV on HAART with most recent CD4 of 442 and undetectable VL on
[**8-1**] who comes with productive cough and fever. He was in his
prior state of health until 2 days ago when he started noticing
productive cough with occasional bright red blood in his sputum.
He also has been having chills, rigors, but has not taken his
temperature at home. He has not noted any changes in the ammount
of activity he can do. He denies any history of travel or sick
contacts, has no pets at home and has been taking his
medications as prescribed, including his HIV regimen. He is
followed by Dr. [**Last Name (STitle) **], who last checked his VL and CD4 ~4
months ago and were undetectable and 442 respectively (per
patient's report). His productive cough is now with dark-red
sputum.
In the ER his initial VS were 99.8 F, HR 76 BPM, BP 133/54 mmHg,
RR 20 breaths x'. He developed low SpO2 (not recorded) and was
placed on NRB. His breathing improved without any specific
therapy and they were able to wean him down to 4L NC, where he
is 93%. He had consolidation syndrome in the LLL and was
corroborated by CXR. He received 750 mg of levofloxacin x1 and
<500 cc of NS. His VS prior to transfer were: HR 82, BP 103/58,
SpO2 93% on 5L, RR 18.
Past Medical History:
#. Coronary artery disease, status post CABG with LIMA to the
LAD in [**2182**].
#. Residual chronic systolic heart failure, with EF of 40%.
#. Hypertension.
#. Dyslipidemia.
#. CVA believed to be hypertensive/hemorrhagic in [**2-/2185**] with
residual left-sided weakness.
#. HIV. viral load was less than 48
copies. His CD4 count is 442 and has been stable around 500
#. HCV genotype 1B; thought to be poor candidate for treatment
given CVD and HIV. Liver biopsies, one in [**2187**] and one in [**2193**]
with the later showing grade 1 inflammation with stage I-II
fibrosis. Liver USG [**2-2**] normal. Alpha fetoprotein was 3.9 back
in [**2195-2-22**]. Normal EGD in [**2192**].
#. Stasis dermatitis
#. Grade II hemorrhoids
#. Right small hydrocele
Social History:
No current or past tobacco use. No history of drug or alcohol
abuse. The patient is single. He lives alone with the help of
PCAs and goes to daycare programs during the day. He ambulates
with a scooter.
Family History:
There is a significant family history of premature coronary
artery disease of the father who had an MI at age 56 and uncles
who have had heart attacks in the past. Otherwise, there is no
other history of unexplained heart failure or sudden death.
Physical Exam:
VITAL SIGNS - Temp 98.9 F, BP 122/62 mmHg, HR 87 BPM, RR 20 X',
O2-sat 93% 3L NC
GENERAL - well-appearing man in NAD, comfortable, appropriate,
not-jaundiced (skin, mouth, conjuntiva), dry mucous membranes,
left-facial droop, slurred speech
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - decreased breath sounds in left anterior lower region
with increased voice transmition and loud ronchi; good air
movement, resp unlabored, no accessory muscle use, no crackles
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
in R leg and doplerable in L leg.
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEUROLOGIC:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual fields are full to confrontation. Non
papilledema on fundoscopic exam. Extraocular movements intact
bilaterally, no nystagmus. Sensation intact V1- V3. Facial
movement asymmetric with L facial droop. Hearing normal to
finger rub bilaterally.
Palate elevation symmetrical. Sternocleidomastoid and trapezius
normal bilaterally. Tongue midline, movements intact.
.
Cerebellum: Normal hand up & down; normal finger-nose (left),
cannot walk, no vertical nystagmus.
.
Motor:
Normal bulk bilaterally. Tone normal in left and increased in
right (spastic). 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 3 throughout
.
Sensation: Intact to light touch, throughout. No extinction to
DSS
Pertinent Results:
Labs on admission:
[**2196-1-12**] 08:30PM WBC-13.8* LYMPH-23 ABS LYMPH-3174 CD3-55
ABS CD3-1731 CD4-24 ABS CD4-751 CD8-30 ABS CD8-967* CD4/CD8-0.8*
[**2196-1-12**] 08:30PM PLT COUNT-187
[**2196-1-12**] 08:30PM NEUTS-70.2* LYMPHS-23.0 MONOS-4.1 EOS-2.2
BASOS-0.5
[**2196-1-12**] 08:30PM WBC-13.8*# RBC-4.79 HGB-14.2 HCT-43.4 MCV-91
MCH-29.8 MCHC-32.9 RDW-14.4
[**2196-1-12**] 08:42PM LACTATE-1.7
[**2196-1-12**] 08:42PM COMMENTS-GREEN
[**2196-1-12**] 09:15PM estGFR-Using this
[**2196-1-12**] 09:15PM GLUCOSE-109* UREA N-17 CREAT-1.3* SODIUM-134
POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-27 ANION GAP-13
Other pertinent results:
[**2196-1-12**] 08:30PM BLOOD WBC-13.8* Lymph-23 Abs [**Last Name (un) **]-3174 CD3%-55
Abs CD3-1731 CD4%-24 Abs CD4-751 CD8%-30 Abs CD8-967*
CD4/CD8-0.8*
[**2196-1-25**] 02:41AM BLOOD Type-ART Temp-36.4 pO2-73* pCO2-61*
pH-7.35 calTCO2-35* Base XS-5
[**2196-1-25**] 02:41AM BLOOD Lactate-0.9
[**2196-1-25**] 02:41AM BLOOD O2 Sat-93
Microbiology:
- ASPERGILLUS ANTIGEN 0.1 (normal <0.5)
- B-D-Glucan <31 pg/mL (Negative = Less than 60 pg/mL)
- Blood cultures - no growth ([**1-12**] x 2, [**1-13**] x 2)
- Sputum cultures - no Legionella or PCP ([**1-13**])
- Sputum cultures - insufficient sample ([**1-13**], [**1-16**], [**1-17**], [**1-18**])
- Sputum cultures - RARE GROWTH Commensal Respiratory Flora.
YEAST sparse growth. ([**1-22**])
- Urinary legionella antigen - negative ([**1-13**])
- BAL - negative for respiratory culture, fungus, PCP, [**Name Initial (NameIs) 11381**]
(smear only; culture still pending). Viral culture pending.
([**1-18**])
- Respiratory screen and viral culture - negative ([**1-18**])
IMAGING:
CXR [**2196-1-12**]: UPRIGHT AP VIEW OF THE CHEST: There is a
consolidative opacity within the left lung base obscuring both
the hemidiaphragm and the left cardiac border, new from the
prior study. The right lung is grossly clear. The cardiac
silhouette is difficult to assess given the presence of the
consolidative process. The pulmonary vascularity is normal.
There is likely a left pleural effusion. No right pleural
effusion or pneumothorax is seen. IMPRESSION: Left basilar
consolidation, with probable small pleural effusion. Findings
are concerning for pneumonia, and a followup radiograph after
interval treatment is recommended to assess for interval
resolution.
Chest CT [**2196-1-16**]:
IMPRESSION:
1. Multiple opacities at the left lung base, concerning for
pneumonia. There is a small left pleural effusion.
2. No obstructing mass is present in the airways, although left
lower lobe bronchi are obscured by motion artifact.
3. Enlarged subcarinal lymph node, likely reactive.
4. Stones within a nondistended gallbladder.
Chest CT [**2196-1-19**]:
IMPRESSION:
1. Interval progression of multifocal pneumonia with more
confluent opacities within the lingula, left lower lobe, and
right lower lobe. No residual pleural effusions. Slight
progression in adenopathy is also likely reactive, but can be
re-assessed on follow up exams once infection resolves.
2. Dilated pulmonary artery consistent with known severe
pulmonary hypertension (also noted on recent echo) which may HIV
induced. Unchanged cholelithiasis without any secondary signs of
acute cholecystitis.
Echocardiogram [**2196-1-19**]:
Poor image quality. The left atrium is normal in size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. LV
systolic function appears depressed (focal distal septal/apical
hypokinesis is suggested). There is no ventricular septal
defect. with normal free wall contractility. The aortic valve is
not well seen. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are not well
seen. No mitral regurgitation is seen. There is severe pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2192-10-2**],
no definite change.
CXR [**2196-1-25**]:
FINDINGS: In comparison with the study of [**1-24**], the endotracheal
tube and nasogastric tube have been removed. Progressive
decrease in opacification at the bases. The right lung is
virtually clear and the left hemidiaphragm is more sharply seen,
with some opacification primarily just above the
costophrenic angle. The upper lung zones are clear and there is
no evidence of pulmonary vascular congestion.
Brief Hospital Course:
52 year-old gentleman with history of HTN, HL, CHA in [**2184**] with
residual L-side weakness, HIV on HAART with most recent CD4 of
442 and undetectable VL on [**8-1**] who comes with productive
cough, hemoptysis and fever. The following issues were addressed
at this admission:
# Community-Acquired Pneumonia. The patient was admitted febrile
with hemoptysis (sputum described as "dark red" on admission).
CXR and CT scan showed evidence of multilobar pneumonia as
above. Multiple attempts at sputum collection yielded inadequate
samples for culture. The patient was initially admitted to the
floor and started on levofloxacin, but when he failed to improve
he was switched to vancomycin, cefepime and metronidazole on
[**1-16**]. On [**1-18**], he became hypoxic with O2 saturation in the upper
80s despite use of face mask oxygen, and he was transferred to
the MICU where he was intubated. He underwent bronchoscopy with
BAL (cultures negative to date; viral cultures and [**Month/Year (2) 11381**] cultures
pending). He initially required high PEEP and was difficult to
wean (despite lack of known underlying lung disease) but was
subsequently able to be liberated from the ventilator and was
extubated successfully on [**1-24**]. He was transferred back to the
floor on [**2196-1-25**] with no subjective shortness of breath and O2
sats in the mid-90s on 4 liters of O2 by nasal canula. Serial
CXRs have shown interval improvement. He should complete a
two-week course of antibiotic treatment to end [**2196-1-29**].
# Pulmonary artery systolic hypertension. Severe per echo report
(see above). This may be secondary to HIV; however, this is a
diagnosis of exclusion. The patient has large neck circumfrence
(grossly) and partial paralysis of tongue secondary to stroke in
[**2184**]. Therefore he is at high risk for sleep apnea, and may
benefit from a sleep study for further work up. Loud P2 and wide
S2 splitting were not appreciated on physical exam.
# Partial seizure activity. The patient was noted to have
partial motor seizure (initially unilateral, later bilateral)
while in the MICU. There was no generalization or loss of
consciousness. The decision was made not to initiate treatment
with antiepileptics at this time, as these were isolated events
in the context of illness. If he develops worsening problems
with seizure activity in the future, he may require treatment at
that time.
# HIV. The patient has been well controlled in the past with
most recent CD4 of 442 and undetectable viral load from 08/[**2194**].
His current CD4 count 750, VL 158 copies/ml. He was continued on
his home doses of HAART.
# Acute renal failure. The patient had mildly elevated
creatinine to 1.3 on admission, which self-resolved prior to
discharge (now creatinine at baseline of 0.8-0.9). This likely
represented prerenal renal failure in the setting of insensible
losses from fever and infection, although the patient denied
decreased PO fluid intake.
# Chronic Diastolic Heart Failure with EF 40%. The patient has
some lower extremity edema which has improved over the course of
this admission. Pleural effusions seen on admission have largely
resolved. He was continued on his home ACEI and beta-[**Year (4 digits) 7005**].
# Coronary artery Disease. Patient is s/p CABG. No active
issues. He was continued on his home beta-[**Last Name (LF) 7005**], [**First Name3 (LF) **], statin
and ACEI.
# Hypertension. The patient was continued on his home
lisinopril and metoprolol.
# Hyperlipidemia. His last lipid panel showed LDL 171, HDL 47,
Chol 245 and TG of 133 in [**2195-2-22**]. He was continued home
pravastatin.
# HCV. No active issues. The patient will continue to follow in
liver clinic with Dr. [**Last Name (STitle) **].
Medications on Admission:
Ritonavir 400 mg [**Hospital1 **]
Saquinavir 200 mg PO BID
Pravastatin 20 mg PO QHS
Aspirin 81 mg PO Daily
Lisinopril 5 mg PO Daily
Toprol XL 12.5 mg PO Daily
Triamcinolone acetonide 0.1% ointment 2 weeks on/2 weeks off
Daily use
Mupirocin 2% ointment [**Hospital1 **]
Urea 20% topical cream Daily
Colace 50 mg TID
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Vancomycin 1250 mg IV Q 12H
4. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours).
5. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q12H (every 12 hours).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000
Injection TID (3 times a day) for While in rehab days.
7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO every
eight (8) hours.
8. Triamcinolone Acetonide 0.1 % Ointment Sig: One (1) Appl
Topical DAILY (Daily).
9. Ritonavir 100 mg Capsule Sig: Four (4) Capsule PO BID (2
times a day).
10. Saquinavir Mesylate 200 mg Capsule Sig: Two (2) Capsule PO
BID (2 times a day).
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: 0.5
Tablet Sustained Release 24 hr PO once a day.
13. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) 10 ML
Intravenous PRN (as needed) as needed for line flush.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
15. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
16. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Six
(6) Puff Inhalation Q4H (every 4 hours) as needed for wheezing.
17. Urea 20 % Cream Sig: As directed Topical once a day: Apply
to affected areas.
18. Mupirocin 2 % Ointment Sig: as directed Topical once a day:
Apply to affected areas daily.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Primary Diagnosis:
-Healthcare associated pneumonia
Secondary Diagnoses:
-HIV infection
-Pulmonary arterial hypertension
-Coronary artery disease
-Hypertension
-Chronic diastolic heart failure
-Seizure disorder
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 for treatment of pneumonia.
Initially you were treated with levofloxacin. After your
symptoms did not improve, your antibiotics were broadened to
vancomycin, cefepime, and Flagyl. We would like you to complete
a 14-day course for health-care associated pneumonia to end on
[**1-29**].
Please note your follow-up appointments below.
Followup Instructions:
PRIMARY CARE - Dr. [**Last Name (STitle) **]
[**Telephone/Fax (1) 3581**]
Tuesday, [**2-2**], 9:45
- Please discuss your new diagnosis of pulmonary artery
hypertension with your primary care doctor. You may be referred
for studies to determine if you have a condition called
obstructive sleep apnea.
Other follow up appointments:
-[**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2196-5-5**] 8:30
-[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2196-12-12**] 9:20
Please continue to have any bloodwork drawn as previously
recommended by your doctors.
Completed by:[**2196-1-26**]
|
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icd9cm
|
[
[
[]
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] |
[
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icd9pcs
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15087, 15142
|
9336, 13086
|
290, 297
|
15398, 15398
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5467, 9313
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325, 1723
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15182, 15216
|
4844, 5448
|
15412, 15544
|
1745, 2505
|
2521, 2729
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,157
| 157,772
|
42467
|
Discharge summary
|
report
|
Admission Date: [**2104-1-17**] Discharge Date: [**2104-1-24**]
Date of Birth: [**2041-2-20**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 32612**]
Chief Complaint:
Pancreatic head mass
Major Surgical or Invasive Procedure:
[**2104-1-17**]:
1. Exploratory laparotomy.
2. Pancreaticoduodenectomy with pylorus preservation.
3. Harvest of pedicled falciform ligament flap for protection of
pancreatic anastomosis.
4. Complex removal of inferior tumor off of the feeding branches
of the superior mesenteric vein.
5. Diagnostic laparoscopy.
[**2104-1-17**]:
Exploratory laparotomy
History of Present Illness:
The patient is a 62-year-old female with a newly diagnosed mass
in the head of her pancreas. She underwent an ultrasound and a
CT scan which demonstrated a mass in the head of the pancreas.
The patient was referred to Dr. [**Last Name (STitle) **] and the team including
Dr. [**First Name (STitle) 908**] at [**Hospital1 18**] for further evaluation. The patient
underwent an ERCP with stent placement on [**2104-1-3**]. The brushings
from the ERCP were evidently negative for tumor. On endoscopic
ultrasound, she was found to have a mass that was measured at
least 2.5 x 3 cm in the head of the pancreas. The mass appeared
to invade the portal vein and superior mesenteric vein. The
celiac axis and SMA appeared free within the limits of the
endoscopic
ultrasound to visualize these. The patient underwent
subsequently a pancreas protocol CT scan ,the images revealed
large pancreatic head mass, pancreatic atrophy and calcification
suggestive of chronic pancreatitis and mildly prominent
peripancreatic and porta hepatis lymph nodes. The patient was
evaluated by Dr. [**Last Name (STitle) **] for possible Whipple resection. All
risks, possible outcomes and benefits were discussed with the
patient during the evaluation. All patient's questions were
answered and she was scheduled for elective Whipple procedure on
[**2104-1-17**].
Past Medical History:
Type 2 diabetes mellitus, endometriosis
Social History:
Patient is married for 40 years and has two kids. She smokes
three-quarters of a pack of cigarettes per day and has for 15
years. She drinks several glasses of wine most nights. She
denies drugs and/or environmental exposures.
Family History:
Her family history is significant for mother that had breast
cancer and died at age 50 and a sister with breast cancer and
currently 61.
Physical Exam:
On discherge:
VS:
GEN: NAD
CV: RRR, no m/r/g
RESP: CTAB
ABD: Midline abdominal incision open to air with steri strips
and c/d/i. Old JP site with occlusive dressing and c/d/i.
EXTR: Warm, no c/c/e
Pertinent Results:
[**2104-1-20**] 04:21AM BLOOD WBC-10.0 RBC-3.13* Hgb-9.9* Hct-28.4*
MCV-91 MCH-31.5 MCHC-34.8 RDW-15.8* Plt Ct-100*
[**2104-1-20**] 04:21AM BLOOD Glucose-102* UreaN-6 Creat-0.6 Na-132*
K-3.6 Cl-101 HCO3-28 AnGap-7*
[**2104-1-16**] 12:20PM BLOOD ALT-22 AST-27 LD(LDH)-190 TotBili-0.7
[**2104-1-20**] 04:21AM BLOOD Calcium-8.1* Phos-2.7 Mg-1.6
[**2104-1-23**] 09:49AM ASCITES Amylase-6
Pathology Examination
SPECIMEN SUBMITTED: FS Whipple, Gallbladder, Jejunum.
Procedure date Tissue received Report Date Diagnosed
by
[**2104-1-17**] [**2104-1-17**] [**2104-1-21**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/rna
DIAGNOSIS:
I. Whipple resection, pylorus-sparing pancreaticoduodenectomy
(A-Y, AE-AN):
A. Diffuse chronic pancreatitis with marked fibrosis,
calcification, duct dilation, and parenchymal atrophy; no
carcinoma seen.
B. Seventeen regional lymph nodes, some with reactive
follicular hyperplasia.
C. Bile duct and duodenal segments, within normal limits.
D. Unremarkable fibroadipose tissue (omentum).
II. Gallbladder (Z):
Unremarkable gallbladder without calculi.
III. Jejunum (AA-AD):
Small intestinal segment, within normal limits.
[**2104-1-18**] ECG:
Sinus bradycardia. The Q-T interval is prolonged. No previous
tracing
available for comparison.
Brief Hospital Course:
The patient with known pancreatic head mass was admitted to the
General Surgical Service for elective Whipple procedure. On
[**2104-1-17**], the patient underwent pancreaticoduodenectomy with
pylorus preservation, harvest of pedicled falciform ligament
flap for protection of pancreatic anastomosis and complex
removal of inferior tumor off of the feeding branches of the
superior mesenteric vein, which went well without complication
(reader referred to the Operative Note for details). Post
operatively patient was extubated and transferred in the PACU,
in the PACU patient was hypotensive required pressors and she
had some new bright red blood output out of her [**Location (un) 1661**]-[**Location (un) 1662**]
drain highly suspicious for post op bleeding. The patient was
brought back on OR, where she underwent exploratory laparotomy.
Ex lap was negative for bleeding and patient was extubated and
transferred in ICU. The patient was re-intubated in ICU
secondary to severe hypoxemia with bradycardia and
unresponsiveness. The patient was hypotensive and acidotic,
repeat blood gas revealed improved acidosis. Neosynephrine gtt
was weaned off overnight, patient received three units of RBC
for HCT 22.5 (post transfusion HCT = 29.7) and extubated. The
patient received two more blood transfusions on POD # 1, and POD
# 2, her HCT was stable after POD 3 and no more blood
transfusions were required prior discharge. On POD # 3, patient
was transferred to the floor in stable condition.
Neuro: The patient received Bupivacaine/Hydromorphone via
epidural catheter with good effect and adequate pain control.
When tolerating oral intake, the patient was transitioned to
oral pain medications. Secondary to regular alcohol use, patient
was placed on CIWA protocol for possible EtOH withdrawal.
CV: The patient was hypotensive and bradycardic post op,
secondary to hypoxemia. ECG revealed sinus bradycardia, pressure
improved overnight on Neosynephrine gtt and Neo was weaned off.
Bradycardia resolved and hypotension improved on POD # 1. The
patient remained stable from a cardiovascular standpoint; vital
signs were monitored with telemetry, no ectopy or arrhythmia
were noticed.
Pulmonary: Post operatively patient required re-intubation for
severe hypoxia with acidosis. Acidosis resolved and hypoxia
improved post blood transfusion. Patient was extubated on POD #
1. 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: Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced when appropriate, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. 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. She received IV
antibiotics for intra operatively and 24 hours post op. Wound
was evaluated daily and no signs or symptoms of infection were
noticed. JP amylase was checked on POD # 6 and JP was removed on
POD # 7 secondary to low amylase level and low output.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly. Patient was
restarted on her home diabetic medications on POD # 6, after her
diet was advanced to regular diabetic.
Hematology: The patient was transfused with 5 units of RBC post
operatively for failed HCT. The patient's complete blood count
was examined routinely; no more transfusions were required.
Patient's HCT was stable low prior 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 a regular
diabetic/low fat diet, ambulating, voiding without assistance,
and pain was well controlled. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
glipizide/metformin 2.5/500 2 tabs daily, diovan 80', amlodipine
10', lipitor 10'
Discharge Medications:
1. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*14 Patch 24 hr(s)* Refills:*0*
2. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) patch
Transdermal once a day.
Disp:*30 patch* Refills:*0*
3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
5. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)) for 2 weeks.
Disp:*56 Tablet(s)* Refills:*0*
6. 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:*5*
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. glipizide-metformin 2.5-500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
Discharge Disposition:
Home With Service
Facility:
Home Health Visting Nurses
Discharge Diagnosis:
1. Chronic pancreatitis
2. Post operative hypoxemia and hypotension
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 [**5-1**] 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.
Followup Instructions:
Department: SURGICAL SPECIALTIES
When: FRIDAY [**2104-2-8**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 79168**], MD [**Telephone/Fax (1) 274**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Please follow up with Dr. [**Last Name (STitle) **] (PCP) in [**1-25**] weeks. You can call
Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 91930**] to schedule an appointment.
Completed by:[**2104-1-24**]
|
[
"276.2",
"250.00",
"303.91",
"291.81",
"285.9",
"E849.7",
"799.02",
"305.1",
"427.89",
"E878.2",
"458.29",
"576.2",
"577.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"52.7",
"54.21",
"51.22",
"96.71",
"54.12"
] |
icd9pcs
|
[
[
[]
]
] |
9564, 9621
|
4040, 8255
|
293, 648
|
9733, 9733
|
2712, 4017
|
10990, 11527
|
2341, 2480
|
8387, 9541
|
9642, 9712
|
8281, 8364
|
9884, 10462
|
10477, 10967
|
2495, 2693
|
233, 255
|
676, 2016
|
9748, 9860
|
2038, 2079
|
2095, 2325
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,107
| 115,471
|
50660
|
Discharge summary
|
report
|
Admission Date: [**2183-5-7**] Discharge Date: [**2183-5-14**]
Date of Birth: [**2103-4-14**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 45**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac Cath with stenting to RCA & intraluminal tPA
History of Present Illness:
80 y/o F with PMHx of HTN, hyperlipidemia who presented with CP
that first began 3 days PTA and radiated to her back. She
reports first episode of CP [**9-19**] began sunday at church with
central chest pressure, lightheadedness, diaphoresis & right arm
pain. The pain lasted approx 6 hrs then resolved spontaneously.
Pt was feeling better on Monday with only mild intermittent CP
and constipation. Then, chest pain awoke her from sleep last
night with assoc left arm pain, diaphoresis & dizziness. Pt
presented to PCP this am still c/o mild residual CP [**2-17**] that
resolved with SL nitro. EKGs were noted to have some mild TWIs
and pt was sent to ED.
.
On arrival to ED, T-97.1, BP 129/52 HR 50 RR 20 Sats 100% on RA.
Pt was denying CP & SOB, noted to be guaic negative. Cardiac
enzymes were positive and TWI noted on EKG, pt was started on
Heparin gtt and admitted for NSTEMI.
.
Pt arrived to floor complaining of mild 3/10 chest pain that
resolved with nitro SL x 1. EKGs essentially unchanged from ED
tracings.
.
On cardiac ROS, pt has dyspnea on exertion with less than 1
block of walking. Sleeps with 4 pillows but they often end up on
floor. Denies PND, ankle edema, palpitations, syncope or
presyncope. Pt denies recent fevers, chills, recent URI. Denies
BRBPR, melena & dysuria. Pt has worsened constipaton over last
month.
Past Medical History:
Hyperlipidemia
Hypertension
Low back pain
Bilateral knee pain
Seborrheic keratoses
S/p L cataract surgery [**2174**]
Social History:
current tobacco use, reports approx 50pack yr history of
smoking. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden cardiac death.
Physical Exam:
VS: T-98.1 BP 126/78 HR 54 RR 20 Sats 100% RA
Gen: WDWN female in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. No lymphadenopathy,
no carotid bruits.
Neck: Supple with JVP of 8cm, no hepatojugular reflex
CV: RRR, quiet heart sounds, prominent S2. No m/r/g. No thrills,
lifts. No appreciable S3 or S4.
Chest: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e
Skin: No stasis dermatitis, ulcers, scars, or xanthomas
Pertinent Results:
[**2183-5-10**] 07:00AM BLOOD WBC-9.2 RBC-3.56* Hgb-10.7* Hct-32.4*
MCV-91 MCH-30.1 MCHC-33.0 RDW-13.0 Plt Ct-321
[**2183-5-7**] 02:05PM BLOOD WBC-11.5* RBC-4.22 Hgb-12.6 Hct-38.7
MCV-92 MCH-29.9 MCHC-32.6 RDW-13.1 Plt Ct-363
[**2183-5-7**] 02:05PM BLOOD Glucose-104 UreaN-10 Creat-0.7 Na-140
K-3.9 Cl-101 HCO3-29 AnGap-14
[**2183-5-7**] 02:05PM BLOOD CK-MB-34* MB Indx-9.8*
[**2183-5-7**] 02:05PM BLOOD CK(CPK)-347*
[**2183-5-7**] 02:05PM BLOOD cTropnT-0.48*
[**2183-5-7**] 11:00PM BLOOD CK-MB-28* MB Indx-8.3* cTropnT-1.01*
[**2183-5-7**] 11:00PM BLOOD CK(CPK)-337*
[**2183-5-8**] 06:40AM BLOOD CK-MB-17* MB Indx-6.7* cTropnT-0.97*
[**2183-5-8**] 06:40AM BLOOD CK(CPK)-254*
[**2183-5-10**] 07:00AM BLOOD Calcium-9.4 Phos-4.1 Mg-1.9
[**2183-5-8**] 06:40AM BLOOD Triglyc-232* HDL-39 CHOL/HD-5.7
LDLcalc-137*
.
[**2183-5-8**]: Cardiac Cath
1. Coronary angiography of this right dominant system
demonstrated 2 vessel coronary artery disease. The LMCA and
LCx had no angiographically apparent flow-limiting disease. The
LAD had a 50% mid-vessel stenosis. The RCA had a 99% proximal
stenosis from a large thrombus.
2. Limited resting hemodynamics revealed mild systemic arterial
systolic
hypertension with a central aortic pressure of 147/71 mmHg.
3. Successful stenting of the proximal RCA with a 4.0 x 12 mm
VISION BMS. Thrombectomy of the proximal RCA with extraction of
some white thrombus but persistent thrombus remained despite
thrombectomy and IC administration of TPA. Final angiography
revealed no residual stenosis in the stent, residual clot in the
vessel and TIMI II flow (See PTCA
comments)
.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Mild systemic arterial systolic hypertension.
3. Thrombectomy of proximal RCA.
4. Stenting of the proximal RCA.
.
[**2183-5-9**] ECHO
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
mild regional left ventricular systolic dysfunction with
hypokinesis of the inferior wall and basal inferior septum (RCA
territory). The remaining segments contract normally (LVEF =
45-50%). Right ventricular chamber size and free wall motion are
normal. The ascending aorta is mildly dilated. The aortic arch
is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Mild (1+) mitral
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 fat pad.
.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Mild pulmonary hypertension. Mildly dilated thoracic
aorta.
.
Compared with the prior study (images reviewed) of [**2182-3-4**], it
appears that the regional LV dysfunction is new, although the
prior study was technically suboptimal. Pulmonary pressures are
higher on today's study.
.
[**2183-5-8**]: Junctional bradycardia. Prior inferoposterior
myocardial infarction. Q-T interval prolongation. Slight ST
segment elevation in leads II, III, aVF. These findings are new
as compared with tracing of [**2165-2-26**]. Followup and clinical
correlation are suggested.
.
Cspine films: Degenerative changes at C5-C6 with narrowing of
the intervertebral disc space, subchondral sclerosis, and
anterior osteophyte formation. If there is concern for nerve
root compression, MR may be performed.
Brief Hospital Course:
80 y/o F with PMHx of HTN, hyperlipidemia who presented with
inferior NSTEMI.
.
# NSTEMI: Pt presented with 3 days of chest pain and was found
to have an inferior NSTEMI. Pt was taken to the cath lab &
found to have an intracoronay thrombus in the RCA. She
underwent PCI to RCA and received intracoronary tPA for
thrombolysis. She complete 36hrs of Integrilin and was monitored
in the CCU for 24hrs post cath. Pt did well and denied any
recurrent CP or SOB while in hospital. Pt was kept in house for
heparin bridge to coumadin given the intracoronary thrombus with
a plan for repeat cath in 4-6wks. Pt was discharged with VNA
to assist with home med teaching & assistance with additional
insurance coverage applications. Pt should continue on Aspirin,
Plavix, Atorvastatin, Metoprolol and Lisinopril. Pt had a TTE on
[**5-9**] that revealed hypokinesis of the inferior wall, basal
inferior septum and EF 45-50%. There was also evidence of mild
pulmonary hypertension. Pt remained euvolemic in house and was
given education about the importance of smoking cessation. Pt
will be following up with PCP for INR monitoring.
.
# Junctional Rhythm: Pt presented on high dose verapamil &
initial ECGs revealed an intermittent junctional rhythm with
very prolonged PR >300msec. Verapamil was stopped repeat EKGs
[**2183-5-10**] showed improved PR interval and return to NSR. A few
days after cath, pt was started on Metoprolol 12.5mg [**Hospital1 **] and
EKGs remained stable with mildly prolonged PR in sinus
bradycardia and q waves in leads II, III and aVF.
.
# HTN: BP was well controlled on regimen of Lisinopril 5mg &
Metoprolol 12.5mg [**Hospital1 **]
.
# R shoulder pain: Pt was c/o shoulder pain and radiating R arm
in house and reported that it had been present for the last
month. ROM was limited by pain. Plain films of shoulder showed
no evidence of fracture or joint space narrowing. Cervical spine
films show DJD & joint space narrowing in C5-C6. Pt denied
weakness, numbness and both strength & sensation were intact on
exam. It was thought likely that C-spine DJD and possible
radiculopathy was contributing to her symptoms. She was treated
with Tylenol 650mg q6hrs and was encouraged to get outpatient
physical therapy.
Medications on Admission:
Diclofenac 75mg daily
Verapamil SR 240mg daily
Verapamil SR 180mg qhs
Lipitor 10mg daily
Glucosamine 500mg TID
Nasacort prn
Discharge Medications:
1. Outpatient Lab Work
Please draw PT/INR and forward results to Dr. [**Last Name (STitle) **] fax [**Telephone/Fax (1) 105404**]
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed): you can take up to three
tabs in 15min for chest pain, please call PCP or come to ED if
the chest pain does not improve .
Disp:*15 Tablet, Sublingual(s)* Refills:*1*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*20 Tablet(s)* Refills:*0*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
9. Nasacort AQ 55 mcg Aerosol, Spray Sig: One (1) Nasal three
times a day.
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
Chest pain
NSTEMI
CAD s/p stenting & intracoronary tPA
.
Secondary:
Hypertension
Hyperlipidemia
Tobacco Dependance
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with chest pain and were found to have a
myocardial infarction. You had a cardiac catheterization and
they placed a stent if your right coronary artery. It is very
important that you continue taking Aspirin & Plavix every day.
We have also started you on a blood thinner called
Coumadin(Warfarin). You will need to get labs drawn regularly
while you taking this medication in order to keep the
appropriate level in your blood. Dr.[**Name (NI) 27495**] office will help
you with this.
.
We have stopped the Verapamil, you should not take that
medication anymore. We have started Metoprolol 12.5mg twice
daily and we have started Lisinopril 5mg daily. We have
increased the Lipitor to 80mg daily. Please discuss these
changes with Dr. [**Last Name (STitle) **] in follow up, you will need to have
labs monitored while on these medications.
.
We have given you a prescription for nitroglycerin to use only
if you develop chest pain. We have also give you prescription
for Colace 100mg twice daily and Pantoprazole 40mg daily.
.
You were given information about quitting smoking. Please try to
quit after you leave the hospital.
.
If you develop any chest pain, shortness of breath, weakness or
any other general worsening of condition, please go directly to
the emergency [**Last Name (un) **].
Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) 911**] in Cardiology on
the [**Location (un) 436**] of the [**Hospital Ward Name 23**] Building on [**6-5**] at 4pm.
.
You have a follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on
Thursday [**5-22**] at 11:10am. Please call [**Telephone/Fax (1) 10688**] if you
have any questions.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]
|
[
"414.01",
"401.9",
"721.0",
"305.1",
"426.11",
"410.41",
"724.2",
"715.96",
"272.4",
"564.00",
"V45.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.66",
"99.20",
"00.40",
"00.45",
"88.56",
"37.22",
"36.06",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
9966, 10023
|
6293, 8536
|
323, 377
|
10191, 10200
|
2755, 4362
|
11564, 12088
|
2023, 2114
|
8711, 9943
|
10044, 10170
|
8562, 8688
|
4379, 6270
|
10224, 11541
|
2129, 2736
|
273, 285
|
405, 1744
|
1766, 1885
|
1901, 2007
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,910
| 129,619
|
33457
|
Discharge summary
|
report
|
Admission Date: [**2124-9-15**] Discharge Date: [**2124-9-26**]
Date of Birth: [**2059-2-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4057**]
Chief Complaint:
Cough, hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
65 yo with metastatic breast cancer with known lung and brain
mets admitted on [**2124-9-15**] for cough and hypoxia. A week and a
half prior to presentation she had whole brain radation. Since
that treatment she had been very fatigued. Also started coughing
up green sputum and increased DOE. Her husband apparently was
sick before. Endorses fevers to ~100.3 each morning that she has
been treating with alleve. She was given Z-pack 5 days ago
without improvement and she got 1 dose of augmentin in clinic on
the day of presentation. Of note, she just finished a
dexamethasone taper on the day of presentation after her whole
brain radiation. She was stable the night of admisison but the
next day she was put on a non-rebreather for hypoxia and
transferred to the MICU. In the MICU she was diuresed, had a
negative CTA, and was started on Vanc/Cefepime/Tamaflu. Tamaflu
was stopped after negative flu cultures.
In clinic, 98.8 121/76 78 18 87% on RA - She came up to 94 % on
3 L NC - patient received fluids.
On ROS, patient endorses mild nausea and constipation for 7
days. She denies chest pain, headaches, abdominal pain, vision
changes, swelling or pain in calves.
Past Medical History:
<b>Oncologic History</b>
<u>Initial diagnosis:</u> stage I breast cancer (ER positive, PR
positive, HER-2 negative by FISH, grade [**1-25**], lymph node
negative.
<u>Treatment:</u> s/p lumpectomy and sentinel lymph node biopsy
followed by XRT and then Arimidex which was stopped after 2
months because the patient developed chest pain which was
determined non-cardiac. She was not placed on any hormonal
therapy.
<u>Recurrence:</u> In [**2-/2123**], CT scan of the chest that showed
multiple lung lesions and cytology showed adenocarcinoma.
- IHC: + gross cystic fluid protein, - TTF-1,
stereotactic biopsy on
[**2119-8-1**] that showed an The
<u>Treatment/Disease Course:</u>
- [**Date range (1) 77603**]: trial of fulvestrant(Faslodex) but taken off
when CT showed new liver mets
- [**2124-6-7**] -: kept on faslodex and aromasin and xomeda added
- [**2124-8-1**]: developed neurological symptoms and MRI showed >25
metastatic lesions, started on Decadron
- [**2124-9-5**]: completed course of whole brain XRT
- [**2124-9-8**]: completed decadron taper
Social History:
She is married and works in health promotion. She is a former
smoker, having quit approximately 30 years ago. Prior to this,
she smoked up to 2 packs of cigarettes per day for 20 years.
She
does have asbestos in her basement, although there have been no
attempts of removal. She has no drug allergy.
Family History:
With respect to her family history, her father was diagnosed
with
emphysema and her mother has COPD.
Physical Exam:
HR 79 BP 112/55 RR 22 O2 92% on 4L NC and showel mask
GEN: NAD
CV: RRR, no m/r/g
RESP: poor air movement, crackles at bases bilaterally, no
wheezing or rhonci
Abd: soft, nt, nd, + bs
Ext: no edema
Neuro: CN 3-12 intact, grossly oriented, 5/5 strength x 4,
coordination intact
Pertinent Results:
Discharge Labs: [**2124-9-26**]
WBC-7.5 RBC-2.99* Hgb-8.9* Hct-26.4* MCV-88 MCH-29.8 MCHC-33.8
RDW-13.9 Plt Ct-519*
Glucose-108* UreaN-7 Creat-0.5 Na-139 K-3.7 Cl-105 HCO3-27
AnGap-11
ALT-36 AST-31 LD(LDH)-289* AlkPhos-77 TotBili-0.6
Albumin-2.8* Calcium-8.1* Phos-3.1 Mg-2.4
.
CXR [**9-15**]:
- marked deterioration of the radiographic image.
- preexisting lung nodules have increased in size
- neralized reticular pattern that was previously invisible is
seen, together with newly appeared small bilateral pleural
effusions
- pattern suggests the presence of lymphangitic carcinomatosis.
- in the medial aspect of the middle lobe, a small area of
hypoventilation has newly appeared.
- Despite the multiple lytic bone lesions seen on the CT
examination from [**2124-8-24**], none of these lesions is
detectable on the chest radiograph.
.
CTA [**2124-9-17**]
1. Worsening of interstitial and bilateral ground-glass opacity
in a
perihilar and upper lobe distribution, given rapid interval
progression, may represent pulmonary edema or multifocal
bronchopneumonia. Recommend short term follow-up to document
resolution given known underlying metastasis. No evidence of
pulmonary embolism.
2. Unchanged diffuse osseous, hepatic and pulmonary metastases.
Brief Hospital Course:
# Hypoxia: The patient was tranferred to the [**Hospital Unit Name 153**] due to hypoxia
requiring a non-rebreather to stabilize her oxygen sats. She
had a convincing story for a viral infection as her and her
husband had URI symptoms and cough for the past few weeks. The
differential initally was broad and she was started on a heparin
gtt due to concern for PE. She was also started on broad
spectrum antibiotics and anti-flu [**Doctor Last Name 360**] (vanc, cefepime, and
tamiflu). Induced sputum was sent to rule out PCP as she had
recently been weaned off steroids in the setting of undergoing
whole brain irradiation. Sputum was negative for PCP. [**Name Initial (NameIs) **]
urinary legionella antigen was sent and was negative. EKG had
no ichemic changes and cardiac enzymes were negative for MI.
She underwent a CTA showed no evidence of PE, but did show a
marked worsening of interstitial and bilateral ground-glass
opacity in a perihilar and upper lobe distribution. LENIs were
also negative for DVT. Tamiflu was stopped when her flu DFA
returned negative. On exam she did not appear volume overloaded.
A TTE was done and showed and EF of 75% and no evidence of wall
motion abnormalities. She was given standing albuterol and
ipatropium nebs. Her hypoxia slowly improved and she was
satting in the mid 90's on 6L NC. Upon abmulating she sated 95%
on 6L and 91% on 4L. She was discharge on home O2 and VNA
services. She will follow up with Dr. [**Last Name (STitle) **].
.
# Breast cancer: Patient received one treatment of chemotherapy
while hospitalized. She tolerated the treatment well. She was
discharged on zofran, ativan, compazine for possible
post-chemotheraphy nausea.
.
# Code Status: Prior to transfer she was DNR/DNI. Upon
discussion, she was willing to be intubated for acute pneumonia
but specifically states that she does not want to be on a
ventilator long term. She has discussed this decision with her
HCP, her husband.
Medications on Admission:
Hydrocodone-Acetaminophen 5 mg-500 mg Tablet
[**12-24**] Tablet(s) by mouth every 6-8 hours [**2124-6-9**]
Lorazepam 0.5 mg Tablet
1 Tablet(s) by mouth every 6 to 8 hours as needed
Ergocalciferol (Vitamin D2) [Vitamin D]
1,000 unit Capsule 1 Capsule(s) by mouth once a day (OTC)
[**2123-5-12**]
Multivitamin
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB/wheezing.
Disp:*120 2.5mg/3mL* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
4. 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*
5. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal [**Hospital1 **] (2 times a day).
Disp:*60 50mcg* Refills:*2*
6. Zofran 8 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for nausea.
Disp:*90 Tablet(s)* Refills:*2*
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety/nausea.
Disp:*120 Tablet(s)* Refills:*1*
8. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed: for nasal congestion.
Disp:*60 Tablet(s)* Refills:*2*
9. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-24**] Sprays Nasal
[**Hospital1 **] (2 times a day) as needed for dryness.
Disp:*1 bottle* Refills:*2*
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulized
Inhalation Q6H (every 6 hours) as needed for wheezing/SOB.
Disp:*120 nebulized* Refills:*2*
11. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO every 6-8 hours as needed for pain.
12. Oxgen
Please provide the patient with oxygen. She is on 4-6L
continuous.
13. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA Care of [**Doctor Last Name **]
Discharge Diagnosis:
Primary Diagnosis:
1) Viral pneumonia
2) Breast cancer
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital for hypoxia. You were treated
with antibioitcs for a likely infection in your lungs. We think
an infection is what caused your breathing difficulty. You will
be discharged on oxygen with nursing and PT services. You were
also given 1 round of chemotherapy while you were hospitalized.
You tolerated this treatment well.
.
We have made the following changes to your medications:
1) Albuterol Sulfate 2.5 mg /3 mL Solution for Nebulization.
One (1) Inhalation Q6H (every 6 hours) as needed for
SOB/wheezing.
2) Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day). As needed for constipation
3) Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4) Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two
(2) Spray Nasal [**Hospital1 **] (2 times a day) for nasal congestion
5) Zofran 8 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for nausea.
6) Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed: for nasal congestion.
7) Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-24**] Sprays
Nasal [**Hospital1 **] (2 times a day) as needed for dryness.
8) Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulized
Inhalation Q6H (every 6 hours) as needed for wheezing/SOB.
Please seek medical care if you have shortness of breath, chest
pain, nausea/vomiting, diarrhea, fevers/chills, dizziness,
fainting.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 17688**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2124-10-4**] 12:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10384**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2124-10-4**] 1:30
Completed by:[**2124-9-26**]
|
[
"198.3",
"480.9",
"197.0",
"518.82",
"V10.3",
"511.9",
"197.7",
"564.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
8647, 8713
|
4651, 6618
|
329, 336
|
8812, 8821
|
3373, 3373
|
10332, 10651
|
2958, 3061
|
6977, 8624
|
8734, 8734
|
6644, 6954
|
8845, 9228
|
3389, 4628
|
3076, 3354
|
9257, 10309
|
275, 291
|
364, 1544
|
8753, 8791
|
1566, 2622
|
2638, 2942
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,615
| 125,022
|
34358
|
Discharge summary
|
report
|
Admission Date: [**2101-6-1**] Discharge Date: [**2101-6-4**]
Date of Birth: [**2035-6-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
exertional neck pain
Major Surgical or Invasive Procedure:
cardiac catheterization with angioplasty and stenting
History of Present Illness:
The patient is a 65 year old woman with history of HTN,
hyperlipidemia, and diet controlled diabetes who presented
intially to [**Hospital3 934**] on [**2101-5-30**] after having 1 week of
exertional angina. She was having pain in the neck and shoulders
after walking 2 flights of stairs at a time. She had no
shortness of breath, diaphoresis, or palpitations during each
event.
She ruled out for MI. She underwent cardiac catheterization and
was found to have an 80% proximal LAD lesion and a 40-50% distal
stenosis of her OM. The LCx had 40-50% distal lesion. The RCA
and LMCA were normal. LVEF was normal. RHC revealed normal
pressures. For the intervention, the patient was transferred to
[**Hospital1 18**].
During the intervention the LAD lesion was stented however a
linear density was seen that was ultimately thought to be due to
eccentric calcification and not dissection. 2 DES were placed in
the LAD and 1 DES was placed in LCX for a 70% distal lesion.
During the procedure she developed neck/throat pain and
intermittently had a LBBB on her EKG. She was started on a NTG
drip and the case was completed as planned.
Of note the patient had recently stopped her lipitor (myalgias
and myositis) and HCTZ. She states that she recently started to
be evaluated by her PCP for anemia which so far has only shown
hypothyroidism. She was recently prescribed thyroid replacement
but has not yet started the prescription.
On review of symptoms, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
She denies exertional buttock or calf pain other than when on
lipitor. All of the other review of systems were negative.
*** Cardiac review of systems is notable for absence of current
chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope.
Past Medical History:
hypertension
hyperlipidemia
diabetes mellitus type 2 (diet controlled)
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. The patient lives
with her husband. She has 6 children from a prior marriage. She
currently works part time in real estate.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother died of heart disease in her 60s. Father
died of heart disease in his 70s.
Physical Exam:
VS: T 97.8 , BP 131/69, HR 65, RR 15, O2 100% on 2L
Gen: obese middle aged woman in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP flat with patient flat.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits. arterial sheath in left
femoral artery
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
EKG demonstrated ([**2101-5-30**]) sinus rhythm at 65 bpm nl axis and
intervals no significant ST-T wave changes
[**2101-6-1**]: post-PCI: sinus @65 with PR prolongation. nl axis. LBBB.
TELEMETRY demonstrated: sinus rhythm with nl axis and intervals
with periods of sinus rhythm with wide complex and leftward axis
(LBBB morphology)
CARDIAC CATH performed at [**Hospital **] Hosp on [**2101-5-31**] demonstrated:
80% prox LAD
40-50% distal OM
LMCA and RCA were normal.
LCX 40-50% distal lesion
RA 12/10/9
RV 29/5
PA 27/12/18
PCW 14/15/11
AO 107/55/78
LV 108/14
[**2101-6-1**]: [**Hospital1 18**]
Right dominant system
LMCA no apparant disease
LAD 80% proximal lesion involving the D1 which had moderate
ostial disease
LCx: 70% distal lesion supplying 2 OMs
PCI: LAD with 2 overlapping Cypher stents, LCX with 1 Cypher
stent. Linear density seen at the distal edge of first LAD stent
felt likely to represent eccentric calcium and not dissection.
Optiray: 370cc
angiomax was given during the procedure.
Imaging:CXR [**2101-5-30**] - clear lungs. no active process
LABORATORY DATA:
OSH records
[**2101-6-1**] - CBC 6.7>27.1<179 MCV 83 RDW 15
[**2101-5-30**] - chem 7
Na 136 K 4.1 Cl 105 CO2 23 BUN 29 Cr 1.3 Glu 105
Ca 9.7 alb 3.5 ALK 88 AST 21 ALT 23 tpro 7.3
CPK 167 MB 2.1
TnI 0.01
[**2101-6-2**] 02:46PM BLOOD CK(CPK)-529*
[**2101-6-3**] 05:56AM BLOOD CK(CPK)-368*
[**2101-6-2**] 05:35AM BLOOD CK-MB-36* MB Indx-10.5* cTropnT-0.20*
[**2101-6-3**] 05:56AM BLOOD CK-MB-18* MB Indx-4.9 cTropnT-0.50*
[**2101-6-2**] 05:35AM BLOOD Triglyc-385* HDL-34 CHOL/HD-5.5
LDLcalc-76
[**2101-6-2**] 05:35AM BLOOD TSH-15*
[**2101-6-2**] 05:35AM BLOOD Free T4-0.74*
[**2101-6-2**] 05:35AM BLOOD calTIBC-298 VitB12-566 Folate-9.0
Ferritn-393* TRF-229
Echo [**2101-6-2**]
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with akinesis of the basal
inferior septum, and hypokinesis of the basal inferio wall and
mid-inferior septum (RCA territory). The remaining segments
contract normally (LVEF = 50-55%). Right ventricular chamber
size and free wall motion are normal. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Mild pulmonary hypertension.
Brief Hospital Course:
In brief the patient is a 65 year old woman with history of
hypertension, hyperlipidemia who was referred for elective PCI
following developing progressive exertional angina.
#CAD: The patient is a 65 year old woman with history of HTN,
hyperlipidemia, diet controlled DM2 presenting for PCI c/b
intermittent LBBB and anginal equivalent.
Patient initially presented to OSH with exertional angina found
to have signficant 2 vessel disease that is now s/p PCI with
stent placement. The patient is was symptom free immediately
following angioplasty with intermittent LBBB on EKG. Transfered
from OSH due to concern regarding LBBB and concern that LAD had
dissected during stent placement. Patient initially had some
nausea, chest pressure and headache following arrival in CCU,
but EKG was unchanged from pre-cath EKG (no LBBB) and symptoms
resolved with anti-emetics and rest. Post-cath check was
unremarkable, and over the next 24 hours of admission the
patient's cardiac enzymes trended up, peaking at CK 529 and
Troponin of 0.58. On [**2101-6-2**] the patient had an echo that showed
a LVEF of 50-55%. Patient began to ambulate on [**2101-6-3**] and
worked with physical therapy on [**2101-6-4**]. Patient was restarted
on home aspirin and ACE-inhibitor and started on plavix and a
beta-blocker.
#Anemia: Patient was noted to be anemic and was transfused 2
units packed RBC's on night of admission and on morning
laboratories found to have an elevated TSH with a suppressed
free T4, suggesting hypothyroidism as the etiology of her
anemia, as iron studies, folate and B12 were normal and stool
guaiacs were negative. Pt was started on levothyroxine.
Medications on Admission:
ASA 81mg daily
Quinapril 20mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*3*
3. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO
daily ().
4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual q5minutes as needed for chest pain: if no
relief with 1 tablet call 911.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
5. Quinapril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
NSTEMI
Hypertension
Secondary:
Obesity
Hyperlipidemia
Discharge Condition:
Good. Chest pain free. Stable vital signs. Tolerating oral
medication and nutrition.
Discharge Instructions:
You were admitted for treatment of exertional chest/neck pain.
You likely suffered a heart attack and you underwent cardiac
catheterization where we have treated the blockages with
angioplasty and stenting. We have found the your thyroid
function was depressed and we have started you on a medication
called Levothyroxine to supplement your thyroid. You will need
to get follow up thyroid function tests in 6-8weeks, please
discuss this with your primary care physician.
Please take your medications as prescribed.
It is very important that you continue to take both your aspirin
and clopidogrel (Plavix) without missing a dose until your
cardiologist tells you to stop. Missing doses could put you at
risk for a severe heart attack or even death. For now you should
expect to take these medications for at least one year.
Please attend the recommended follow-up appointments.
If you develop any new or concerning symptoms such as chest
pain, shortness of breath, severe nausea, or severe bleeding;
please seek medical attention as soon as possible.
Followup Instructions:
Primary Care Doctor: Dr. [**First Name4 (NamePattern1) 333**] [**Last Name (NamePattern1) 40075**] on Thursday [**6-16**]
at 10:45. Please call [**Telephone/Fax (1) 40076**] with questions.
Cardiology: Dr. [**First Name8 (NamePattern2) 518**] [**Last Name (NamePattern1) 8579**]. You have an appointment for
Monday, [**6-27**] at 9:45am. The office is in [**Hospital 59243**] Medical
Building across from [**Hospital **] Hospital, [**Apartment Address(1) **]. Please call
[**Telephone/Fax (1) 23882**] with questions.
|
[
"280.9",
"278.00",
"410.71",
"272.4",
"426.3",
"414.01",
"401.9",
"250.00",
"244.9",
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] |
icd9cm
|
[
[
[]
]
] |
[
"36.07",
"00.66",
"00.41",
"88.56",
"00.47",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
8818, 8824
|
6379, 8041
|
332, 388
|
8932, 9019
|
3851, 6356
|
10124, 10652
|
2774, 2938
|
8128, 8795
|
8845, 8911
|
8067, 8105
|
9043, 10101
|
2953, 3832
|
272, 294
|
416, 2414
|
2436, 2509
|
2525, 2758
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,839
| 157,281
|
4363
|
Discharge summary
|
report
|
Admission Date: [**2136-6-16**] Discharge Date: [**2136-7-4**]
Date of Birth: [**2064-6-16**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Keflex / Gentamicin / Cipro Cystitis
Attending:[**First Name3 (LF) 3021**]
Chief Complaint:
Leg pain.
Major Surgical or Invasive Procedure:
[**2136-6-20**] Arthrocentesis (hip joint tap).
[**2136-6-21**] Left hip girdlestone procedure with Dr. [**Last Name (STitle) **].
History of Present Illness:
71 y/o w/ metastatic melanoma with progressive left proximal
lower extremity pain, now unable to bear weight. Pain started
[**2136-6-11**], and progressed rather quickly. Visited ED [**2136-6-12**]
received femur x-ray which showed lytic lesions but no
pathologic fracture, also LENI negative for DVT, remains on
coumadin now supratherapeutic. He was recently started on
morphine 15 mg ER of which he took 3 doses over 4 days and
Morphine IR which also makes him "loopy" per his wife.
.
Initial vitals 98.8 106 136/84 20 99% No fever. No N/V, CP, SOB,
abd pain. Has had recent urinary retention while using morphine
and has required Foley catheter placement on [**6-14**] by urology.
Poor PO intake.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight gain.
Denies blurry vision, diplopia, loss of vision, photophobia.
Denies headache, sinus tenderness. Denies chest pain or
tightness, palpitations. Denies cough, shortness of breath, or
wheezes. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain. Denies dysuria, stool or urine incontinence.
Denies rashes or skin breakdown. No numbness/tingling in
extremities. All other systems negative.
Past Medical History:
-PRIOR TREATMENT: Mr. [**Known lastname 18817**] [**Last Name (Titles) 1834**] wide local excision
of
a 1.5-mm thick superficial spreading melanoma from his inner
aspect of his left thigh in [**2121**]. a sentinel lymph node biopsy
was performed at that time. This report was remarkable for
bilateral calf DVT into the femoral and popliteal veins with
probable pulmonary embolism on CT scan. He has remained on
Coumadin since that time. He developed biopsy-proven recurrence
in left inguinal area, which on review, was felt to be within
the
lymph nodes with evidence of extracapsular extension into the
resection margin. He [**Year (4 digits) 1834**] left inguinal node dissection on
[**2132-10-4**] with pathology revealing metastatic melanoma with a
soft tissue, not extending to the margins. He received adjuvant
radiation therapy to the inguinal area. He began his adjuvant
interferon therapy on [**2133-1-28**]. Mr. [**Known lastname 18818**] course was
complicated by urinary tract infection and thus being off of the
interferon from [**2133-8-21**] through [**2133-8-31**] being on
antibiotics. His urine culture was clear as of [**8-31**] and he
resumed therapy that day. Mr. [**Known lastname 18818**] interferon was
discontinued on [**2133-11-19**] due to prostatitis flare. He was
diagnosed with prostate cancer [**2134-3-25**] with biopsy-positive
prostate cancer [**Doctor Last Name **] 3+3. He was followed from [**3-/2134**] until
[**2135-8-3**] when screening showed a RUL nodule.
-- CT torso [**2135-8-8**] which showed a 25 x 23 mm right upper lobe
nodule and a 3mm R. apical nodule with no other disease in the
chest, abdomen of pelvis.
-- [**2135-8-29**] PET-CT: FDG avid lesion in the right upper lung 2.
FDG
avid bilateral hilar nodes 3. FDG avid lesion in the inferior
left abdominal wall 4. FDG avid mass in the left scapula and
multiple FDG avid skeletal sites.
-- [**2135-8-29**] MRI Brain: No evidence of intracranial metastases.
-- [**2135-9-13**] Scapular Bx: Malignant epithelioid malignancy, S-100
positive, and negative for keratin cocktail, MART-1, and HMB-45.
Similar to primary melanoma. BRAF V600E Mutant
-- [**2135-9-20**] consented for DF-HCC 09-406 (RO5185426 or
Dacarbazine). Deemed ineligible due to prostate cancer.
-- [**2135-10-25**] C1D1 Dacarbazine 1000mg/m2
-- [**2136-2-23**] CT torso with no new lesions, slight decrease in
groin
met, stable bony disease
-- [**2136-2-23**] MRI brain without CNS disease
-- [**2136-5-22**] C11D1 Dacarbazine 1000mg/m2
.
Other PMHX:
-DVT [**2120**] following melanoma excision
- Left groin LN disection with resultant left edema
Social History:
He once owned his own courier company. He sold it in [**2132-3-9**]
and now works for another person. Lives with his wife. [**Name (NI) **] is
a Physical therapist and helping out a lot. No T/A/D.
Family History:
Non-contributory.
Physical Exam:
ADMISSION EXAM:
VS: 100.5 152/96 100 18 94% RA
GEN: Elderly man in NAD, awake, alert, but slow to respond
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and
without lesion
NECK: Supple, no JVD
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, NT, ND, no HSM, bowel sounds present
EXT: No c/c/e, Left leg slighly larger than right (chronic from
surgeries), 2+ DP/PT bilaterally, Left groin with erythema and
lymphadenopathy.
SKIN: right scapular lesion with skin tear/burst blister, warm
skin
NEURO: oriented x 3, normal attention, CN II-XII intact, [**4-12**]
strength in upper extremities, limited by pain in lower
extremites, intact sensation to light touch
Pertinent Results:
ADMISSION LABS:
[**2136-6-16**] 11:25AM PLT COUNT-207#
[**2136-6-16**] 11:25AM NEUTS-85.8* LYMPHS-9.1* MONOS-5.0 EOS-0
BASOS-0.1
[**2136-6-16**] 11:25AM WBC-7.4# RBC-3.45* HGB-12.5* HCT-36.0*
MCV-104* MCH-36.1* MCHC-34.6 RDW-13.7
[**2136-6-16**] 11:25AM GLUCOSE-187* UREA N-18 CREAT-0.7 SODIUM-133
POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-24 ANION GAP-15
[**2136-6-16**] 02:59PM PT-39.2* PTT-37.9* INR(PT)-4.0*
[**2136-6-16**] 03:20PM URINE MUCOUS-MANY
[**2136-6-16**] 03:20PM URINE RBC-10* WBC-10* BACTERIA-NONE YEAST-NONE
EPI-0
[**2136-6-16**] 03:20PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-TR
[**2136-6-16**] 03:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.025
.
[**2136-7-2**] CXR: FINDINGS: As compared to the previous radiograph,
there is no relevant change. Minimal plate-like areas of
atelectasis at the left lung base. No focal parenchymal opacity
suggesting pneumonia. No pleural effusions. Pulmonary edema.
Unchanged normal size of the cardiac silhouette. Minimal
tortuosity of the thoracic aorta. Unchanged right-sided PICC
line.
.
[**2136-6-29**] LE doppler U/S: Negative.
.
[**2136-6-28**] CXR: IMPRESSION: Mild bibasilar atelectasis. No evidence
of acute cardiopulmonary disease.
.
[**2136-6-27**] CXR: In comparison with study of [**6-22**], there is blunting
of the left costophrenic angle, suggestive of pleural effusion.
However, no evidence of acute focal pneumonia or vascular
congestion.
.
[**2136-6-26**] MRI HIP: IMPRESSION:
1. Contrast not administered.
2. Interval girdlestone procedure with removal of left femoral
head. Fluid in left actebulum and surrounding greater trochanter
may be post surgical.
3. Persistent high signal in left iliacus muscle on STIR imaging
in keeping with intramuscular edema but muscle expansion has
decreased with further decreases in size of intramuscular fluid
locules.
4. Stable bone mets in right upper femur and right inferior
pubic ramus.
.
[**2136-6-22**] CT HEAD: IMPRESSION: No intracranial hemorrhage, edema,
or mass effect. No evidence of metastatic disease. MRI with and
without contrast would be more sensitive if there is high
clinical concern.
.
[**2136-6-21**] ECHO: The left ventricular cavity is small. Left
ventricular systolic function is hyperdynamic (EF 80%). Right
ventricular chamber size and free wall motion are normal. The
mitral valve leaflets are not well seen (mitral valve prolapse
is probably present). Trivial mitral regurgitation is seen.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Small, hyperdynamic left
ventricle.
.
[**2136-6-20**] CXR: IMPRESSION: No acute intrathoracic process.
Unchanged sclerotic metastasis in the upper thoracic spine.
.
[**2136-6-18**] MRI PELVIS/THIGH: IMPRESSION:
1. Asymmetric enhancement and edema extending from the medial
inferior left psoas muscle, majority of left iliacus muscle with
extension into the proximal left thigh to involve the left
iliopsoas, left obturator externus, pectineus, adductor muscle
group, quadratus femoris and gluteus minimus musculature with
mild enhancement and edematous changes. In addition, there are
small locules of rounded fluid in the left iliacus muscle
posteriorly, which demonstrate non-enhancement centrally with
the largest pocket with layering debris measuring approximately
1.3 x 2.3 cm. This constellation of findings is concerning for
an infectious or inflammatory process in the correct clinical
setting. Inflammatory neoplastic process is also a possible
consideration.
2. Left femoral neck likely osseous metastatic lesion is stable
in size in comparison to prior comparisons. No pathologic
fracture.
3. Small left hip joint effusion with likely reactive edema in
the medial and posterior left acetabulum. An infectious etiology
is not entirely excluded given adjacent edematous marrow and
soft tissues.
.
[**2136-6-16**] CT LEFT PROX LEG: Sclerotic foci in the right L5
vertebral body (2:7) measuring 10 mm (previously measuring 9
mm), left ilium (2:7) measuring 13 mm (previously measuring 14
mm), left greater trochanter mixed lytic and sclerotic (2:57)
measuring 5 mm (prior measuring 5 mm) and left proximal femur
mixed lytic/sclerotic (2:67) measuring 13 mm (prior measuring 11
mm) are essentially unchanged in size to slightly increased in
appearance compared to the prior examination. No acute fracture
is seen. IMPRESSION: Multiple osseous lesions, as above,
consistent with known history of metastasis, stable to slightly
increased. No acute fracture.
.
[**2136-6-12**] LEFT FEMUR/HIP X-RAY: IMPRESSION: Metastatic lesions in
the proximal femora bilaterally without left femoral fracture.
.
[**2136-6-12**] LLE DOPPLER U/S: IMPRESSION: No left lower extremity DVT.
.
DISCHARGE LABS:
[**2136-7-4**] WBC 7.4, HB 9.8, HCT 28.4, MCV 97, PLT 300.
[**2136-7-4**] PT 13.1, INR 1.1, PTT 27.3
[**2136-6-27**] ESR 130
[**2136-7-1**] ESR 126
[**2136-6-17**] RETIC 1.1
[**2136-7-4**] GLUCOSE 124, BUN 36, CREAT 2.1, NA 139, k 4.6, CL 105,
CO2 26.
[**2136-6-29**] ALT 17, AST 22, LDH 272, ALP 57, T BILI 0.4
[**2136-6-28**] CK 56
[**2136-7-2**] ALBUMIN 2.5, CA 8.9, PHOS 3.6, MG 2.6
[**2136-6-17**] B12 414, FOLATE 9.7
[**2136-6-28**] HBA1C 6.5%
[**2136-6-27**] CRP 165
[**2136-7-1**] CRP 131.1
[**2136-6-17**] PSA 19.2
Brief Hospital Course:
72yo man with metastatic melanoma, hx of DVT on warfarin, and
prostate CA (not treated) admitted for left proximal leg pain
with weight bearing x1-2wks, fever. Also foley catheter placed
prior to admission for urinary retention while on morphine. MRI
[**2136-6-17**] demonstrated inflammation of his left iliopsoas muscle
and a left hip effusion. Ortho was [**Month/Day/Year 4221**] and upon
discussion, it was initially decided that no operative
intervention was necessary. Infectious Disease was [**Month/Day/Year 4221**]
and Interventional Radiology aspirated the left hip, which
showed a WBC > 20,000 and GPCs (eventually speciated to MSSA).
He was taken urgently to the OR for wash out. During surgery,
the severity of the infection led to a left femoral head
resection. He tolerated the procedure without intra-operative
complication, and was transferred to the floor per routine.
Pain was intially controlled with parenteral narcotics with
assistance from the Palliative Care service. Eventually, he was
transitioned to a PO pain regimen to good effect. Once MSSA was
speciated, vancomycin was changed to nafcillin after a
successful nafcillin desensitization in the ICU without hives,
edema, or anaphylaxis. Repeat MRI did not show any remaining
joint effusion.
.
On POD#3, Mr. [**Known lastname 18818**] creatinine rose to 1.2 from baseline
0.7, and subsequently to 2.2 on POD#4. The renal service was
[**Known lastname 4221**] and his antibiotics were changed from nafcillin to
daptomycin. He was transferred back to the Hospitalist Oncology
service on POD#6 for continued management of his kidney issues,
which subsequently stabilized. He was restarted on warfarin
with an enoxaparin bridge for DVT treatment considering his past
histories of DVTs and PE. Fevers persisted for about one week
post-op, but repeat cultures and CXR remained negative. He also
required RBC transfusions for anemia of inflammation. He was
transferred to rehab once afebrile with the plan to continue
daptomycin for six weeks total, then follow-up with Orthopedics
for a hip replacement.
.
# MSSA septic hip and infective myositis: Hip wash out and
femoral head resection [**2136-6-22**]. Nafcillin changed to daptomycin
[**2136-6-28**] due to [**Last Name (un) **]. ID and ortho [**Last Name (un) 4221**]. Repeat MRI without
evidence of fluid re-accumulation. Plan to continue daptomycin
x6wks total while checking CK qwk, next [**2136-7-5**]. Physical
therapy: No weight bearing to left hip changed to weight bearing
as tolerated. Ortho and reconstructive surgery F/U in [**3-14**] weeks
with repeat MRI +/- arthrocentesis prior to hip replacement.
.
# Fever: Due to septic joint and infective myositis. Repeat CXR
negative X2. C. diff negative x1. Echo [**2136-6-21**] negative. LE
doppler U/S negative. Repeat ESR and CRP still elevated.
Repeat cultures no growth to date.
.
# Nafcillin desensitization: In the [**Hospital Unit Name 153**], Mr. [**Known lastname 18817**] [**Last Name (Titles) 8783**] nafcillin densensitization and received a total of 3
doses of nafcillin while in the [**Hospital Unit Name 153**] without hives, edema, or
anaphylaxis. He was also hemodynamically stable without periods
of hypotension throughout the desensitization.
.
# Acute renal failure: Stable. Due to AIN from nafcillin vs.
ATN due to sepsis/pre-renal vs. obstruction (urinary retention).
Renal service [**Hospital Unit Name 4221**]. Nafcillin switched to daptomycin
[**2136-6-28**].
.
# Hyponatremia: Resolved with IV fluids.
.
# Metastatic melanoma: Dr. [**Last Name (STitle) 1729**] is planning to enroll Mr.
[**Known lastname 18817**] into a clinical trial after resolution of current
infection. Asymptomatic from cancer disease.
.
# Prostate CA: PSA 19.2, increased from 10.5 on 12/[**2134**].
Follow-up as outpatient. Continued calcium and vitamin D.
.
# UTI: MSSA and coag-negative Staph, 10,000-100,000
ORGANISMS/ML. Foley catheter removed. Changed nitrofurantoin
to vancomycin [**2136-6-19**] for MSSA UTI and septic arthritis, then to
nafcillin with sensitivities, then to daptomycin due to [**Last Name (un) **].
Repeat U/A negative.
.
# Hyperglycemia: Mild. HbA1c 6.5. Insulin sliding scale
stopped.
.
# Urinary retention: Developed in setting of narcotic analgesia.
Foley catheter placed prior to admission. Resolved with
tamsulosin. Foley removed.
.
# DVT: Warfarin increased to 6mg daily and bridged with
enoxaparin while subtherapeutic. INR goal 2.5-3.0 per ortho.
.
# Macrocytic anemia: Transfused 1U pRBC [**2136-7-2**] and 1U [**2136-7-3**].
Adequate B12 and folate. Low retic suggested decreased
production, likely anemia of inflammation.
.
# Pain (LLE): OxyContin 10mg [**Hospital1 **] with prn oxycodone.
.
# FEN: Regular diet.
.
# DVT PPx: On chronic antociagulation for h/o DVT/PE.
.
# GI PPx: PPI and bowel regimen.
.
# Precautions: Fall.
.
# Lines: PICC line.
.
# CODE: FULL.
Medications on Admission:
ALPRAZOLAM - 0.25 mg Tablet - [**12-11**] Tablet(s) PO once before your
MRI
MORPHINE - 15 mg Tablet PO q4-6 as needed for severe pain
MORPHINE - 15 mg Tablet Extended Release PO twice a day
ONDANSETRON HCL - 8 mg PO q8 prn Nausea
OXYCODONE-ACETAMINOPHEN 5 mg-325 mg Tablet PO q6 hrs as needed
for pain
POLYETHYLENE GLYCOL 3350 - 17 gram Powder 1 packet PO daily hold
for loose stool
PROCHLORPERAZINE MALEATE - 5 mg Tablet PO q4-6 as needed for
nausea
WARFARIN [COUMADIN] - 2 mg Tablet - 3 Tablet(s) PO once a day or
as directed
CALCIUM CARBONATE - 500 mg (1,250 mg) 2 Tablet(s) PO once a day
CHOLECALCIFEROL (VITAMIN D3) 2,000 unit PO once a day
PSYLLIUM [METAMUCIL]
SENNOSIDES - 8.6 mg Tablet - 1 Tablet(s) by mouth [**Hospital1 **] hold for
loose stool
ALLERGIES: PCN, Gentamicin, Keflex, Ciprofloxacin
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. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours) for 1
months.
Disp:*60 Tablet Extended Release 12 hr(s)* Refills:*0*
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for pain.
7. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush for 6
weeks.
Disp:*qs ML(s)* Refills:*0*
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
Dose PO DAILY (Daily) as needed for constipation.
11. ondansetron HCl 4 mg Tablet Sig: 1-2 Tablets PO every eight
(8) hours as needed for nausea.
12. prochlorperazine maleate 5 mg Tablet Sig: 1-2 Tablets PO
every eight (8) hours as needed for nausea.
13. warfarin 2 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM: Goal INR 2.5-3.0.
14. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH
MEALS).
15. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
16. enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) mg
Subcutaneous Q12H (every 12 hours): Until INR >2.
17. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
18. daptomycin 500 mg Recon Soln Sig: Four [**Age over 90 8821**]y (440)
mg Intravenous Q24H (every 24 hours): Six weeks total, finishing
[**2136-8-1**].
19. Outpatient Lab Work
Dx: Septic arthritis, metastatic melanoma, prostate cancer.
Labs: CBC, chem7, CK.
Draw weekly until [**2136-8-9**].
Please fax to [**Telephone/Fax (1) 1419**] (Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care-
Discharge Diagnosis:
Left hip septic arthritis (hip infection).
Left psoas infective myositis (muscle infection).
Fever.
Metastatic melanoma.
Prostate cancer.
Acute kidney failure.
Urinary tract infection.
Anemia.
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 left hip pain thought to be due to either
metastatic melanoma or prostate cancer. However, MRI revealed a
severe infection of the hip joint (septic arthritis) and
surrounding muscles (myositis). You were started on IV
antibiotics and Infectious Disease specialists and Orthopedic
surgeons were [**Hospital 4221**]. You [**Hospital 1834**] arthrocentesis where
fluid was removed from the hip. This fluid was grossly infected
with Staphylococcus aureus bacteria. The orthopedic surgeons
took you to the operating room to wash out the infection, but
found the region to be so infected that they needed to remove
the head of the femur (leg bone). Your kidney function also
worsened, so the Kidney doctors [**First Name (Titles) **] [**Last Name (Titles) 4221**]. They thought it
may have been due to your antibiotic (nafcillin), so this was
changed to daptomycin. You will need to remain on daptomycin
for six weeks total finishing [**2136-8-1**]. After this, MRI of the
hip will need to be done and possibly another needle aspiration
to prove the infection has cleared. Once the infection is fully
gone, the orthopedic surgeons can perform a hip replacement.
Meanwhile, you will receive physical therapy and IV antibiotics
at a rehab facility. You did require red blood cell
transfusions for anemia and you may require additional blood
transfusions in the future. Therefore, your blood counts will
need to be monitored regularly.
.
You have been prescribed a narcotic pain medication. Please
take only as directed and do not drive or operate any machinery
while taking this medication. There is a 72 hour (Monday
through Friday, 9am to 4pm) response time for prescription
refill requests. There will be no prescription refills on
Saturdays, Sundays, or holidays. Please plan accordingly.
.
Wound Care:
- Keep Incision clean and dry.
- Do not soak the incision in a bath or pool.
Activity:
- Continue to weight-bear as tolerated.
- External shoe lift to his affected leg.
.
Other Instructions:
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Take all medications as instructed.
- Continue taking blood thinners as directed.
- If you have any increased redness, drainage, swelling,
numbness, or if you have a temperature greater than 101.5,
please call the office or come to the emergency department.
.
MEDICATION CHANGES:
1. Daptomycin x6 weeks total (last day [**2136-8-1**]).
2. Enoxaparin (Lovenox) 70mg subcutaneous injection 2x a day
until warfarin (Coumadin) is therapeutic (INR 2.5-3.0).
3. OxyContin 10mg 2x a day.
4. Oxycodone 5-10mg as needed for breakthrough pain.
5.
3. Tamsulosin (Flomax) daily to prevent urinary retention.
Followup Instructions:
Please have weekly labs including CBC, chem7, LFTs, and CK faxed
to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] at [**Telephone/Fax (1) 1419**].
.
Please call the Infectious Disease office to schedule a
follow-up appointment in 4 weeks at [**Telephone/Fax (1) 457**].
.
Please call the Nephrologist (Kidney doctor) Dr. [**First Name8 (NamePattern2) 18819**] [**Name (STitle) 14005**] and
Dr. [**First Name4 (NamePattern1) 429**] [**Last Name (NamePattern1) 118**] in 2 weeks at [**Telephone/Fax (1) 721**].
.
Please call you oncologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1729**] to schedule a
follow-up appointment in 4 weeks at [**Telephone/Fax (1) 13016**].
.
Department: [**Hospital **] HEALTHCARE OF [**Location (un) **]
When: WEDNESDAY [**2136-8-1**] at 2:10 PM
With: [**First Name11 (Name Pattern1) 20**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3070**]
Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground
Campus: OFF CAMPUS Best Parking: Parking on Site
.
Department: ORTHOPEDICS
When: FRIDAY [**2136-8-3**] at 11:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: SURGICAL SPECIALTIES: UROLOGY
When: THURSDAY [**2136-11-22**] at 2:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 11307**], MD [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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27,172
| 183,106
|
49113
|
Discharge summary
|
report
|
Admission Date: [**2111-9-5**] Discharge Date: [**2111-9-22**]
Date of Birth: [**2055-11-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Ibuprofen / Ciprofloxacin
Attending:[**First Name3 (LF) 11040**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Endotracheal intubation
OG tube
Central Venous Line
History of Present Illness:
55-year-old male who is s/p orthotropic liver [**First Name3 (LF) **] in [**Month (only) 205**]
[**2108**] for alcoholic cirrhosis on chronic sirolimus immune
suppression who presented with four days of shortness of breath
and cough. Cough was producing green sputum. The patient had
been started on Azithromycin by PCP 3 days prior. Denied fevers,
chills, chest pain, nausea, vomiting, diarrhea, and abdominal
pain.
At OSH, initial vitals were T 97.4 BP 199/85 HR 76 RR 28 87% on
4L nasal cannula. He reportedly appeared uncomfortable and in
respiratory distress. He stated that he felt dehydrated. CXR
showed a LLL pna. Patient was put on a Non-rebreather, and was
satting 92-94%. ABG was 7.43/30/51 on an unclear amount of
oxygen. WBC was 10.3. Trop I was 0.02. BNP was 114. Patient was
given Vancomycin 750mg IV x1 and Flagyl 500mg IV x1 prior to
transfer.
In the ED, initial VS T 100, BP 134/84, HR 96, RR 22. Patient
was 89% on NRB, and RR in 30s, so was intubated. CXR confirmed a
LLL pneumonia. Patient was given Gentamicin 80mg IV x1. He was
intubated and given Propofol for sedation. BPs dropped to
70s-80s on propofol, so sedation was switched to Midazolam and
Fentanyl.
On arrival to ICU patient was intubated and sedated, not able to
provide any ROS.
Past Medical History:
#. Alcoholic cirrhosis, s/p Liver [**Year (4 digits) **] [**2109-6-6**], [**2109-6-23**]
exploration for hematoma and fluid collection, last liver biopsy
[**2110-3-14**] no acute cellular rejection, but sig for increased iron
deposition.
-H/o malnutrition
-Prior ESLD c/b ascites, hepatorenal syndrome, grade II
esophageal varices and portal gastropathy, candidal and
bacterial (SBP) peritonitis
Post-[**Month/Day/Year **] course has been complicated by diarrhea and
malnutrition s/p extensive workup that has not found a cause.
This diarrhea is controlled with cholestyramine, Imodium,
tincture of opium, and he has [**12-31**] bowel movements a day.
#. Recurrent UTIs: Most recent cultures ([**2110-5-7**]) grew pan
sensitive kleb pnemonia and corynebacterium, but in the past has
grown out resistant strains of pseudomonas sensitive only to
meropenem ([**3-6**]), to amikacin ([**2-3**]).
#. History of Torsades while on ciprofloxacin.
- Of note: recent hospitalization [**4-5**] w/ multiple episodes of
VT/torsades s/p magnesium & cardioversion x2. At that time
thought [**12-30**] to meds (Reglan, celexa, lyrica and Bactrim) and
contribution from congenital long QTc. QTc was 499-536 despite
holding meds and given daily magnesium and potassium.
- Cardiology evaluated him ad thought not a candidate at that
time for implantable device given recent infections. Followed as
outpatient by cardiology thought pt stress cardiomyopathy,
recommended avoiding zofran.
#. Anemia with baseline Hct 27-30
#. Hydroureteroephrosis/Urinary retention: Seen by [**Month/Day (2) **] as
outpatient. Most recent OMR note: secondary to recurrent
infections and that intermittent catheterization led to
hydronephrosis. Managed w/ indwelling foley.
#. Colorectal cancer (stage unknown) s/p colectomy in [**11/2108**]
#. Cervical stenosis
#. History of C Diff colitis
#. History of depression
#. BPH
#. Chronic pancytopenia
.
PSH:
s/p colectomy in [**11/2108**]
s/p OLT [**2109-6-6**],
s/p exlap for hematoma and fluid collection [**2109-6-23**]
s/p exlap/LOA [**8-5**]
s/p exlap/LOA/washout, temp closure [**8-5**]
s/p exlap/abd closure, cmpt separation [**8-5**]
s/p trach [**8-5**]
s/p R hip fx [**2110-1-23**]
Social History:
Lives with daughter. Wife died 4 weeks ago. Has not had any
ETOH use in "years." Smoking history: 1/2ppd for 20 yrs, quit
over 5 years ago. No illicit drug use
Family History:
NC
Physical Exam:
Admission Physical:
VS: Temp: 96.2 BP:107/81 HR: 98 RR: 23 O2sat 100%
GEN: Emaciated, chronically ill appearing man, intubated and
sedated, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy. Supraclavicular
wasting, no jvd, no carotid bruits, no thyromegaly or thyroid
nodules
RESP: CTA b/l with good air movement throughout on anterior exam
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: WWP.
SKIN: no rashes/no jaundice/no splinters
NEURO: Intubated, sedated.
Discharge Physical:
T 97.8, P 75, BP 126/78, RR 18, O2 99% on 40% trach mask
Notably changed for patient having new tracheostomy. Few wet
crackles at bases. Otherwise persistently emaciated appearing.
exam otherwise unremarkable and unchanged.
Pertinent Results:
===================
LABORATORY RESULTS
===================
On Admission:
WBC-11.3*# RBC-3.71*# Hgb-10.1* Hct-32.5*# MCV-88 RDW-16.2* Plt
Ct-373#
----Neuts-74* Bands-17* Lymphs-4* Atyps-1*
PT-15.0* PTT-31.5 INR(PT)-1.3*
Glucose-147* UreaN-45* Creat-1.9* Na-148* K-3.8 Cl-112* HCO3-19*
ALT-15 AST-27 CK(CPK)-56 AlkPhos-105 TotBili-0.3
Albumin-3.1* Calcium-8.9 Phos-4.4 Mg-2.2
On Discharge:
WBC-2.6* RBC-2.99* Hgb-8.9* Hct-25.6* MCV-86 RDW-16.2* Plt
Ct-225
PT-13.2 PTT-30.4 INR(PT)-1.1
Glucose-90 UreaN-22* Creat-1.2 Na-139 K-4.0 Cl-107 HCO3-24
AnGap-12
ALT-16 AST-25 LD(LDH)-167 AlkPhos-82 TotBili-0.2
Calcium-7.9* Phos-2.0* Mg-2.2
=====================
MICROBIOLOGY RESULTS
=====================
[**2111-9-16**] 3:08 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2111-9-16**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2111-9-19**]):
Commensal Respiratory Flora Absent.
PSEUDOMONAS AERUGINOSA. ~[**2100**]/ML. OF TWO COLONIAL
MORPHOLOGIES.
YEAST. ~7000/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 16 S
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 4 S
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ =>16 R
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2111-9-16**]):
TEST CANCELLED, PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2111-9-17**]):
NEGATIVE for Pneumocystis jirovecii (carinii)..
POOR QUALITY SPECIMEN. SENSITIVITY OF DETECTION [**Month (only) **] BE
ADVERSLY
AFFECTED.
Interpret negative results with caution.
FUNGAL CULTURE (Preliminary):
YEAST.
ACID FAST SMEAR (Final [**2111-9-17**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
Blood Cultures 10/9, [**9-16**]: NGTD
Urine Culture [**9-5**]: NGTD, Urine Legionella Antigen: (-)
===============
OTHER RESULTS
===============
CXR [**2111-9-5**]:
IMPRESSION:
1. Ill-defined patchy opacity within the left lung base
concerning for
pneumonia. Hazier opacification in the right lung base may
represent second area of infection or possibly atelectasis.
2. Bilateral pleural effusions, small to moderate in size on the
right, and small on the left
Chest Radiograph [**2111-9-16**]:
FINDINGS:
In comparison with the study of [**9-15**], the degree of pulmonary
vascular
congestion appears to have decreased. There is increased
opacification at the left base consistent with pneumonia.
Bilateral pleural effusions with some compressive atelectasis
are again seen.
Transthoracic Echocardiogram [**2111-9-14**]:
Conclusions:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets are mildly thickened (?#).
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
Compared with the prior study (images unavailable for review) of
[**2110-3-24**], regional and global systolic function have improved.
Brief Hospital Course:
55-year-old male who is s/p orthotropic liver [**Year (4 digits) **] in [**Month (only) 205**]
[**2108**] for alcoholic cirrhosis, history of colon cancer s/p
colectomy, on rapamune who presented with hypoxic respiratory
failure and SIRS from L sided pneumonia.
1) Acute hypoxic respiratory failure: The patient presented with
hypoxia and a clear left lower lobe infiltrate. He was started
empirically on From LLL PNA. Treated for HAP with Vanc,
Meropenem, Azithro given frequent hospitalizations and
penicillin allergy. He received 5 days of azithromycin and 8
days of meropenem/vancomycin for HCAP. No organisms were
obtained from initial BAL or sputum cultures so this treatment
was empiric. His respiratory status eventually improved and he
was extubated on [**2111-9-12**]. Antibiotics were stopped on [**9-13**].
Unfortunately, after having persistently improving respiratory
status the patient dramatically desaturated on the morning of
[**2111-9-16**] and was emergently reintubated after a brief trial of
NIPPV. After intubation sats failed to improve so he underwent
semi-urgent bronchoscopy revealing significant mucus plugging as
well as an aspirated tablet. After removal of mucous plugs and
the tablet he improved and was rapidly weaned to fairly minimal
ventilator settings. Due to his previous failure, poor
nutritional status, and great weakness decision was made that he
would be unlikely to clear secretions adequately and to pursue
tracheostomy for better pulmonary rehab and clearance of
secretions. Patient agreed and he was trached on [**2111-9-19**].
He was quickly weaned down from pressure support to 40% trach
mask, which he had tolerated >24 hours at the time of discharge.
2) Sepsis: Patient was meeting criteria for sepsis on admission
with leukocytosis and tachypnea and also had hypotension
requiring norepinephrine for blood pressure support later in his
course. With treatment of pneumonia as explained above his
pressures improved and he had been off pressors >72 hrs at time
of discharge.
3) End stage liver disease s/p [**Year (4 digits) 1326**]: The patient has a
liver [**Year (4 digits) **] and is on sirolimus chronically for immune
suppression. He was followed by the hepatology service who
titrated his sirolimus levels. He never had a transaminitis or
signs of liver dysfunction. Rapamycin trough was good at 5.6 on
current dose.
4) Acute Kidney Injury:The patient has a history of chronic
kidney disease with most recent baselines around 1.5. Briefly
rose to 1.9 during this hospitalization but trended back down to
1.2 prior to discharge with good supportive care.
5) Cytopenias: Patient has been intermittently cytopenic in the
past likely due to sirolimus. With improvement in his sepsis
cell lines dropped. He received four units of pRBC's during the
hospitalization with last transfusion on [**9-18**].
6) Nutrition: Patient has remained chronically thin and somewhat
emaciated appearing since his [**Month/Year (2) **]. At time of admission
he was very cachectic appearing and may have been some worsening
of baseline poor nutritional status in the context of his wife's
recent death. He was maintained on tube feeds throughout his
hospitalization. After tracheostomy PEG was discussed but not
desired by hepatology due to infection risk. He had some
intolerance of tube feeds and high residuals for which he was
started on metoclopramide and rate was lowered with a more dense
formula with improvement. He will need transition to a softer
dobhoff feeding tube once final decision regarding tube feed
strength and rate is made.
7) Chronic diarrhea: The patient has chronic diarrhea at
baseline for which he is on DTO and choleystyramine. These were
stopped during his intubation as he was having no bowel
movements. At time of discharge given recent trouble with high
residuals both these medications were being held.
8) Pain : The patient complains of chronic neck and leg pain
when extubated. This was being treated with small doses of PO
hydromorphone with reasonable effect. His outpatient
amitryptyline was also continued.
9) Depression: He was continued on him home mirtazapine and
amitryptyline in the hospital.
He remained on heparin for DVT prophylaxis. He remained full
code.
Medications on Admission:
1. Amitriptyline 50mg po qhs
2. Cefpodoxime 100mg po -started [**9-3**]?
3. Cholestyramine 4g po bid
4. Mirtazapine 15mg po qhs
5. Opium Tincture 1mL po tid PRN diarrhea
6. Oxycodone 10mg po q6h PRN pain
7. Compazine 10mg po tid PRN nausea
8. Rapamune 2mg po daily
9. Calcium Carbonate -Vit D3 - 500 mg (1,250mg)-400 unit Tablet
po bid
10. Ferrous sulfate 325mg po tid
11. Loperamide 4mg po q4h PRN diarrhea
12. Multivitamin po daily
13. Thiamine 100mg po daily
Discharge Medications:
1. amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. oxycodone 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
4. metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
5. sirolimus 1 mg/mL Solution Sig: One (1) mg PO DAILY (Daily).
6. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO three times a day.
7. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit Tablet
Sig: One (1) Tablet PO twice a day.
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
11. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12 hrs
on, followed by 12 hrs off.
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. Meropenem 500 mg IV Q8H
16. meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous every eight (8) hours for 11 days: Last doses on
[**2111-10-3**].
17. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) treatment Inhalation Q4H (every 4
hours) as needed for wheezing.
18. ipratropium bromide 0.02 % Solution Sig: One (1) Nebulizer
Inhalation Q6H (every 6 hours) as needed for wheezing.
19. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] -for continueing med care
Discharge Diagnosis:
Primary:
Pneumonia with sepsis
Hypoxic respiratory failure
Severe malnutrition
Secondary:
Alcoholic cirrhosis, status-post orthotopic liver [**Hospital3 **]
Anemia
Pancytopenia
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. [**Known lastname 102989**],
It was a pleasure taking care of you. You were admitted to [**Hospital1 18**]
for shortness of breath, cough, and eventual respiratory
failure. You required mechanical ventilation to help with your
breathing, and ultimately had a tracheostomy tube placed. You
were given antibiotics to treat a presumed pneumonia. Your liver
and kidney function were generally normal during the
hospitalization. You were continued on your anti-rejection
medications, for your liver [**Hospital1 **]. You were started on tube
feeding for nutritional support, but it was unclear if you were
digesting much of it, as your nurses were suctioning high levels
of tube feeds back up through your feeding tube. You became
medically stable enough to be transferred to a rehabilitation
center, where you will continue receiving all the care you
require, and you will undergo more aggressive physcial therapy,
to help you regain your strength.
.
The following changes were made to your medications:
- Discontinued cefpodoxime, an antibiotic you were taking before
your admission
- Discontinued cholestyramine, loperamide and tincture of opium,
because your diarrhea improved and these can worsen your
digestion of your tube feeds
- Discontinued prochlorperazine (Compazine) because it can
interact with METOCLOPRAMIDE, which we started at 5 mg with
meals and at bedtime, to help you digest your tube feeds
- Decreased your dose of SIROLIMUS to 1 mg daily, to keep it at
the appropriate levels
- Started HEPARIN injections, 5,000 units subcutaneously, three
times daily, to prevent blood clots
- Started NYSTATIN oral suspension, taken orally four times
daily AS NEEDED for thrush
- Started SENNA, one tab taken orally twice daily AS NEEDED for
constipation
- Started LIDOCAINE patch 5% adhesive patch applied topically
for 12 hours at a time, followed by 12 hours off, as needed for
back pain
- Started PANTOPRAZOLE 40 mg tablets, taken orally once daily
- Started MEROPENEM, an antibiotic to treat your pneumonia. You
will receive 500 mg through the IV every eight hours, through
[**2111-10-3**]
- Started ALBUTEROL nebulizers, one nebulizer treatment every
four hours as needed for shortness of breath or wheezing
- Started IPRATROPIUM nebulizers, one nebulizer treatment every
six hours as needed for shortness of breath or wheezing
- Started Heparin Flush (10 units/ml) 2 mL IV PRN line flush,
this is for your PICC line maintenance
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2111-11-4**] 1:20
You may hear from the [**Month/Day/Year **] center in the next week or two
to discuss scheduling an earlier appointment. If you do not hear
from them by the end of this week, please call to discuss
scheduling an earlier appointment with Dr. [**Last Name (STitle) 696**].
|
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75,983
| 126,484
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3130
|
Discharge summary
|
report
|
Admission Date: [**2134-2-11**] Discharge Date: [**2134-2-17**]
Date of Birth: [**2056-1-8**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
dyspnea, weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 14812**] is a 78 yo male with hx of recent PNA, sCHF (EF
15-20%), and CAD s/p CABG and ICD placement who was admitted
from the ED where he presented with persisent dyspnea and cough
despite recent treatment for PNA. He had a recent admission
from [**Date range (1) 14813**] for PNA. He was treated with a 5 day course of
levofloxacin. His hospital course was complicated by acute
renal failure and bacterial conjunctivitis. Since discharge he
states he has not felt well. He has continued to have a
productive cough (denies blood in his sputum). He has also felt
feverish. He admits to general weakness. He also reports
decreased po intake over the past couple days due to decreased
appetite.
Of note he had two car accidents in the last day and was
evaluated afterwards in the ED.
In the ED, intial VS: T 98.1 BP 143/92 HR 68 RR 22 Sat 98%
on RA. He was found to have a worsening RLL PNA on CXR and
given cefepime and vancomycin. Per report from the ED, halfway
through the vancomycin infusion he developed acute dypsnea and
tachypnea, redness on his arm where the vanc was infusing, and
tachycardia. He was placed on a NRB and treated with nebs. The
infusion was stopped and an EKG was performed which showed ST
elevation V2-V4, TWI V5, V6 (different from his initial EKG).
Cardiology was consulted who looked at his older EKGs and think
the ST changes seen were consistent with his older EKGs (he has
an aneurysm). Labs and CXR were rechecked without much
difference from his inital workup. It was concluded that the
reaction likely wasn't from vanc and the rest of the vancomycin
was infused. He was admitted to the ICU instead of the floor
because of some concern that he was having an allergic reaction
to the vanc. Right before he left the ED he spiked and was given
tylenol.
On ROS he denies HA, myalgias, arthralgias, nausea, vomiting,
abdominal pain, constipation, diarrhea, blood in his stool, or
other symptoms.
On arrival to the MICU he was quickly weaned off the NRB to 4 l
NC. He denied any chest pain or acute reaction to the
vancomycin in the ED.
Past Medical History:
-Large anterior wall MI in [**2119**], LV aneurysm, and likely LV
thrombus.
-CABG, in [**2119**] anatomy as follows: LIMA to Diag, SVG to OMB, SVG
to RCA
-Chronic systolic congestive heart failure (EF ~15-20%)
-Sustained monomorphic VT treated with sotalol and ICD
implantation.
- Prior stroke in [**2118-12-30**], with an initial change in
speech and difficulties with memory that resolved after one to
two days. In [**2119-3-2**], he developed a left sided sensory
loss that has persisted after a stroke.
-Dyslipidemia
-HTN
-Stage II-III chronic kidney disease (Cr baseline ~ 1.3)
-Splenectomy after a splenic infarct
-Secondary polycythemia [**Doctor First Name **]
-Diabetes mellitus, type II
Social History:
Pt lives in apartment independently with wife. [**Name (NI) **] one son and
one grandson. Is a retired engineer but is taking classes at
[**Hospital1 498**] in marketing.
Tob: (~60 years), still smoking 5 cig/day
No history of alcohol abuse
Family History:
His brother died of MI at age 61. Mother and father had no heart
disease.
Physical Exam:
GEN: Elderly male laying in bed in NAD
HEENT: PERRL, EOMI, anicteric, MM dry, op without lesions,
dentures in place.
RESP: Breathing comfortably. Expiratory wheezing left>right.
RLL with possible egophany and increased crackles compared to
LLL with slight crackles.
CV: RRR, no MRG.
ABD: +BS, soft NTND
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: Alert and appropriate.
Discharge:
98.2 130/80 79 20 96% RA
GEN: Elderly male sittin in bed in NAD
HEENT: PERRL, EOMI, anicteric, mmm, op without lesions, dentures
in place.
RESP: rhonchi diffusely, + end expiratory wheezes, Decreased
breath sounds at R base.
CV: RRR, no MRG.
ABD: +BS, soft NTND
EXT: no c/c/e
NEURO: Alert and appropriate.
Pertinent Results:
Admission labs:
Na 131 K 4.8 Cl 100 Bicarb 23 BUN 20 Cr 1.3 Glu 129
.
WBC 8.0 Hct 46.7 Plt 513
N 73% L 11% M 15% Atypical 1%
.
PT 56.1 PTT 40.1 INR 6.3
.
Lactate 1.7 00> 1.5
.
Trop 0.03 --> 0.04
.
Micro:
UA 0-2 WBC, neg luek, neg nitr
UCx - pending
BCx x 2 - pending
.
EKG:
normal sinus rhythm, STE in V2-V5 (unchanged compared to old
EKG)
.
Imaging:
CXR: RLL infiltrate
CXR PA/LAT DECUB [**2-12**]:
Three views including a right lateral decubitus view. Comparison
with the
previous study done [**2134-2-12**]. There is continued evidence of
pulmonary
vascular congestion and interstitial infiltrates, consistent
with mild edema. Heart is enlarged and the patient is status
post median sternotomy as before. There is a small right
pleural effusion. There is slight redistribution of pleural
fluid on the lateral decubitus view. An ICD remains in place.
IMPRESSION: Small amount of free flow of right pleural fluid.
CXR PA/LAT DECUB [**2-15**]:
The size of the right pleural effusion has increased somewhat
since
the prior decubitus film of [**2-12**]. A small-to-moderate
sized right
pleural effusion is now present.
No other changes are noted.
IMPRESSION: Increased size of right effusion.
Brief Hospital Course:
78 yo male with hx of recent PNA, sCHF (EF 15-20%), and CAD s/p
CABG and ICD placement here with persisent PNA and possible
allergic reaction to vancomycin.
.
# Dyspnea/PNA: The patient was treated with a 5 day course of
levofloxacin recently without much clinical improvement. His
CXR shows a RLL infiltrate. There was no CXR from his previous
admission to compare it to (the PNA was diagnosed on an abd CT).
During his previous admission he was legionella antigen
negative. White count not elevated (although it was elevated on
admission during his last hospitalization). PNA may be
persisent partially treated PNA versus resistant PNA. In [**Name (NI) **], pt
was on vancomycin, however was dc'ed for quesitonable allergic
reaction and low likelihood for MRSA PNA. Then was on cefepime
and levofloxacin, however was switched to azithromycin and
ceftriaxone considering this PNA is likely continued CAP from
previous admission. He was also found to have non-loculated
pleural effusion in RLL, which was evaluated by IP, however was
not drained considering appeared clinically much better on
ceftriaxone/azithromycin, so was lses likely to be an empyema or
infectious process. Bcx with no growth, was weaned off O2 prior
to discharge, satting high 90s on RA, afebrile for >48 hrs prior
to discharge. Transitioned to cefpodoxime with which he was
discharged for a total 10 day course.
.
#Pleural effusion: Had non-loculated pleural effusion as above,
initially was evaluated by IP for potential drainage considering
patient continued to be febrile with no symptomatic improvement
after discharge before, however INR was supratherapeutic. As
INR drifted down, clinically improved and was afebrile so
thoracentesis was deferred. Pleural effusion thought more
likely to be due to chronic sCHF and so patient was started on
lasix 20 mg PO every other day. Would check Cr as outpatient to
evaluate renal function while on furosemide and evaluate volume
status for continued need for diuresis.
.
# ? Reaction to vancomycin: The patient was described as
developing acute dyspnea, redness around the infusion site, and
also developed a fever after the vanc infusion. Not a typical
vanc infusion reaction or allergic reaction, but concerning so
vancomycin was held and was added to allergy list.
.
# Hyponatremia: Na of 131 on admission with history of poor po
intake. Likely hypovolemic hyponatremia, which he had had in
the past. Has EF of 15-20%. Received IVF in ED, however held
off while on floor due to concern for his chronic sCHF, PO
intake was encouraged.
.
# Supratherapeutic INR: The patient's INR was 6.3 on admission,
then elevated to 8.2. He has a history of LV aneurysm and
thrombus and has a goal INR of [**3-4**]. Likely elevated in the
setting of levofloxacin. Coumadin was held, and levofloxacin
was stopped. Initially INR increased to 10, however no bleeding,
but was given 5 mg of vitamin K prophylactically. INR drifted
down, did not receive further vitamin K or FFP, did not have any
active bleeding. Discharged on home coumadin dose of 2.5 mg
daily
.
# sCHF: Recent TTE with EF of 15-20%. Appeared euvolemic on
exam. Home carvedilol and enalapril continued.
.
# Hx of CAD: EKG without changes from baseline, cardiology
consulted and confirmed that ST changes were there at baseline
likely [**3-3**] known LV aneurysm. Trop slightly up initially peaking
at 0.06, but trended down at discharge. He denies current or
recent chest pain. Continued ASA, carvedilol, enalapril,
atorvastatin, and isosorbide mononitrate.
.
# Hx of VT s/p ICD placement: Device was interrogated, found to
be working appropriately. Continued home sotalol.
.
# CKD: Baseline Cr of 1.0-1.3, Cr at admission at baseline.
Renally dosed medications, trended Cr, remained stable.
.
# Diabetes: Patient not currently on diabetic medications, but
has h/o DM. In hospital, had QID fingersticks, SSI. Not
continued on discharge.
.
Code: Full code, confirmed with the patient
Medications on Admission:
1. atorvastatin 80 mg Tablet PO DAILY
2. carvedilol 12.5 mg Tablet PO BID
3. enalapril maleate 5 mg Tablet Sig: 0.5 Tablet PO DAILY
4. isosorbide mononitrate 30 mg Tablet SR 24 hr PO DAILY
5. warfarin 2.5 mg Tablet PO Once Daily
6. aspirin 81 mg PO DAILY
7. sotalol 80 mg PO BID
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. enalapril maleate 5 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
6. sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day).
7. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1)
Ophthalmic TID (3 times a day).
8. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 10 days.
Disp:*19 Tablet(s)* Refills:*0*
9. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO every other day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital for pneumonia, for which you were
treated with IV antibiotics. Please continue taking antibiotics
(cefpodoxime and azithromycin) until [**2134-2-26**]. For your heart
failure, you should weigh yourself every morning, [**Name8 (MD) 138**] MD if
weight goes up more than 3 lbs.
Changes to your medications:
START taking cefpodoxime 200 mg twice a day until [**2134-2-26**]
Followup Instructions:
Please go to your appointment with your primary care doctor, Dr.
[**Last Name (STitle) 3357**], on Monday, [**2134-2-22**], the number is ([**Telephone/Fax (1) 14814**]. You
should have your INR (coumadin number) checked at this
appointment.
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2134-2-17**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2134-2-17**]
|
[
"585.3",
"E930.8",
"584.9",
"289.0",
"372.00",
"486",
"428.0",
"414.00",
"V45.02",
"276.1",
"V45.81",
"428.22",
"786.09",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10662, 10668
|
5484, 9474
|
288, 294
|
10722, 10722
|
4247, 4247
|
11301, 12044
|
3428, 3504
|
9804, 10639
|
10689, 10701
|
9500, 9781
|
10873, 11182
|
3519, 4228
|
11211, 11278
|
230, 250
|
322, 2433
|
4263, 5461
|
10737, 10849
|
2455, 3153
|
3169, 3412
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,085
| 198,028
|
10072
|
Discharge summary
|
report
|
Admission Date: [**2129-6-7**] Discharge Date: [**2129-6-15**]
Date of Birth: [**2095-11-30**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Transferred from [**Hospital1 **] [**Location (un) 620**] for streptococcus pneumoniae sepsis
and mental status changes
Major Surgical or Invasive Procedure:
Intubation
Lumbar puncture
Thoracentesis
TTE
History of Present Illness:
[**Known firstname 402**] [**Known lastname 33654**] is a 33-year-old woman with a history of
Hodgkin??????s disease and splenectomy 20 years ago who presented to
[**Hospital1 **] [**Location (un) 620**] with pneumococcal sepsis on [**2129-6-1**] and was
transferred to the [**Hospital1 **] [**Location (un) 86**] MICU on [**6-7**]. She was in her USOH
until [**6-1**], when she developed chills, diarrhea, dry heaves, and
had several near-syncopal episodes. She was taken to the [**Location (un) 620**]
ED, where she was febrile, tachycardic, and hypotensive. Blood
cultures were drawn, which eventually grew strep pneumoniae in
[**4-11**] bottles. She was fluid resuscitated, given Xigris, and
treated with vancomycin and ceftriaxone. Follow-up blood
cultures were negative. She developed hypoxemic respiratory
failure due to fluid overload and required intubation. Two days
after admission she was noted to be minimally responsive. A head
CT was negative, and the family requested transfer to [**Hospital1 **] [**Location (un) 86**]
for further neurologic workup. Also of note, during her [**Location (un) 620**]
admission the patient developed hyperbilirubinemia (TBili 3.8,
direct 3.3), elevated ALK (274), and thrombocytopenia (nadir
32). In addition, a CXR on [**6-1**] showed a consolidation at the
right base.
The patient was transferred to the [**Hospital1 **] [**Location (un) 86**] MICU on [**6-7**]. Her
MICU course was notable for:
1) ID: The patient was continued on vancomycin/ceftriaxone with
a planned 14-day course. An LP was negative. She had a
thoracentesis on [**6-8**] of her right basilar consolidation;
analysis was consistent with a transudate and fluid sent for
culture showed no growth. She had a persistently elevated WBC in
the 20s to 30s with intermittent low-grade fevers. Repeat blood
cultures and a urine culture showed no growth. Stool was
negative for C. Diff.
2) Pulmonary: The patient responded well to diuresis and was
extubated on [**6-9**]. Thoracentesis as above.
3) GI: The patient continued to have hyperbilirubinemia,
elevated ALK, and slightly elevated AST/ALT. A RUQ ultrasound
was negative.
4) Heme: The patient had a persistently low HCT (27 to 28), but
her thrombocytopenia resolved. She had a negative hemolysis and
DIC/TTP/HUS workup. HIT antibody was negative at [**Location (un) 620**]. Stool
was guaiac negative.
5) Neuro: Neurology consult felt that the patient??????s mental
status changes were likely due to toxic metabolic abnormalities
and sedating medication. However, given the finding of upgoing
toes on physical exam, they recommended a brain and c-spine MRI.
By the day of transfer to the floor, the patient??????s mental status
had returned to [**Location 213**].
6) Nutrition: The patient was maintained on TPN and tube feeds
while intubated. She failed a swallow study after extubation and
was on maintenance IVF on transfer to the floor.
Past Medical History:
1) Hodgkin??????s disease [**2108**], s/p XRT, ABVD, and splenectomy
2) Premature ovarian failure
3) Splenectomy as above; had pneumovax in [**2124**]
4) Hypothyroidism
Social History:
Lives with her husband, adopted 8-week-old baby boy, and dog.
Works at [**Company 33655**] in [**Location (un) 86**]. No smoking, EtOH, or drugs.
Family History:
NC
Physical Exam:
PE on admission to floor from MICU:
Vitals: Tc 98.6, BP 120/70, P 98, R 20, O2 Sat 98% on RA
Gen: NAD, tired-appearing
HEENT: Bilateral subconjunctival hemorrhages. No cervical LAD.
Cards: RRR, no m/g/r
Pulm: Coughs with deep inspiration. CTAB.
Abd: Soft, NT, ND. Positive bowel sounds in all 4 quadrants
Ext: No LE edema. Excoriated papules on L inner thigh (biopsied)
Neuro: EOMI, PERRL. Oriented x 3. Upgoing toes bilaterally.
Pertinent Results:
Labs on transfer to floor from MICU:
WBC 23.3, HGB 8.9, HCT 27.4, MCV 91, RDW 15.5, PLT 313
Diff: N85, B1, L8, M4, E0, B0, atyp 1, metas 1
PT 12.7, PTT 24.4
Fibrinogen 575
Na 142, K 4.3, Cl 111, HC03 22, Glucose 80
ALT 73, AST 75, ALK 402, TBili 2.0,
Lipase 235
Ca 7.7, Phos 2.4, Mg 1.8
Micro:
-- [**6-7**] CSF: gram stain and culture negative
-- [**6-7**] Blood cultures from [**6-7**] x2: no growth to date
-- [**6-7**] Urine culture negative
-- [**6-8**] Skin blister sent for herpes culture ?????? pending
-- [**6-8**] Pleural fluid: GRAM STAIN 2+ (1-5 per 1000X FIELD):
POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID
CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE
(Preliminary): NO GROWTH.
-- [**6-9**] C. Diff negative
CXR [**6-9**]: A right-sided central venous catheter is seen with the
tip positioned in the distal SVC. Again seen are bilateral
pleural effusions. There has been interval removal of an ET and
NG tube. Scattered left retrocardiac atelectasis is noted. The
pulmonary vasculature is unchanged. IMPRESSION: Interval removal
of an ET and NG tube. Bilateral pleural effusions are again
seen, without any interval change.
RUQ US [**6-7**]: Normal decompressed gallbladder. No evidence of
intrahepatic bile duct dilatation.
Brief Hospital Course:
1) Pneumococcal sepsis: The patient was maintained on
ceftriaxone while in house. Vancomycin was discontinued after
[**6-14**] as cultures from [**Hospital1 **] [**Location (un) 620**] showed sensitivity to
ceftriaxone. The patient will complete the last two days of a
14-day course of antibiotics with po levofloxacin at home, as
cultures were sensitive to levofloxacin. The source of her
sepsis was felt to be pulmonary based on an infiltrate seen on
CXR at [**Location (un) 620**]. While on the floor, the patient's leukocytosis
resolved and she remained afebrile.
The patient will follow up with Dr. [**Last Name (STitle) 5840**] at infectious disease
clinic on [**6-27**] for discussion of repeating the pneumovax vs.
Prevnar.
2) Mental status changes: The patient's mental status changes
had resolved by the time she was transferred to the floor. Brain
and C-spine MRIs were negative.
3) Anemia: While in house the patient had a stable anemia with
HCT about 27. MCV and RDW were normal. She was guaiac negative
and had a negative hemolytic workup. Iron studies were negative
for iron deficiency. Her anemia was felt to be secondary to bone
marrow suppression due to infection. A reticulocyte count was
low, consistent with bone marrow suppression.
4) Thromocytopenia/thrombocytosis: The patient was initially
thrombocytopenic, with platelets 91 on transfer from [**Location (un) 620**].
HIT antibody sent at [**Location (un) 620**] was negative. DIC and hemolysis
labs were negative; there were no schistocytes on peripheral
smear. After several days the patient's thrombocytopenia
resolved and she developed thrombocytosis, with platelets
reaching a peak of 1306 on discharge. A peripheral smear was
negative for platelet clumping. This thrombocytosis was felt to
be reactive in the setting of infection and asplenia. Heme/onc
was curbsided and recommended against aspirin treatment. The
patient will get a follow-up platelet count checked with her
PCP.
5) Hyperbilirubinemia/transaminitis: After reaching a peak TBili
of 4.6, the patient's hyperbilirubinemia had resolved by the
time of discharge. Her LDH had normalized (peak 307). Her ALT,
AST, and ALK elevations had improved, though all were still
elevated at discharge (ALT 91 from peak 103, AST 59 from peak
82, ALK 227 from peak 407). A RUQ ultrasound was negative for
liver lesions or intrahepatic bile duct dilatation. These lab
abnormalities were felt to have been caused by TPN.
6) Chemical pancreatitis: The patient had an elevated amylase
(peak 170) but never had abdominal pain. Her amylase had
decreased to 131 by discharge.
7) Heart murmur: A I-II/VI systolic murmur was heard on exam on
the day of discharge. A TTE was done to rule out endocarditis;
it showed no vegetation.
8) Dysphagia: The patient received TPN and tube feeds while
intubated. After extubation she failed a swallowing study. She
refused NG tube placement and received only maintenance IVF
until passing a repeat swallowing study three days later. This
study did, however, show trace aspiration, and the patient will
have a repeat swallowing study as an outpatient.
9) Skin lesions: In the MICU the patient was noted to have
several small erythematous papules on her left inner thigh.
Cultures were sent for herpes, which were still pending at
discharge.
10) Subconjunctival hemorrhages: The patient had bilateral
subconjunctival hemorrhages secondary to traumatic intubation.
An ophthalmology consult at [**Location (un) 620**] ruled out endophthalmitis
and intraocular hemorrhage.
11) Hypothyroidism: The patient was maintained on iv
levothyroxine until she was taking po's, when she was
transitioned to po levothyroxine. She will have her TSH checked
as an outpatient.
12) Ovarian failure: The patient's estrogen/progesterone
replacement therapy was reinstituted as per her home regimen
after she began taking po's.
13) Disposition: The patient will continue to work with physical
therapy as an outpatient.
14) Code status: Full code
Medications on Admission:
Home meds prior to admission:
1. Levothyroxine 75mcg po q24h
2. Medroxyprogesterone Acetate 10mg po on days [**1-17**] of cycle
3. Estradiol 2mg po q24h
Discharge Medications:
1. Levothyroxine 75mcg po q24h
2. Medroxyprogesterone Acetate 10mg po on days [**1-17**] of cycle
3. Estradiol 2mg po q24h
4. Levofloxacin 500mg po qd x 2 days, first dose 6/9
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Pneumococcal sepsis
Hypoxic respiratory failure
Hyperbilirubinemia
Transaminitis
Thrombocytopenia
Reactive Thrombocytosis
Anemia
Chemical pancreatitis
Pleural effusion
Discharge Condition:
Ambulating with PT, urinating/BMing on own, tolerating po diet
Discharge Instructions:
If you have fevers/chills, shortness of breath, or abdominal
pain, please call your doctor or come to the ER.
Please complete all your antibiotics.
Please have your platelet count checked on Friday [**6-17**].
Followup Instructions:
1) You have an appointment at the infectious disease clinic
([**Telephone/Fax (1) 457**]) with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5840**]. Date/Time: [**2129-6-27**] 9:30 a.m.
The specific question to address with Dr. [**Last Name (STitle) 5840**] is whether the
standard pneumovax or Prevnar is more appropriate for you.
2) Please call your PCP to make an appointment within the next
two weeks. You will need to get your TSH (thyroid test)
rechecked and to follow up on the biopsy of your L thigh
lesions.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2129-7-10**]
|
[
"995.92",
"038.2",
"518.81",
"577.0",
"785.52",
"287.5",
"285.9",
"511.9",
"V10.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"03.31",
"99.15",
"96.04",
"34.91",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
9948, 9997
|
5550, 9545
|
434, 480
|
10208, 10272
|
4263, 5527
|
10532, 11194
|
3794, 3798
|
9748, 9925
|
10018, 10187
|
9571, 9725
|
10296, 10509
|
3813, 4244
|
275, 396
|
508, 3423
|
3445, 3615
|
3631, 3778
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,136
| 115,206
|
9058
|
Discharge summary
|
report
|
Admission Date: [**2132-4-27**] Discharge Date: [**2132-5-1**]
Date of Birth: [**2065-10-16**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
(R)UQ abdominal and epigastic pain radiating to the back.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 31303**] is a 66 yo F with CLL s/p multiple rounds of
chemotherapy, last in [**10-9**] (Campath), with ongoing bulky
adenopathy and splenomegaly who presents today with [**Date Range 5283**] and
epigastric pain that radiates to her back. The pain started an
hour or so after dinner and grew progressively worse throughout
the evening. The pain is sharp and constant, rated as a [**9-11**] on
arrival and [**6-11**] out of 10 currently. She has been nauseated
throughout the evening and morning as well. She reports one
episode of emesis. She denies fevers or chills. She has been
having regular BM's. She denies melena, hematochezia, or
[**Male First Name (un) 1658**]-colored stools. She knows that she has cholelithiasis, but
denies any history of biliary colic.
Past Medical History:
Oncologic Hx:
She completed two cycles of R-CVP back in [**7-/2130**] as part of her
initial treatment for CLL. She did not have a significant
response to treatment though her white count did normalize after
treatment. However, the patient remained with a predominance of
lymphocytes. She continued to have bulky lymphadenopathy both
above and below the diaphragm following this treatment, did have
slight interval decrease overall with the exception of a slight
increase in the size of her lymph nodes in the right
supraclavicular chain. She has remained with massive
splenomegaly. She had an extended hospitalization in [**8-/2130**] for
further workup for fever and night sweats. Her disease status
was reassessed with a bone marrow biopsy, which confirmed her
known history of CLL. She also had a lymph node biopsy of the
right supraclavicular node in order to rule out transformation
of her disease, which was also consistent with CLL without any
evidence of transformation. However, there was note of caseating
granuloma concerning for TB. She did have a PPD placed, which
was positive. Of note, she also developed a rash in this
setting, which eventually resolved. However, it was thought to
be related to TB, noted to be granuloma annulare on biopsy.
Ultimately, it was felt that she had extrapulmonary TB. She was
ultimately started on TB medication regimen with rifampin, INH,
ethambutol, and pyrazinamide. The patient was started on that at
the time of discharge from hospital on [**2130-8-18**]. At that
point, she was still having high fevers. After a few days of
being on this regimen, her high fevers improved. Of note, due to
a poor tolerability with anorexia, nausea, weight loss, and
fatigue, we switched her regimen. The ethambutol and
pyrazinamide were discontinued on [**2130-8-28**] and moxifloxacin
was added. She completed a six-month course of her TB medicines,
which she completed back in 02/[**2131**]. The patient refused to take
the medications any longer. She then had a slowly rising white
blood count over the past
couple of months. Also has had a depressed platelet count. Her
CT scans have overall been stable, but remained with persistent
bulky disease above and below the diaphragm with massive
splenomegaly. Our recommendation had been to proceed with a
fludarabine-based regimen given her bulky disease, but until
recently the patient refused any treatment and we had been
monitoring her off treatment. She noted at the beginning of
[**2-/2131**] of her plans to go to [**Country 27587**] in [**Month (only) 116**] for five or six
months. As a result, she agreed to receive treatment with FCR
regimen, which she began on [**2131-2-14**]. The goal of this was to
cytoreduce her disease before she leaves for [**Country 27587**]. Our plan
is to try to get two cycles in with time to recover prior to her
departure. She presents today for evaluation and countcheck
following her second cycle.
.
OTHER Past Medical History:
1. CLL. Please refer to OMR note [**2131-4-4**] for extensive details.
2. Extrapulmonary TB diagnosed [**8-8**], now s/p 6 months of 4-drug
therapy with rifampin, INH, ethambutol, and pyrazinamide.
3. Hypothyroidism
4. OA
4. OA
Social History:
From [**Country 27587**]. Tobacco: [**1-6**] PPD x 45 years, no alcohol, other
drugs. Lives at home with her husband, daughter, and grandson.
Owns and works at her own business "Helping hands" as a home
health aide.
Family History:
Non-contributory
Physical Exam:
VS: T: 99.3 PO,BP: 134/64, HR: 81, RR: 18, SaO2: 96% RA
GEN: Well appearing, pleasant female in NAD.
HEENT: Sclerae anicteric. O-P intact.
NECK: Supple. No lympadenopathy.
LUNGS: CTA(B).
CARDIAC: RRR; nl S1/S2 w/o m/c/r.
ABD: Normoactive BSX3. Soft/NT/ND.
EXTREM: No c/c/e.
NEURO: A+Ox3. Non-focal/grossly intact.
SKIN: Intact.
Pertinent Results:
[**2132-4-27**] 04:55PM GLUCOSE-87 UREA N-11 CREAT-0.6 SODIUM-141
POTASSIUM-4.4 CHLORIDE-114* TOTAL CO2-22 ANION GAP-9
[**2132-4-27**] 04:55PM ALT(SGPT)-134* AST(SGOT)-148* ALK PHOS-138*
AMYLASE-1756* TOT BILI-0.6
[**2132-4-27**] 04:55PM LIPASE-2693*
[**2132-4-27**] 04:55PM ALBUMIN-3.3* CALCIUM-7.8* PHOSPHATE-3.3
MAGNESIUM-1.7
[**2132-4-27**] 04:55PM IgG-597*
[**2132-4-27**] 04:55PM WBC-1.2* RBC-2.94* HGB-9.2* HCT-27.1* MCV-92
MCH-31.4 MCHC-34.1 RDW-14.1
[**2132-4-27**] 04:55PM PLT COUNT-46*
[**2132-4-27**] 03:42AM LACTATE-1.1
.
[**2132-4-27**] Abdominal U/S:
1. Cholelithiasis with mild intrahepatic biliary dilatation.
Common bile
duct is dilated measuring up to 9 mm but appears to taper
distally. This is likely due to mass effect from surrounding
lymph nodes and could be confirmed with CT.
2. Fatty infiltration of the liver.
3. Multiple pathologic enlarged lymph nodes at porta hepatis
consistent with patient's known CLL.
Brief Hospital Course:
Patient admitted to SICU on [**2132-4-27**] for abdominal pain and
hypotension. Hypotension responded to multiple IV fluid boluses.
Made NPO. Status post ERCP with sphincterotomy and sludge/stone
removal from CBD; tolerated well. Foley placed. Given IV
Dilaudid for pain with good effect. Started on IV Zoysn.
Hemodynamically stable. Oncology consulted during this
admission; recommendations appreciated and followed.
[**2132-4-28**]: Diet advanced to sips; tolerated well. Transferred to
[**Hospital Ward Name 121**] 9 inpatient floor. Remained stable. Labs improved.
[**2132-4-29**]: Diet advanced to clears; continued good tolerability.
Foley discontinued. Ambulated frequently.
[**2132-4-30**]: Advanced to regular diet with good intake. Started on
Neupogen for leukopenia with associated total granulocyte count
of 380.
[**2132-5-1**]: Total granulocyte count 1600. IV antibiotics
discontinued. Voiding, ambulating independently. Tolerating
regular diet. Discharged home on Augmentin for three remaining
days. Has follow-up this Saturday at the [**Hospital **] Clinic;
follow-up labs to be done at that time to determine if futher
Neupogen dose needed. patient hemodynamically stable.
Medications on Admission:
Levothyroxine 137mcg Po daily; Vitamin D
Discharge Medications:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Levoxyl 137 mcg Tablet Sig: One (1) Tablet PO once a day.
4. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO three
times a day for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Gallstone Pancreatitis and cholangitis.
Secondary: CLL s/p multiple rounds of chemotherapy
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 [**Hospital 1440**], 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 [**5-11**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
You have an appointment THIS SATURDAY [**5-3**] at Heme/[**Hospital **] clinic:
BED 4-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F Date/Time:[**2132-5-3**] 10:30
You have an appointment with Dr. [**Last Name (STitle) **] (Surgery) on [**2132-5-12**] at 11:45am; Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**]. Tel:
([**Telephone/Fax (1) 2828**].
Other appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2132-5-12**] 9:00
Provider: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**]
Date/Time:[**2132-5-12**] 9:00
Completed by:[**2132-5-1**]
|
[
"576.8",
"574.50",
"576.1",
"204.10",
"577.0",
"244.9",
"288.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"51.88"
] |
icd9pcs
|
[
[
[]
]
] |
7959, 7965
|
6011, 7203
|
371, 378
|
8110, 8119
|
5034, 5988
|
9635, 10369
|
4653, 4671
|
7295, 7936
|
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|
7229, 7272
|
8143, 9612
|
4686, 5015
|
274, 333
|
406, 1195
|
4175, 4404
|
4420, 4637
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,461
| 191,374
|
54508
|
Discharge summary
|
report
|
Admission Date: [**2154-8-21**] Discharge Date: [**2154-8-26**]
Date of Birth: [**2082-5-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known firstname **] [**Known lastname 951**] is a 72 year old woman with a history of
progressive pulmonary fibrosis, CAD s/p CABG x 4 [**2137**], moderate
AS, hypothyroidism. She presented to an OSH with increased
shortness of breath, fatigue and recent chills. She was treated
empirically for community acquired pneumonia with levaquin, CHF
exacerbation wtih lasix, IPF with prednisone and azathioprine,
empiric PCP treatment with IV bactrim and prednisone. Despite
these interventions patient denies significant improvement in
shortness of breath.
.
She was presented with the option of bronchoscopy and possible
biopsy to further evaluate her respiratory status. She initially
agreed and due to her high supplemental oxygen requirement she
was transferred to [**Hospital1 18**] for this procedure.
.
On arrival to the ICU her only specific complaint is
constipation. She reports that she has reconsidered the
bronchoscopy and has decided not to pursue any invasive
procedures out of fear that she would not be able to be
extubated and that it may not change her management or
prognosis. She reports she has not had further episodes of
chills since her admission. She does not feel like she is in
respiratory distress when at rest with high flow oxygen.
.
Past Medical History:
Pulmonary fibrosis: started on supplemental oxygen [**4-29**]
CAD s/p CABG x 4 [**2137**]
Moderate AS
HTN
Hypothyroidism
Hyperlipidemia
Irritable Bowel Syndrome
GERD
s/p right endarterectomy [**2123**]
s/p CCY
s/p sigmoid colectomy with reversal [**2146**]
.
Social History:
She lives with her husband. She is unemployed. She ambulates
without the aid of a cane or walker. At baseline can walk around
the house without a problem. She reports a remote smoking
history of [**10-9**] pack-yrs (quit when she was 36 years old). She
denies any alcohol, illicit drugs or herbal medication use. She
does admit to taking several vitamins/supplements.
Family History:
Her father, brother, and mother all with coronary artery
disease. She reports her brother had similar lung disease. She
is unaware of any other specific lung disease in her family but
reports her mother did have part of her lung removed.
Physical Exam:
GA: AOx3, NAD
HEENT: PERRLA. dry MM. no LAD. no JVD. neck supple.
Cards: RRR, 3/6 systolic murmur heard throughout
Pulm: inspiratory crackles at bilateral bases L>R, mildly
labored breathing
Abd: soft, NT, +BS. no rebound/guarding.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes, warm, dry
Neuro/Psych: CNs II-XII intact. Sensation intact. Moving all
four extremities. Conversant, fluent speech, follows commands.
Pertinent Results:
MICRO ([**Location (un) **])
.
[**2154-8-18**] Urine cx: No growth
.
[**2154-8-16**] Blood cx: No growth
.
Imaging:
.
[**2154-8-21**] EKG: sinus rhythm, borderline LAD, NI, TWI aVR, V1, no
ST-T wave changes.
.
[**2154-8-18**] CT Chest w/o contrast:
MARKED WORSENING OF GROUND-GLASS OPACITIES WITHIN BOTH LUNGS IN
THE
BASES WORSE THAN THE UPPER LUNGS AS COMPARED TO [**2154-6-10**]. WITH
THE
BACKGROUND INTERSTITIAL PULMONARY FIBROSIS, THIS COULD REPRESENT
AN
ACUTE EXACERBATION OF IPF, THOUGH THE FACT THAT NEW AREAS APPEAR
AFFECTED RAISES THE QUESTION OF A SUPERIMPOSED ATYPICAL
INFECTION, DRUG REACTION, OR ACUTE HYPERSENSITIVITY PNEUMONITIS.
MEDIASTINAL
ADENOPATHY IS LIKELY REACTIVE AND UNCHANGED. MILDLY ENLARGED
PULMONARY ARTERY LIKELY REFLECTS PULMONARY ARTERIAL
HYPERTENSION.
.
[**2154-8-20**] CXR: INCREASED LUNG MARKINGS WHICH COULD REPRESENT
GENERALIZED PNEUMONIA BUT COULD ALSO REPRESENT PULMONARY
CONGESTION WITH SOME INTERSTITIAL AND AIR SPACE EDEMA.
Admission Labs:
[**2154-8-22**] 05:04AM BLOOD WBC-13.0*# RBC-3.73* Hgb-11.4* Hct-34.0*
MCV-91 MCH-30.5 MCHC-33.5 RDW-15.3 Plt Ct-334#
[**2154-8-22**] 05:04AM BLOOD Glucose-81 UreaN-27* Creat-1.2* Na-127*
K-4.1 Cl-86* HCO3-32 AnGap-13
[**2154-8-22**] 03:30PM BLOOD B-GLUCAN-PND
[**2154-8-22**] 05:04AM BLOOD Calcium-9.6 Phos-4.0 Mg-2.3
[**2154-8-24**] 03:46AM BLOOD TSH-0.96
[**2154-8-24**] 03:46AM BLOOD Cortsol-15.8
Discharge Labs:
[**2154-8-26**] 04:36AM BLOOD WBC-12.4* RBC-3.41* Hgb-10.3* Hct-31.7*
MCV-93 MCH-30.3 MCHC-32.6 RDW-15.0 Plt Ct-462*
[**2154-8-26**] 04:36AM BLOOD Glucose-110* UreaN-24* Creat-1.0 Na-128*
K-5.4* Cl-93* HCO3-24 AnGap-16
[**2154-8-26**] 04:36AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.1
[**2154-8-26**] 10:14AM BLOOD Type-ART pO2-72* pCO2-38 pH-7.44
calTCO2-27 Base XS-1
[**2154-8-22**]:
CXR: IMPRESSION: Worsening bilateral interstitial opacities.
Differential include acute excacerbation of UIP, superimposed
edema and/or infection.
Brief Hospital Course:
# Acute on chronic hypoxia: Patient's hypoxia is likely
secondary to progressive pulmonary fibrosis as diagnosed on
imaging. Baseline oxygen requirement of 4 L NC at home. Patient
refused a bronchoscopy as she did not want to risk chance of
being intubated indefinitely. Given that we could not get a firm
diagnosis from a bronch, it was decided to treat her for an IPF
exacerbation as well as for infection.
Regarding her IPF exacerbation, she was continued on duonebs
prn, NAC 1200 mg po tid, and tessalon perles prn. She was
continued on azathioprine as well as prednisone 40 mg [**Hospital1 **], which
was transitioned to 60 mg daily. This will be slowly tapered by
decreasing 5 mg weekly and she will follow up with her
pulmonologist at the end of the month for further management.
***Note, prednisone is not for PCP treatment, but for IPF. This
should not be stopped once PCP treatment is completed. ***
She was also diuresed with improvement in her hypoxia given her
history of CHF. She reached a euvolemic state but still required
supplemental oxygen with 5 liters NC and 60% shovel mask with O2
sats in low 90s. This was stable through most of her
hospitalization. She should attempt to be further weaned in
rehab.
Her elevated WBC and increased sputum were initially concerning
for infection so she was started on a course of therapeutic
bactrim, zosyn, and levaquin at the OSH. Zosyn was discontinued
given negative sputum cultures. Levaquin was continued for a
full 7 day course. Given worsening ground glass opacities on CT
and mildly elevated LDH and hypoxia she was empircally treated
with bactrim and will complete a 21 day course of PCP [**Name Initial (PRE) 31304**].
She is due to stop Bactrim [**2154-9-7**]. Notably, b-glucan was
negative at outside hospital, and pending at lab drawn at [**Hospital1 18**].
Since her oxygenation and white count improved at treatment dose
was started, it was felt she should complete this regimen. Her
wbc prior to d/c trended down to 12.4, (peaking at
14.4).
-WBC should be trended at rehab until within normal limits.
-PCP treatment ending [**2154-9-7**]
-f/u beta glucan from [**Hospital1 18**]
# Hyponatremia: Felt to be secondary to SIADH as Urine Na of 77.
She was continued on a water restriction of 1 liter per day. Her
serum Na nadir'd at 122. Prior to discharge was 128. She should
continue on a water restriction with trending of her Na. Her
mental status was intact.
- Trend Na
# Hyperkalemia: Noted on day prior to d/c. Peaking at 5.7. She
was given Kayexelate with improvement to 5.4. She developed no
EKG changes. This was felt to be secondary to Bactrim. Her
potassium should be checked daily to [**Hospital1 **] until stable. She had
no signs of adrenal insufficiency.
- Trend K
# CAD: Patient with known CAD s/p CABG x 4 in [**2137**]. Continued on
aspirin. BB was initially held, but slowly titrated back to home
dosage of atenolol 75 [**Hospital1 **].
# Hypothyroidsim: TSH checked within normal limits at 0.96.
Continued home levothyroxine 125 mcg daily.
# Constipation: Likely exacerbated by immobility and
dehydration. She was started on an aggressive bowel regimen with
docusate, senna, miralax daily, bisacodyl prn, benefiber, and
lactulose prn resulting in bowel movements. She should continue
to be given a chronic bowel regimen to ensure a regular cycle.
Prophylaxis: Continued protonix 40 mg daily and SQ heparin while
not ambulating.
#Code: FULL CODE
#Communication: Patient; [**Name (NI) **] [**Name (NI) **] (HCP/daughter)
[**Telephone/Fax (1) 111532**] (h) [**Telephone/Fax (1) 111533**] (c)
Medications on Admission:
Lac-hydrin 12% apply daily
Atenolol 75 mg [**Hospital1 **]
Azathioprine 50 mg po bid
Benzonatate 100 mg q6h prn
Clonazepam 0.5 mg po bid
Levothyroxine 125 mcg po daily
Pantoprazole 20 mg po bid
NAC 1200 mg po tid
Prednisone
Nystatin
Aspirin 81 mg po daily
Capsaicin
Multivitamin with minerals
Benefiber
Glutathione
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): To be continued until patient
persistently ambulates.
2. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day:
To be decreased by 5 mg q Monday starting [**2154-9-2**].
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB.
15. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
16. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: Three
(3) Tablet PO TID (3 times a day): PCP [**Name Initial (PRE) 31304**].
Stop date: [**2154-9-7**].
17. Acetylcysteine 600 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
18. Acidophilus 175 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for with meals.
19. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
20. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
21. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Interstitial pulmonary fibrosis
Presumed PCP pneumonia
Presumed Community Acquired Pneumonia
SIADH
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 due to increasing oxygen requirments. This was
felt to be an exacerbation of your lung disease, interstitial
pulmonary fibrosis, and a possible infection. You were given
antibiotics for this.
Your new medications changes include:
1. Prednisone 60 mg daily
2. Continue Bactrim DS 3 tabs three times per day until [**9-7**]
3. Continue nebulizers, NAC, azathioprine, tessilon pearles
4. Bowel Regimen
It is important that you keep all of your doctor's appointments.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 3070**]
Date/Time:[**2154-9-4**] 10:30
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2154-9-18**] 2:00
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2154-9-18**] 2:00
[**2154-9-18**] 02:30p , [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD, PULMONARY, [**Hospital Ward Name **]
CLINICAL CTR, [**Location (un) **], PULMONARY UNIT-CC7 (SB)
|
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"428.0",
"414.00",
"486",
"564.00",
"276.7",
"V64.2",
"564.1",
"253.6"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10996, 11062
|
4974, 8576
|
323, 329
|
11214, 11214
|
3020, 3989
|
11905, 12511
|
2317, 2559
|
8941, 10973
|
11083, 11193
|
8602, 8918
|
11397, 11882
|
4423, 4951
|
2574, 3001
|
276, 285
|
357, 1630
|
4005, 4407
|
11229, 11373
|
1652, 1913
|
1929, 2301
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,483
| 169,324
|
41225
|
Discharge summary
|
report
|
Admission Date: [**2107-5-10**] Discharge Date: [**2107-5-19**]
Date of Birth: [**2028-11-7**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
ERCP
IR guided biliary drain placement
History of Present Illness:
This is a 78 year old woman who lives in [**Hospital3 **] and referred
to [**Hospital1 18**] for abdominal pain, weight loss, and jaundice. Her
symptoms started with bilateral, crampy lower quadrant abdominal
pain and an increase in bowel movements without true diarrhea.
She also noted an 8 lb weight loss along with appetite loss
since [**2107-1-12**]. Most recently, her son noted jaundice,
pale stools, and very dark urine. She underwnet a CT of the
abdomen on [**2107-4-7**] in her area and revealed a double duct sign
with dilation of the main PD to 4 mm along with dilation of the
gallbladder. There was evidence of a hypodense focal lesion in
the head of the pancrease measuring 1.4 cm as well as
ill-defined hypodense lesions in the right and left lobes of the
liver. Because of these findings, she had an EUS on [**4-26**] which
was not too helpfull. The EUS showed multiple small
sub-centimeter cysts in the head of pancreas without mass. The
PD was dilated to 7 mm in head and 5 mm in body and was tortuous
with a few dilated side branches. The gallbladder contained
sludge. The CBD was dilated to 15 mm in diameter with no stones
or strictures. She was also found to have a small superficial
ulcer at the antrum of stomach. A biopsy to a polyp adjacent to
minor ampulla was nondignostic. Subsequently, she had MRCP on
[**5-6**] that showed biliary and pancreatic ductal dilatation which
appears to be due to compression or involvement by a 1.9 cm mass
concerning for malignancy such as due to invasive neoplasm in
the setting of side branch IPMN; partially cystic
adenocarcinoma, or cholangiocarcinoma. The MRCP also confirmed
numerous hepatic lesions. Today, [**5-10**], she underwent an
unsuccessful attempt for an ERCP. Specifically, attempts to
achieve deep bile duct cannulation were unsuccessful. Post ERCP,
she developed low grade fever, relative hypotension, and
tachycardia. IR, therefore, was contact[**Name (NI) **] for PTC to resolve the
biliary obstruction for a possibility of cholangitis. In regards
to review of systems, she was noted to have new dyspnea on mild
exertion in the ERCP recovery room. All remaining systems were
reviewed and symptoms were negative.
Past Medical History:
1. HTN
2. GERD
3. Breast cyst
4. Hyperlipidemia
5. tobacco use
6. Back surgery
7. Vertigo
Social History:
She lives alone in [**Hospital3 **] with 2 sons. [**Name (NI) 4906**] recently
deceased. One son lives about one hour away. She has never
smoked. No alcohol abuse.
Family History:
No pancreatic, liver, or GI cancers
Physical Exam:
GENERAL: Frail elderly woman with generalized weakness and
remarkable jaundice
Eyes: NC/AT, PERRL, EOMI without nystagmus, remarkable jaundice
Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Respiratory: Mild crackles at the very bases and decreased
breath sounds bilaterally
Cardiovascular: tachycardia, heart rate 106 regular with AS
murmur
Gastrointestinal: soft, normoactive bowel sounds, no masses or
organomegaly noted. Tender diffusely without rigidity.
Skin: no rashes or lesions noted.
Extremities: leg edema, mild
Neurologic:
-mental status: Alert, oriented x 3. Able to answer questions
appropriately without delirium or focol motor deficits.
Generalized weakness.
Pertinent Results:
MRCP:
1. Biliary and pancreatic ductal dilatation which appears to be
due to
compression or involvement by a 1.9-cm mass with non enhancing
and
hypoenhancing components and adjacent periductal
hyperenhancement. These
findings are concerning for malignancy, such as due to invasive
neoplasm in the setting of side branch IPMN; partially cystic
adenocarcinoma, or
cholangiocarcinoma.
2. Numerous hepatic lesions, at least one of which is consistent
with
perfusional abnormalities. Others demonstrate both ring pattern
of
hyperenhancement and hypoenhancement and are concerning for
metastasis
although foci of infection could have a similar appearance.
Peri-biliary
enhancement in segment VIII is consistent with chronic biliary
obstruction or cholangitis.
3. Distended Courvoisier-type gallbladder with small stones or
sludge. There is no acute cholecystitis.
4. Compression deformities of T11, T12, and L1 which are not
fully imaged on this study.
[**2107-5-10**] 08:20AM BLOOD WBC-11.0 RBC-3.08* Hgb-9.9* Hct-29.7*
MCV-97 MCH-32.2* MCHC-33.4 RDW-14.9 Plt Ct-495*
[**2107-5-10**] 05:24PM BLOOD WBC-7.0 RBC-3.04* Hgb-10.0* Hct-29.8*
MCV-98 MCH-33.0* MCHC-33.6 RDW-15.1 Plt Ct-460*
[**2107-5-11**] 04:18AM BLOOD WBC-6.6 RBC-2.17*# Hgb-7.2*# Hct-21.3*#
MCV-98 MCH-33.1* MCHC-33.7 RDW-15.1 Plt Ct-299
[**2107-5-12**] 03:53AM BLOOD WBC-8.8 RBC-2.66* Hgb-8.5* Hct-24.9*
MCV-94 MCH-32.1* MCHC-34.2 RDW-17.1* Plt Ct-325
[**2107-5-13**] 03:40AM BLOOD WBC-11.7* RBC-2.97* Hgb-9.5* Hct-27.0*
MCV-91 MCH-31.9 MCHC-35.0 RDW-16.7* Plt Ct-376
[**2107-5-14**] 03:26AM BLOOD WBC-11.8* RBC-2.99* Hgb-9.6* Hct-27.6*
MCV-93 MCH-32.2* MCHC-34.8 RDW-16.3* Plt Ct-381
[**2107-5-15**] 03:02AM BLOOD WBC-11.0 RBC-2.94* Hgb-9.4* Hct-27.6*
MCV-94 MCH-31.9 MCHC-34.0 RDW-16.3* Plt Ct-371
[**2107-5-16**] 02:55AM BLOOD WBC-14.3* RBC-3.03* Hgb-9.9* Hct-28.4*
MCV-93 MCH-32.5* MCHC-34.8 RDW-16.0* Plt Ct-351
[**2107-5-17**] 03:48AM BLOOD WBC-13.3* RBC-3.04* Hgb-9.9* Hct-29.3*
MCV-96 MCH-32.6* MCHC-33.8 RDW-16.0* Plt Ct-323
[**2107-5-18**] 04:10AM BLOOD WBC-14.7* RBC-2.84* Hgb-9.3* Hct-26.9*
MCV-95 MCH-32.6* MCHC-34.4 RDW-16.0* Plt Ct-279
[**2107-5-18**] 03:21PM BLOOD WBC-18.4* RBC-3.04* Hgb-10.0* Hct-29.0*
MCV-96 MCH-32.9* MCHC-34.4 RDW-15.9* Plt Ct-298
[**2107-5-19**] 04:00AM BLOOD WBC-17.0* RBC-2.90* Hgb-9.3* Hct-27.4*
MCV-94 MCH-31.9 MCHC-33.8 RDW-16.1* Plt Ct-255
[**2107-5-10**] 05:24PM BLOOD Neuts-66 Bands-2 Lymphs-27 Monos-3 Eos-0
Baso-0 Atyps-0 Metas-2* Myelos-0
[**2107-5-12**] 03:53AM BLOOD Neuts-79.1* Lymphs-14.0* Monos-5.9
Eos-0.6 Baso-0.4
[**2107-5-16**] 02:55AM BLOOD Neuts-82.4* Lymphs-13.5* Monos-1.6*
Eos-2.4 Baso-0.2
[**2107-5-10**] 08:20AM BLOOD PT-14.2* PTT-22.9 INR(PT)-1.2*
[**2107-5-19**] 04:00AM BLOOD PT-20.3* PTT-21.8* INR(PT)-1.9*
[**2107-5-10**] 08:20AM BLOOD UreaN-7 Creat-0.5 Na-133 K-4.1 Cl-100
HCO3-25 AnGap-12
[**2107-5-10**] 05:24PM BLOOD Glucose-80 UreaN-8 Creat-0.6 Na-135 K-3.6
Cl-101 HCO3-24 AnGap-14
[**2107-5-11**] 04:18AM BLOOD Glucose-139* UreaN-7 Creat-0.4 Na-132*
K-3.1* Cl-104 HCO3-22 AnGap-9
[**2107-5-12**] 03:53AM BLOOD Glucose-173* UreaN-6 Creat-0.4 Na-131*
K-3.0* Cl-102 HCO3-23 AnGap-9
[**2107-5-12**] 04:59PM BLOOD Glucose-108* UreaN-6 Creat-0.4 Na-134
K-3.3 Cl-101 HCO3-25 AnGap-11
[**2107-5-13**] 03:40AM BLOOD Glucose-122* UreaN-4* Creat-0.4 Na-136
K-3.9 Cl-104 HCO3-26 AnGap-10
[**2107-5-15**] 03:02AM BLOOD Glucose-169* UreaN-6 Creat-0.5 Na-136
K-3.7 Cl-97 HCO3-31 AnGap-12
[**2107-5-15**] 03:45PM BLOOD Glucose-170* UreaN-7 Creat-0.5 Na-133
K-3.8 Cl-94* HCO3-29 AnGap-14
[**2107-5-16**] 02:55AM BLOOD Glucose-135* UreaN-5* Creat-0.4 Na-133
K-3.3 Cl-92* HCO3-33* AnGap-11
[**2107-5-16**] 12:56PM BLOOD Glucose-170* UreaN-5* Creat-0.4 Na-129*
K-3.8 Cl-90* HCO3-30 AnGap-13
[**2107-5-16**] 09:46PM BLOOD Glucose-145* UreaN-7 Creat-0.4 Na-130*
K-3.8 Cl-91* HCO3-33* AnGap-10
[**2107-5-17**] 03:48AM BLOOD Glucose-121* UreaN-8 Creat-0.4 Na-128*
K-3.8 Cl-90* HCO3-30 AnGap-12
[**2107-5-17**] 05:26PM BLOOD Glucose-127* UreaN-9 Creat-0.4 Na-132*
K-4.0 Cl-94* HCO3-32 AnGap-10
[**2107-5-18**] 04:10AM BLOOD Glucose-98 UreaN-7 Creat-0.4 Na-133 K-3.3
Cl-97 HCO3-31 AnGap-8
[**2107-5-18**] 03:21PM BLOOD Glucose-95 UreaN-7 Creat-0.4 Na-133 K-3.7
Cl-94* HCO3-29 AnGap-14
[**2107-5-19**] 04:00AM BLOOD Glucose-125* UreaN-8 Creat-0.5 Na-135
K-3.2* Cl-96 HCO3-32 AnGap-10
[**2107-5-10**] 08:20AM BLOOD ALT-182* AST-189* AlkPhos-504* Amylase-35
TotBili-17.4* DirBili-13.6* IndBili-3.8
[**2107-5-14**] 03:26AM BLOOD ALT-98* AST-102* AlkPhos-248*
TotBili-9.8*
[**2107-5-18**] 03:21PM BLOOD ALT-223* AST-266* LD(LDH)-483*
AlkPhos-317* TotBili-12.7*
[**2107-5-19**] 04:00AM BLOOD ALT-226* AST-266* LD(LDH)-449*
AlkPhos-284* TotBili-12.4*
[**2107-5-16**] 02:55AM BLOOD proBNP-[**Numeric Identifier 89802**]*
[**2107-5-10**] 05:24PM BLOOD Calcium-8.6 Phos-3.0 Mg-1.4*
[**2107-5-11**] 04:18AM BLOOD Albumin-1.9* Calcium-6.9* Phos-3.4 Mg-1.8
Iron-25*
[**2107-5-19**] 04:00AM BLOOD Calcium-7.7* Phos-2.3* Mg-2.1
[**2107-5-11**] 04:18AM BLOOD calTIBC-130* Ferritn-893* TRF-100*
[**2107-5-10**] 06:02PM BLOOD Type-[**Last Name (un) **] pO2-48* pCO2-44 pH-7.35
calTCO2-25 Base XS--1 Comment-GREENTOP
[**2107-5-11**] 04:33AM BLOOD Type-ART Temp-37.7 Rates-/16 FiO2-50
pO2-117* pCO2-33* pH-7.42 calTCO2-22 Base XS--1 Intubat-NOT
INTUBA Vent-SPONTANEOU Comment-SIMPLE FAC
[**2107-5-16**] 06:59AM BLOOD Type-ART Temp-36.6 Rates-/30 FiO2-80 O2
Flow-10 pO2-56* pCO2-42 pH-7.50* calTCO2-34* Base XS-7 AADO2-473
REQ O2-80 Intubat-NOT INTUBA Comment-VENTIMASK
[**2107-5-10**] 4:15 pm BILE
**FINAL REPORT [**2107-5-16**]**
GRAM STAIN (Final [**2107-5-10**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final [**2107-5-16**]):
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
VIRIDANS STREPTOCOCCI.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Final [**2107-5-16**]): NO ANAEROBES ISOLATED.
IMAGING
ERCP [**5-10**]
IMPRESSION:
Limited exam due to inability to cannulate bile duct, however,
partial filling of the bile duct demonstrated distal stricture
with proximal dilation and pancreatic ductal dilation.
.
TTE [**5-12**]
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). The right ventricular cavity is mildly dilated with
normal free wall contractility. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a very small pericardial
effusion.
IMPRESSION: Normal left ventricular cavity size and wall
thickness with preserved global and regional biventricular
systolic function. Mildly dilated right ventricle. Mildly
dilated ascending aorta. Mild to moderate tricuspid
regurgitation. Moderate pulmonary artery systolic hypertension.
Left pleural effusion. Very small pericardial effusion.
.
LENI [**5-16**]
IMPRESSION: No evidence of DVT
.
CT chest [**5-17**]
Moderate bilateral effusions with adjacent compressive
atelectasis. Extensive fibrotic lung disease with an apical
predominance.
3mm RML perifissural nodule is probably a lymph node. No
pulmonary mass.
The heart size is normal. There is no pathologic mediastinal or
hilar
lymphadenopathy. Right IJ line is in SVC.
Abdominal contents notable for PTC biliary ring cath, small HH,
right renal cyst.
Brief Hospital Course:
This is a 78 year old woman who lives in [**Hospital3 **] and referred
to [**Hospital1 18**] for abdominal pain, weight loss, and jaundice. He blood
tests and examination were consistent with obstructive jaundice
(AP: 504 Tbili: 17.4). She underwent several studies including
CT of the abdomen, EUS, MRCP, and failed ERCP (today). These
studies so far suggest head of the pancreatic cancer with
metastatic liver disease. Today, the unsuccessful attempt for an
ERCP failed to achieve deep bile duct cannulation. Post ERCP,
she developed low grade fever, relative hypotension, dyspnea,
and tachycardia. IR, therefore, was contact[**Name (NI) **] for immediate PTC
to resolve the biliary obstruction for a possibility of
cholangitis. I spoke to her son, who wished for DNR and DNI
status. I explained the very likelihood of metastatic pancreatic
cancer as well as a possibility of cholangitis. She would need
IV fluid support, broad spectrum antibiotics aimed at biliary
pathogens (E-coli and Enterococcus are the most important 2
pathogens), and discontinuation of her antihypertensive
medications (except for Atenolol, gradual weaning unless she is
frankly hypotensive or septic). We will order bile and blood
cultures. We will also order CXR PA/lateral because of subtle
hypoxia. She should be monitored for ARDS from cholangitis. MICU
treatment maybe indicated despite DNR/DNI wishes. She will
remain NPO. Further management will depend on family wishes and
PTC.
*ICU COURSE*
Pt was admitted from ERCP to [**Hospital Unit Name 153**] for continued monitoring given
hypotension and pressor requirement during biliary drain
placement concerning for post-procedure cholangitis. She was
weaned from Neo prior to arrival to floor however required
multiple IVF boluses with 2L normal saline and 2L LR to maintain
blood pressures >100 sbp. R radial arterial line was placed to
monitor MAP with goal >65. CVL in R IJ placed for additional
hemodynamic monitoring of CVP and volume resuscitation. She was
started on vasopressin with improvement in her pressures.
# Resp failure: Pt developed worsening O2 requirement concerning
for volume overload and worsening pleural effusions on chest
xray after large volume fluid resuscitation. She was started on
lasix gtt with tolerance from her BP and treated empirically for
COPD exacerbation w steroids which was stopped after 2 days wo
improvement. Her chest xray supported volume overload with
evidence of pleural effusions, compressive atelectasis and her
exam was notable for crackles. She was trialed on bipap which
she was only able to tolerate r a few hours before becoming very
agitated overnight and self-dc'ing the apparatus. She was placed
back on NRB face mask. CT chest was ordered when her hypoxia did
not improve after 3 days of diuresis. Results of the cat scan
were notable for extensive fibrotic changes throughout the lungs
most likely c/w lymphangitic carcinomatosis related to her
likely pancreatic ca. She continued on a NRB face mask. Family
meeting was held and decision was made to discharge her to an
LTAC per her wishes. She was made DNR/DNI. Morphine IV was
started for palliation of her dyspnea. Lasix drip was continued
with the hope that aggressive diuresis might improve her comfort
given the extensive fluid collections noted on imaging. On [**5-19**]
she was made CMO, started on a morphine drip with ativan and all
other non-comfort medications were discontinued. She was unable
to be discharged to an LTAC given her rapid decompensation on
the intended day of her discharge. She passed away in the ICU.
# Hypotension: Likely related to sepsis physiology from
post-instrumentation cholangitis. Received multiple IVF boluses
for resuscitation and pressure support with Vasopressin. She was
initially started on unasyn, flagyl, and cipro for biliary
microbial coverage; however, preliminary bile cultures revealed
gpc's in pairs, gnr, gnc and so antibiotics were changed to
linezolid and zosyn for better coverage. Speciation revealed
pan-sensitive klebsiella and rare strep viridans. Blood and
urine cultures were and were negative during her stay. Linezolid
was stopped after 7 days however zosyn was continued until the
day she was made CMO and passed away.
.
# Biliary stricture: New stricture, liver lesions, and head of
pancreas mass since [**2105-2-12**], concerning for malignancy in
setting of constitutional symptoms. s/p unsuccessful ERCP.
Biliary drain output was monitored. Biliary cultures as
mentioned above grew pan-sensitive klebsiella. Pain was treated
with dilaudid and she was eventually transitioned to morphine
drip when she was made CMO.
.
# Anemia: Likely anemia of chronic inflammation with drop in
hematocrit secondary to hemodilution from aggressive volume
resuscitation. She was transfused 1u pRBC on the day after
admission for low Hct likely felt to be hemodilution.
Thereafter Hct was monitored closely and remained stable.
.
# Malignancy: Symptomatic with fatigue, weight loss, malaise for
the past few months with imaging concerning for pancreatic mass
causing biliary obstruction and liver metastases. Initial family
wishes were for IR guided drain placement with biopy/brushing to
obtain official diagnosis and pathology however the pt's
worsening respiratory issues prohibited this elective procedure.
CT chest findings were felt to be lymphangitic carcinomatosis
related to her underlying malignancy however it is possible for
her to have had IPF with chronic symptoms at baseline.
CODE STATUS: confirmed w HCP/son [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (1) 89803**],
initially DNR/Ok to intubate and changed to DNR/DNI.
Medications on Admission:
Alendronate 70 mg tablets po every week
Atenolol 75 mg po daily
HCTZ 12.5 daily
Aspirin 81 mg daily
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Metastatic ca, unknown underlying primary but likely pancreatic
fibrotic lung disease
Discharge Condition:
Deceased
Discharge Instructions:
You were admitted to the hospital after you had low blood
pressure and an infection in your bile. You had an ERCP what was
unable to open the compression in your bile system caused by the
mass in your pancreas. Interventional radiology placed a drain
to relieve the obstruction. You required high volume fluid
resuscitation after the procedure for your low blood pressure.
This caused fluid to build up in your lungs due to the high
volume needed as well as your low protein.
You developed worsening shortness of breath that we believe was
secondary to volume overload. We started you on a diuretic drip
which took off excess fluid on your lungs. We obtained a CT
chest when you didn't improve after taking off fluid and it
showed extensive scarring either [**3-16**] chronic underlying lung
disease or scarring related to an extension of your cancer.
A family meeting was held and the decision was made to discharge
you to a care facility which could accomodate your
oxygen/breathing needs.
Followup Instructions:
None
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"518.81",
"276.2",
"401.9",
"157.8",
"038.9",
"780.4",
"V49.86",
"530.81",
"196.1",
"576.2",
"995.92",
"305.1",
"197.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"51.98",
"00.14",
"51.10"
] |
icd9pcs
|
[
[
[]
]
] |
17984, 17993
|
12155, 17800
|
323, 364
|
18123, 18133
|
3701, 12132
|
19174, 19317
|
2896, 2933
|
17951, 17961
|
18014, 18102
|
17826, 17928
|
18157, 19151
|
2948, 3541
|
272, 285
|
392, 2586
|
3556, 3682
|
2608, 2699
|
2715, 2880
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,889
| 177,327
|
37416
|
Discharge summary
|
report
|
Admission Date: [**2193-11-3**] Discharge Date: [**2193-11-12**]
Date of Birth: [**2142-10-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Planned admission for aortic valve replacement
Major Surgical or Invasive Procedure:
[**2193-11-4**] - Aortic Valve Replacement (25mm St. [**Male First Name (un) 923**] Mechanical
valve) / Sternal plating with Talon System.
History of Present Illness:
51 year old male with no known hx of CAD, admitted to [**Hospital1 5979**] on [**10-26**] with increasing shortness of breath. Patient
reports that he has had worsening DOE for [**5-6**] wks. He states
that it is worse when walking up stairs or on an incline. Also
reports large wt gain but could not quantify an exact amount and
increase swelling of his LE b/l. At the OSH he was ruled out for
MI. An Echo was done which revealed an LVEF 30-35%. He underwent
diuresis with IV lasix and his resp status improved. An ETT was
done that showed inferolateral ischemia. He was transfered to
[**Hospital1 18**] for cath. Cath showed patent coronaries, but did show AS
w/ a peak to peak gradient of 80 mmHg and high filling
pressures. ECHO showed severe AS (valve area <0.8cm2), EF of 45%
by ECHO. He was seen by cardiothoracic surgery who recommended
valve replacement with mechanical valve, however recommend
plavix washout therefore surgery was scheduled for Mon [**11-4**]. Pt
requested discharge from the hospital while awaiting surgery and
is now being readmitted for the surgery. Since his discharge two
days ago, pt states that his SOB and LE edema have continued to
improve and he is feeling significantly better than he was on
admission to the OSH. He denies any new or worsening symptoms
including chest pain, fever, chills, or increased
errythema/edema of the lower extremities. He has been taking all
of his medications as prescribed on discharge.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, myalgias, joint
pains, hemoptysis, black stools or red stools. He denies recent
fevers, chills or rigors. He denies exertional calf pain. All of
the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope.
Past Medical History:
Gastric banding procedure
Sleep apnea on CPAP
Prior staph infection of the spine
Cellulitis to right leg currently on keflex
1. CARDIAC RISK FACTORS: No lipid panel on file, sleep apnea
2. CARDIAC HISTORY: Pericarditis with pericardial effusion s/p
pericardial window
Social History:
Lobster distributer.
-Tobacco history: denies
-ETOH: 1-2 drinks/mo
-Illicit drugs: denies
Family History:
Dad with MI at age 75. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
VS: T 96.6, BP 121/71, HR 75, RR 22, Sat 96% RA
GENERAL: Obese male, in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8 cm.
CARDIAC:RR, normal S1, S2. III/VI rumbling SEM best heard at
RSB, radiates to carotids. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. BS distant but clear.
No crackles, rhonchi or wheezes.
ABDOMEN: Soft, obese, NTND. No HSM or tenderness. No abdominial
bruits.
EXTREMITIES: No c/c. 1+ edema b/l LE. No femoral bruits or
hematoma over inscision. Erythemathous, region of R leg appears
to have receeded from demarcation. No warmth, not painful to
palpation. No open ulcers.
SKIN: Chronic venous stasis changes in lower extremities.
PULSES: 2+ radial
NEURO: A+O x3, no focal deficits, 2+ biceps reflexes.
Pertinent Results:
[**2193-11-3**] 07:55PM PT-12.6 PTT-27.3 INR(PT)-1.1
[**2193-11-3**] 07:55PM PLT COUNT-261
[**2193-11-3**] 07:55PM WBC-9.5 RBC-5.38 HGB-13.5* HCT-42.8 MCV-80*
MCH-25.1* MCHC-31.5 RDW-15.5
[**2193-11-3**] 07:55PM TRIGLYCER-155* HDL CHOL-31 CHOL/HDL-5.5
LDL(CALC)-108
[**2193-11-3**] 07:55PM CALCIUM-9.2 PHOSPHATE-4.5 MAGNESIUM-1.9
CHOLEST-170
[**2193-11-3**] 07:55PM GLUCOSE-119* UREA N-29* CREAT-1.1 SODIUM-137
POTASSIUM-4.8 CHLORIDE-101 TOTAL CO2-28 ANION GAP-13
2D-ECHOCARDIOGRAM ([**2193-10-31**]):
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is regional left ventricular systolic
dysfunction with severe inferior, inferolateral hypokinesis and
mild anterolateral hypokinesis. Overall left ventricular
systolic function is mildly depressed (LVEF= 45 %). The right
ventricular cavity is mildly dilated. The ascending aorta is
mildly dilated. The aortic arch is mildly dilated. The number of
aortic valve leaflets cannot be determined. The aortic valve
leaflets are moderately thickened. There is critical aortic
valve stenosis (valve area <0.8cm2). Mild to moderate ([**11-30**]+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
IMPRESSION: Regional left ventricular systolic dysfunction.
Severe aortic stenosis. Mild to moderate aortic regurgitation.
Mild mitral regurgitation. Moderate pulmonary artery systolic
hypertension.
.
ETT:
At OSH, Nuclear:
Anteroseptal ischemia, fixed inferolateral wall defect, dilated
LV w/ gen hypokinesis, EF 30%.
.
CARDIAC CATH:
1. Coronary arteries are normal.
2. Critical aortic stenosis.
3. Elevated right and left sided filling pressures
4. Moderate systolic ventricular dysfunction.
.
HEMODYNAMICS: AS w/a peak to peak gradient of 80 mmHg and high
filling pressures.
Brief Hospital Course:
Mr. [**Known lastname 349**] was admitted to the [**Hospital1 18**] on [**2193-11-3**] for surgical
management of his aortic valve stenosis. The next morning he was
taken to the operating room where he underwent and aortic valve
replacement using a 25mm St. [**Male First Name (un) 923**] Mechanical valve. Given his
large habitus, a Talon sternal plating system was used.
Postoperatively he was taken to the intensive care unit for
monitoring. The following morning he awoke neurologically intact
and was extubated. Coumadin was started for anticoagulation for
his mechanical valve with a goal INR of 2.5-3.0. He had acute
renal insufficiency post-operatively with a peak creatinine of
2.4 but was improved at the time of discharge. Heparin was
initiated until his INR was therapeutic. He was transferred to
the step down unit on post operative day # 3. On the floor he
had adequate urine output with IV lasix, was ambulating in the
halls with assistance and he was tolerating a full diet. He did
have sternal erythema (no drainage) and was started on kefzol
with a plan for 7 days of Keflex and a wound check in 1 week.
Beta blockers were titrated up and an ACE-I was added for blood
pressure control. He was receiving coumadin for the
mechanical valve and by post-operative day 8 he was ready for
discharge to home with a therapeutic INR. His INR will be
followed by his cardiologist [**Male First Name (un) **] Yeghazarians phone
[**Telephone/Fax (1) 12551**].
Medications on Admission:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Carvedilol 6.25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*0*
4. Zyrtec 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 4 days.
Disp:*16 Capsule(s)* Refills:*0*
6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours) for 6 days.
Disp:*12 Capsule(s)* Refills:*0*
6. Outpatient Lab Work
INR draw on [**2193-11-13**] and fax results to Dr. [**Last Name (STitle) 84109**] office
[**Telephone/Fax (1) 84110**] for coumadin dosing.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: to be
evaluated when leg edema resolves.
Disp:*30 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day: to be
discontinued when lasix stopped.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
11. Coumadin 2 mg Tablet Sig: as directed Tablet PO once a day:
dose to be determined by Dr. [**Last Name (STitle) 32668**] for Mech AVR. Goal
INR 2.5-3.
Disp:*150 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Aortic stenosis s/p AVR(25mm St. [**Male First Name (un) 923**] Mechanical)
Pericarditis with pericardial effusion s/p pericardial window
Gastric banding procedure
Sleep apnea on CPAP
Prior staph infection of the spine
Cellulitis to right leg currently on keflex
Pneumonia 6 month ago
Acute renal insufficiency, resolved
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming, and look at your incisions
2) Please NO lotions, cream, powder, or ointments to incisions
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart
4) No driving for approximately one month until follow up with
surgeon
5) No lifting more than 10 pounds for 10 weeks
6)Please call with any questions or concerns [**Telephone/Fax (1) 170**]
7)Your INR and coumadin will be managed by Dr. [**Last Name (STitle) **]
office as confirmed with [**First Name8 (NamePattern2) 57342**] [**Last Name (NamePattern1) **] RN. Your next INR draw
will be [**2193-11-13**].
Followup Instructions:
Please call to schedule appointments
Surgeon Dr [**Last Name (STitle) **] on [**12-5**] at 1:15 PM [**Telephone/Fax (1) 170**]
Primary Care Dr. [**First Name (STitle) **] in [**11-30**] weeks [**Telephone/Fax (1) 6699**]
Cardiologist Dr [**Last Name (STitle) **] [**Name (STitle) **] in [**11-30**] weeks [**Telephone/Fax (1) 12551**]
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
The VNA will draw your INR on [**2193-11-13**] and fax results to Dr.
[**Last Name (STitle) 84109**] office fax [**Telephone/Fax (1) 84110**]
Completed by:[**2193-11-12**]
|
[
"428.22",
"V45.86",
"278.01",
"998.0",
"424.1",
"327.23",
"584.9",
"428.0",
"416.8",
"682.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.22",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
9711, 9786
|
6001, 7475
|
370, 511
|
10151, 10151
|
3985, 5978
|
11046, 11670
|
2855, 2993
|
8183, 9688
|
9807, 10130
|
7501, 8160
|
10296, 11023
|
3008, 3966
|
2667, 2731
|
284, 332
|
539, 2439
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10165, 10272
|
2461, 2647
|
2747, 2839
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,946
| 182,954
|
3676
|
Discharge summary
|
report
|
Admission Date: [**2154-9-10**] Discharge Date: [**2154-9-19**]
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
mechanical ventilation
bronchoscopy
History of Present Illness:
Mr [**Known lastname 16620**] is a [**Age over 90 **] year old Farsi speaking male with PMH CAD
s/p 3v CABG ([**3-/2154**]), SSS s/p PPM, DVT on warfarin, margional
zone lymphoma, CKD, presented to [**Hospital6 **] for
weakness with course complicated by anemia of acute blood loss
and hypoxemic respiratory failure and is transferred by med
flight to [**Hospital1 18**] for further management.
According to the report, he was admitted to [**Hospital6 33**]
[**2154-9-4**] with complaints of weakness x 3 weeks with loose watery
stools. He had been exercising on a treadmill when his legs gave
out and he slumped to his knees without headstrike. He was
febrile to 103.3 initial labs showed WBC 9 HCT 25.8, MCV 96, Na
133, Cr 2.0, BNP 9035 (previously [**2142**]'s at [**Hospital1 18**]). He was given
IV fluids and on [**2154-9-5**] became hypotensive, HCT returned at
19.4, he was transfused 2 units PRBc and developed acute onset
dyspnea and hypoxia, CXR showed bilateral "white out". He was
transferred to the CCU for SVT to 170's with hypotension. His
course was further complicated by afib with RVR, he was given
amiodarone which was discontinued when he developed hypotension.
He was started on norepinephrine and dobutamine. He developed
worsening hypoxia and was started on BiPAP. Diuresis was
attempted however Creatinine increased and no improvment in
oxygenation was noted. ECHO showed known aortic stenosis and EF
50-55% with known apical hypokinesis. WBC increased to 14.
Clnical picture was thought to be TRALI vs pneumonia, he was
treated with vancomycin and pip/tazo and blood cultures had
reportedly been negative. Code status was changed from DNR to
full code on the family's request. Given that he receives his
care at [**Hospital1 18**], transfer was arranged to [**Hospital1 18**]. At the time of
transfer, he was on dobutamine 2.5mcg/kg, norepinephrine 0.1
mcg/kg, furosemide 10mg/h with metoprolol 2.5 Q4H IV. He was
electively intubated prior to transfer.
On arrival to the MICU, he was intubated, sedated and not
responsive to commands, unable to contribute to the history. In
discussion with the son, he had been in his usual state of [**Location (un) **]
prior to admission though he had had loose stools and some
children in the house had had similar symptoms. The son [**Name (NI) 15598**]'t
think the patient had had any pulmonary symptoms.
Review of systems:
Unable to obtain due to sedation
Past Medical History:
- CABG [**2154-4-3**] LIMA->LAD, SVG->OM, SVG->Diag
- NSTEMI [**1-/2154**] at [**Hospital1 18**] and [**2-/2154**] [**Hospital3 **]
- Sick Sinus Syndrome s/p DDD pacemaker ([**Company 1543**])
- Hypertension
- Hyperlipidemia
- Peripheral vascular disease
- Recurrent left lower extremity DVT
- SIADH with hyponatremia
- Chronic renal insufficiency (1.5-1.9)
- Bilateral carotid artery stenosis
- Right lower lobe pulmonary thrombosis
- Nephrolithiasis left staghorn calculus
- BPH
- Anemia
- Cataracts
- Vertigo
- Spleenic margional zone lymphoma s/p 4 cycles of Bendamustine
+ Rituxan
Social History:
30 pack-year tobacco history; quit 45 years ago. Denies current
alcohol use or any illicit drug use. Lives at home with his
wife. Originally from [**Country **] but born in [**Country 16622**]. Used to
work for the Ministry of Justice.
Family History:
Brother: lung cancer.
Mother: uterine cancer.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
Admission Examination
Vitals: T:98.2 BP:99/50 P:110 R:24 O2:92% Assist control Vt
400x16 Peep 5 100% Fio2
General: Elderly male sedated intubated
[**Country 4459**]: Left surgical pupil, sclera anicteric, MMM, oropharynx
clear, [**Country 3899**], PERRL
Neck: supple, JVP 10cm, no LAD
CV: Irregular, normal S1 + S2, SEM at RUSB
Lungs: L>R inspiratory rales with scattered ronchai anteriorly.
Abdomen: overweight, soft, non-tender, non-distended, bowel
sounds present
GU: erythemia and white discharge in the skin folds near pannus
and right [**Last Name (un) **]. foley in place
Ext: Cool, burises on wrists bilaterlly, , well perfused, 2+
pulses, no clubbing, cyanosis or edema
Neuro: Unable to assess due to sedation.
Pertinent Results:
ADMISSION LABS
==============
[**2154-9-10**] 10:45PM BLOOD WBC-13.0*# RBC-2.71* Hgb-8.6* Hct-25.5*
MCV-94 MCH-31.6 MCHC-33.6 RDW-16.4* Plt Ct-92*
[**2154-9-10**] 10:45PM BLOOD Neuts-95* Bands-0 Lymphs-2* Monos-3 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2154-9-10**] 10:45PM BLOOD PT-71.3* PTT-89.5* INR(PT)-7.2*
[**2154-9-10**] 10:45PM BLOOD Glucose-156* UreaN-57* Creat-3.2*# Na-133
K-3.5 Cl-99 HCO3-19* AnGap-19
[**2154-9-11**] 12:53AM BLOOD Fibrino-320#
[**2154-9-11**] 12:53AM BLOOD FDP-10-40*
[**2154-9-10**] 10:45PM BLOOD ALT-9 AST-44* LD(LDH)-476* AlkPhos-90
TotBili-1.1
[**2154-9-10**] 10:45PM BLOOD Albumin-3.4* Calcium-8.0* Phos-3.2 Mg-1.7
LACTATE TREND
==============
[**2154-9-10**] 11:54PM BLOOD Lactate-2.2*
[**2154-9-11**] 05:00AM BLOOD Lactate-1.8
[**2154-9-11**] 07:46AM BLOOD Lactate-1.9
Brief Hospital Course:
Mr. [**Known lastname 16620**] is a [**Age over 90 **] year old male with a history of CAD s/p 3v
CABG, CKD, DVT on warfarin, and marginal zone lymphoma who was
transferred to [**Hospital1 18**] for management of hypoxemia and
hypotension. He passed away on [**2154-9-19**].
Septic Shock: The patient was transferred to [**Hospital1 18**] with shock
and respiratory failure. No infectious source was identified
except a BAL which grew acid fast bacilli which was consistent
with TB by PCR (confirmatory cultures still pending). However
this was thought to be most likely an incidental finding and not
the underlying cause of the patient's decline. Despite broad
spectrum antibiotics the patient's status continued to decline
with progressive multi-organ failure including ARDS, renal
failure, digital gangrene, and stroke. He passed away on [**2154-9-19**]
at 10:45AM. Cause of death was cardiopulmonary arrest from
septic shock and ARDS.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Wheezing
2. Atorvastatin 80 mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU [**Hospital1 **]
4. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
5. Nitroglycerin SL 0.3 mg SL PRN chest pain
6. Ondansetron 4 mg PO Q8H:PRN Nausea
7. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
8. Polyethylene Glycol 17 g PO DAILY
9. Ranitidine 150 mg PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Senna 1 TAB PO BID:PRN constipatin
12. PredniSONE 10 mg PO DAILY
13. Metoprolol Succinate XL 25 mg PO DAILY
14. Warfarin 3 mg PO 6X/WEEK ([**Doctor First Name **],MO,TU,WE,TH,FR)
15. Warfarin 2 mg PO DAYS (SA)
16. Magnesium Oxide 250 mg PO DAILY
17. Clopidogrel 75 mg PO DAILY
18. azelastine *NF* 137 mcg NU 2 puffs
19. Tamsulosin 0.4 mg PO HS
20. Calcium Citrate + D with Mag *NF* (calcium-mag-vit
B6-D3-minerals) 250-40-5-125 mg-mg-mg-unit Oral Daily
21. tolnaftate *NF* 1 % Topical [**Hospital1 **]
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
|
[
"V58.61",
"244.8",
"288.60",
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"287.5",
"V13.01",
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"585.3",
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] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.72",
"38.97",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
7431, 7440
|
5328, 6270
|
224, 261
|
7492, 7502
|
4495, 5305
|
7559, 7570
|
3602, 3738
|
7398, 7408
|
7461, 7471
|
6296, 7375
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7526, 7536
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3753, 4476
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|
176, 186
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289, 2663
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2739, 3326
|
3342, 3586
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,658
| 188,188
|
50628
|
Discharge summary
|
report
|
Admission Date: [**2179-1-13**] Discharge Date: [**2179-2-10**]
Date of Birth: [**2110-3-24**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents / Linezolid
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
transfer from OSH w/ sepsis, respiratory failure
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Intern Admission Note:
.
History of Present Illness: Mr. [**Known lastname **] is a 68 yo male with
PMH as listed below who is being transferred from the MICU.
Refer to initial MICU note for more details. He presented to
[**Hospital 1474**] Hospital with fever, dyspnea, and hypotension. He was
thought to be in septic shock secondary to a pneumonia. He was
transferred to the [**Hospital Unit Name 153**] on [**1-13**] for further management. He was
initially sedated and unresponsive and required pressors to
maintain his blood pressure. He then had significant run of
hemodynamically stable VT which was unresponsive to
antiarrythmics and he required 1 shock. He was transferred to
the MICU for possible temporary wire placement.
.
Of note, pt has history of VT s/p ablation and ICD placement in
[**2-16**]. The ICD was removed in [**10-16**] secondary to infected leads.
He was hospitalized again in [**12-16**] for hypotension secondary to
RP bleed.
.
In the MICU he was agressively treated with antibiotics and
given IVFs given clinical picture consistent with sepsis.
Possible sources of infection included pneumonia and sacral
decubitus ulcer. Pt underwent bronchoscopy which showed collapse
of LLL. Pt afebrile and hemodynamically stable upon transfer to
medical floor this afternoon.
.
Past Medical History:
1)CAD s/p CABG CABG [**2163**] (LIMA->LAD, SVG->D->OM2 jump graft,
SVG->LPDA)
- cath([**2177-1-31**]: patent LIMA->LAD, patent SVG->diagonal and OM2.
Occluded SVG-> L PDA.
- Underwent [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2->proximal and distal left circumflex/PVA
2)HTN
3)Hyperlipidemia
4)s/p VT ablation and ICD implantation [**2-16**]; ICD removed [**10-16**]
for infected pacer wires.
5)COPD
6)Gout
7)chronic LLE ulcers
8)PVD/claudication
- s/p right external iliac artery stent [**8-/2176**]
- complicated by LUE hematoma, ? nerve injury;
- s/p right to left fem-fem bypass grafting in [**2178-5-11**]
9)spinal stenosis
- s/p back surgery
[**82**])bilateral renal masses
11)s/p L inguinal hernia repair
12)s/p cataract surgery
.
Medications on transfer:
Mexiletine 150 mg PO Q8H
Metoprolol 25 mg PO TID
Acetaminophen 325-650 mg PO Q4-6H:PRN
Meropenem 500 mg IV Q8H
Albuterol 6 PUFF IH Q6H:PRN
Aspirin 325 mg PO DAILY
Pantoprazole 40 mg IV Q24H
Ascorbic Acid 500 mg PO BID
Papain-Urea Spray 1 Appl TP [**Hospital1 **]
Atorvastatin 20 mg PO DAILY
[**Hospital1 2768**]
Bisacodyl 10 mg PO DAILY
[**Hospital1 **] 10 mg PO DAILY
Captopril 6.25 mg PO TID
Docusate Sodium (Liquid) 100 mg PO BID
Tobramycin 100 mg IV Q12H
.
Allergies: Heparin agents/Amiodarone/Linezolid
.
Social History: Single, lives alone. Active smoker of 10
cigarettes per day. Has smoked 1-2 packs per day for [**10-25**]
years. Denies ETOH. Retired construction worker.
.
Family History: NC
.
Physical Exam:
vitals T 96.7 BP 94/60 AR 78 RR 24 O2 sat 96% RA
Gen: Awake and alert, NAD
HEENT:MMM
Heart: distant heart sounds, no audible murmurs
Lungs: poor air movement bilaterally @ posterior lung bases,
scattered crackles
Abdomen: soft, NT/ND, +BS
Extremities: [**3-14**]+ pitting edema bilaterally in both LE and
hands; examination of sacral decub deferred to AM
.
Laboratory results: see below
.
Relevant Imaging: Refer to initial MICU note
.
A/P: Mr. [**Known lastname **] is a 68 yo male with PMH significant for CAD,
CHF, VT s/p ablation and ICD placement in [**2-16**] w/ ICD removal
for infected wires in [**10-16**], transferred from [**Hospital1 1474**] for
septic shock now extubated.
.
1)Sepsis/ID: Likely secondary to sacral decubitus ulcer and
pneumonia. WBC elevated at 26 on admission, now 20 this AM.
Likely elevated in setting of steroids. Blood cultures positive
for E coli, sputum growing Enterococcus and Acinetobacter, foot
culture growing Enteroccus and E coli, sacral decubitus growing
staph species, GNRs (ESBL klebsiella), diphtheroids. Refer to
OMR for sensitivity data. Currently afebrile and hemodynamically
stable. ID following closely.
- MRI of lumbar/sacral spine given sacral decubitus ulcer and
underlying osteomyelitis
- Ct Meropenem and Tobramycin; doses modified this PM as per ID
- Check Tobramycin level after 3rd dose
- f/u ID reccs
.
2)Respiratory failure: Secondary to VAP. Bronchoscopy on [**1-19**]
revealed large mucus plug in LLL with progression to LLL
collapse on repeat bronchoscopy on [**1-21**]. O2 sat currently
stable.
- Aggressive chest PT
- Routine nebs
.
3)VT: patient has a h/o VT s/p ablation. Underwent ICD placement
but was removed for infected wires. Patient had episode of VT in
the setting of Levophed in the [**Hospital Unit Name 153**]. No responsive to
Procainamide and required 1 shock.
- Ct Mexiletine
- Per EP: If patient is in VT will try Lidocaine 75-100mg/kg
bolus followed by 1-2 mg/kg maintenance
.
4)CAD: s/p CABG in [**2163**] and PCI of proximal and distal left
circumflex. Patient did present with elevated troponins at OSH
in the setting of sepsis.
- Ct ASA, Lipitor, beta-blocker, and ace-inhibitor
.
5)CHF: ECHO in [**9-16**] with EF~25-30%. Patient has evidence of
fluid overload in his lower extremities and crackles on
pulmonary exam.
- Ct beta blocker and ace-inhibitor, titrate up as HR & BP able
to tolerate
.
6)Sacral decubitus ulcer: Patient likely has osteomyelitis since
the ulcer is probable to bone. Plastics was consulted and did
not feel he was a surgical candidate given his hemodynamic
status.
- MRI of lumbar and sacral spine, as per ID reccs
- ? reconsult plastics pending MRI
- Kinair bed
- Ct [**Hospital1 **] wet to dry dressing
- kinair bed with q3hour rotation
.
7)Thrombocytopenia: Patient has history of HIT, diagnosed in
most recent admission. [**Month (only) 116**] be medication related secondary to
Linezolid.
- Ct to monitor
- Transfuse if plt<[**Numeric Identifier 961**]
.
8)Gout: Patient's L knee was recently tapped by rheumatology on
[**1-18**] and [**1-20**]. Aspirated fluid consistent with gout. Patient was
started on [**Month/Year (2) 2768**] and Colchicine in MICU. L elbow joint
erythematous, edematous, and painful on exam.
- Ct [**Month/Year (2) 2768**] taper
- Ct Colchicine
- Daily joint examinations
.
9)Hypertension: Patient's regimen was initially held given
hypotension and sepsis. Restarted on beta-blocker and
ace-inhibitor. Tolerating well.
- Ct current regimen
.
10)FEN: Ct tube feeds, ground diet with thin liquids
.
11)Prophylaxis: No DVT prophylaxis given HIT, PPI
.
12)Code: FULL, but will verify with HCP
.
13)Access: LIJ central line
.
14)Communication: With patient, health care proxy
.
15) Dispo: Pending clinical improvement
[**Known lastname **]
Saturday
*Triggered for hypotension, gave 1 unit of blood, blood pressure
remained in high 80s. He has been hypotensive most of the day
in the 80s, gave him 250 cc of fluid, concerned for fungal
infection (started him on meropenem), if continues to be
hypotensive, consider give stress dose steroids. Attending
wanted paracentesis to rule out SBP or fungal SBP given
abdominal distension and pain. By abdominal ultrasound unable
to find a place to tap him, tonight going for ultrasound guided
paracentesis. D/ced his NPH as its been held for several doses
now and he has normal blood sugars.
68 M c hx CAD s/p 4V CABG in [**2163**], CHF (EF < 20%), VT s/p
ablation and ICD in [**2-16**] c ICD removal for infected wires in
[**10-16**], HIT, PVD who was recently hospitalized at [**Hospital1 18**] [**12-16**] for
hypotension [**2-12**] RP bleed related to hemorrhagic renal cyst
rupture; required 11 u pRBCs, 5 u FFP and no intervention
performed. Hospitalization complicated by MRSA line infection
for which he finished a 14d course of vancomycin, sacral ulcer,
HIT, and gout flare. Discharged to extended care facility.
.
Presented to OSH c dyspnea, fever, hypotension. Required BiPaP
in ED and eventually intubated at OSH for hypotension requiring
pressors. Treated for septic shock thought [**2-12**] PNA with 5 days
of ceftriaxone, levofloxacin, clindamycin, and 1 day of
vancomycin. Had sacral decub ulcer ctx + for staph, GNR,
diptheroids, sputum ctx + for enterococcus, blood ctx + for e.
coli, foot ulcer ctx + for enterococcus, GNR, e.coli. Required
phenylephrine in addition to fluid resuscitation to maintain
MAP. Also treated with hydrocortisone but unclear if cortisol
stimulation test was performed.
.
Transfered for further management of respiratory failure,
sepsis.
.
In [**Name (NI) 153**], pt. sedated and unresponsive. Presented on
phenylephrine and switched to norepinephrine. Developed
tachycardia at 150 bpm. Initially treated with carotid massage,
diltiazem boluses and gtt without success. EKG done c/w WCT,
likely VT. EKG reviewed by cardiology. VT broke after
norepinephrine stopped and phenylephrine restarted. He was then
transferred to the [**Hospital Ward Name 517**] ICU to be closer to cardiac
support services if there was recurrence of VT.
.
MICU Course:
# Resolving sepsis/ID: Polymicrobial source (sacral decubitis).
Likely some contribution of cardiogenic shock. WBC count
significantly elevated to 26 on admission, now down to 15 on
[**2179-1-15**]. Blood cultures positive for E coli. Possible sources
include sacral decub, foot ulcer. Sputum grew enterococcus at
OSH. Foot culture growing Enteroccus and E coli. His sacral
decub grew staph species, gram negative rods (ESBL klebsiella),
diphtheroids. Cath tip pulled [**1-8**] grew coag negative staph.
U/A and culture negative for infection. Required phenylephrine
in addition to fluid resuscitation to maintain MAP at OSH. Also
treated with stress dose steroids. Off pressors since [**2178-1-17**]. CT
abd/pelvis on [**2179-1-23**] to eval for fluid collection in pelvis
(which would indicate extension of sacral osteo) showed only
stable/unchanged RP hematoma, no abscesses. D/C'd vanc since
active pathogens seem to be E coli in blood ([**4-14**] blood culture
bottles positive at OSH) and Acinetobacter in sputum; covering
with meropenem and tobramycin. Appreciate ID input. Sputum
cultures 4+ GNR--A. baumannii, 2+ GPC (pairs/clusters), 2+
yeast; BAL confirmed Acinetobacter from LLL. Surveillance blood
cultures here at [**Hospital1 18**] [**1-14**], [**1-15**] NGTD. Trough level of tobra
5mg/kg (extended interval dose) was high at 4.7, so
extended-interval dosing not feasible. Currently on tobramycin
100mg IV Q8H; peak and trough after dose on [**1-25**] were
appropriate. Will plan for 14 day course of tobra for VAP
(through [**2179-2-4**]). Restarted meropenem per ID recs on [**1-22**] to
double-cover Acinetobacter. After Acinetobacter is treated with
14 day course, will need to define course for
osteomyelitis/sacral decubitus, which seems to be the source of
E coli septicemia and is also colonized with ESBL Klebsiella, so
would consider total 6 weeks meropenem, but will need to discuss
further with ID.
.
# Respiratory failure: likely secondary to sepsis, but now with
VAP. ronchoscopy [**2179-1-19**]: large mucus plug and sputum in LLL.
Repeat bronch [**2179-1-21**] for LL collapse & extubated after bronch
on [**2179-1-21**]. Aggressive chest PT for help with clearing
secretions has helped him to keep the LUL aerated but the LLL is
still collapsed. Since pt cannot sit in chair [**2-12**] sacral
decubitus, sit up as much as bed allows. Continuing nebs and
have weaned FiO2 to room air.
.
# VT: patient has a h/o VT s/p ablation. Had AICD in place but
was recently removed for wire infection. Appeared to be in Afib
on presentation to ICU on [**2179-1-13**] but quickly converted to VT
with start of levophed. Levophed changed to phenylephrine and VT
broke. VT recurred [**1-14**], w/ diff. morphology, briefly pulseless.
Procainamide did not break VT. 200J delivered x1 w/ conversion
to a. fib and then quickly to sinus rhythm w/ baseline LBBB. Was
then hypotensive and bradycardic requiring vasopressin to
maintain sbp, but has since been off pressors and in SR with
freq PVCs, occ salvos VT. Trial of procainamide gtt d/c'd for
lack of response. Currently maintained on oral mexiletine
without further VT, although frequent ventricular ectopy on
telemetry. EP consult recommends Lidocaine 75-100mg/kg bolus
followed by 1-2 mg/kg maintenance if VT recurs and daily K
repletion to 4.4, Mg to 2.2
.
# CAD: s/p 4 vessel CABG in [**2163**] (LIMA->LAD, SVG->D->OM2 jump
graft,
SVG->LPDA. Most recent cath on [**2177-1-31**] showed patent LIMA->LAD,
patent SVG->diagonal and OM2, and occluded SVG-> L PDA. At that
time he underwent [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2->proximal and distal left
circumflex/PVA. Cannot assess for symptoms of ischemia currently
as patient intubated and sedated. However, patient did have a
troponin elevation at OSH to peak of 0.95 and MB index peak at
9.7, likely enzyme leak in setting of sepsis. Continue asa 325
mg daily, atorvastatin 20mg.
.
# CHF: most recent ECHO documenting EF [**2178-10-6**] showed LVEF
25-30%. Some evidence of mild volume overload on CXR. Restarting
beta blocker at low dose and titrating up as BP tolerates.
Restart ACE inhibitor at low dose and titrating up as BP
tolerates. PRN [**Month/Day/Year **] for 500-1L negative/24hrs; once total body
euvolemic will most likely still need standing [**Month/Day/Year **].
.
# Sacral decub: osteomyelitis as probes to bone. Seen by wound
care consult and plastics cx: rec Kinair bed. No debridement
currently [**2-12**] to hemodynamic status and anticoag with ASA; when
other issues more stable will need more definitive debridement.
Cont. enzymatic debridement with accuzyme and [**Hospital1 **] wet to dry. ID
consult recommended MRI of Lspine and sacrum to assess extent of
infectious process.
.
# thrombocytopenia: improved after stopping Linezolid, which we
have listed as an allergy. ? myelosuppression in setting of
sepsis, also h/o HIT but has not received any heparin products.
.
# Gout: L knee tapped by rheum on [**1-18**], re-tapped [**2178-1-20**] since
still erythematous and painful despite steroids, so concern for
septic joint, but aspirated fluid still c/w gout. On [**Month/Day/Year **]
taper; have added colchicine for pain control. Rheumatology
consult team asked for bilateral foot and knee xrays for joint
space disease when more able to cooperate with exams in
radiology.
.
# HTN: Now that hypotension/sepsis resolving, will slowly add
back antihypertensives
.
# PVD/claudication: s/p right external iliac artery stent [**8-/2176**]
also s/p right to left fem-fem bypass grafting in [**2178-5-11**]:
no active issues
.
# Hyperlipidemia: cont atorvastatin
.
# FEN: Ground diet with thin liquids; tube feeds held as stomach
distended requiring NGT suction. Now that he is taking po diet,
he needs a calorie count to confirm that he is taking adequate
po nutrition; his albumin is 2.1 and already has significant
skin breakdown, which will benefit from aggressive nutrition
support.
Past Medical History:
1)CAD s/p CABG CABG [**2163**] (LIMA->LAD, SVG->D->OM2 jump graft,
SVG->LPDA)
- cath([**2177-1-31**]: patent LIMA->LAD, patent SVG->diagonal and OM2.
Occluded SVG-> L PDA.
- Underwent [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2->proximal and distal left circumflex/PVA
2)HTN
3)Hyperlipidemia
4)s/p VT ablation and ICD implantation [**2-16**]; ICD removed [**10-16**]
for infected pacer wires.
5)COPD
6)Gout
7)chronic LLE ulcers
8)PVD/claudication
- s/p right external iliac artery stent [**8-/2176**]
- complicated by LUE hematoma, ? nerve injury;
- s/p right to left fem-fem bypass grafting in [**2178-5-11**]
9)spinal stenosis
- s/p back surgery
[**82**])bilateral renal masses
11)s/p L inguinal hernia repair
12)s/p cataract surgery
.
Social History:
Active smoker of 10 cigarettes per day. Has smoked 1-2 packs per
day for 10-15 years. Denies ETOH. Retired construction worker.
Family History:
Non-contributory
Physical Exam:
VS- 128/50, 80s, 100.6, ventilated: AC 500*28, Fi02 0.5, PEEP 5
HEENT- R IJ in place, good skin turgor, difficult to assess JVP
LUNGS- crackles b/l, coarse
HEART- irregularly irregular, S1, S2. difficult to hear murmurs
ABD- soft, nd, nt, bs+, + dullness to percussion at flanks,
anasarca.
EXT- L foot dusky with cool toes but warm dorsal/plantar
surface. capillary refill intact in toes, fingers. dopplerable
pulses diffusely. 2+ pitting edema b/l arms.
BACK- large 6 cm diameter, erythematous ulcer across sacrum.
Pertinent Results:
ekg-
[**2178-12-17**] - sinus tachycardia, LAD, interventricular conduction
delay, abnormal R wave progression
[**2179-1-14**] 0:19 - WCT c/w VT; axis shift in inferior leads, no
clear evidence of AV dissociation
[**2179-1-14**] 0:41 - atrial fibrillation 60-90, LAD, similar QRS
morphology V1-V3. occasional PVCs
.
STUDIES (OSH):
CXR [**1-12**]: cardiomegaly with some improvement in RUL infiltrate
KUB [**1-9**]: large accumulation of fecal material throughout the
colon
..
ABG [**1-8**]: 7.29/40/66
ABG [**1-13**]: 7.35/36.3/113.6
Digoxin 0.7
BNP [**1-8**]: 2930
Lactic acid 6.0->4.1
am cortisol 41.7 (H)
TSH 1.58
Prealb 11.2
.
WBC ([**Date range (1) 64566**]): 7.4-> 1.5-> 2.9 -> 12.6->18.6->21.5->27
.
[**1-13**]: 27> 37.6 (41 [**1-7**]) <56 (177 [**1-7**]) ; 79N, 16 B, 1 M
.
[**1-7**]:
[**Age over 90 **]|103|68<106
4.5| 26|1.9
.
TnI: 0.18->0.14->0.11->0.95([**1-10**])
CK: 33->135->146->124
MB: 2.4->4.6->3.6->9.7
.
Cultures:
blood cx's [**1-13**]: pending
blood cx's [**1-7**]: E coli 2/2 bottles
urine cx [**1-13**]: pending
urine cx [**1-8**]: negative
[**1-8**] catheter tip: coag neg staphy
coccyx cx [**1-11**]: staph species, gram negative rods, diphtheroids
tracheal aspirate [**1-10**]: enteroccus
foot cx [**1-11**]: enterococcus, gram neg rods, E coli
.
TTE for endocarditis after E coli bacteremia and persistent
leukocytosis: No definite evidence of vegetations.
.
CT Abd/Pelvis for occult abscess:
1. Very large hematoma extending from the left kidney inferiorly
down into the pelvis. In comparison to prior MRI, size is
approximately stable.
2. No evidence of abdominal or pelvic abscess.
3. Increased left-sided pleural effusion with associated
compressive atelectasis. Stable small right-sided pleural
effusion with associated compressive atelectasis.
4. Right lower lobe nodule has increased in size since [**2176**]. A 6
month follow- up exam is recommended.
5. Multiple bilateral renal cysts and additional hypoattenuating
lesions, too small to characterize. Better characterization was
performed on the prior MRI.
6. Marked arteriosclerotic changes with aneurysmal dilatation of
the aorta and the iliac branches as described.
7. Mild anasarca.
Brief Hospital Course:
68 yo M with a h/o CAD s/p 4V CABG ([**2163**]), CHF(EF < 25-30%), VT
s/p ablation and ICD in [**2-16**] w/ ICD removal for infected wires
in [**10-16**], HIT, PVD, recently hospitalized at [**Hospital1 18**] [**12-16**] for
hypotension [**2-12**] RP bleed recently transferred from [**Hospital1 1474**] for
septic shock from pneumonia/sacral decubitus, intubated, also
with recurrent VT, now extubated with LLL collapse
.
# Respiratory failure: likely secondary to sepsis, but now with
VAP.
- bronchoscopy [**2179-1-19**]: large mucus plug and sputum in LLL. BAL
as above. repeat bronch [**2179-1-21**] for LL collapse & extubated
after bronch on [**2179-1-21**]
- Attempted to wean patient for several days unsuccessfully. On
[**2-9**], a family meeting concluded that his wishes were for no
prolonged intubation and he was made CMO and extubated without
event. He expired peacefully on the morning of [**2-10**].
.
# Sepsis/ID: Polymicrobial source (sacral decubitis). Likely
some contribution of cardiogenic shock. WBC count significantly
elevated to 26 on admission, now down to 15 on [**2179-1-15**]. Blood
cultures positive for E coli. Possible sources include sacral
decub, foot ulcer. Sputum grew enterococcus at OSH. Foot culture
growing Enteroccus and E coli. His sacral decub grew staph
species, gram negative rods (ESBL klebsiella), diphtheroids.
Cath tip pulled [**1-8**] grew coag negative staph. U/A and culture
negative for infection. Required phenylephrine in addition to
fluid resuscitation to maintain MAP at OSH. Also treated with
stress dose steroids. Off pressors since [**2178-1-17**].
- CT abd/pelvis on [**2179-1-23**] to eval for fluid collection in
pelvis (which would indicate extension of sacral osteo) showed
only stable/unchanged RP hematoma, no abscesses.
- D/C'd vanc since active pathogens seem to be E coli in blood
([**4-14**] blood culture bottles positive at OSH) and Acinetobacter in
sputum; covering with meropenem and tobramycin. Appreciate ID
input.
- sputum cultures 4+ GNR--A. baumannii, 2+ GPC (pairs/clusters),
2+ yeast; BAL confirmed Acinetobacter from LLL.
- Surveillance blood cultures here at [**Hospital1 18**] [**1-14**], [**1-15**] NGTD
- trough level of tobra 5mg/kg (extended interval dose) was high
at 4.7, so extended-interval dosing not feasible. Currently on
tobramycin 100mg IV Q8H; peak and trough after dose on [**1-25**] were
appropriate.
- restarted meropenem per ID recs on [**1-22**]
.
# VT: patient has a h/o VT s/p ablation. Had AICD in place but
was recently removed for wire infection. Appeared to be in Afib
on presentation to ICU on [**2179-1-13**] but quickly converted to VT
with start of levophed. Levophed changed to phenylephrine and VT
broke. VT recurred [**1-14**], w/ diff. morphology, briefly pulseless.
Procainamide did not break VT. 200J delivered x1 w/ conversion
to a. fib and then quickly to sinus rhythm w/ baseline LBBB. Was
then hypotensive and bradycardic requiring vasopressin to
maintain sbp, but has since been off pressors and in SR with
freq PVCs, occ salvos VT
- procainamide d/c'd for lack of response
- holding digoxin currently
- EP - if in VT, will try Lidocaine 75-100mg/kg bolus followed
by 1-2 mg/kg maintenance
- K repletion to 4.4, Mg to 2.2
- Pt underwent multiple shocks for VT on [**2-9**]. Was switched to
Amiodarone and Lidocaine with no further arrhythmias prior to
his death.
.
# CAD: s/p 4 vessel CABG in [**2163**] (LIMA->LAD, SVG->D->OM2 jump
graft,
SVG->LPDA. Most recent cath on [**2177-1-31**] showed patent LIMA->LAD,
patent SVG->diagonal and OM2, and occluded SVG-> L PDA. At that
time he underwent [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2->proximal and distal left
circumflex/PVA. Cannot assess for symptoms of ischemia currently
as patient intubated and sedated. However, patient did have a
troponin elevation at OSH to peak of 0.95 and MB index peak at
9.7, likely enzyme leak in setting of sepsis.
- asa 325 mg daily
- atorvastatin
.
# CHF: most recent ECHO documenting EF [**2178-10-6**] showed LVEF
25-30%. Some evidence of mild volume overload on CXR.
- restarting beta blocker at low dose and titrating up as BP
tolerates
- restart ACE inhibitor at low dose
.
# Sacral decub: osteomyelitis as probes to bone
- wound care consult
- Plastics cx: rec Kinair bed. No debridement currently [**2-12**] to
hemodynamic status and anticoag with ASA; when other issues more
stable will need more definitive debridement.
- cont. enzymatic debridement with accuzyme and [**Hospital1 **] wet to dry
- kinair bed with q3hour rotation
.
# thrombocytopenia: improved stopping Linezolid. ?
myelosuppression in setting of sepsis, also h/o HIT but has not
received any heparin products.
.
# Gout: L knee tapped by rheum on [**1-18**], re-tapped [**2178-1-20**] since
still erythematous and painful despite steroids, so concern for
septic joint, but aspirated fluid still c/w gout. Was continued
on [**Month/Day/Year **] taper; added colchicine for pain control.
.
# HTN: Now that hypotension/sepsis resolving, will slowly add
back antihypertensives
.
# PVD/claudication: s/p right external iliac artery stent [**8-/2176**]
- complicated by LUE hematoma, ? nerve injury;
- s/p right to left fem-fem bypass grafting in [**2178-5-11**]
.
# Hyperlipidemia: continued atorvastatin
Medications on Admission:
[**Year (4 digits) **] 20 qd
potassium 100 qd
digoxin 0.125 qd
epogen 6000 sc tiw
aspirin 81 qd
RISS
combivent 4 puffs qid
ativan 1-2 mg q4 PRN
propofol for comfort
clindmycin 600 IV q8
nexium 40 qd
accuzyme to sacral wound qd
tylenol
fentanyl 100 ucg q3d
lactulose
lipitor 20 qd
senokot
MVI
metoprolol 25 qd
lisinopril 5 qd
phoslo
mexitil 150 q8h
ferrous sulfate 325 qd
ceftriaxone 1 g qd
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
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14,824
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46859
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Discharge summary
|
report
|
Admission Date: [**2164-6-12**] Discharge Date: [**2164-6-25**]
Date of Birth: [**2090-4-8**] Sex: F
Service: MEDICINE
Allergies:
Beta-Adrenergic Blocking Agents
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
intubation
closed reduction of left shoulder dislocation
central venous line catheter
History of Present Illness:
Patient is a 74 yo female with hx of DMII who was recently
admitted from [**Date range (1) 99426**] for fevers thought to be secondary
to cellulitis and shoulder pain found to have rotator cuff tear.
She was discharged to a NH. She was recently admitted to [**Last Name (un) 1724**]
from [**Date range (3) 99427**] secondary to swelling of her left arm and
US was negative for a DVT and was started emperically on
antibiotics for a cellulitis without improvement. On [**6-11**] she
was again sent to an OSH ED and diagnosed with a UTI and was
continued on levofloxacin. She was at that time also found to
have a new left shoulder dislocation which they were unable to
reduce and she had no recent history of trauma. Pt family
requested she be evaluated at the [**Hospital1 18**] and so she was
transfered.
.
In ED, she was found to have a UTI and PNA. Given 3g Unasyn and
tylenol for a fever. Ortho consulted for left shoulder
dislocation and recommended CT left shoulder and plan for closed
reduction tomorrow AM.
.
History obtained by admitting team included that she has had
left shoulder pain for 10 days and has not been eating well for
3-4 days because of the pain. No dysuria and no abdominal pain.
No nausea/vomiting. No chest pain or shortness of breath. No
coughing.
.
Upon arrival to floor blood pressure was 88/doppler, HR 100.
She was given 250cc bolus and repeat BP 75/doppler. Then given
1 liter bolus with improvement in SBP to 100. Also had diarrhea
on floor after kaexylate.
.
Further history could not be obtained. Patient states that she
was in pain all over, worse in left hand. Otherwise, reported
breathing was normal. Patient tearful, asking to be released.
Past Medical History:
1. hypothyroidism
2. DM II
3. HTN
4. Hypercholesterolemia
5. psoriasis
6. L ear deafness due to mumps [**2105**]
7. left shoulder dislocation
Social History:
retired > 15 y; lives at home with husband who has bladder
cancer. difficult family situation as per prior psych/sw notes.
[**2-13**] pack year smoking hx 40 y prior. drinks EToh [**2-13**]*/week.
Family History:
non-contributory
Physical Exam:
PE: Tm 101.6, Tc 98.3 (ax), 125/45, 100, 20, 100% on 2L
GEN- short asian woman lying in moderate distress [**3-15**] pain
HEENT- PERRL, crusting around eyes b/l, Dry MM
NECK- no JVD appreciated
CV- tachycardic, regular, [**4-16**] SM loudest LUSB
CHEST- decreased breath sound on left base but o/w clear
ABD- soft, NT/ND, +BS, ventral hernia
EXT- + LUE swelling, left shoulder with poor ROM; + 2 brachial
pulses bilaterally,
Skin - extensive psoriatic involvement over trunk, arms, legs,
face - silvery scale.
Pertinent Results:
ABG: 7.36/ 46 /83
K:5.4 Lactate:3.4
.
UA: RBC [**7-21**], WBC >50, Bact Many, Epi <1
.
OSH [**2164-6-10**]: Chem 7 notable for K 5.4, BUN/Cr= 15/1.9, CBC with
9.0 WBC, hct 29, plt 250.
.
CXR: Left lower lung opacity, possibly representing atelectasis
versus pneumonia.
.
EKG: sinus tachycardia @ 105, nl axis, nl intervals, no ST-T
wave changes, no peaked T waves
.
Shoulder/Wrist/Elbow Xrays: positive for left shoulder
dislocation
.
RUQ US: Cholelithiasis without evidence of acute cholecystitis.
.
Echo: Mild symmetric left ventricular hypertrophy with normal
cavity
size and systolic function (LVEF>55%). Regional left ventricular
wall motion is normal in those walls which were visualized.
Moderate pulmonary artery systolic hypertension.
.
Shoulder MRI: Anterior dislocation of the shoulder. Markedly
atrophic musculature about the shoulder, as described, as well
as nonspecific edema in the subcutaneous tissues. Does this
patient have any history of an underlying disorder such as
muscular dystrophy? No definite rotator cuff tear identified,
though this evaluation is limited as described above.
Probable tear of the long head of the biceps tendon at the level
of the
humeral head. [**Doctor Last Name **]-[**Doctor Last Name 3450**] and reverse [**Doctor Last Name **]-[**Doctor Last Name 3450**] deformities
.
Chest CTA: Large left subpectoral hematoma. Redemonstration of
anterior left shoulder dislocation. Moderate bilateral pleural
effusions and bilateral lower lobe atelectasis.
Brief Hospital Course:
The patient's ICU course is briefly summarized by problems
below. Ultimately the patient was made DNR/DNI and expired on
[**6-25**] from profound respiratory acidosis in setting of altered
mental status. Her pain was difficult to control without
causing respiratory depression. Family felt adament about pain
control but declined re-intubation knowing that she would likely
succomb to respiratory failure.
.
1. Hypotension: The patient was admitted from the OR with low
blood pressures, and was initially treated with neo which was
transitioned to levophed. His pressures improved with saline
boluses and pressors were quickly titrated off. This was
considered likely related to septic shock secondary to pneumonia
and UTI as well as hypovolemia given dramatic improvement with
saline. She was treated broadly for infection with Vanco and
Zosyn. She remained hemodynamically stable throughout the
remainder of her hospitalization and eventually required
antihypertensives for high blood pressures.
.
2. Respiratory distress: The patient was intubated in the OR for
closed reduction of left shoulder dislocation, but remained
intubated in the setting of hypotension and pressor
requirements. She remained intubated for a imaging exams and
possible return to the OR. When it was decided that the patient
would not be taken urgently to the OR, she was weaned and
extubated on [**2164-6-19**]. She was treated for a left lower lobe
pneumonia with Vancomycin and Zosyn. Her sputum culture grew
MRSA and acinetobacter. Her respiratory status was later
complicated by development of respiratory acidosis in the
setting of lethargy [**3-15**] pain control. Multiple attempts were
made to control pain without causing sedation unsuccessfully.
Anesthesia/Pain was consulted for assistance but the patient
continued to be lethargic with pain control and in significant
pain without. After family meeting, the focus of care was
shifted to a priority for comfort, and the patient was made
DNR/DNI knowing that she would likely pass from respiratory
faliure.
.
3. Pain/Left anterior shoulder dislocation: The patient was
admitted with a left shoulder dislocation without a clear
inciting event. She was neurovascularly intact. Orthopedics saw
the patient and took her for a closed reduction on [**2164-6-13**].
Unfortunately, the procedure was unsuccesful. An MRI showed
continued dislocation with atrophy of the surrounding
musculature. Orthopedics did not think that there was an urgent
need to bring the patient to the OR for an open reduction,
especially in the setting of multiple infections and overall
poor medical status. They manipulated her arm and felt that her
pain was not related to the shoulder dislocation. Afterwards, a
hematoma under the left pectoralis, which was thought to be
related to the manipulation.
.
4. UTI: The patient was admitted with fevers and hypotension and
found to have a positive UA and urine culture which grew E.
coli, which was resistent to fluoroquinolones. She was treated
with Vancomycin and Zosyn.
.
3. PNA: The patient was noted to have a left lower lobe
infiltrate on CXR. Sputum culture grew MRSA and acinetobacter
and she was treated with a 10-day course of Zosyn and
Vancomycin.
.
4. ARF: The patient was admitted with a creatinine of 1.8. FENa
was less than 1%. Her creatinine improved with fluids to 1.2.
.
5. Epistaxis: An NG was attempted but resulted in epistaxis,
likely anterior. ENT saw the patient and packed the nare with
good hemostasis. Her HIT was negative and she had no evidence of
DIC/TTP.
.
6 Psoriasis: The patient has a history of severe psoriasis with
history of admissions for exfoliation. She was treated with
Soriatane 10 mg po qod which was temporarily held for increased
LFTS. She was also given creams and had improvement in her
exfoliation.
.
7. LFT elevations: The patient had an acute elevation in her
LFTs which improved throughout her hospital course. This was
considered secondary to shock liver from hypotension.
Medications on Admission:
Outpatient MEDS:
RISS
Soriatane 10 mg po qod (for psoriasis) - should be increased to
10 mg po qd on [**2164-6-16**]
Ibuprofen prn
Levofloxacin 250 po qd (unclear exact start date, to go to the
[**2164-6-16**])
Tylenol prn
Bisacodyl
MOM
Mylanta prn
Levothyroxine 50 mcg po qd
Lisinopril 5 mg po qd
Remeron 22.5 po qhs
Dovenox/Eucyrn cream (unknown doses)
.
MEDS on Transfer:
Levothyroxine Sodium 50 mcg PO DAILY
Piperacillin-Tazobactam Na 2.25 gm IV Q8H
Acetaminophen 325-650 mg PO Q4-6H:PRN
Heparin 5000 UNIT SC TID
Soriatane *NF* 10 mg Oral qod
Hydrocerin 1 Appl TP QID
Insulin SC Sliding Scale
Vancomycin HCl 1000 mg IV Q48H
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
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"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
9283, 9292
|
4584, 8573
|
297, 384
|
9343, 9352
|
3063, 4561
|
9408, 9545
|
2500, 2518
|
9251, 9260
|
9313, 9322
|
8599, 8956
|
9376, 9385
|
2533, 3044
|
252, 259
|
412, 2101
|
2123, 2266
|
2282, 2484
|
8974, 9228
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,271
| 150,725
|
9069
|
Discharge summary
|
report
|
Admission Date: [**2163-1-28**] Discharge Date: [**2163-2-5**]
Date of Birth: [**2089-10-1**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 73 year old male who
presents with colorectal metastasis to the liver. The
patient has stage III colon cancer diagnosed in [**2162-4-13**],
and underwent right colectomy at that time. The patient has
done well, but has had mild elevation in his AFP. The
patient underwent follow-up CT scan in [**2162-9-13**], which
demonstrated apparently three lesions of the right lobe of
the liver. The patient was assessed approximately one month
prior and was actually a candidate for right hepatic
lobectomy. The patient underwent a cardiac evaluation and he
has been cleared. The patient presents to undergo hepatic
lobectomy.
PAST MEDICAL HISTORY:
1. Colon cancer with liver metastasis, status post right
colectomy.
2. Dyspnea and left ventricular hypertrophy.
3. Hyperlipidemia.
4. Hypertension.
PHYSICAL EXAMINATION: On physical examination, the patient's
blood pressure was 130/95, pulse 65 and regular. The chest
was clear. Pulses were brisk without any bruits. The
patient's abdomen was soft, nontender, nondistended, no
hepatosplenomegaly and no edema.
HOSPITAL COURSE: The patient was admitted to the Transplant
Surgery service and underwent right hepatic lobectomy.
Postoperatively, the patient did well. The patient was put
on epidural for pain management and encouraged on incentive
spirometry. On postoperative day one, the patient was awake
and alert, following commands. The patient's abdomen was
distended with clean and dry dressings. The patient was kept
NPO with pain control with the epidural. The patient was
transferred to the floor on postoperative day number two.
The patient had low grade temperature of 100.4. Otherwise,
the patient had stable vital signs. The patient was
encouraged to be out of bed and ambulate. On postoperative
day number three, the patient had no complaints and remained
afebrile with stable vital signs. The patient was advanced
to clear liquid diet and was given some Lasix just to
decrease the edema. The patient's epidural was stopped and
he was changed to Morphine. On postoperative day number
four, the patient had no complaints, was afebrile with stable
vital signs. The abdomen was soft and appropriately tender,
nondistended. The patient's diet was advanced and tolerated.
On postoperative day number five, the patient continued to do
well and remained afebrile with stable vital signs. The
Foley was removed and the patient was put on Dulcolax to help
with bowel movements. On postoperative day number six, the
patient had no complaints, with stable vital signs. Physical
therapy was consulted to see if the patient is safe to go
home. The patient was put on Lasix just to continue with
diuresis. On postoperative day number seven, the patient was
afebrile but had low blood pressure of 100/60. The patient's
Norvasc was held and Diovan was held and plan to discharge
home. The patient's blood pressure improved. On
postoperative day number eight, the patient continued to have
some low blood pressure of 88/56. The patient's Lasix was
stopped and he was encouraged to be out of bed and ambulate.
Physical therapy said that the patient would do well with
another day of physical therapy and therefore the patient was
kept for another day. The patient also complained of bouts
of bloody bowel movements. Rectal examination revealed no
internal or external hemorrhoids. However, the patient was
guaiac positive. The patient was set up for an outpatient
colonoscopy during the week, On postoperative day number
nine, the patient was doing well, afebrile with normal vital
signs. The patient was discharged home.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home with services.
DISCHARGE DIAGNOSES:
1. Status post right hepatic lobectomy.
2. Colon cancer, status post colon resection.
3. Hypertension.
4. Hyperlipidemia.
MEDICATIONS ON DISCHARGE:
1. Tylenol 50 mg p.o. once daily.
2. Allopurinol 150 mg p.o. once daily.
3. Lipitor 10 mg p.o. once daily.
4. Timolol 0.25% drops twice a day.
5. Prednisolone 0.12% drops once daily.
6. Levofloxacin 500 mg p.o. once daily for one week.
7. Percocet p.r.n. pain.
8. Acetazolamide 50 mg p.o. twice a day.
FOLLOW-UP PLANS: Please follow-up with Dr. [**First Name (STitle) **] in two
weeks. Please call his office for a follow-up appointment.
Please follow-up with Dr. [**Last Name (STitle) 150**] of oncology on [**2163-2-7**].
Please follow-up with Dr. [**Last Name (STitle) 497**] for outpatient colonoscopy
next week. Please call his office for an appointment Please
follow-up with primary care physician about blood pressure
medications.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**]
Dictated By:[**Last Name (NamePattern1) 3118**]
MEDQUIST36
D: [**2163-2-6**] 10:37
T: [**2163-2-6**] 11:45
JOB#: [**Job Number 31327**]
|
[
"401.9",
"412",
"413.9",
"197.7",
"272.4",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22",
"50.3",
"99.07",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
3865, 3992
|
4018, 4329
|
1251, 3769
|
989, 1233
|
4347, 5039
|
155, 790
|
812, 966
|
3794, 3844
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,496
| 127,002
|
5542
|
Discharge summary
|
report
|
Admission Date: [**2131-12-26**] Discharge Date: [**2132-1-15**]
Date of Birth: [**2053-10-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
HD line placed in LIJ, also tunneled HD line placed
CVVHD, intermittent HD
ERCP
History of Present Illness:
78yo man with h/o MGUS, CRI (baseline Cr 2.0-2.8), HTN, DMII who
presented to the ER today with a complaint of dyspnea which he
says has been wrosening over the last month. He also saw his
PCP [**Name9 (PRE) 22343**] with complaint of decreased appetite and 20 pound
weight loss over the last two months. The patient reports
feeling weak of late. When questioned, he also notes having a
metallic taste in his mouth, pruritis, difficulty sleeping, and
"fogginess" of his mental status.
.
On arrival to the ER the pt was found to have peaked T waves on
his EKG and a potassium of 7.0, for which he received calcium
gluconate, bicarb, insulin, and kayexelate 30mg x 2 with no
response. ABG was 6.94/8/160. Bicarb was <5. Cr was 10.8
(baseline 2). LFTs were all elevated. He was mildly tachycardic
to the 90s-110s. He was given levo/flagyl because he "looked
bad" and was hypothermic to 33 degrees celsius rectally, in
order cover possible infectious sources in the abdomen although
his examination and other vital signs were benign. Blood and
urine cultures were drawn and are pending. He was seen by renal
in the ER to discuss emergent hemodialysis. He received a total
of 4L of D5W with 3amps bicarb. He was transferred to the MICU
where a L IJ dialysis cath was placed sterilely and HD was
begun. Labs immediately before dialysis showed a bicarb of 18,
K of 6.5, Cr 9.
.
The patient remained responsive throughout and was able to
answer questions and follow commands. at present he reports
feeling dyspneic only, a little bit better than when he arrived.
He denies CP, N/V.
.
ROS: denies cp, cough, n/v
Past Medical History:
- MGUS: BM bx [**11-15**] shows Normocellular bone marrow with
trilineage maturing hematopoiesis and mild plasmacytosis. This
findings, in the absence of other major/minor criteria for
plasma cell myeloma, are consistent with monoclonal gammopathy
of unknown significance (MGUS).
- Skeletal survey [**11-15**] shows No evidence of lytic lesions.
Followed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
- [**11-16**]: FREE KAPPA, SERUM 109.0, FREE LAMBDA, SERUM 33.5
(up from 53 and 30 in [**5-17**])
- [**11-16**] urine positive IgG kappa protein but neg Bence [**Doctor Last Name **]
(increased from year prior)
- DM II
- HTN
- anemia of chronic disease
- Ecoli urosepsis (pansensitive) requiring ICU admission [**7-17**]
- hypercholesterolemia
- hypoglycemia - seen in the ER last month for FS 30 thought to
be [**3-15**] glipizide use with worsening renal fxn.
Social History:
married with 3 children. 30py tobacco history but none x 40yrs.
occasional EtOH.
Family History:
father MI (40s), mother had bipolar disorder.
Physical Exam:
PE: 96.8, 136/45, 106, 25, 99% on 4LNC
gen: tachypneic, increased work of breathing, alert, responsive
HEENT: PERRLA, MMdry, no sinus tenderness, NCAT, sclerae mildly
icteric
Neck: supple, no LAD, JVP flat
Cor: unable to clearly auscultate given loud lung sounds. tahcy,
regular
Pulm: bilateral transmitted coarse bronchial sounds
Abd: soft, NT, ND, no RUQ tenderness, +BS, no HSM
Ext: no c/c/e, w/w/p, 1+ dp pulses bilateally
Skin: no rashes, not jaundiced
Pertinent Results:
On arrival remarkable for ABG acidemia to 6.94, CO2 8, bicarb
<5, KC 7407, INR 1.7. K 8.5, Cr 12.2, [**Doctor First Name **] 663, lipase 951.
lactate 11.9.
.
Studies:
CXR: No acute process.
.
EKG: sinus rhythm at 100, nl axis, peaked Tx, no ischemic
changes, old Q in III, QRS 156.
FIBRINOGE-437* D-DIMER-2828*
LIPASE-951* ALT(SGPT)-139* AST(SGOT)-209* ALK PHOS-723*
AMYLASE-663* TOT BILI-3.1*
.
Creatinine: baseline 2, on admission 10.8
Urine microscopy- [**3-18**] wbc, [**3-18**] rbc, 2 MBC, no acanthocytes
urine protein: cr = 9.0
Hep B S ag -, ab- , core ab -
Hep C neg
ANCA, [**Doctor First Name **], DSDNA, [**Last Name (un) 15412**] -
cryoglobulin neg
cea 5.9
CA9-19 444
C3 32--> 144 C4 3-->50
Myeloma labs: IgG 1780 ([**11-16**] it was 1652), IgM 49 (33), IgA 619
(448)
no BJ proteins in urine
Crits: baseline since [**2130**] around 26-30. Admission crit 30.5,
33.6--> next day 22.9 Given 13 u PRBC in ICU and at baseline
since [**1-1**]
Iron studies: TIBC 136 Iron 168 ferrtiin 1505 haptoglobin < 20,
blood smear- no schistocytes
DIC labs:FDP 10-40, D-dimer 1600-2800, fibrinogen 288-496
[**Name (NI) 2591**] PT 17.8--> peak 22.4--> 13
PTT 54.4--> peak > 150--> 26.1
INR 1.7--> peak 2.2 --> 1.1
Micro
[**12-26**] [**2-14**] coag neg staph
[**12-29**] bld cx neg
ucx neg
aso neg
Studies:
Studies:
admission CXR: No acute process.
.
[**12-28**] Ct abdomen- indicated for crit drop after line placement:
right groin hematoma in abductor component of right ant thigh
.
[**12-28**] US no AV fistula or pseudoaneurysm, mod B/L groin
hematomas
.
[**12-29**] echo- excellent global LV sys fxn with mild mid cavitary
gradient
.
[**1-1**] RUQ US:
1. Normal Doppler ultrasound evaluation of the liver.
2. Sludge in the gallbladder with probable adherent stones.
Dilated common
bile duct with sludge/debris seen within it
.
Renal US
Small atrophic but stable left kidney. No evidence of renal
obstruction.
.
[**1-1**] RUQ US nl liver, sludge GB, dilkated CBD with
sludge/debris within
.
[**1-2**] ERCP: erythema/erosions in antrum c/w gastritis. H pylori
equivocal. Cannulation biliary duct successful. Major papilla
bulging and oozing blood. Brushing of CBD sent. Cholangiogram
showed dilation CBD to 12 mm and panc duct to 6 mm. Dark bile
and sludge flowed p stent.
.
[**1-4**] MRI kidney- mod stenosis L renal artery and diminished
size of left vs. right kidney.
.
[**1-9**] MRCP Prominent papilla and dilated distal CBD and panc
duct- ampullary adenoca and no adj vasc invation. No mass seen
in pancreas.
Brief Hospital Course:
78yo man with h/o DMII, HTN, MGUS presents with new onset ARF on
CRI with critically high lab values as well as acidemia to 6.94
and hypothermia to 33 degrees celsius.
.
# ARF on CRI: Pt has many possible etiologies for this.
Initially it seemed most likely transformation of his MGUS to MM
with resultant renal failure, although Heme/onc was consulted
and with results of IgG and spep/upep, this seemed unlikely.
Additional etiologies arose once the patient was found to have a
hypocomplentemia of GN or possibly ATN. However, complement
increased when rechecked. Other possibilities include cardiac
origin with poor forward flow although history does not suggest
this and pt has maintained good BP throughout this
hospitalization. Possible progression of underlying HTN/DM
nephropathy as pt has had a slow increase in his Cr since [**Month (only) 958**],
however fast jump from 2.8 to 10.8 since [**Month (only) **] makes this seemed
less likely. Per renal consult saw muddy brown casts on urine
microscopy and by the end of hospitalization, the patient's
urine output was 1-2 L per day signifying this was probably ATN.
A renal bx was never done as by the time pt was stable enough
to have one, his urine output improved markedly. Additionally,
it was noted on imaging that the patient has a size discrepancy
in his kidneys and an MRA showed moderate renal artery stenosis
of right renal artery.
Throughout his stay in the MICU, the patient was emergently
dialyzed and then received about 36 hours of CVVHD secondary to
borderline blood pressures. On transfer to the floor, pt had
dialysis every T/Th/Sat. Last dialysis was [**2132-1-15**]. Labs should
be checked the am of each dialysis session. At the time of
discharge it is not clear that he will need permenant dialysis.
This should be readdressed.
.
#Ampullary CA- Patient found to have all of his LFTs elevated.
Initially, this was thought to be due to shock liver. As they
continued to trend up, more concern for cholangitis. Patient
went to ERCP and was found to have a submucosal mass at the
ampulla and brushings were taken. In addition, a stent was
placed. LFTs trended down daily thereafter. Patient was also
treated with a 14 day course of levaquin and flagyl.
.
#Gastritis- During this hospitalization, pt found to have guaic
positive stools. During the ERCP, an endoscopy was performed and
gastritis was found. H. Pylori was equivocal. He received 14
days of flagyl, [**Hospital1 **] protonix, and 7 days of clarithromycin which
should be continued for 7 more days.
.
# coagulopathy - when patient was admitted, he had several days
of PTT>150 for unclear reasons. Thought that perhaps this was
secondary to DIC as PT/INR were also elevated, but DIC labs were
wnl on serial checks over the course of 5 days. [**Hospital1 2591**] are now
within normal limits, although the patient did need to be
supported with several units of FFP and ddAVP.
.
# Anemia- in the setting of bilateral groin hematomas and right
sided adductor compartment bleed, seen on CT, secondary to
emergent attempts at HD catheter placement (eventually placed in
the RIJ). Patient received a total of 8 units of pRBC's with a
transfusion threshold of >25. Hct's stabilized on [**1-1**]. Aspirin
was d/c'd in the setting of acute bleed.
.
# elevated cardiac enzymes: EKG with peaked T waves but no
ischemic changes. Likely troponin elevated in setting of
decreased clearance with ARF, however it peaked at 2.2 s/p
dialysis for unclear reasons as [**Name (NI) **] showed EF>55% with normal LV
function. Was initially beta blocked and on aspirin but in the
setting of acute bleed and hypotension requiring pressors
transiently, these were d/c'd. On transfer to floor, BP stable
and pt was put back on metoprolol. He also had a pmibi which was
normal.
.
# DMII: given renal failure held oral hypoglycemics. Pt with
very elevated FS on floor after receiving 4 L of D5 as well as
D50 for hypekalemia. Insulin gtt was transitioned over to RISS.
Patient was maintained on 13 units of glargine in the am and
sliding scale for coverage.
.
# HTN: pt has h/o htn but after HD has been relatively
hypotensive. Only restarted metoprolol. Held lisinopril, hctz
and amlodipine which have been unnecessary since starting
dialysis.
.
FEN: check lytes before dialysis, phoslo, encourage po intake.
.
.
Medications on Admission:
lipitor 40mg po qday
metformin 1000mg po bid
lisinopril 30mg po qday
amlodipine 2.5mg po qday
HCTZ 12.5mgpo qday
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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
3. Epoetin Alfa 10,000 unit/mL Solution Sig: 10,000 units
Injection ASDIR (AS DIRECTED): please give with dialysis.
Disp:*qs qs* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Clarithromycin 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Insulin Glargine 100 unit/mL Solution Sig: Thirteen (13)
units Subcutaneous qam.
Disp:*qs qs* Refills:*2*
8. Humalog 100 unit/mL Solution Sig: give per sliding scale
Subcutaneous per sliding scale.
Disp:*qs qs* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary
1. Acute on chronic renal failure on HD
2. Ampullary Cancer
3. Gastritis with melanotic stools
4. B/L groin hematomas
5. Demand ischemia
Secondary
1. MGUS
2. DM
3. HTN
Discharge Condition:
HD stable and afebrile.
Discharge Instructions:
You were admitted with acute on chronic renal failure and
started dialysis. While in the hospital your liver function
tests were abnormal and an ERCP was done and a stent was placed.
Biopsy was obtained at that time and showed adenocarcinoma of
the ampulla. Surgery was consulted and you will have a Whipple
procedure on [**2132-1-28**] with Dr. [**Last Name (STitle) 468**].
Please take all your medications as directed.
Please follow-up with all of your outpatient appointments.
Please return to the ED or contact your doctor if you experience
fever, chills, shortness of breath, chest pain, abdominal pain
or any other concerning symptoms.
Followup Instructions:
Before your surgery, you will need to see Dr. [**First Name8 (NamePattern2) 251**] [**Name (STitle) **], MD
Phone:[**Telephone/Fax (1) 476**] Date/Time:[**2132-1-21**] 9:30 am. His office is
located on the [**Location (un) 10043**] of the [**Hospital Ward Name 23**] Building.
After rehab, call your PCP within [**Name Initial (PRE) **] week to make a follow-up
appointment.
Provider: [**Name10 (NameIs) **] [**Doctor Last Name **] [**Doctor Last Name 22344**], OD Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2132-2-14**] 9:30
|
[
"156.2",
"403.90",
"276.50",
"279.03",
"285.21",
"998.12",
"285.1",
"276.2",
"250.00",
"585.9",
"576.1",
"584.9",
"578.9",
"276.7",
"440.1",
"286.9",
"287.5",
"535.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"99.07",
"51.87",
"99.04",
"51.14",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
11706, 11777
|
6188, 9478
|
336, 418
|
11998, 12024
|
3649, 6165
|
12719, 13254
|
3106, 3153
|
10683, 11683
|
11798, 11977
|
10546, 10660
|
12048, 12696
|
3168, 3630
|
9495, 10520
|
277, 298
|
446, 2063
|
2085, 2990
|
3006, 3090
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,350
| 146,277
|
29827
|
Discharge summary
|
report
|
Admission Date: [**2130-2-6**] Discharge Date: [**2130-2-17**]
Date of Birth: [**2057-6-18**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Latex / bacitracin
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Admission for autologous stem cell transplant
Major Surgical or Invasive Procedure:
Subclavian CVL placement
History of Present Illness:
Ms. [**Known lastname **] is a 72yoF with IgG Kappa MM with complex
cytogenetics (ISS stage III) who is s/p RVD x6 and admitted for
auto-SCT with melphalan conditioning.
She was diagnosed with MM in 07/[**2129**]. She received Velcade and
dexamethasone x6 cycles. Revlimid was trialed during the 5th
cycle, however, she developed a rash and it was discontinued.
She has acheived PR. Repeat skeletal survery on [**2130-1-12**] showed
multiple lytic lesions, known T9 compression fx, no new lesions.
On [**1-20**] she had uncomplicated Cytoxan collection. Today she is
admitted for auto-SCT with melphalan conditioning.
.
Currently she feels well. Denies complaints.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies blurry vision, diplopia, loss of vision,
photophobia. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations, lower
extremity edema. Denies cough, shortness of breath, or wheezes.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
melena, hematemesis, hematochezia. Denies dysuria, stool or
urine incontinence. Denies arthralgias or myalgias. Denies
rashes or skin breakdown. No numbness/tingling in extremities.
All other systems negative.
Past Medical History:
ONCOLOGIC HISTORY:
[**Known firstname **] [**Known lastname **] is a 72-year-old woman who was diagnosed with
multiple myeloma in [**2129-7-8**] and found to have a T9 compression
fracture. She had beta-2 elevated at 15.1, IgG of 7802 with
suppression of IgM and IgA, serum viscosity of 2.5, UPEP was
without Bence-[**Doctor Last Name **] proteins. Skeletal survey showed a lytic
lesion in the skull and T9 compression fracture. She was anemic
with a hematocrit of 21.9. She had a normal creatinine, calcium
of 8.4, and albumin of 2.5. Bone marrow biopsy showed nearly
entirely plasma cells on the smear. The core only showed rare
monoclonal plasma cells. Cytogenetics showed a complex
karyotype and she is considered to have stage III disease by ISS
classification. She was started on therapy with Velcade and
dexamethasone. She received a total of 6 cycles of Velcade and
dexamethasone. The addition of revlimid was trialed during the
5th cycle, however, she developed a rash and the medication was
stopped after a few doses. She has achieved a PR.
.
PAST MEDICAL HISTORY:
Multiple myeloma
-known T9 fracture
sleep apnea - uses dental guard (no CPAP)
s/p hysterectomy
cataracts
GERD
Constipation
Back pain
Social History:
Patient is divorced since [**2105**] and lives by herself in [**Location (un) 620**].
She has two sons, one of whom lives in [**Name (NI) 1411**] and the other
lives in [**Location **], NY. She denies any tobacco or EtOH use. She
works as
the Director of International Students at Mt. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1688**].
Family History:
Mother died of lung and ovarian cancer at age 77. Father died of
"mini-strokes" at age 88. She has one sister who has a history
of some type of cancer, but she is alive and well.
Physical Exam:
Admission:
Vitals - T 98.4 BP 128/76 HR 79 RR 18 02 sat 99%RA
GENERAL: Well-appearing woman who appears younger than her age
in no acute distress.
HEENT: PERRL, EMOI, Conjunctiva clear, Sclera anicteric.
Oropharynx is moist without erythema, lesion, or thrush.
NECK: Supple, without lymphadenopathy
HEART: RRR nl S1 S2, no m/r/g
LUNGS: Clear to auscultation bilaterally, no
wheezes/rhonchi/rales, breathing non-labored
ABDOMEN: soft NTND +BS, no HSM
SKIN: Warm, dry, and intact. Port-A-Cath in the right chest
wall without erythema or tenderness.
EXTREMITIES: WWP, no c/c/e
NEURO: AAOx3, CN II-XII grossly intact, 5/5 strength in
extremities, DTRs 2+ and symmetric, sensation grossly intact,
FTN normal.
Discharge: Patient Passed
Pertinent Results:
Admission Labs:
[**2130-2-6**] 11:35AM BLOOD WBC-5.0# RBC-3.68* Hgb-10.7* Hct-32.2*
MCV-87 MCH-29.0 MCHC-33.1 RDW-14.6 Plt Ct-318#
[**2130-2-6**] 11:35AM BLOOD Neuts-80* Bands-0 Lymphs-10* Monos-9
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* NRBC-1*
[**2130-2-7**] 12:15AM BLOOD Glucose-111* UreaN-20 Creat-0.9 Na-140
K-4.6 Cl-107 HCO3-26 AnGap-12
[**2130-2-6**] 11:35AM BLOOD ALT-18 AST-22 LD(LDH)-326* AlkPhos-113*
TotBili-0.3 DirBili-0.1 IndBili-0.2
[**2130-2-6**] 11:35AM BLOOD TotProt-6.4 Albumin-4.2 Globuln-2.2
Calcium-9.7 Phos-4.2 Mg-2.5
Discharge: Patient passed away.
Brief Hospital Course:
Pt was admitted for autologous SCT with melphalan conditioning.
Her course was complicated by febrile neutropenia with
nausea/vomiting/diarrhea. She was started on IV cefepime (since
[**2130-2-9**]), IV vancomycin/flaygl/micafungin. She was
persistently febrile with T 101-102. C diff was negative x3. On
[**2-15**] pt became tachycardic in 110s-120s, hypotensive with SBP
88-90 (baseline SBP 120-140s) despite receiving 1.5L IVF slowly
and increased RR, and she was transferred to the [**Hospital Unit Name 153**].
Norovirus PCR returned positive same day.
Patient transferred day 5 s/p transplant to MICU with
hypotension, neutropenia, and neutrophilic enterocolitis in
setting of positive [**Location (un) **] virus. Patient's clinical condition
rapidily deteriorated requiring intubation for acute hypoxemic
respiratory failure. Patient required multiple pressors for
hypotension. Surgical options were explored for ischemic
colitis but deemed not possible in close consultation with the
surgical team given risks. Patient was also considered for
granulocyte infusion but following a multipdiciplinary team
family meeting, decision was made to not give the infusion.
Despite maximal medical therapy patient passed away after being
made comfort measures only from sepsis from gastrointestinal
source with secondary cause of septic shock with multiple organ
failure with family at bedside.
Medications on Admission:
-acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
-atovaquone 750 mg/5 mL Suspension Sig: Ten (10) ml PO DAILY
(Daily).
-clonazepam 0.5 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
-omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
-oxycodone 10 mg Tablet Extended Release 12 hr Sig: Three (3)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
-pramipexole 0.5 mg Tablet Sig: One (1) Tablet PO qHS ().
-ZOMETA
-calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO DAILY (Daily).
-cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
-magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily).
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: multiple myeloma, colitis, septic shock
Discharge Condition:
Patient expired
Discharge Instructions:
Patient expired
Followup Instructions:
Patient expired
|
[
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icd9cm
|
[
[
[]
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[
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"38.91",
"99.14",
"41.04",
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icd9pcs
|
[
[
[]
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7187, 7196
|
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|
359, 385
|
7288, 7305
|
4286, 4286
|
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|
3331, 3511
|
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3526, 4267
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|
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|
413, 1086
|
4302, 4860
|
2806, 2942
|
2958, 3315
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,403
| 106,152
|
49081
|
Discharge summary
|
report
|
Admission Date: [**2185-9-7**] Discharge Date: [**2185-9-23**]
Date of Birth: [**2100-1-5**] Sex: F
Service: MEDICINE
Allergies:
Levofloxacin / Morphine / Zosyn
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Pulmonary edema, intubation
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
85 y/o with hx of CVA in the past and baseline left sided
weakness who initially presented to [**Hospital1 **]-[**Location (un) 620**] with abdominal
pain. CT scan at BIN revealed uncomplicated diverticulitis, and
was started on zosyn. She received 600cc of fluid in setting of
IV contrast (pt w/ Cr of 2.2 at BIN) and developed respiratory
distress with BP of 209/90 per report. This was thought to be
flash pulmonary edema, and was treated with 60mg IV lasix and
nitro paste. Also received ASA. Pt was sedated with propofol
as well as receiving several doses of ativan and was intubated.
No ABG obtained at that time. Pt then apparently developed
hypotension, possibly in setting of lasix, nitro and propofol,
and was started on levophed at 0.03. R IJ and 2 18's were
placed, and transferred to [**Hospital1 18**].
On arrival to [**Hospital1 18**] propofol ggt was stopped and started on
fent/versed. On admission, vitals were BP: 99/69, HR: 74, RR
23. Lactate 2.7. Vent settings were AC: TV-500, 5 PEEP, 100%
FiO2. ABG was 7.32/45/171 on these settings.
Pt also had EKG at BIN which showed Lateral ST depressions, and
upright T waves. Repeat at [**Hospital1 18**] showed TWI in AVL, V5-V6.
Troponin noted at 1.51 on admission.
Vitals on transfer to ICU: T:99.0, HR: 81, BP: 144/72, RR: 16,
100% on vent. On 0.02 of levophed.
Past Medical History:
-Right caudate CVA presumptively embolic
-GERD
-Hypertension
-Gait ataxia
-Low back pain with history of laminectomy
-History of pneumonia
-Trigeminal neuralgia
Social History:
Patient has daughter ([**Name (NI) **]) who is NICU RN involved in care and
son who is a Rabbi [**First Name8 (NamePattern2) **] [**Name (NI) **]. Patient is divorced. Recently
moved from [**Location (un) **] to [**Hospital3 4103**] nursing facility. She does not
smoke or drink alcohol. No history of illicit drug use. Prior to
hospitalization, she was ambulating well with a walker.
Family History:
Notable for congestive heart failure. Mother died at 74. Father
died at 72 from pulmonary embolism. Sister at 82 with myasthenia
[**Last Name (un) 2902**]. Brother 84 with heart disease. There is a family
history of diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T:99.0, HR: 81, BP: 144/72, RR: 16, 100%
General: Intubated, sedated, non responsive to verbal or tactile
stimulation
HEENT: Sclera anicteric, PERRLA, neck supple, no JVD
Lungs: Bilateral coarse breath sounds
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mildly distended. No tenderness illicited, bowel
sounds present
GU: foley
Ext: Bilaterally inverted feet, cool feet, 2+ pulses, trace
edema
DISCHARGE PHYSICAL EXAM:
Tm 97.8 120-140/52-70 60-76 20 95-97% on RA
.
EXAM:
General: Chronically ill appearing. Awake, oriented x 3; NAD,
conversant this AM
HEENT: Sclera anicteric, oropharynx with dry mucous membranes,
no thrush, PERRL, EOMI
Neck: supple, no LAD, JVP is difficult to assess
Lungs: Improved. Scattered crackles at bases bilaterally; no
wheezing
CV: Regular rate and rhythm, normal S1 + soft S2, +[**1-22**] murmur
heard best at LUSB, radiates to carotids - pulsus tardus
present, no rubs or gallops
Abdomen: soft, mildly tender in RUQ, non-distended, normoactive
bowel sounds present, no rebound tenderness or guarding, no
organomegaly; bruises from subQ heparin
Ext: Muscle wasting in all limbs; Warm, well perfused, 1+
pulses, no clubbing, cyanosis or pitting edema
Neuro: PERRL, EOMI, L arm and leg significantly weaker than on R
but able to perform hand grip and lift leg off bed; babinski's
downgoing, sensation intact, reflexes brisk on L
Access: PIVs
Pertinent Results:
Labs/Studies:
[**2185-9-23**] 05:42AM BLOOD WBC-14.5* RBC-3.39* Hgb-10.9* Hct-33.6*
MCV-99* MCH-32.1* MCHC-32.4 RDW-16.5* Plt Ct-538*
[**2185-9-23**] 05:42AM BLOOD PT-33.2* PTT-31.0 INR(PT)-3.4*
[**2185-9-22**] 06:03AM BLOOD PT-34.1* PTT-29.0 INR(PT)-3.5*
[**2185-9-23**] 05:42AM BLOOD Glucose-116* UreaN-47* Creat-1.8* Na-135
K-3.9 Cl-99 HCO3-26 AnGap-14
[**2185-9-8**] 11:00AM BLOOD CK-MB-9 cTropnT-1.16* proBNP-[**Numeric Identifier **]*
[**2185-9-19**] 03:23AM BLOOD CK-MB-4 cTropnT-0.34*
[**2185-9-23**] 05:42AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.9
[**2185-9-8**] 02:35AM BLOOD calTIBC-166* VitB12-528 Folate-13.6
Hapto-139 Ferritn-577* TRF-128*
[**2185-9-12**] 06:39AM BLOOD Triglyc-215*
[**2185-9-16**] 05:02PM BLOOD TSH-4.2
.
[**9-21**] C.diff negative
[**9-19**] blood cultures x 2: NGTD
.
[**9-22**] CXR:
Pulmonary edema has resolved. There are low lung volumes with
bibasilar
atelectasis. There is no pneumothorax or pulmonary effusions.
Cardiomegaly
is stable. There are no new lung abnormalities.
.
[**9-21**] TTE:
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. The aortic arch is mildly
dilated. The aortic valve leaflets are moderately thickened.
There is moderate aortic valve stenosis (valve area 1.0-1.2cm2).
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. There is a
very small pericardial effusion.
peak velocity: 3.3 m/s; peak gradient 44; valve area 1.1 cm2
.
[**9-19**] EKG:
Possible ectopic atrial rhythm. Left axis deviation may be due
to left anterior
fascicular block, although is non-diagnostic. Anterolateral lead
ST-T wave
changes are non-specific. Since the previous tracing of [**2185-9-17**]
ectopic atrial
rhythm and further ST-T wave changes are both now present.
.
[**9-21**] Swallow:
IMPRESSION: Penetration and aspiration with thin barium.
.
[**9-23**] Swallow: Much improved but still some degree of aspiration
of thin liquids.
Brief Hospital Course:
85F yo F p/w diverticulitis c/b shock and respiratory failure
after receiving IVF. She was intubated for presumed pulmonary
edema c/b post-intubation/lasix hypotension and elevated cardiac
biomarkers in the setting of critical AS.
.
# Shock: Likely both cardiogenic and septic - secondary to IVF
followed by lasix, nitro paste in the setting of critical AS and
patient being volume depleted from diverticulitis and having a
UTI. Pt was weaned off pressors. Pt was then started on lasix
ggt with good output and stable BPs. Patient likely pre-load
dependent given critical AS. She completed a 7-day course of
cefepime, flagyl, and vancomycin - which provided coverage for
UTI, pneumonia, and diverticulitis.
.
# Critical AS, improved to Moderate AS: Valve area 1.1 cm2 on
TTE [**9-21**], consistent with moderate AS once she was no longer
septic. Likely cause of pulmonary edema and subsequent
hypotension in setting of fluid shifts. Pt had hypertensive
episode and had acute pulmonary edema secondary to aortic
stenosis. Cardiology was consulted and patient was not
considered for replacement valve or valvuloplasty at that time
because of her critical condition at the time. She was
scheduled for follow-up with cardiology - Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **].
.
#Respiratory failure: Flash pulmonary edema with xray showing
bilateral pleural effusions and edema. Likely secondary to
critical AS. The patient was diuresed with lasix ggt to optimize
volume status before extubation. Goal diuresis of negative [**11-20**]
liters was met on multiple days and pt respiratory status
improved. Her RSBI score gradually decreased and she was able
to tolerate PSV settings while being weaned off of sedation. Pt
was eventually extubated, but shortly after extubation, she
began to have stridor. We administered racemic epi, and heliox,
but ultimately pt was reintubated. She was given 48 hours and
then another trial of extubation occured, this time with
steroids given 12 hours prior to extubation and then Q4hrsx3
after extubation. Pt was successfully extubated. She
subsequently had episodes of subjective respiratory distress,
but all the while was satting in the high 90's and without
stridor. These symptoms were best controlled with seroquel to
calm her down. Pt continued to diurese and she was eventually
transitioned to PO lasix. He respiratory status stabilized and
was ready to be called out of the [**Hospital Unit Name 153**]. On the floor, the
patient was diuresed with 40 mg PO Lasix per day with good
response. Her pulmonary edema improved - by clinical exam and
Xray and the patient was thought to be nearly euvolemic on the
day of discharge. The patient was not discharged on diuretics
because of her dependent on preload given moderate-severe aortic
stenosis.
.
#Hypertension: The patient was very hypertensive in the ICU and
upon transfer to the floor. Her BP regimen was changed to
captopril 12.5 mg tid and her pressures normalized. She was also
on metoprolol 75 mg tid for atrial fibrillation with rapid
ventricular response.
.
#Anemia: Required 4 units PRBCs throughout admission with last
being on [**9-8**]. with goal to keep Hct >30. Likely related to
elevated coags. Anemia work up showed iron 9, tibc 166, ferritin
577, TRF 128. B12/folate/hapto are wnl. These indicate likely
iron deficiency anemia with component of anemia of chronic dz.
Her Hct was stable ~34 on the days leading up to discharge.
.
#Diverticulitis: Pt presenting to OSH with abdominal pain found
to have diverticulitis of the left colon. Likely explained her
leukocytosis as high as 28 (trended down to 14.5), as well as
her hypotension. Abdomen was soft on the day of discharge. She
was tolerating prethickened liquids and soft foods on the 2 days
leading up to discharge.
.
#Renal failure: Per family, baseline is 1.3-1.6, and on
admission to [**Hospital1 18**] is 2.1 but has trended up to 2.7 - thought to
be [**12-21**] to contrast nephropathy. Creatinine was at her baseline -
1.8 on the day of discharge.
.
#Elevated troponin: Though to be demand ischemia given sepsis,
blood loss, and fluid shifts in the setting of critical AS.
Trops peaked at 1.37 on [**9-8**] but now trended downward. She was
discharged on aspirin 81 mg qday and metoprolol.
.
#History of Afib: Per discussion with family, patient does not
really have history of afib. Coumadin was started for hx of CVA.
The patient had episodes of Afib w/RVR that required an esmolol
or dilt drip. After transfer to the floor, the patient remained
in sinus rhythm with infrequent, spontaneously remitting
episodes of tachycardia - possibly Afib w/ RVR - though appeared
regular and could have represented AVNRT. She was discharged on
metoprolol 75 mg tid and coumadin. She became supratherapeutic
on coumadin and her dose was held on [**9-22**] and [**9-23**] - on the day
of discharge, INR was 3.4. She is to restart coumadin on Sunday,
[**9-25**] at 1 mg qday. She should have her INR checked on Tuesday,
[**9-27**].
.
#Trigeminal Neuralgia: Not taking tegretol at home per records
we have available.
.
#Nutrition: The patient was eating soft solids on the day of
discharge. She had 2 swallow studies which showed aspiration of
thin liquids and she was received nectar pre-thickened liquids.
Her second swallow showed much improvement and she will need
repeat eval at rehab.
.
#The patient received subQ heparin before she was therapeutic on
coumadin. On the day of discharge, INR was 3.4. The patient
remained full code after her transfer from the ICU. Long family
discussions were held and they are still in the process of
finalizing their thoughts. At this time, the patient is FULL
CODE.
.
Communication was primarily with the patient's daughter [**Name (NI) **]
[**Name (NI) 6311**] at [**Telephone/Fax (1) 103000**] ([**Telephone/Fax (1) 103001**]).
Medications on Admission:
(Per [**Hospital **] [**Hospital 620**] clinic note on [**8-15**], doses unknown)
Atenolol 75 mg daily
Pantoprazole 40 mg daily
Benicar 40 mg daily
Multivitamin daily
Acetaminophen 1g QID
Warfarin 2mg QMTWRF, 1mg Q sat and sun
Senna 2 tabs daily
Vitamin D 400 units
Tegretol 100mg PO BID -- unable to find this med listed
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. aspirin 81 mg Tablet, Chewable [**Month/Year (2) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
4. trazodone 50 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
5. acetaminophen 325 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO TID (3
times a day) as needed for pain, fever.
6. metoprolol tartrate 50 mg Tablet [**Month/Year (2) **]: 1.5 Tablets PO TID (3
times a day).
7. captopril 12.5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO TID (3 times
a day).
8. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) ml PO BID (2
times a day) as needed for constipation.
10. benzonatate 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO TID (3
times a day) as needed for cough.
11. multivitamin Oral
12. Coumadin 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day:
Please hold dose on [**2185-9-24**]. Restart on Sunday, [**2185-9-25**] with INR
check on Tuesday, [**2185-9-27**].
13. Vitamin D-3 400 unit Tablet, Chewable [**Month/Day/Year **]: One (1) Tablet,
Chewable PO once a day.
14. Outpatient Lab Work
Please check INR on Tuesday [**9-27**].
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Primary:
Aortic Stenosis - moderate
Hypoxic Respiratory failure - s/p intubation
Hospital-acquired pneumonia
Diverticulitis
Atrial fibrillation with rapid ventricular response
Acute pulmonary edema
Non-ST elevation myocardial infarction
.
Secondary:
Hypertension
Cerebrovascular accident
Chronic kidney disease stage III
Discharge Condition:
Mental Status: Clear and coherent - hard of hearing, confused
sometimes about details of history but oriented
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 6311**],
It was a pleasure caring for you at [**Hospital1 827**]. You were initially admitted for diverticulitis,
however, you became hypertensive and, with IV fluids, had fluid
accumulate in your lungs. You were intubated for this condition
and you were on a ventilator for several days. Your hospital
course was complicated by pneumonia and atrial fibrillation with
rapid ventricular response (an abnormal, fast heart rhythm). You
improved with antibiotics and we worked to get the fluid out of
your lungs with a medication called furosemide (Lasix). You will
need close follow-up for a condition we discovered, which is
known as aortic stenosis. This is a narrowed heart valve. We
have made a follow-up appointment with an excellent [**Hospital1 18**]
Cardiologist, Dr. [**Last Name (STitle) **]. This appointment information is listed
below. We also performed 2 swallow studies, which showed that
you did have a problem swallowing thin liquids - the second
study showed improvement, however. You will be followed up for
this condition at the Rehab facility.
.
We made the following changes to your medications:
We stopped Atenolol and STARTED Metoprolol 75 mg three times per
day for heart rate
We stopped Benicar and STARTED Captopril 12.5 mg three times per
day for blood pressure
We STARTED Aspirin 81 mg once per day
We CHANGED pantoprazole to lansoprazole once per day for
heartburn
We STOPPED Tegretol (carbamazepine) because it was not clear you
were taking this for trigeminal neuralgia.
We CHANGED your Coumadin dosing; you will restart coumadin on
Sunday, [**9-25**] at 1 mg per day - you will need your INR checked on
Tuesday [**9-27**] and may need your coumadin adjusted to 2 mg if your
INR is too low
.
Your follow-up information is listed below.
Followup Instructions:
Department: [**Last Name (un) 12214**] [**Doctor Last Name **] MED GRP
When: THURSDAY [**2185-10-20**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], MD [**Telephone/Fax (1) 5068**]
Building: [**Location (un) **] ([**Location (un) 86**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"428.0",
"785.52",
"280.9",
"585.9",
"427.31",
"584.5",
"785.51",
"424.1",
"410.71",
"486",
"038.42",
"562.11",
"403.90",
"599.0",
"995.92",
"428.31",
"276.0",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
14073, 14167
|
6228, 12112
|
317, 342
|
14532, 14532
|
4035, 6205
|
16607, 17093
|
2316, 2546
|
12484, 14050
|
14188, 14511
|
12138, 12461
|
14790, 15903
|
2561, 3030
|
15932, 16584
|
250, 279
|
370, 1713
|
14547, 14766
|
1735, 1897
|
1913, 2300
|
3055, 4016
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,832
| 166,993
|
32730
|
Discharge summary
|
report
|
Admission Date: [**2102-11-28**] Discharge Date: [**2102-12-8**]
Service: MEDICINE
Allergies:
Sedatives, Barbiturate, Classifier
Attending:[**First Name3 (LF) 5119**]
Chief Complaint:
unwitnessed fall at home/[**Hospital3 **] facility, rapid heart
rate
Major Surgical or Invasive Procedure:
PICC line placement
Central Line placement
History of Present Illness:
Mrs. [**Known lastname 10528**] is a [**Age over 90 **]-year-old female with PMH significant for
atrial fibrillation,HTN, breast cancer (s/p mastectomy [**2049**]),
hypothyroidism, who was originally admitted on [**11-28**] following an
unwitnessed fall at home. Prior to ED arrival the patient had
been evaluated by her PCP at her [**Hospital3 **] facility for
left shoulder pain which was felt to be due to an effusion.
According to patient she went into her bathroom, remembers
sitting on the toilet, then she fell to the floor. She did not
recall feeling lightheaded or dizzy. She denied any
palpitations, chest pain, or acute onset of shortness of breath.
She did not believe that she lost consciousness and could recall
details of her entire fall. Patient believes she was on the
floor for a few hours because she found it very difficult to
pull herself up. She reported that she thought she may have hit
her head and left shoulder.
.
In the ED her initial vitals were T 98F, HR 156, BP 160/80, RR
22, and O2 sat 95% on RA. She was found to be in rapid atrial
fibrillation to the 150's and was started on a diltiazem drip
with initial good effect. She received a dose of ciprofloxacin
for a positive UA in the setting of a leukocytosis to 19. CT of
the head and neck were negative for any fractures, and no
intracranial bleeds were noted. Bilateral shoulder x-rays were
negative for fractures or dislocations.
.
At time of arrival to the medical floor patient's rate was down
to the 60's-70's. She denied any palpitations, CP or SOB. Her
main complaint was left sided shoulder pain, which had been
chronic for some time. She denied any recent illnesses including
URI symptoms, urinary symptoms, diarrhea, nausea or vomiting.
She reported poor appetite for a few days. .
.
On the medical floor, she subsequently had multiple triggers for
atrial fibrillation with RVR. Blood cultures from admission grew
GPC so she was started on Vancomycin on [**11-29**]. Due to complaints
of left shoulder pain, she then underwent arthrocentesis of the
left shoulder. Culture of the joint fluid ultimately yielded
MSSA, as did multiple blood cultures ([**2-24**] from [**11-28**], [**12-29**] from
[**11-29**], and [**12-25**] from [**11-30**]). She was seen by the cardiology service
who recommended changing her from diltiazem for metoprolol.
.
Of note, her fluid balance remained positive throughout the
beginning of her hospital course, and her weight increased from
68->73kg. Due to concern over ARF, she received IVFs and she
then developed fluid overload, pulmonary edema and hypoxia which
required transfer to the MICU for stabilization. Her MICU course
was complicated by AFib/Flutter with RVR occasionally requiring
IV nodal agents. She was aggressively diuresed in the MICU with
IV furosemide and at time of transfer, her shortness of breath
had abated and her oxygen saturation level was much improved to
96% on 5L NC.
.
Once she stabilized she was transferred to [**Hospital1 1516**]/Cardiology
service for ongoing management and continued on Diltiazem drip
for rate control. At time she transferred out of MICU, she was
receiving Diltiazem Extended-Release 300 mg PO daily and
Metoprolol Tartrate 25 mg PO TID, with additional IV agents as
needed.
The patient's bacteremia was felt to be related to an underlying
endocarditis.
Echocardiogram on [**2102-11-30**] showed EF of 70%, mild AS, and at least
moderate 2+ mitral regurgitation. No comparisons existed in our
system. Patient was also complaining of diffuse generalized
abdominal pain that had been present for 2 days near the end of
her MICU course prior to transfer to cardiology service. The
patient had not had a bowel movement in about 4 days. Surgical
service was called due to preliminary read on abdominal CT which
showed SBO and incarcerated right inguinal hernia which was
reported to be at transition point near terminal ileum. Surgery
consult called and evaluation on the floor found that hernia was
reducible. Primary team placed NGT for ease of her abdominal
pain and distension from SBO/ileus. Surgical options were
limited due to multiple co-morbidities, especially her
bacteremia, suspected endocarditis, unstable atrial fibrillation
with RVR and her ongoing dyspneic episodes. This prompted
multiple discussions with patient and family surrounding goals
of care during the last days of her hospital course. The
palliative care service had been following the case and had
multiple patient/family meetings. She pulled her NGT out on two
occasions and her mentation was less clear toward the end of her
hospital course. She was given low doses of morphine, Tylenol,
and anti-emetics for SBO-related abdominal pain control.
Ultimately, the patient's family (HCP/son) asked for no
additional invasive measures, especially surgery. Code status
was changed to DNR/DNI, and she was soon made comfort measures
only per family's wishes. Sadly, she passed away soon thereafter
on the morning of [**2102-12-8**].
Past Medical History:
-Breast Cancer, s/p L mastectomy in [**2049**]
-Atrial Fibrillation, rate controlled on metoprolol, unclear if
on coumadin
-Hypothyroidism
-Hypertension
-? RA
-HTN
-h/o falls
-OA, DJD hips/knees
-uterine prolapse
Social History:
Lived at Foley Senior House/[**Hospital3 400**] Center. Used to live
in [**First Name8 (NamePattern2) 42531**] [**Last Name (NamePattern1) 3908**] and worked as administrative assistant. She
enjoys painting. She has nursing assistance at facility to help
with her medications. Smoked cigarettes for 20-30 years and quit
50 years ago. Denies any ETOH use. No prior drug use history.
She is wheelchair bound due to multiple prior falls.
Family History:
non-contributory
Physical Exam:
Initial Admission Exam:
Vitals 98.5F, HR 144, BP 141/86, RR 19, O2 Sat 92% on 5L
General Thin elderly woman moaning
HEENT Sclera anicteric, conjunctiva pale, dry MM
Neck +JVD
Pulm Lungs with occasional wheeze bilaterally (exam limited by
patient pain on movement)
CV Tachycardic irregular S1 S2 soft systolic murmur at apex
Abd Soft nontender +bowel sounds
Extrem Warm 2+ distal pulses 2+ bilateral LE edema. L shoulder
very tender to light touch.
Neuro Alert and awake, oriented x3 and attention intake. Moving
all extremities.
Derm No peripheral stigmata of endocarditis
.
.
Exam on transfer out of MICU to the [**Hospital1 1516**] Cardiology service:
HR 130s, BP 118/72, O2Sat 95% on 6L NRB, RR 28, afebrile
GEN: Pallid, frail appearing female with slight nasal flaring
but no accessory muscle use, no complaints of pain
HEENT: NC/AT, EOMI, PERRLA
NECK: JVP at 8-9cm, supple
COR: Irregular rhythm, rapid rate. S1 and S2 appreciated, loud
S2 and 3/6 systolic flow murmur at sternal border, no rubs, 2+
carotids B/L
PULM: coarse breath sounds over anterior lungs/upper posterior
fields and decreased lung sounds at bases bilaterally. She has
large left breast mastectomy scar and a small scabbed over sore
over left chest about size of a quarter, rounded. No active
bleeding or discharge at site.
ABD: Diffuse distension, soft, +extreme tenderness at RLQ and
mild tenderness over umbilical area, + rebound tenderness,
reducible right inguinal hernia noted.
EXT: Pitting edema of lower extremities bilaterally
Pertinent Results:
ADMISSION LABS:
[**2102-11-28**] 11:17AM GLUCOSE-150* LACTATE-2.2* NA+-139 K+-3.5
CL--98* TCO2-23
[**2102-11-28**] 11:17AM freeCa-1.06*
[**2102-11-28**] 11:10AM GLUCOSE-156* UREA N-44* CREAT-1.5* SODIUM-137
POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-24 ANION GAP-20
[**2102-11-28**] 11:10AM CALCIUM-9.2 PHOSPHATE-3.5 MAGNESIUM-2.2
[**2102-11-28**] 11:10AM NEUTS-79* BANDS-3 LYMPHS-8* MONOS-10 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2102-11-28**] 11:10AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2102-11-28**] 11:10AM PT-15.3* INR(PT)-1.3*
[**2102-11-28**] 11:10AM PLT COUNT-288#
URINE STUDIES:
[**2102-11-28**] 11:00AM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2102-11-28**] 11:00AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-TR
[**2102-11-28**] 11:00AM URINE RBC-0 WBC-[**1-25**] BACTERIA-MOD YEAST-MOD
EPI-0-2 TRANS EPI-3.5
[**2102-11-28**] 11:00AM URINE HYALINE-[**1-25**]*
[**2102-11-28**] 11:00AM URINE AMORPH-FEW
.
CARDIAC ENZYMES
[**2102-11-28**] 08:50PM CK(CPK)-686*
[**2102-11-28**] 08:50PM CK-MB-12* MB INDX-1.7 cTropnT-0.03*
[**2102-11-28**] 11:10AM CK(CPK)-1585*
[**2102-11-28**] 11:10AM cTropnT-0.02*
[**2102-11-28**] 11:10AM CK-MB-22* MB INDX-1.4
[**2102-11-29**] 06:10AM BLOOD CK-MB-7 cTropnT-0.02*
.
LABS [**2102-12-7**]:
[**2102-12-7**] 06:59AM BLOOD WBC-36.2* RBC-4.69 Hgb-13.9 Hct-40.4
MCV-86 MCH-29.6 MCHC-34.4 RDW-13.8 Plt Ct-430
[**2102-12-7**] 06:59AM BLOOD Glucose-147* UreaN-35* Creat-1.3* Na-141
K-3.7 Cl-101 HCO3-25 AnGap-19
[**2102-12-7**] 06:59AM BLOOD Mg-2.0
.
BNP level:
[**2102-12-1**] 04:34AM BLOOD proBNP-[**Numeric Identifier 76269**]*
.
ABG STUDIES:
[**2102-12-1**] 04:35AM BLOOD Type-[**Last Name (un) **] pO2-103 pCO2-39 pH-7.34*
calTCO2-22 Base XS--4 Intubat-NOT INTUBA
.
LACTATE:
[**2102-12-6**] 09:32PM BLOOD Lactate-2.2*
.
ADDITIONAL STUDIES:
.
[**2102-11-28**] CT HEAD: No evidence of fracture, hemorrhage or acute
finding. Chronic small vessel ischemic disease and age-related
parenchymal change.
.
CXR [**2102-11-28**]: Extensive costochondral calcification again results
in apparent opacities projecting over the lower lobes
bilaterally, particularly on the right. There is no focal
consolidation or superimposed edema. There is a tortuous
atherosclerotic aorta, which remains well defined in its
descending extent and stable from the prior exam. The cardiac
silhouette size remains enlarged but also stable. No definite
effusion or pneumothorax is seen. The bones are diffusely
osteopenic which reduces the sensitivity for detecting subtle
nondisplaced fracture. Within that limitation, there is
suggestion of a right scapular fracture.
.
[**2102-11-28**] B/L SHOULDERS, THREE VIEWS:
LEFT SHOULDER: The bones are severely osteopenic which reduces
the sensitivity for detecting subtle nondisplaced fracture.
Within that limitation, no fractures are evident. The
glenohumeral and acromioclavicular articulations are within
normal limits. The regional soft tissues are unremarkable. The
visualized adjacent lung is clear.
RIGHT SHOULDER: Similar to the left, there is severe osteopenia
which limits the evaluation. Within that limitation, no
fractures or dislocations are evident. The regional soft tissues
are unremarkable. The visualized adjacent lung is clear.
IMPRESSION: No radiographic evidence for bony trauma to either
shoulder within the limitation of severe baseline osteopenia.
.
[**2102-11-28**] CT C-SPINE WITHOUT IV CONTRAST: There is no fracture or
malalignment. There is mild linear lucency which likely
represents artifact traversing the left articular facet of C7
and T1 vertically. There is grade 1 anterolisthesis of C6 on C7.
The lung apices demonstrate septal thickening, which can be seen
with volume overload. A small amount of intravenous air is
incidentally noted. Soft tissues are otherwise unremarkable.
.
[**2102-12-1**] CXR: IMPRESSION: Diffuse overall increase in haziness
over the right hemithorax consistent with increased right
pleural effusion. Possible worsening mild fluid congestion.
Increased left retrocardiac opacity consistent with
atelectasis/however an aspiration/pneumonia cannot be excluded.
.
[**2102-11-30**] TTE: The left atrium is mildly dilated. The right atrium
is moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is unusually small. Overall
left ventricular systolic function is normal (LVEF 70%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets are moderately
thickened. There is mild aortic valve stenosis (area
1.2-1.9cm2). The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. There is severe mitral
annular calcification. At least moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
[**2102-12-7**] CT ABD/CHEST/PELVIS:
IMPRESSIONS:
1. Right inguinal hernia containing small bowel with no current
evidence of
strangulation.
2. Wedge-shaped hypodensity at the left kidney, likely infarct
in this
patient with history of endocarditis.
3. Cholelithiasis
4. Left inguinal hernia and umbilical hernia.
5. Diverticulosis.
6. Dense atherosclerotic calcific disease.
7. Bilateral pleural effusions, right lung atelectasis and
scattered sub 5-mm pulmonary nodule with no specific followup
indicated for the nodules absent, any known malignancy, or
neoplastic risk factors.
8. Right breast calcifications, comparison with mammography is
recommended.
.
.
EKGs:
.
[**2102-12-8**] EKG: Atrial fibrillation with rapid ventricular rate
124. Non-diagnostic repolarization abnormalities. Compared to
the previous tracing of [**2102-12-4**] cardiac rhythm is now atrial
fibrillation with a rapid ventricular rate.
.
[**2102-12-3**] EKG: rate 75, Sinus rhythm. Occasional premature atrial
contractions. Probable inferior wall myocardial infarction of
indeterminate age. Compared to prior the patient is now back in
sinus rhythm. Q waves in the inferior leads are more prominent.
.
[**2102-11-28**] EKG: rate 147, Atrial fibrillation with rapid ventricular
response
Possible prior inferior myocardial infarction but is
nondiagnostic
Left ventricular hypertrophy Nonspecific ST-T abnormalities
Since previous tracing of [**2102-5-2**], atrial fibrillation has
replaced sinus
bradycardia and further ST-T wave changes present
.
.
MICROBIOLOGY:
.
[**2102-12-8**] URINE CULTURE : Final- NO GROWTH
.
[**2102-12-6**] BLOOD CULTURE -NO GROWTH
[**2102-12-4**] BLOOD CULTURE -NO GROWTH
[**2102-12-2**] BLOOD CULTURE -NO GROWTH
.
.
[**2102-12-1**] 1:35 am BLOOD CULTURE
STAPH AUREUS COAG +.
Aerobic Bottle Gram Stain (Final [**2102-12-1**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2102-12-1**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
.
.
[**2102-11-30**] 6:55 am BLOOD CULTURE
STAPH AUREUS COAG +.
Aerobic Bottle Gram Stain (Final [**2102-12-1**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2102-12-1**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
.
[**2102-11-29**] 6:00 pm BLOOD CULTURE
Blood Culture, Routine (Final [**2102-12-5**]):
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED ON CULTURE # 265-0094S [**2101-11-27**].
Anaerobic Bottle Gram Stain (Final [**2102-11-30**]):
GRAM POSITIVE COCCI IN CLUSTERS.
.
[**2102-11-29**] 3:20 pm BLOOD CULTURE
Blood Culture, Routine (Final [**2102-12-5**]):
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 76270**], [**2102-11-28**].
Anaerobic Bottle Gram Stain (Final [**2102-12-1**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS
.
.
[**2102-11-29**] JOINT FLUID: [**2102-11-29**] 2:52 pm JOINT FLUID//Left shoulder.
[**2102-11-29**] GRAM STAIN:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2102-12-2**]):
STAPH AUREUS COAG +. SPARSE GROWTH.
________________________________________________________
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
...............................................................
.
[**2102-11-28**] 11:00 am BLOOD CULTURE
Blood Culture, Routine (Final [**2102-12-4**]):
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED ON CULTURE # 265-0094S [**2102-11-28**].
Anaerobic Bottle Gram Stain (Final [**2102-11-29**]):
GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS.
Brief Hospital Course:
In summary, the patient is a [**Age over 90 **]-year-old female who has known
history of atrial fibrillation (not anticoagulated due to
falls), HTN, and breast cancer, who presented after an
unwitnessed fall. Unfortunately, she went on to have a
complicated hospital course which included unstable and
refractory atrial fibrillation with RVR, shoulder effusion with
+MSSA, GPC bacteremia, suspected endocarditis, and dyspnea with
hypoxia. Despite antibiotics, she had a persistent leukocytosis
and septic picture, and declined further after developing an
acute small bowel obstruction/ileus with complex inguinal
hernias. She was maintained as comfort measures only towards the
end of her hospitalization per HCP/family's wishes and she
passed away on [**2102-12-8**]. Additional hospital course details
outlined below:
.
# Small Bowel Obstruction: Soon after transfer to cardiology
service on [**2102-12-7**] the patient was noted to have markedly worse
abdominal pains which she had been having for 2 days prior. She
reported no bowel movements in 5 days. Physical exam revealed
severe abdominal pain, rebound tenderness at RLQ & LLQ, diffuse
distension. Lactate went up to 2.2 and WBC went up to 36 range
by [**2102-12-7**]. A large right inguinal hernia noted on exam, but was
reducible. CT abdomen was done and confirmed SBO and potential
incarcerated right inguinal hernia which was at a transition
point near terminal ileum. Surgery consult called and advised
NGT to help reduce distension. Team felt patient's surgical
options were limited due to her worsening co-morbidities,
especially her bacteremia /borderline sepsis, suspected
endocarditis, and unstable atrial fibrillation with RVR. Patient
also expressed she did not want any invasive means. No surgical
interventions were pursued and patients status changed to
comfort measures only. NGT was removed, and she was given
Morphine IV and PR Tylenol as needed and IV PPI and IV Zofran
for nausea relief.
.
#. Atrial fibrillation: Presented to ED with atrial fibrillation
to 140s with RVR. At times atrial fibrillation changed over to
atrial flutter and converted back to NSR with rate in 70s after
10 mg boluses of IV diltiazem x2. However, rate very poorly
controlled on the medical floor after admission, though she
initially responded to diltiazem in ED. She had limited response
to PO metoprolol, IV diltiazem boluses. TSH was WNL this
admission. Volume overload and hyperadrenergic state likely
contributed to her refractory tachycardia. Given age and fall
risks she was felt to be a poor candidate for anticoagulation
and was not placed on any Coumadin, but her ASA was increased to
325mg daily dosing. Once she was transferred to the MICU it
appeared that her acute, severe abdominal pain was also
exacerbating her atrial fibrillation. This pain continued and
SBO diagnosed. Unfortunately, as aforementioned, surgery was
essentially not an option as she became more unstable and ill
later in her hospital course. Cardiology consulted after patient
transferred back to medical floor from ICU and alternative
medications for rate and some rhythm control discussed.
Amiodarone was considered risky in that it could switch quickly
back to sinus and promote a CVA as she had been in atrial
fibrillation, poorly controlled, with little anticoagulation.
She was not stable enough for TEE either. Esmolol was
entertained but she had demonstrated that she was very prone to
hypotension with prior beta blockade, and had poor response in
general thus far to other beta blockers. Digoxin was less
desireable due to her CHF and chance that it would worsen her
diastolic function and make her more unstable. Thus, the team
continued with uptitration of Diltiazem drip and Metoprolol
Tartrate 5 mg IV Q4H. With this regimen she had a few
hypotensive episodes which were short lived, but her rate was a
little better controlled to the 115-120 range, but she soon
climbed into the 130s again. After She was soon made CMO,
telemetry and cardiac medications discontinued per HCP/family's
wishes.
.
#. Leukocytosis: She had staphylococcus aureus bacteremia (MSSA)
and new septic arthritis with MSSA as well. Her persistent MSSA
bacteremia at beginning of hospital stay, ongoing tachycardia,
poor appetite, & fevers all concerning for endocarditis, though
no obvious vegetations seen on TTE. She was initially continued
on Vancomycin and Gentamicin per ID recommendations, and peaks
and troughs were monitored. After some initial culture data
returned she was placed on Cefazolin and Gentamicin, and then
when results showed MSSA, she was placed on Nafcillin 2 g IV Q6H
therapy. Daily surveillance blood cultures collected until she
finally cleared around [**2102-12-2**]. She had been having high WBC
counts to 25-36 at time she transferred to cardiology floor on
[**2102-12-7**] . Initial concern was for possible C.difficile in
setting of recent antibiotics and her abdominal pain, however,
she reported no bowel movements in days so that was inconsistent
with C.difficile. CT abdomen revealed SBO as clear source of her
pain. [**Month (only) 116**] have had elevated leukocytosis from worsening SBO
alongside MSSA endocarditis. Of note, her CT had additional
question of pyelonephritis, but repeat UA was unremarkable for
infection. Lactate rose up to 2.2. She remained afebrile towards
end of hospital course but mentation worsened gradually. Given
eventual CMO status, and family wishes, antibiotics
discontinued, and surveillance cultures stopped.
.
#. Hypoxia: She had multiple desaturations after admission and
needed to go to ICu for fluid overload and was stabilized with
IV diuresis, high flow oxygen, and nebulizers. SOB was likely
from IVFs for ARF treatment causing excess congestion from her
poorly pumping heart in setting of persistent atrial
fibrillation. Moreover, additional fluids and her ARF secondary
to suspected rhabdomyolysis s/p fall probably contributed to a
lesser extent. She stabilized from her hypoxia in the ICU and
was 93-98% on room air on [**2102-12-7**]. However, she was still having
intermittent desaturations to the low 90s. Team titrated up
oxygen as needed for comfort with goal sats >92%. She had noted
increased accessory muscle use and profound weakness on [**2102-12-8**].
At that time family asked she be made CMO, she passed away hours
later.
.
# Hypertension: Home amlodipine and lisinopril were held in
setting of rapid atrial fibrillation and hypotensive tendency.
.
#. Unwitnessed Fall: No evidence of pauses on telemetry. No loss
of consciousness per patient. Neuro exam WNL and no bleeds on CT
so a neurological event unlikely. She may have been unstable and
lightheaded in the setting of rapid atrial fibrillation with
hypotension /poor CO, alongside the physiologic BP drop with a
concomitant vagal maneuver, as her fall occured while she was on
the toilet just after a bowel movement.
.
#Acute Renal Failure: On admission her Cr peaked to 1.5. This
was likely secondary to rhabdomyolysis effects after her fall.
This is corroborated on labs with +blood and high protein in
urine, a CPK of 1585, and potassium elevation on presentation to
ED. Given IVF hydration and BUN/Cr trended back to baseline.
.
#Left shoulder pain : Orthopedics and Rheumatology both offered
recommendations and followed the patient. Shoulder tap showed no
crystals and fluid did not indicate septic joint, but sparse
+MSSA found on culture. Unlikely the main source of her
bacteremia. Swollen, painful left shoulder. She was given pain
control with standing Tylenol and breakthrough oxycodone. Later,
IV morphine given.
.
#.Fluids, Electrolytes and Nutrition: Made NPO after SBO
discovered, she was given small amounts of IVFs (D51/2 NS) while
NPO. Given history of pulmonary edema no large boluses ordered.
Initially electrolytes were monitored and repleted daily as
needed. Once CMO, no longer checked daily electrolytes.
.
#Access: During hospital course she had peripheral IVs, and PICC
line was placed as well.
.
#. Prophylaxis: She was given SC heparin for DVT prevention and
she was continued on IV Protonix. At beginning of hospital stay
she was given Colace/Senna for constipation and bowel regimen
but this was later discontinued once SBO discovered.
.
#. Code Status: The patient was initially maintained as a full
code. Several conversations took place with palliative care team
who helped medical team with this difficult case. Ultimately the
patient and HCP/family opted to change code status to DNR/DNI
and shift goals of care to less invasive means with limited
procedures or interventions which were felt to offer more risks
than benefits as the patient became progressively more ill
despite collected efforts from the primary medical, ID,
Surgical, Rheumatology, and Cardiology services. Family asked
that patient be shifted to comfort measures only by the last day
of her hospitalization, leading up to [**2102-12-8**], when the patient
sadly passed away.
.
Medications on Admission:
Home Meds:
-Amlodipine 10 mg daily
-ASA 81 mg daily
-Lisinopril 40 mg daily
-Metoprolol Succinate 50 mg daily
-Zofran 4 mg Q6-8hrs:PRN
.................................
MEDICATIONS ON TRANSFER from MICU to [**Hospital1 1516**]/Cardiology floor on
[**2102-12-7**]:
APAP
ASA 81MG
CAPTOPRIL 6.25MG TID
DILTIAZEM 300MG XR DAILY
DOCUSATE 100MG PO BID
SENNA 1 TAB PO BID
HEPARIN SC
IPRATROPIUM NEBULIZER
LACTULOSE 30MG PO TID
LEVOTHYROXINE 100MCG DAILY
METOPROLOL TARTRATE 50MG TID
MILK OF MAGNESIA
NAFCILLIN 2G IV Q6H, DAY 1=[**12-7**]
OMEPRAZOLE 40MG DAILY
ONDANSETRON 4MG IV Q8H
COMPAZINE 10MG IV Q6H PRN
Discharge Medications:
patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
patient expired
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]
Completed by:[**2102-12-12**]
|
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"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
26159, 26168
|
16501, 25466
|
312, 357
|
26227, 26244
|
7636, 7636
|
26308, 26497
|
6073, 6091
|
26119, 26136
|
26189, 26206
|
25492, 26096
|
26268, 26285
|
6106, 7617
|
204, 274
|
385, 5368
|
9621, 16478
|
7652, 9612
|
5390, 5604
|
5620, 6057
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,202
| 140,605
|
22778
|
Discharge summary
|
report
|
Admission Date: [**2179-4-13**] Discharge Date: [**2179-4-21**]
Date of Birth: [**2101-1-2**] Sex: M
Service: [**Last Name (un) **]
HISTORY: The patient is a 78-year-old male who on admission
looked younger than his stated age and presented for surgical
evaluation of a sigmoid polyp. The patient had been
previously seen in the office by Dr. [**Last Name (STitle) 957**] who counseled
the patient that he had a sigmoid polyp with adenocarcinoma
arising in an adenoma growing on a stalk. Dr. [**Last Name (STitle) 957**]
recommended that he had a 12 percent possibility of having
nodal metastases from this adenocarcinoma. He also recounted
that he had a history of a number of months, including
several admissions to [**Hospital3 1196**] for GI
bleeding at which time at one point he required 6 units of
packed red blood cells which finally became quiescent. The
patient had been colonoscoped twice during this incident and
for some reason the polyps were not found. The colonoscopy
was finally done on [**2179-2-24**] by Dr. [**Last Name (STitle) **] who
found several polyps which he resected and 1 mid sigmoid
which was clipped at 40 cm appeared to have a cancer in the
stalk and a pathological examination did prove this to be the
case. He had, had obstructive symptoms previously and
diverticulosis of the colon. The descending, transverse, and
ascending colon, and the 3 cm polyp, the one that was deemed
to have malignancy in it by pathology was deemed suspicious
for adenocarcinoma. Therefore the patient was counseled to
have a colectomy. The patient had no known drug allergies.
His past medical history also as above included, besides his
gastrointestinal history, included a history of C.
Difficile. The patient has had no previous operations. His
medications on admission included digoxin 0.125 p.o.,
metoprolol 25, and Lipitor 10. The patient denied a history
of heart disease, hypertension, diabetes, lung disease,
asthma, or radiation therapy. He did if course, have the
known diagnosis of cancer. He is married. He had four
children, a daughter who died quite young at the age of 30 of
breast cancer. The patient does not drink and had a 50 pack
year of cigarette smoking.
According to the exam by Dr. [**Last Name (STitle) 957**] he stated that he was a
big man, looking younger than his stated age with a weight of
210 pounds, blood pressure was 160/96, temperature was 96.8.
His heart rate was 92. His respirations were 20. His HEENT
was normal including the eye grounds which showed remarkably
preserved small vessel disease. Tympanic membranes were
normal as were mucous membranes. Dr. [**Last Name (STitle) 957**] did not recount
hearing bruits and he did feel the thyroid slightly, but no
abnormal nodules were noted. He described his chest as
barrel, his diaphragm moved 3-4 cm. His heart was not
enlarged. It was regular at sinus rhythm. A2 was greater than
P2, but there were no murmurs appreciated. The abdomen was
benign except for incontinence for which the patient wears a
diaper.
IMPRESSION: Dr.[**Name (NI) 6275**] impression at the time of his
office evaluation was carcinoma of the sigmoid colon,
residual carcinoma, following polypectomy with a return, he
would be admitted to hospital for sigmoid resection. On [**4-13**], the patient was in the preoperative holding area and was
identified and he had also recently been diagnosed with an
abdominal aortic aneurysm. On [**2179-4-13**] he underwent an
operation. Preoperative doses was colon cancer.
Postoperative the same. Procedure was rectosigmoid colectomy.
Surgeon was Dr. [**Last Name (STitle) 957**]. Please see operative dictation. The
procedure performed was rectosigmoid resection with
coloproctostomy, intraoperative sigmoidoscopy was performed.
The patient tolerated the procedure well. The EBL was
described as minimal and the patient was extubated and taken
to the PACU.
The patient postop was complaining of some pain. He was using
a PCA well, no flatus was reported on the night of the
operation. The patient was on telemetry and the patient was
seen by Dr. [**Last Name (STitle) 957**] on rounds and he was doing quite well.
Postoperative check, the patient was afebrile 99.5, 98.8, 95,
140/64, 20, 97 percent on 2 liters, n.p.o. He was making
adequate urine. He was awake, no acute distress, His abdomen
was soft and nontender. The incision was clean, dry, and
intact.
Postoperative day #1, the patient was without complaints, was
soft. Dressings were intact and we were awaiting bowel
function.
On postoperative day #2, there was no untoward events. The
patient was out of bed to chair for a significant point of
the day. He was afebrile. His heart rate was 80, 110/70, 17,
95 percent on room air. The patient was n.p.o. He made 1,860
cc of urine. He was in no acute distress. His lungs were
clear to auscultation bilaterally. He was doing well. He was
awaiting GI function. The patient was seen by physical
therapy on [**4-15**]. Their assessment was that the patient was a
78-year-old status post sigmoid colectomy who presented, that
he was doing well, was ambulating, and needed follow up for
transfer training and functional mobility and improved
endurance. On [**4-15**], the urologic team came by because the
patient had hematuria that had been noted in the operating
room, but had not resolved. The patient was without urinary
symptoms. The patient was 99.1, 98.8, 116/78, 78, 20, satting
93% on 2 liters at the time of urologic evaluation. He was
described as comfortable. His lungs were described as clear
anterior. His abdomen was described as soft with a clean
dressing and there was no suprapubic tenderness. His lower
extremities were warm and no edema. The patient's white count
was 11.3, his hematocrit was 41.8. CT from [**4-9**] was
reviewed by them which showed multiple simple renal cysts.
Disposition by the urologic staff, was to leave the Foley
catheter indwelling and was planned to book a cystoscopy
several weeks after discharge and the patient was to begin
Flomax to help aid with voiding after catheter was to be
removed.
On postoperative day #3, the patient was without the
complaint. Had still had not passed any flatus. His T-max
was 99.2, T-current was 97.4,96, 142/70, 20, 94% on 2
liters. The patient was n.p.o. Gave 1,560 in IV fluids. 2,200
in urine. The patient was ambulating up and around. His
abdomen was described as nontender with positive bowel
sounds. On [**4-17**], the patient continued to be progressing
well and was alert and oriented on the floor. Nontender
abdominal examination. Foley was making adequate urine
output.
On [**4-18**], postoperative day #5, the patient still had not
reported any significant flatus. He was afebrile, 98.6, heart
rate was 78, he was 124/80, and he was satting 93% on 2
liters. He had made 1,550 cc of urine over the 24 hours. He
was doing well. He was placed on maintenance IV. He was out
of bed and using incentive spirometry. On [**4-18**],
approximately 7:45 at night, anesthesia was called because
the 78-year-old patient appeared to be on the floor in
respiratory distress. He was having difficulty breathing. Non-
rebreather mask. His O2 sats were in the mid 80s. Dentures
were removed and given to the RN and a rapid sequence
intubation was used, passed easily through the vocal cords.
The patient was intubated and the patient was transferred to
the ICU. The events that were encountered on [**4-18**], was
that approximately at 3:00 p.m. the patient had a large loose
stool times two, was complaining of increased abdominal pain
and cramping. Skin was described as pale and [**Doctor Last Name 352**] by the
nurse. His heart rate had gone up to 110 and at 5:00 p.m. he
had another large loose stool and had reported increased
weakness, increased shortness of breath, and his respiratory
rate increased to approximately 40 and his heart rate to the
120s. A 1 liter bolus was given. ABGs were sent as were labs.
As breathing difficulties continued, the decision was made to
intubate the patient. The patient was afebrile at the time
of the event 97.1, heart rate 120 though. Blood pressure was
low in 80 to 60 range and the patient's respiratory rate was
30 and he was satting between 87 and 94% prior to the EKG and
ABG being performed. The patient was assessed by the chief
resident and due to respiratory distress the patient was
intubated with the help of anesthesia staff. After intubation
the patient's oxygen saturation rose to approximately 97 %.
Right IJ was inserted by the chief resident under sterile
technique. Chest x-ray was okay. There was no pneumothorax. A-
line was started and the patient was started on Levophed for
hemodynamic support .The patient's ABG at the time of
preparation for intubation was 7.34, 91, 27, 15, with a base
deficit of 9. Repeat ABG was 7.28, 34, 450, 17, and -9 and a
lactic acid of 6.1. That was after intubation and CVL. There
was concern for sepsis versus a potential pulmonary emboli,
also vascular surgery was notified and an ultrasound was
performed because there was a known history of a AAA. There
was concern for potential rupture, as for Vascular Surgery
was notified and discussion undertaken about the possibility.
Vascular Surgery consult was attained and their assessment
was low likelihood for ruptured AAA given stable hematocrit,
acidosis, and septic etiology. There was concern for
ischemia or infarction or another possible intra-abdominal
process abscess such as leak. Cardiology came and saw the
patient, because the patient had acutely developed
tachycardia, respiratory distress, and had continued to be
hypotensive despite Levophed with blood pressure 73/88 in the
ICU on pressor medications. Cardiology recommends a Swan to
assess the etiology of shock and PA pressures. Dr. [**First Name (STitle) 2819**], the
attending surgery staff, evaluated the patient, gathered all
the appropriate information and realized the patient was on
pressors and his abdomen was distended and he had guarding
and rebound and he wrote that barring some other septic foci
which is not apparent at this time, it was likely that an
anastomotic leak was the cause and recommended emergent
exploration. This was discussed with the family.
On [**2179-4-19**], the patient was taken to the operating room
for an acute abdomen and sepsis. Postoperative diagnosis was
anastomotic disruption and fecal peritonitis. Please see
operative dictation. The procedure was an exploratory
laparotomy with a wash out and the patient was left with a
left transverse colectomy and ostomy and drains were placed
x4 and the abdomen was left open. The patient's condition was
described as guarded.
The patient was subsequently admitted to the ICU.
Postoperative day number zero on [**2179-4-19**], in the early
morning in the ICU and postoperative day #6 from the original
surgery, the patient's temperature is 101.1 T-max, current
was 95.8. He was sinus tach at 106. He was 113/67 and had
sustained pressures as low as 89/57 overnight. Was satting
95%. Pulmonary artery pressure was 34/14. His CVP was 15.
His gas was 7.11,39, 271,13 -16. He was on AC 100 percent,
tidal volume was 650, rate of 25, PEEP of 5. The patient is
making minimal urine output. His white count was 7.5. His
hematocrit was 38. His lactic acidosis had come down from 9.7
to 7.6. Discussion was that the patient would need more
volume for resuscitation, add fluconazole, and given albumin.
Also we would give some bicarb for the pressors to be more
effective as the patient's pH was low. Cardiac, check enzymes
and attempt to wean Levophed when able.
On [**4-20**], postoperative day #7, and take back postoperative
day #1, the patient was on vancomycin, levofloxacin, Flagyl,
and fluconazole. His Apache score was described as 32. His
FIO2 was weaned and he was considered to be in sepsis. His
needle was weaned to off and Xigris drip was started. The
patient was positive 24 liters. Assessment was that the
patient was in septic shock and was being aggressively volume
resuscitated. On [**2179-4-20**], the patient was prepped and
draped and additional large-bore access was performed. A
right subclavian Cordis catheter was placed with Seldinger
technique without difficulty. The line was secured in place.
The patient tolerated procedure well. No pneumothorax after
chest x-ray. On [**2179-4-20**], the patient was taken back to
the operating room again, surgeon, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2819**] with Dr.
[**Last Name (STitle) **] as well, and Dr. [**First Name (STitle) **] was the chief resident.
Preoperative diagnosis and anastomotic leakage with sepsis an
open abdomen. Postoperative diagnosis was anastomotic
lesion, with sepsis, open abdomen with a necrotic ascending
colon and patchy ischemia of the small bowel. Procedure
performed was an exploratory laparotomy and completion total
colectomy, abdominal washout, omentectomy, and end ileostomy
creation. Please see operative dictation. Condition was
described as guarded.
On [**2179-4-20**], at 3:00 p.m. Dr. [**First Name (STitle) 2819**] had a discussion with
family about DNR/DNI status and it was agreed upon that the
patient would not be shocked or have chest compressions. On
[**2179-4-21**], Dr. [**First Name (STitle) 2819**], surgery staff, described the
condition as continued to deteriorate. He described him as
oliguric, renal failure, and increasingly having a need for
fluid requirement with a lactic acidosis. The patient
continued to deteriorate from a septic shock due to the leak
from his anastomosis characterized by overwhelming sepsis,
metabolic lactic acidosis, respiratory failure, renal
failure, and the patient's metabolic acidosis could no longer
be compensated despite bicarb drips and boluses. The patient
suddenly around 11:00 a.m. became asystolic. Per family's
wishes no DC cardioversion or compressions were initiated and
the patient was pronounced. The medical examiner was
contact[**Name (NI) **] in regards to potential postmortem examination.
However, this was declined. The patient died on [**2179-4-21**].
DIAGNOSIS: Sepsis, profound metabolic acidosis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 26005**]
Dictated By:[**Last Name (NamePattern1) 7823**]
MEDQUIST36
D: [**2179-5-5**] 18:08:27
T: [**2179-5-7**] 14:26:55
Job#: [**Job Number 58919**]
|
[
"401.9",
"441.4",
"785.52",
"427.5",
"997.4",
"557.0",
"788.37",
"518.81",
"153.3",
"599.7",
"038.8",
"427.31",
"584.9",
"562.11",
"995.92",
"567.2",
"600.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"45.73",
"46.01",
"00.11",
"45.24",
"46.11",
"54.4",
"38.93",
"99.04",
"45.76",
"89.64",
"96.04",
"00.17",
"45.75",
"38.91",
"96.71",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,721
| 149,001
|
23697
|
Discharge summary
|
report
|
Admission Date: [**2117-5-21**] Discharge Date: [**2117-5-26**]
Date of Birth: [**2056-6-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Sub glottic stenosis
Major Surgical or Invasive Procedure:
rigid bronchoscopy
History of Present Illness:
HPI:
60YO f with CRI, obesity/hypoventilation syndrome s/p trach,
HTN, type II DM who has tracheal stenosis and presents for IP
intervention.
Pt had bronchoscopy done at [**Hospital6 6689**] [**5-20**]/ with
significant subglottic stenosis with almost complete
obliteration of the true vocal cord area (unable to pass
bronchoscope through this area). Also noted was significant
posterior pharyngeal tissue collapse and just distal to the
bottom of the trach tube there was obvious granulation tissue
occluding the orifice about 50%.
Pt says that she had URI symptoms in the past week but no
fever/chills. She has required regular suctioning for secretions
She notes that 5 times in the past there has been blood with
suctioning but that this has not occurred in about 5 days. Pt
notes left leg pain that has been exacerbated by the ambulance
ride. She usually takes tylenol for this.
ROS; -SOB -CP - h/a -n/v/d - BRBPR
LABS: see below
CXR:
Past Medical History:
PMH:
recent stay at [**Hospital6 6689**] for hypercarbic
respiratory failure, treated with zosyn. [**Date range (1) 32718**]
tracheal stenoisis
CRI
obesity/hypoventilation syndrome
sleep apnea
s/p tracheostomy (approximately 16 years ago in [**Male First Name (un) 1056**] when
pt had cardiopulmonary arrest
HTN
TYPE II DM
hyperlipidemia
hypothyroidism
s/p cholecystectomy
Social History:
SH: sons live in [**Name (NI) 6691**]
-tob -etoh
Physical Exam:
PE: morbidly obese, comfortable
VS: 99.5 70 (61-83) 127/67 100 % AC 600X12/PEEP 5 40%
HEENT: EOMI , anicteric, mildly dry MM
neck: supple, JVP difficult to appreciate [**3-10**] habitus
lungs: CTA, -rales -wheezes. decreased BS
heart: RRR - murmurs
abd: soft NT markedly obese, organomegaly cannot be appreciated
ext: -e/c/c
neuro: CN intact
Pertinent Results:
[**2117-5-21**] 06:55PM WBC-6.3 RBC-3.60* HGB-11.1* HCT-32.0* MCV-89
MCH-30.8 MCHC-34.6 RDW-14.1
[**2117-5-21**] 06:55PM NEUTS-52.8 LYMPHS-39.4 MONOS-4.8 EOS-2.5
BASOS-0.5
[**2117-5-21**] 06:55PM PLT COUNT-225
[**2117-5-21**] 06:55PM PT-13.5 PTT-24.7 INR(PT)-1.2
[**2117-5-21**] 06:00PM TYPE-[**Last Name (un) **] TEMP-37.3 PH-7.44 COMMENTS-GREEN TOP
[**2117-5-21**] 06:00PM LACTATE-2.1*
[**2117-5-21**] 06:00PM freeCa-1.12
[**2117-5-21**] 05:30PM GLUCOSE-92 UREA N-25* CREAT-1.7* SODIUM-141
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-30* ANION GAP-13
[**2117-5-21**] 05:30PM CALCIUM-8.8 PHOSPHATE-3.0 MAGNESIUM-1.7
IRON-30
[**2117-5-21**] 05:30PM calTIBC-198* VIT B12-570 FOLATE-11.0
FERRITIN-223* TRF-152*
[**2117-5-21**] 05:30PM TSH-2.0
*
[**2117-5-22**] 10:32AM BLOOD Type-ART Tidal V-600 PEEP-5 FiO2-100
pO2-136* pCO2-37 pH-7.49* calHCO3-29 Base XS-5 AADO2-571 REQ
O2-90 Intubat-INTUBATED Vent-CONTROLLED
*
CT OF THE CHEST AND TRACHEA WITHOUT INTRAVENOUS CONTRAST:
Assessment of the airways demonstrates a high-grade subglottic
stenosis, just above the insertion point of the tracheostomy
tube. At this level, there is a near pinpoint diameter of the
airway lumen. There is associated soft tissue thickening around
the airway with probable proximal extension of the narrowing to
the glottis. The stenosis also appears to extend along most of
the length of the tracheostomy tube, although grading of the
stenosis is difficult due to collapse of the airway around the
tubing. Assessment of this portion of the airway is also
difficult due to a component of expiratory phase in this scan.
Below the tracheostomy tube, the distal trachea returns to a
normal caliber. Dynamic airway images demonstrates
bronchomalacic changes involving the lobar and segmental bronchi
and to a lesser extent the main stem bronchi. Note is also made
of an unusual geometry of the insertion of the tracheostomy tube
with a rather lateral orientation, entering from the right side.
Assessment of the lungs demonstrates minor linear opacities in
the right lung consistent with dependent atelectasis or
scarring. A calcified pleural plaque is noted along the left
posterior diaphragm. There are no confluent areas of
consolidation or effusions. The heart, pericardium, and great
vessels are unremarkable. There is a left-sided PICC line
present with the tip terminating in the central portion of the
left brachiocephalic vein as it enters the SVC. There are no
pathologically-enlarged areas of adenopathy. The visualized
portions of the upper abdomen are remarkable for a small hiatal
hernia and evidence of prior cholecystectomy. The osseous
structures demonstrate no suspicious lytic or sclerotic lesions.
IMPRESSION:
1. High-grade subglottic stenosis with pinpoint area of the
airway just above the insertion of the tracheostomy tube. The
circumferential thickening and narrowing appears to extend
proximally to the glottic region and distally along most of the
course of the tracheostomy tube.
2. Bronchomalacic changes involving the lobar and segmental
bronchi and to a lesser extent the main stem bronchi
bilaterally.
3. Minor linear atelectasis or scarring in the right lung.
ADDENDUM:
Multiplanar and 3d images are somewhat limited by motion and
indwelling tube. They confirm stenosis and malacia.
*
IMPRESSION: Successful placement of a 45 cm total PICC line with
the tip in the left brachiocephalic vein, ready for use
*
AP SEMI-UPRIGHT VIEW OF THE CHEST: The study is limited
secondary to underpenetration. The patient is rotated to the
right. There is bibasilar atelectasis. No evidence of
pneumothorax. A tracheostomy tube is demonstrated with a PICC
line, the distal tip of which is not well seen but appears to
terminate in the left brachiocephalic vein.
IMPRESSION: Limited study secondary to underpenetration. Likely
bibasilar atelectasis.
Brief Hospital Course:
A/P
1) Resp; Pt is on vent at night and trach mask during the day
and did very well at normal settings. Airway is most pressing
issue given marked sub-glottal stenosis. Pt transferred to
[**Hospital1 18**] for planned intervention by IP with hopes of revision and
laser ablation. Findings below:
Patient has a long tracheostomy tube approximately
extending 3 to 4 cartilaginous rings above the carina.
There is evidence of very severe tracheomalacia with
evidence of severe anterior motion of the posterior
tracheal wall with just simple suction from the
bronchoscope, and almost complete obstruction of the
distal trachea. There was also evidence of severe
bronchomalacia. Because of the patient's body habitus, the
patient is ventilator-dependent at night and she already
has a long tracheostomy tube and no further interventions
were done.
IP discussed with Pt's primary physician, [**Name10 (NameIs) **] [**Last Name (STitle) 14502**], who agreed
to accept Pt back to rehab post intervention. Pt to return to
[**Hospital **] Rehab. Pt to continue with evening Ventilation:
AC/600/12/0.40/5.
2) ID- On admission Pt with possible tracheo-bronchitis, given
increased secretions. Pt covered with levo empirically to
reduce secretions. Sputum culture negative, CXR clear and Pt
remained afebrile without leukocytosis. Antibiotics
subsequently discontinued.
3) TYPE II [**Name (NI) 1568**] Pt continued on normal regimen of Glargine 10
units qhs, glipizide 10 mg [**Hospital1 **] and covered with a Humalog
sliding scale. Pt to continue on same regimen upon discharge.
5) CRI: Cr stable near baseline per outside labs.
6) CVS: Pt with probable CAD remained on outpatient regimen of
ASA and Statin. Unclear as to EF but no evidence of depressed
function so ACEIs not started but should be considered by PCP.
[**Name10 (NameIs) **] remained on outpt CCB for HTN and remained under good control
during hospitalization.
7) Hypothyroid- Continued thyroid hormone replacement
8) Prophylaxis: Pt maintained on PPI and heparin SC.
9) IV: PICC placed by IR without complication as Pt had poor
access.
10) Dispo: Discharged from MICU to Rehab
Medications on Admission:
meds;
lipitor 20mg PO QD
levothyroxine 0.05mg QD
glipizide 10mg PO BID
aspirin 81mg PO QD
Pumicort
Ventoin neb 0.5 ml Q4h
nifedipine XL 60mg PO QD
lantus 10U SC QPM
Humalog SS
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
(5000) units
units Injection TID (3 times a day).
9. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
11. medication
please cover with insulin sliding scale QACHS.
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70 mg/dL [**2-7**] amp D50 [**2-7**] amp D50 [**2-7**] amp D50 [**2-7**] amp D50
71-150 mg/dL 0 Units 0 Units 0 Units 0 Units
151-200 mg/dL 2 Units 2 Units 2 Units 2 Units
201-250 mg/dL 4 Units 4 Units 4 Units 4 Units
251-300 mg/dL 6 Units 6 Units 6 Units 6 Units
301-350 mg/dL 8 Units 8 Units 8 Units 8 Units
351-400 mg/dL 10 Units 10 Units 10 Units 10 Units
Instructons for NPO Patients: 1/2 dose glargine
12. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] NURSING HOME
Discharge Diagnosis:
primary:
tracheal malacia
obesity-hypoventilation syndrome
secondary:
Htn
DM2
hypothyroid
hyperlipid
Discharge Condition:
stable
Discharge Instructions:
please call your PCP or return to Ed if you have problems
breathing, fever or worsening sputum production; or any other
concerns.
please take all medications as prescribed.
please make all follow up appointments.
Followup Instructions:
please call your PCP Dr [**Last Name (STitle) 14502**] ([**0-0-**]) and make an
appointment to be seen in one week.
please call your primary pulmonary doctor and make a follow up
appointment.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"278.00",
"244.9",
"466.0",
"272.0",
"518.83",
"518.0",
"753.10",
"780.57",
"593.9",
"V44.0",
"414.01",
"401.9",
"786.09",
"478.74"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"32.01",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10263, 10334
|
6066, 8252
|
342, 363
|
10480, 10488
|
2184, 6043
|
10751, 11083
|
8479, 10240
|
10355, 10459
|
8278, 8456
|
10512, 10728
|
1816, 2165
|
282, 304
|
391, 1336
|
1358, 1734
|
1750, 1801
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,412
| 130,271
|
2110
|
Discharge summary
|
report
|
Admission Date: [**2111-1-31**] Discharge Date: [**2111-2-5**]
Date of Birth: [**2055-7-21**] Sex: M
Service: MEDICINE
Allergies:
Crixivan
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Fevers, night sweats, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
55 M with AIDS, most recent CD4 count 45 on [**First Name3 (LF) 2775**], VL 1,560 in
OMR (100,000 per pt), h/o PCP, [**Name10 (NameIs) **], and [**Name10 (NameIs) 1074**] pancreatitis who
presents with 1 wk fevers, chills, night sweats and two days
diarrhea and cough. Pt reports fevers 102.6 for 5 days as well
as fatigue. Seen in clinic [**1-27**] for fever, and labs drawn
(including blood cultures, urine culture, CBC, LFT's, ESR). At
that time his physical exam was unremarkable, and O2 sat 98%
(resting). The blood work showed a decrease in Hb from 15.3 to
13.8, and an ESR 109, but blood/urine cxs NGTD. He was sent to
[**Hospital1 18**] for rehydration, stool for culture, O and P, [**Hospital1 **], repeat
CBC, also concern for PCP/TB/lymphoma.
.
In [**Hospital1 18**] ED, febrile to 104, tachy 90s-100s, given 2L IVF after
which pressures dropped to 80s-90s systolic, lactate 1.8, cr at
baseline. Received additional 3.5L IVF with SBP rise to 120s, HR
80s. Received levaquin for diarrhea and respiratory symptoms
(cough). He defervesced to 100.3 in the ED. Also had nausea but
no vomiting, no headache. 20-g pIV, 16-g left. Admitted to MICU
for rule out TB and GI infectious work.
Past Medical History:
HIV (diagnosed in 8/94 via PCP): CD4 count of 14 in [**1-15**]
History of PCP, [**Name10 (NameIs) 11395**], [**Doctor First Name **], [**Doctor First Name 1074**] retinitis, [**Doctor First Name 1074**] pancreatitis,
enterobacter sepsis, wasting syndrome
HIV neuropathy
Chronic renal insufficiency
Hepatitis B
Nephrolithiasis [**1-10**] crixivan
PTX [**1-10**] pentamidine
Depression
PSH: Right nephrectomy (kidney donor for brother) [**2079**]
Retinal implants bilat (10 yrs ago)
Social History:
He lives with his girlfriend [**Name (NI) **] in [**Location (un) 686**], MA in his
house with his two daughters and his grandchildren. Works as
substance abuse counselor for drug abusers with HIV/AIDS. His
girlfriend came to visit him in the hospital. He has not used
drugs, tobacco, or alcohol for 18 years.
Drugs: None currently. Heroin 2g/d IV from age 14-38 (quit 18
years ago). Cocaine 0.5 g/d (speedball) IV from age 21-38.
Tob: 2 packs per day for 20 years (40 pack-years), quit 18 years
ago
Alc: 1 pint/week, quit 18 years ago
Family History:
Father killed, died of head trauma at age 25. Mother died of
stomach CA at age 62. 2 brothers deceased from DM (one of which
had juvenile DM and received a kidney from pt). 1 brother alive
at 57 with DM.
Physical Exam:
PE on admission to floor [**2111-2-3**]:
T99.5 BP116/70 HR 82 RR 18 98%ra
Gen - NAD, A/Ox3, lying in bed, conversant, cooperative
HEENT - MMM, OP benign.
NECK - no posterior/anterior LAD, no JVD appreciated.
CV - RRR, no murmurs or rubs appreciated.
LUNGS - crackles heard at lung bases bilaterally, R>L with
occasional end-expiratory wheeze, good air movement bilaterally,
ABD - NABS, soft, non-tender, non-distended. No organomegaly
appreciated.
EXT - no edema. 2+ dorsalis pedis, posterior tibial pulses
bilaterally
SKIN: No rashes/lesions, ecchymoses.
NEURO - A&Ox3. Able to follow commands and answer questions
appropriately.
Pertinent Results:
[**2111-1-31**] 02:55PM BLOOD WBC-5.2 RBC-3.64* Hgb-12.6* Hct-34.0*
MCV-93# MCH-34.7* MCHC-37.1* RDW-15.7* Plt Ct-313
[**2111-2-5**] 07:20AM BLOOD WBC-4.6 RBC-3.36* Hgb-11.3* Hct-32.2*
MCV-96 MCH-33.7* MCHC-35.2* RDW-15.8* Plt Ct-359
[**2111-1-31**] 02:55PM BLOOD Neuts-68.3 Lymphs-24.7 Monos-3.4 Eos-2.7
Baso-0.8
[**2111-2-4**] 07:25AM BLOOD Neuts-74.9* Lymphs-20.4 Monos-2.2 Eos-2.3
Baso-0.1
[**2111-2-5**] 07:20AM BLOOD PT-12.5 PTT-30.7 INR(PT)-1.1
[**2111-2-2**] 07:30PM BLOOD QG6PD-9.6
[**2111-2-3**] 11:55AM BLOOD Ret Aut-1.0*
[**2111-1-31**] 02:55PM BLOOD Glucose-127* UreaN-27* Creat-3.4* Na-133
K-4.9 Cl-103 HCO3-20* AnGap-15
[**2111-2-5**] 07:20AM BLOOD Glucose-93 UreaN-22* Creat-2.2* Na-130*
K-4.4 Cl-106 HCO3-15* AnGap-13
[**2111-1-31**] 02:55PM BLOOD ALT-35 AST-43* CK(CPK)-141 AlkPhos-151*
TotBili-2.8*
[**2111-2-5**] 07:20AM BLOOD ALT-31 AST-34 LD(LDH)-324* AlkPhos-174*
TotBili-0.9
[**2111-1-31**] 02:55PM BLOOD Lipase-65*
[**2111-1-31**] 02:55PM BLOOD cTropnT-0.01
[**2111-1-31**] 02:55PM BLOOD CK-MB-3
[**2111-1-31**] 02:55PM BLOOD Albumin-3.3* Calcium-8.4 Phos-2.2* Mg-2.0
[**2111-2-5**] 07:20AM BLOOD Albumin-3.0* Calcium-8.2* Phos-4.5 Mg-2.4
[**2111-2-2**] 07:30PM BLOOD TotProt-5.6*
[**2111-2-3**] 11:55AM BLOOD Hapto-<20*
[**2111-2-3**] 03:37AM BLOOD calTIBC-138* VitB12-284 Folate-6.8
Ferritn-1492* TRF-106*
[**2111-2-3**] 03:37AM BLOOD Osmolal-272*
[**2111-2-2**] 07:30PM BLOOD PEP-NO SPECIFI
[**2111-1-31**] 03:02PM BLOOD Lactate-1.8
.
Imaging:
.
ECG [**2111-2-1**]: Sinus rhythm with slowing of the rate as compared
with prior tracing of [**2111-1-31**]. Otherwise, no No diagnostic
interval change.
.
CXR [**2111-2-1**]: Progressive distention of mediastinal veins suggest
volume overload also responsible for increased cardiac diameter
and pulmonary vascular engorgement, though there is no clear
pulmonary edema. Bibasilar infrahilar opacification is
attributable to atelectasis. Pleural effusion if present, is not
appreciable. No pneumothorax.
.
CT chest/abd/pelvis [**2111-2-1**]: CT CHEST WITHOUT INTRAVENOUS
CONTRAST: Mediastinal and hilar lymph nodes are numerous, but do
not meet CT criteria for pathologic enlargement. There are no
pathologically enlarged axillary nodes. A right axillary node
that was previously enlarged in [**2107**], has decreased in size. A
small cluster of epicardial nodes measures up to 8 mm in short
axis dimension and is increased in size. Apart from coronary
artery calcifications, the heart and pericardium, and central
airways, appear unremarkable. Linear atelectasis or scarring is
present in the right lower lobe, with additional areas of
dependent atelectasis bilaterally. In the left lower lobe, a
3-mm noncalcified nodule is seen (2:39). There is a 4-mm nodule
in the right middle lobe (2:28) with additional tiny
noncalcified nodules seen bilaterally in subpleural location
(2:24, 26). In [**2107**], innumerable nodules were present
bilaterally, a pattern that has nearly entirely resolved. No
areas of consolidation or ground- glass opacification are
identified. There is no pleural or pericardial effusion.
CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Allowing for
non-contrast technique, the liver, pancreas, and adrenal glands
appear unremarkable. There is splenomegaly, with the spleen
measuring 15 cm. There has been prior right nephrectomy with
multiple surgical clips in the renal fossa. No masses are
identified in the nephrectomy bed. A small linear density,
likely calcified, could be postoperative (2:67). The left kidney
appears unremarkable. Numerous enlarged lymph nodes are present
about the lesser curvature, celiac axis, and in the periportal
and peripancreatic retroperitoneum. The largest individual node
measures 2.9 x 1.8 cm (2:52). Review of previous CT of [**11-9**], [**2107**], shows that these nodes have increased uniformly in size
and number. There is no evidence of bowel obstruction. The
appendix is normal. No ascites or free intraperitoneal air.
CT PELVIS WITHOUT INTRAVENOUS CONTRAST: The bladder, distal
ureters, prostate and seminal vesicles, rectum and sigmoid colon
appear unremarkable. There are no pathologically enlarged pelvic
or inguinal lymph nodes.
BONE WINDOWS: No lesions worrisome for osseous metastatic
disease are identified.
IMPRESSION:
1. Bilateral subcentimeter pulmonary nodules could relate to an
infectious or inflammatory process, but are much improved from
prior CT of [**2107**]. No pulmonary consolidation to suggest
pneumonia.
2. Progression of adenopathy in the epicardium, upper abdominal
retroperitoneum and epigastrium. Differential diagnosis includes
infectious etiology or lymphoproliferative disorder.
3. Splenomegaly, increased from [**2108-11-8**].
.
Labs still pending are acid fast culture, HISTOPLASMA ANTIGEN,
EBV PCR, ASPERGILLUS GALACTOMANNAN ANTIGEN, PARVOVIRUS B19
ANTIBODIES (IGG & IGM), COCCIDIOIDES ANTIBODY, Bartonella
hensalae/[**Last Name (un) 7570**] IgG/IgM Antibody Panel
Pertinent negative results are listed below:
-CXR negative
-UA clear
-cryptococcal antigen negative
-pneumocystic jirovecii carinii negative
-cyclospora negative
-cryptosporidium negative
-giardia negative
-O&P negative
-c. diff negative
-acid fast smear - negative x3
-[**Last Name (un) 1074**] not detected
-Legionella urinary antigen negative
Brief Hospital Course:
55yoM with AIDS, CD4 count 45 on [**Last Name (un) 2775**], last viral load 1,560
p/w fevers, chills, night sweats, cough, and diarrhea, admitted
to MICU for diarrha work-up and rule out TB.
.
1. Fevers, diarrhea, night sweats: Pt has been on [**Last Name (un) 2775**] with
most recent CD4 count in [**2110-12-9**] of 48 and VL 1,560. He
has a history of multiple AIDS-defining illnesses including PCP,
[**Name10 (NameIs) 1074**], and [**Doctor First Name **]. He came in with a complaint of approximately 2
weeks of fevers & diarrhea. In [**Hospital1 18**] ED, he was febrile to 104,
tachycardic in the 90s-100s. He was given 2L IVF after which
his pressures dropped to 80s-90s systolic. Lactate was 1.8 and
Cr at baseline. He received an additional 3.5L IVF with SBP rise
to 120s, HR 80s. Received levaquin for diarrhea and respiratory
symptoms (cough). He defervesced to 100.3 in the ED. Also had
nausea but no vomiting, no headache. He was admitted to MICU for
rule out TB and GI infectious work up. CXR was negative. CT
scan of the chest, abdomen, and pelvis revealed progression of
adenopathy in the epicardium, upper abdominal retroperitoneum
and epigastrium. Differential diagnosis radiologically included
infectious etiology or lymphoproliferative disorder.
.
Given intermittent [**Name (NI) 2775**] (Pt reports history of non-compliance
with medication) and prolonged depressed CD4 counts, there was
concern for initial manifestation of AIDS-defining lymphoma or
malignancy, or TB or other opportunistic infection. Stool
cultures, afb smears, PCP smears, ova and parasite evaluations
were all performed. Infectious disease team followed the
patient throughout his course. Labs still pending are acid fast
culture, HISTOPLASMA ANTIGEN, EBV PCR, ASPERGILLUS
GALACTOMANNAN ANTIGEN, PARVOVIRUS B19 ANTIBODIES (IGG & IGM),
COCCIDIOIDES ANTIBODY, Bartonella hensalae/[**Last Name (un) 7570**] IgG/IgM
Antibody Panel
Pertinent negative results are listed below:
-CXR negative
-UA clear
-cryptococcal antigen negative
-pneumocystic jirovecii carinii negative
-cyclospora negative
-cryptosporidium negative
-giardia negative
-O&P negative
-c. diff negative
-acid fast smear - negative x3
-[**Last Name (un) 1074**] not detected
-Legionella urinary antigen negative
.
2. Renal failure. Pt has chronic renal failure. He has one
kidney; the other kidney was donated to his brother >20 yrs
prior. His baseline cr ranges from about 2-2.5, with worsening
over previous 2 yrs. UA showed significant proteinuria, no
whites. His urine output was maintained. Renal U/S [**6-15**] ruled
out obstructive uropathy. Possible causes, as per outpatient
notes include: FSGS [**1-10**] HIV, nephropathy, prior IV heroin use,
renal ablation, FSGS [**1-10**] kidney donation [**2079**], membranous
nephropathy [**1-10**] hepatitis B infection.
.
3. HIV - Patient has a history of non-compliance with his
medications. He reports he has been taking his [**Month/Day (2) 2775**] for
previous 2 months and for 1 out of the last 1.5 years. While in
the hospital, patient was maintained on his outpatient [**Month/Day (2) 2775**]
therapy and Bactrim prophylaxis for PCP. [**Name10 (NameIs) 11396**] for [**Name10 (NameIs) **]
prophylaxis was discussed, given patient's most recent CD4 count
<50. It was decided that this should be held until blood
cultures return negative. It should be started as an outpatient
by his primary care physician when all cultures are negative.
.
4. Hyponatremia: Sodium 129. Etiologies include hyervolemic,
hypovolemic or euvolemic hyponatremia. Pt has little evidence
of third spacing to suggest hypervolemia with decreased
circulating volume: No dependent edema. No ascites. Pt does
have some scattered crackles over lung bases bilaterally. Most
likely etiology is hypovolemic hyponatremia. Causes include
renal loss and extra-renal losses. Expect Una>20 and FEna>1%
with renal etiology. Una 89, Fena calculated at 2.85%, both
consistent with renal loss. Given Pt's HIV history with chronic
renal failure, HIV nephropathy likely. GI losses could also be
contributing given Pt's recent history of diarrhea (expect
Una<10 and Fena<1% with GI etiology). Patients sodium corrected
with normal saline.
.
5. Anemia: Patient's Hct ranged from 28-31. MCV was normal,
and iron studies revealed low iron (18), high TIBC (138), high
ferritin (1492). Low iron with high ferritin with a normocytic
anemia is consistent with anemia of chronic disease.
Haptoglobin <20 and retic count 1.0. Low haptoglobin suggests
possible hemolytic anemia. Low retic count suggests there might
be a hematologic component of the anemia. Differential did not
show schistocytes. Etiology can be further pursued by
outpatient team.
.
6. Metabolic Acidosis: Patient's bicarbonate was 14 with a
normal anion gap, consistent with a Non anion gap acidosis.
Most likely etiologies are GI losses (given Pt's h/o diarrhea)
and RTA (either defective distal H+ secretion or decresed
proximal bicarb reabsorption). Acidosis corrected with normal
saline.
.
Full code during admission and time of discharge
.
The discharge summary was discussed and reviewed in full by
medical resident [**First Name4 (NamePattern1) 803**] [**Last Name (NamePattern1) **], MD.
Medications on Admission:
Combivir 1 tab po bid
Ritonavir 100 mg po daily
Atazanavir 300 mg po daily
Bactrim 1 tab 3x/week
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
2. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
3. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet
PO BID (2 times a day).
4. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
1. Viral infection
2. Immune reconstitution syndrome
3. lymphoproliferative disorder
Secondary Diagnosis:
AIDS
HIV nephropathy
Discharge Condition:
Good condition. Vital signs stable. Able to tolerate regular
diet and ambulate independently.
Discharge Instructions:
You presented to the Emergency Department with fevers, night
sweats, and diarrhea. You were admitted to the Medical
Intensive care unit to manage your fever and shaking. You were
given Tylenol and Demerol to control your fever. You were
maintained on your outpatient medications including your [**Last Name (NamePattern1) 2775**]
(Combivir, Atazanavir, and Ritonavir)and Bactrim prophylaxis.
Over the course of 4 days, your night sweats, fever, and
diarrhea resolved.
.
To determine the cause of your presentation, multiple tests for
infection were sent. You were put on respiratory precautions
until we were able to rule out tuberculosis. All of these
tests, including the test for tuberculosis (TB), came back
negative. However, there are a few tests for infection that are
still pending. These should be followed up by your primary care
provider.
.
You had a CT scan of your chest, abdomen, and pelvis. This
showed enlargement of lymph nodes in the epicardium (around the
heart), in the upper abdominal retroperitoneum and in the
epigastrium (above the stomach). Because we did not find an
infectious cause of your symptoms, this was concerning for a
lymphoproliferative disorder. To further test this, we talked
to you about doing a lymph node biopsy. Because the affected
lymph nodes are not located superficially, this would require an
invasive procedure. This can be further pursued on an
outpatient basis.
.
Another possible cause of your symptoms is Immune Reconstitution
Inflammatory Syndrome. This can occur in patients who initiate
[**Last Name (NamePattern1) 2775**] in the setting of a low CD4count (below 50cell/microL).
As the immune cells are stimulated to grow by the antiretroviral
medication, patients can develop a worsening of clinical
symptoms related to an opportunistic infection like a virus.
.
Please take all of your medications as prescribed.
.
Please keep all of your follow-up appointments.
.
If you develop further fevers, night sweats, diarrhea, or any
other symptoms that are concerning to you, please return to the
Emergency Department for evaluation.
Followup Instructions:
PCP: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] at [**Hospital **] Community Health Center on
Friday, [**2111-2-13**] at 10:00 am. [**Telephone/Fax (1) 11397**]
.
Ophtho: Please schedule follow-up appointment as discussed.
Completed by:[**2111-2-8**]
|
[
"357.4",
"238.79",
"276.51",
"042",
"285.21",
"276.1",
"583.81",
"585.9",
"070.32",
"276.2",
"079.99"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14613, 14619
|
8791, 14059
|
299, 305
|
14809, 14907
|
3483, 8768
|
17055, 17349
|
2605, 2814
|
14206, 14590
|
14640, 14744
|
14085, 14183
|
14931, 17032
|
2829, 3464
|
229, 261
|
333, 1526
|
14765, 14788
|
1548, 2030
|
2046, 2589
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,634
| 136,812
|
7529
|
Discharge summary
|
report
|
Admission Date: [**2106-4-14**] Discharge Date: [**2106-4-21**]
Service: CME
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **] year old female
patient with a history of chronic obstructive pulmonary
disease, coronary artery disease, hypertension and
cerebrovascular accident who presents with shortness of
breath and cough. The patient states that she has no idea
why she was brought to the Emergency Department and denies
any symptoms. She reports an occasional nonproductive cough
that she has had "for years" and feels that she has been
experiencing alternating chills and feeling hot. A progress
note in the patient's chart from her [**Hospital3 **] facility
indicates that the patient has had shortness of breath and
cough for one day with chills but no fever. She has been
recently evaluated as an outpatient for bradycardia. She was
seen by her cardiologist, Dr. [**Last Name (STitle) 27521**] and had a Holter
monitor on [**2106-4-2**], that showed first degree AV block with a
rate that ranged between 35 to 53 beats per minute.
In the Emergency Department, the patient was given nebulizer
treatment, started on antibiotics for presumed chronic
obstructive pulmonary disease exacerbation. She was noted to
have lateral ST depressions and given Aspirin. She continues
to deny chest pain, palpitations, shortness of breath,
fevers, nausea, vomiting, abdominal pain, bright red blood
per rectum, melena, dysuria, urinary frequency and urgency.
PAST MEDICAL HISTORY: Chronic obstructive pulmonary disease
with asthmatic component.
Hypothyroidism.
Gastroenteritis.
Anxiety.
Insomnia.
Hypertension.
Osteoporosis.
History of cerebrovascular accident with residual right sided
weakness.
Scoliosis.
Coronary artery disease.
History of kidney mass.
History of lower gastrointestinal bleed.
Status post total abdominal hysterectomy, bilateral salpingo-
oophorectomy.
Left cataract.
Bradycardia followed by outpatient cardiologist with a Holter
monitor on [**2106-4-2**], with first degree AV block and a heart
rate ranging between 35 to 53 beats per minute.
ALLERGIES: Penicillin, Erythromycin, Valium, Compazine,
Demerol, Percodan.
MEDICATIONS ON ADMISSION:
1. Levothyroxine 50 mcg p.o. once daily.
2. Combivent two puffs four times a day.
3. Flovent two puffs four times a day.
4. Protonix 40 mg once daily.
5. Lisinopril 5 mg p.o. once daily.
6. Norvasc 5 mg twice a day.
7. Lasix 40 mg once daily.
8. Senna one once daily.
9. Dulcolax 10 mg once daily p.r.n.
10. TUMS 500 mg twice a day.
SOCIAL HISTORY: The patient lives at [**Location (un) 5481**] in
[**Hospital3 **] section. She has a 24 hour caregiver. The
patient quit smoking fifty years ago but previously was a
heavy smoker, though states that she never inhaled. The
patient denies use of alcohol or drugs.
PHYSICAL EXAMINATION: Temperature 98.1, blood pressure
144/38, heart rate 41, respiratory rate 20, oxygen saturation
94 percent in room air and 96 percent on three liters. In
general, a well appearing elderly female in no acute
distress. Skin is warm and dry with decreased skin turgor.
Head, eyes, ears, nose and throat examination - The pupils
are equal, round and reactive to light and accommodation.
Extraocular movements are intact. Dry mucous membranes. The
oropharynx is clear. Neck is supple, full range of motion,
no jugular venous distension or lymphadenopathy. The heart
was bradycardic with regular rhythm, no murmurs, rubs or
gallops. Lungs - diffuse expiratory wheezes with bibasilar
rales, left over right. The abdomen revealed normoactive
bowel sounds, soft, nontender, nondistended. Rectal is
guaiac positive per Emergency Department. Extremities - no
cyanosis or clubbing, one plus bilateral lower extremity
edema with right worse than left. Neurologically, the
patient is awake, alert and oriented times three.
LABORATORY DATA: White blood cell count was 8.5 (80 percent
neutrophils, 13 percent lymphocytes), hematocrit 27.4,
platelet count 277,000. Sodium 133, potassium 4.8, chloride
94, bicarbonate 24, blood urea nitrogen 39, creatinine 2.0,
glucose 111. CK 152, CK MB 3.0, troponin 0.04. INR 1.1.
Chest x-ray showed equivocal retrocardiac opacity.
Electrocardiogram showed sinus bradycardia at 40 beats per
minute. First degree AV block with PR interval 220, left
axis deviation, right bundle branch block with a left
anterior fascicular block, 0.[**Street Address(2) 11725**] depressions in
V4 through V6.
HOSPITAL COURSE: Shortness of breath - Though the patient
denied shortness of breath on admission, a progress note from
[**Location (un) 5481**] nursing facility suggested that the patient had
been having shortness of breath and cough for approximately
one day with difficulty ambulating, needing to travel in a
wheelchair. The patient was afebrile on admission with a
normal white blood cell count but had significant wheezing
and rales on physical examination with a possible left lower
lobe opacity seen on chest x-ray. The etiology of the
patient's shortness of breath was considered a likely chronic
obstructive pulmonary disease exacerbation and the patient
was started on Albuterol and Atrovent nebulizers. The
patient was also started on Doxycycline given the concern for
pneumonia on chest x-ray. She was also continued on steroids
given evidence of severe airway obstruction. The patient's
shortness of breath was also considered possibly related to a
coronary event and she was admitted for rule out myocardial
infarction. The patient's enzymes were cycled and were
negative. The patient's electrocardiogram performed on
hospital day number two was concerning for 2:1 heart block
and the cardiology consult service was contact[**Name (NI) **] for
evaluation.
The patient was taken to the Coronary Care Unit late on
hospital day number two and received a temporary wire. The
following day the patient received a permanent dual chamber
rate responsive pacemaker. The patient was transferred back
to the general medicine service where she continued to
exhibit signs of chronic obstructive pulmonary disease
exacerbation and nebulizers, steroids and antibiotics were
continued. The patient's respiratory status improved
throughout the remainder of her hospitalization and oxygen
was eventually weaned. Once the patient was transferred out
of the Coronary Care Unit, she appeared to have an element of
heart failure in addition to her chronic obstructive
pulmonary disease. She was given 20 mg of intravenous Lasix
with impressive urine output and improvement in her overall
fluid status. The patient was eventually restarted on her
outpatient dose of Lasix once her renal function improved to
baseline and remained hemodynamically stable throughout the
remainder of her hospitalization.
Heart block - As noted previously, the patient's
electrocardiogram was significant for a 2:1 heart block and
cardiology consult service was contact[**Name (NI) **] for evaluation. The
patient received a temporary pacing wire on the evening of
hospital day number two and on hospital day number three
received a dual chamber pacemaker.
Renal - The patient was admitted with a creatinine of 1.8,
considered likely secondary to hypovolemia. Her calculated
fractional excretion of sodium was 0.13 percent suggesting a
prerenal cause. The patient's creatinine improved to 1.1
with hydration. Once the patient's creatinine had improved
to baseline, her Lasix and ace inhibitor were restarted and
the patient's creatinine was noted to be stable.
Gastrointestinal - The patient was admitted with a history of
gastrointestinal bleed with guaiac positive stools on
admission. Her hematocrit was noted to trend down after
transfusion of one unit of packed red blood cells on
admission. Given guaiac positive stools and her history of
gastrointestinal bleed in addition to use of steroids for
chronic obstructive pulmonary disease exacerbation, the
gastroenterology consult service was contact[**Name (NI) **]. The results
of that consultation and potential esophagogastroduodenoscopy
are pending at the time of dictation.
Hypertension - The patient had moderate control of her blood
pressure throughout her admission. Her calcium channel
blocker and ace inhibitor were continued.
Hematology - As noted previously, the patient's hematocrit
was noted to drop after transfusion with one unit of packed
red blood cells on admission. Given guaiac positive stools
and the patient's history of gastrointestinal bleed,
gastroenterology consult service was contact[**Name (NI) **] for possible
esophagogastroduodenoscopy and/or colonoscopy. The results
of this consultation are pending at the time of dictation.
The remainder of the [**Hospital 228**] hospital course, discharge
diagnoses, medications and follow-up will be dictated at the
time of discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 27522**]
Dictated By:[**Last Name (NamePattern1) 12325**]
MEDQUIST36
D: [**2106-4-19**] 11:24:17
T: [**2106-4-19**] 14:58:16
Job#: [**Job Number 27523**]
|
[
"244.9",
"276.5",
"427.89",
"438.89",
"280.0",
"491.21",
"486",
"729.89",
"426.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.83",
"37.72",
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2204, 2544
|
4497, 9120
|
2850, 4479
|
118, 1479
|
1502, 2178
|
2561, 2827
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,508
| 187,140
|
43326
|
Discharge summary
|
report
|
Admission Date: [**2112-9-2**] Discharge Date: [**2112-9-6**]
Date of Birth: [**2032-3-6**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
dysarthric speech & gait difficulties
Major Surgical or Invasive Procedure:
[**2112-9-2**]
1. Suboccipital craniotomy for resection of right cerebellar
metastases, opening greater than 5 cm, autologous
duraplasty using pericranial graft.
2. Right-sided frontal EVT placement.
History of Present Illness:
The patient is 80-year-old gentleman who was diagnosed with
stage IV [**Doctor Last Name 10834**] level V melanoma of the right nasolabial fold
in [**2108**]. He had a wide local excision completely excised with
residual superficial spreading melanoma.
His sentinel lymph nodes were negative. Routine chest x-ray in
[**2112-2-6**] showed multiple bilateral nodular opacities
measuring up to 1-2 cm. A left upper lobe wedge biopsy was
consistent with metastatic melanoma. A CT scan also showed a
10.5 mm pericarinal lymph node and MRI of the head showed two
metastatic lesions, one in the left frontal and one in the right
inferior frontal. He received SRS to both on [**2112-4-6**]. He
started on Temodar 75 mg per meters squared times six weeks and
two weeks off on [**2112-4-18**]. One month followup MRI on [**5-2**], [**2112**], showed resolution of the right frontal met to 50%
decrease of the left frontal met. Good response of lung mets on
[**2112-6-6**], torso CT. His second cycle of Temodar was
interrupted for diarrhea and then was restarted in the end of
[**Month (only) **]. On [**2112-8-25**], torso CT showed some progression of the
lung nodules. The abdominal and pelvic CT was negative for
disease. He is here for his five month post-radiation MRI. The
patient states that since last being seen, he has been having
some difficulties with double vision, unsteady gait, and some
incoordination. He denies any headaches, no nausea or vomiting.
He states that he has not noticed if he is veering to one side
more than the other. The diplopia has been for four days and his
imbalance has been for two weeks. He also thinks he might have
some slurred speech.
Past Medical History:
1. Atrial fibrillation, on anticoagulation.
2. Hypertension.
Surgical History:
1. Excision of the facial melanoma
2. Tonsillectomy.
Social History:
He never smoked. He drinks half a bottle of wine at night. He is
married. He has five children. His son [**Name (NI) **] is present today: he
is NP. He has seven grandchildren. He lives in [**Location 17927**]. He
used to work in the insurance business. He is retired now.
Family History:
No melanoma in his family. His father died of a stroke. He
believes his mother died of a stroke. His family history
knowledge is limited as his family was [**Doctor First Name **] Scientist and
did not seek medical attention.
Physical Exam:
PHYSICAL EXAMINATION:
VITAL SIGNS: His blood pressure is 126/74, pulse of 74,
respirations of 16, and temperature of 97.6.
GENERAL: He is alert, pleasant elderly gentleman, who looks
younger than his stated age.
CARDIOVASCULAR: The patient has a grade 2/6 systolic ejection
murmur heard best at the right upper sternal border.
LUNGS: Clear to auscultation bilaterally.
NEUROLOGIC: HEENT: Head was normocephalic and atraumatic.
Eyes, pupils equal, round, and reactive to light. Extraocular
movements were intact on the left, but he did have a mild right
sixth palsy. Visual fields are full. There was no nystagmus.
Funduscopic exam showed blurred disks bilaterally. Mouth, tongue
was midline. Palate elevates symmetrically. Neck was soft and
supple. Cranial nerves II through VII and IX through XII were
intact. Motor was [**6-9**] bilaterally, normal tone, and no drift.
Sensation was intact to light touch throughout. There was no
extinction to double simultaneous stimulation. Cerebellar: The
patient had some decrease in foot tapping on his right foot, but
this was subtle compared to the left. Other than that, he had
normal appendicular coordination. With gait, he did appear
actually to have a difficulty positioning his left foot somewhat
and not so much with the right. There was some unsteadiness of
the gait and he was unable to tandem, however, he was able to
toe and heel walk reasonably well.
Pertinent Results:
[**2112-9-2**] 02:21PM BLOOD WBC-8.6 RBC-3.26* Hgb-10.4* Hct-30.8*
MCV-95 MCH-31.8 MCHC-33.6 RDW-14.8 Plt Ct-171
[**2112-9-2**] 07:26AM BLOOD PT-13.1 PTT-23.8 INR(PT)-1.1
[**2112-9-2**] 02:21PM BLOOD Glucose-156* UreaN-26* Creat-1.0 Na-137
K-3.7 Cl-98 HCO3-26 AnGap-17
[**2112-9-2**] 02:21PM BLOOD Calcium-9.3 Phos-3.9 Mg-1.5*
CT HEAD W/O CONTRAST 0729/05 6:19 pm
CT HEAD WITHOUT IV CONTRAST: The patient has undergone
suboccipital craniotomy with an osseous defect, parenchymal
defect, pneumocephalus, and small amount of adjacent hemorrhage.
Small amount of pneumocephalus is seen layering anteriorly in
the anterior and middle cranial fossae. There has been interval
placement of a right frontal intraventricular catheter, which
terminates near the right-sided foramen of [**Last Name (un) 2044**]. There is a
small amount of hemorrhage layering within the occipital [**Doctor Last Name 534**] of
the right lateral ventricle. The known hemorrhagic metastasis is
again identified within the right posterior parietal lobe with
surrounding edema. There is a small amount of mucosal thickening
within the right maxillary sinus. The mastoid air cells are
clear.
IMPRESSION: Postoperative changes, as described above.
CT HEAD W/O CONTRAST [**2112-9-4**] 4:00 PM
CT OF THE HEAD WITHOUT IV CONTRAST: A perforated ventricular
drain is seen entering the right ventricle from the frontal
aspect, terminating in what appears to be the medial aspect of
the right thalamus. There is no hydrocephalus or shift of
normally midline structures. However, in the interval, there is
loss of the [**Doctor Last Name 352**]-white junction, and hypodensity in the right
frontal lobe, most likely indicating a subacute infarction. The
previously identified hyperdense mass with vasogenic edema in
the right parietal lobe is stable. Pneumocephalus in the right
cranial hemisphere overlying the right frontal lobe is again
seen, though smaller than the previous exam. Also noted is
craniotomy defect overlying the right subocciput, a defect in
the brain tissue at the right cerebellum and surrounding edema,
and small foci of hyperdensity, all consistent with
postoperative changes, and not significantly changed in the
interval. Surrounding osseous and soft tissue structures are
also unchanged.
IMPRESSION: Interval development of subacute infarct in right
middle cerebral artery territory
CT HEAD W/O CONTRAST [**2112-9-5**] 11:45 PM
FINDINGS: There is interval development of hemorrhage into a
subacute right frontal lobe infarction, as indicated by new
hyperdensity, and there is expansion of the affected area. Mass
effect is increased and there is narrowing of the right lateral
ventricle and mild shift of the midline structures to the left.
The left lateral ventricle is unchanged in size. The large right
parietal lobe intraparenchymal hemorrhage, and postoperative
changes in the cerebellum are unchanged. Additional hemorrhages
in the right caudate head and left medial cerebellar hemisphere
are stable. The degree of pneumocephalus is slightly less
compared to yesterday. A ventricular drainage catheter is
unchanged in position.
IMPRESSION: Expanded infarction and new hemorrhage in the right
frontal lobe
Pathology [**2112-9-2**]
Tissue diagnosis
Cerebellum with METASTATIC MALIGNANT MELANOMA
Note: Immunohistochemistry reveals positive staining for
melanoma antigen HMB-45.
Brief Hospital Course:
Patient admitted on day of surgery for elective suboccipital
craniotomy for resection of right cerebellar metastasis (from
melanoma) with autologous duraplasty using pericranial graft. A
right sided frontal EVT was also placed intraoperatively.
Post-operatively the patient remained intubated, initially
secondary to prone position of the surgery to protect the airway
from edema post-op. The patient waxed and waned in alertness
and mental status, therefore he remained intubated and was
transferred to the SICU on POD#1 after being observed in the
PACU overnight. Blood pressure was maintained on a
nitroprusside drip post-operatively. He was noted to have a
post-op hematocrit of 28, therefore he was transfused 1unit of
PRBC on POD#0. Post-transfusion HCT was 33. A CT showed
post-op changes in addition to a previously identified
metastasis in the right posterior parietal lobe. The
ventriculostomy drain was open to drainage and was clamped on
POD#2. ICPs were monitored and were noted to be within normal
ranges. The patient was still minimally responsive and was
noted to move his right side more than the left to stimuli,
therefore a CT head was ordered on POD#2. A new right sided MCA
infarct was seen on the CT in addition to slightly increased
amount of hemorrhage into a parietal metastasis. The patient's
family was informed of this finding. The patient continued to
be observed in the ICU and his level of consciousness remained
unchanged. The patient was made DNR by his family at this time.
A repeat CT on POD#3 showed interval worsening of the infarct
with new hemorrhage into that area. A family meeting was held
on POD 4, [**2112-9-6**] and the decision was made to continue comfort
care only. The patient was extubated following this decision
and expired soon after.
Medications on Admission:
Decadron 4mg tid
Keppra 250mg 5 tabs twice a day
Coumadin 5mg daily
Doxazocin 1mg daily
Lipitor once daily,
Digoxin half a tablet a day
Metoprolol 50 mg twice daily.
Discharge Disposition:
Expired
Discharge Diagnosis:
Metastatic Melanoma
Discharge Condition:
Expired
|
[
"V58.61",
"172.3",
"197.0",
"196.1",
"401.9",
"198.3",
"427.31",
"997.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.12",
"99.07",
"01.59",
"02.2",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
9816, 9825
|
7794, 9599
|
354, 556
|
9888, 9898
|
4395, 7771
|
2721, 2949
|
9846, 9867
|
9625, 9793
|
2964, 2964
|
2986, 4376
|
277, 316
|
584, 2257
|
2279, 2414
|
2430, 2705
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,095
| 157,689
|
43607
|
Discharge summary
|
report
|
Admission Date: [**2139-7-21**] Discharge Date: [**2139-8-6**]
Service: SURGERY
Allergies:
IV Dye, Iodine Containing / Vasotec / Levofloxacin / Morphine
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Multi-trauma
Major Surgical or Invasive Procedure:
[**2139-8-4**] Percutaneous tracheostomy tube and percutaneous
endoscopic-guided gastrostomy tube.
History of Present Illness:
This 84-year-old female status post multiple trauma in the past
now with hip fracture, T10 vertebral body fracture and multiple
rib fractures. Transported to [**Hospital1 18**] for further management of
her injuries.
Past Medical History:
Hypertension
Parkinson's Disease
Chronic Headaches
h/o Cervical radiculopathies and myelopathy
Osteoarthritis
Osteoporosis w/ L3/L4 compression fractures
Choledocholithiasis s/p ERCP w/ stent placement
Cardiac History: HTN,heart block, presumed Afib with RVR (on
coumadin)
Pacemaker/ICD placed: [**4-/2139**]
Social History:
Russian speaking only, lives with elderly husband, has [**Name (NI) 269**]
[**Last Name (LF) 20515**], [**First Name3 (LF) **] and daughter live nearby. No history of alcohol
abuse, smoking, illicits/IVDU.
Family History:
No family history of premature coronary artery disease or sudden
death.
Physical Exam:
Upon admission:
PE: 97.7, 62, 142/62, 18, 99 $L NC
Gen: Awake, alert, oriented x 3, appears uncomfortable
HEENT: yellow/bluish bruising over L. side of face, PERRL, EOMI
Heart: RRR
Lungs: CTAB, L. chest wall tederness diffusely
Abd: obese, soft, NT/ND, +bs
Spine: tender to palpation approximately T3-4 and T10-11
regions;
no c-spine tenderness
LE: warm, well perfused, no edema
Strength: [**4-6**] UE b/l, Quads [**1-6**] b/l, unable to hold against
gravity; dorsiflexion and plantar flexion [**3-7**] b/l
Sensation: Intact to light touch
Reflexes: unable to test
Propioception intact
Toes downgoing bilaterally
Rectal exam normal sphincter control
Pertinent Results:
[**2139-7-21**] 03:45PM LACTATE-2.4* K+-4.4
[**2139-7-21**] 03:40PM GLUCOSE-150* UREA N-30* CREAT-0.9 SODIUM-137
POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-25 ANION GAP-16
[**2139-7-21**] 03:40PM CK(CPK)-77
[**2139-7-21**] 03:40PM cTropnT-0.01
[**2139-7-21**] 03:40PM WBC-14.4*# RBC-4.05* HGB-11.5* HCT-36.0
MCV-89 MCH-28.5 MCHC-32.0 RDW-16.0*
[**2139-7-21**] 03:40PM PLT COUNT-316
[**2139-7-21**] 03:40PM PT-25.3* PTT-30.2 INR(PT)-2.5*
Head CT scan [**2139-7-21**]
FINDINGS: There is no acute intra- or extra-axial hemorrhage,
edema, mass
effect, shift of normally midline structures, or acute major
vascular
territorial infarction. The ventricles and sulci are prominent,
compatible
with age-related atrophy. There is extensive periventricular
white matter low
attenuation, compatible with chronic small-vessel ischemic
disease. Visualized
paranasal sinuses reveal mild mucosal thickening of the right
maxillary sinus.
Osseous structures reveal no evidence of a fracture. There is
extensive
calcification of the carotid arteries bilaterally in its
cavernous portions.
Motion slightly limits evaluation.
IMPRESSION: No acute intracranial process. Extensive chronic
small-vessel
ischemic disease.
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
CT Chest, Abdomen, Pelvis [**2139-7-21**]
CT OF THE CHEST WITHOUT IV CONTRAST: Coronary artery
calcifications are seen.
There is a small amount of pericardial fluid. Otherwise, the
heart is
unremarkable. There are atherosclerotic calcifications of the
thoracic aorta.
No pathologic mediastinal, hilar or axillary lymphadenopathy is
identified.
There are small bilateral pleural effusions, left greater than
right, with
associated atelectasis on the left side. The lungs otherwise are
grossly
clear without focal consolidation or pulmonary edema.
CT OF THE ABDOMEN WITHOUT IV CONTRAST: Non-contrast liver
demonstrates tiny
calcific densities, likely reflecting calcified granulomas. The
spleen and
right adrenal gland are unremarkable. Both kidneys demonstrate
rounded
hypodensities, incompletely characterized without IV contrast.
Within the
left adrenal gland, there is a 10-mm nodule, unchanged from
[**2138-8-11**], of indeterminant etiology.
The stomach, small bowel, and colon are unremarkable. Again
noted is a
spigelian hernia on the right containing a loop of large bowel.
There is no
free fluid, free air, or pathologic adenopathy. The pancreas is
fatty
infiltrated and atrophic.
CT OF THE PELVIS WITHOUT IV CONTRAST: Foley catheter is present
within the
urinary bladder. The rectum is unremarkable. There is no pelvic
free fluid
or adenopathy.
OSSEOUS STRUCTURES:
1. There are fracture deformities of nearly every rib
anterolaterally, some
with bridging callus, and some without, suggesting that these
are of varying
ages of healing.
2. There is a comminuted fracture of the right inferior and
superior pubic
rami. There is a nondisplaced fracture of the left sacral ala,
at the level
of the promontory. The exact extent of this is difficult to
assess secondary
to diffuse osteopenia.
3. There is buckling of the medial acetabulum on the right,
suggesting a
nondisplaced fracture/buckling.
4. There are chronic compression deformities of L3 and L4,
similar in
appearance to [**2138-8-11**].
5. There is an obliquely oriented fracture of the T10 vertebral
body,
extending from the mid portion of the intervertebral body wall,
to the
junction of the inferior endplate and posterior wall, involving
both anterior
middle columns, with distraction of the fracture fragments. This
is an
unstable fracture.
6. There is a compression deformity of the T3 vertebral body, of
indeterminant age.
7. There is ankylosing of the long segment of the thoracic
vertebral bodies.
IMPRESSION:
1. Obliquely oriented fracture of the T10 vertebral body,
involving both
anterior middle columns, which is an unstable fracture.
2. Multiple pelvic fractures, including right superior and
inferior pubic
rami, left sacral ala, and possibly the medial acetabulum on the
right.
3. Numerous rib fractures bilaterally, of varying ages of
healing.
4. Compression deformities of the L3, L4, and T3 vertebral
bodies. The L3
and L4 are similar in appearance to [**2138-8-11**]. The T3
compression
deformity is of indeterminant age.
5. Left adrenal nodule, stable from [**2138-8-11**]. However,
this is of
indeterminant etiology, and if clinically indicated, MRI may be
obtained for
further characterization.
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
CT Thoracic Spine [**2139-7-22**]
FINDINGS: Distracted fracture of T10 vertebral body is
redemonstrated. The
fracture remains obliquely oriented, extending from the mid
portion of the
anterior vertebral body to the junction of the inferior endplate
and posterior
wall. As previously indicated, the fracture involves both the
anterior and
middle columns.
There is approximately 14 mm of distraction in the craniocaudal
dimension,
greatest anteriorly. There is a moderate amount of dense
material, best seen
on axial images (3, 61), centered within this fracture, most
consistent with
hematoma. There is no retropulsion of bony fragments. Visualized
outline of
the thecal sac appears unremarkable, but please note that CT is
unable to
provide intrathecal or ligamentous detail comparable to MRI.
Diffuse osteopenia limits sensitivity for additional
nondisplaced fractures.
There is slight compression deformity of T3 vertebral body, with
roughly 25%
loss of vertebral body height. Diffuse longitudinal ankylosis of
the
visualized spine is unchanged.
Incidental note made of small-to-moderate bilateral pleural
effusions, left
greater than right. Pacemaker wires are seen in place. There is
moderate
three-vessel coronary artery calcification, and diffuse
atherosclerotic
calcification of the aorta.
IMPRESSION:
1. Unchanged appearance of T10 vertebral body distracted
fracture, which as
previously indicated involves both the anterior and middle
columns, and is
unstable.
2. Slight compression deformity of T3, with roughly 25% loss of
vertebral
body height.
3. Unchanged diffuse longitudinal ankylosis of the thoracic
spine.
4. Small bilateral pleural effusions.
5. Coronary artery calcification.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**2139-7-23**]
Left Atrium - Long Axis Dimension: *4.7 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.0 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.8 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.5 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Left Ventricle - Lateral Peak E': 0.09 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.05 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 13 < 15
Aorta - Sinus Level: 3.3 cm <= 3.6 cm
Aorta - Ascending: *4.1 cm <= 3.4 cm
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A ratio: 0.90
Mitral Valve - E Wave deceleration time: 224 ms 140-250 ms
TR Gradient (+ RA = PASP): *61 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2139-4-8**].
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Increased IVC diameter
(>2.1cm) with >55% decrease during respiration (estimated RA
pressure (0-10mmHg).
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%). Suboptimal technical
quality, a focal LV wall motion abnormality cannot be fully
excluded. No resting LVOT gradient.
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
AORTA: Normal aortic diameter at the sinus level. Moderately
dilated ascending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Severe PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: Left pleural effusion.
Conclusions
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-10mmHg. 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. The right ventricular cavity is mildly
dilated with normal free wall contractility. The ascending aorta
is moderately dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is severe
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Severe pulmonary hypertension. Mildly dilated right
ventricle with preserved biventricular systolic function. Mild
aortic regurgitation.
Compared with the prior study (images reviewed) of [**2139-4-8**],
right ventricle is slightly more dilated and pulmonary
hypertension is more severe (precise difference in PA pressures
between the studies is difficult to give, since prior study was
technically suboptimal).
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
KUB [**2139-8-5**]
FINDINGS: This is an extremely limited study. There are no
definitive large
or small bowel dilatation. There are no definitive air-fluid
levels noted.
The visualized lung bases are clear. There is noted to be a
gastrotomy tube
in place. The osseous structures demonstrate changes consistent
with severe
degenerative joint disease and old healed fractures.
IMPRESSION: No dilated loops of large and/or small bowel
suggestive of
possible obstruction or ileus.
Brief Hospital Course:
She was admitted to the Trauma Service. Orthopedic Spine Surgery
was consulted given the unstable T10 fracture; initially
discussions took place for surgical intervention and then it was
decided to opt for conservative management. She was fitted for a
TLSO brace which will need to be worn a all times when out of
bed.
Orthopedics was also consulted for the pelvic fractures and she
can remain weight bearing as tolerated and will follow up in
[**Hospital 5498**] clinic in about 1 month after hospital discharge.
She remained in the Trauma ICU for several days and was then
transferred to the regular nursing unit. She developed
respiratory distress while on the nursing unit and was then
transferred back to the ICU where she was sedated and intubated.
Because she was unable to be weaned from the ventilator the
decision was made after family/team discussions to place a
tracheostomy and percutaneous feeding tube. The procedure took
place on [**2139-8-4**] without any complications.
Geriatrics was also consulted given her age, co-morbidities and
history of multiple trauma from falls. Several recommendations
were made pertaining to her medications; including to withhold
the Coumadin given her risk of falling. It was recommended for
pain control to schedule Tylenol; use prn Ultram and Oxycodone
in low dose.
She did develop MRSA in her sputum and is being treated for the
pneumonica with Vancomycin; stop date [**2139-8-10**].
She was evaluated by Physical therapy and is being recommended
for rahb after her acute hospital stay. The screening process
was initiated and she was discharged to rehab on HD #16.
Medications on Admission:
Klonopin, Ultram, ASA, Sinemet, Carvidopa-levodopa, Amio, HCTZ,
Fosamax, Lopressor
Discharge Medications:
1. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
2. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day): OU.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
ML Injection TID (3 times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
8. Clonidine 0.1 mg/24 hr Patch [**Hospital1 **] Sig: One (1) Patch [**Hospital1 **]
Transdermal QTHUR (every Thursday).
9. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ML's PO BID
(2 times a day).
10. Amiodarone 200 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30)
ML's PO twice a day as needed for constipation.
13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) NEB Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
15. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
16. Insulin Regular Human 100 unit/mL Solution Sig: One (1) DOSE
Injection four times a day as needed for per sliding scale: See
Attached sliding scale.
17. Vancomycin in Dextrose 1 gram/250 mL Solution Sig: One (1)
GM Intravenous every twelve (12) hours for 4 days: stop date
[**2139-8-10**].
18. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply
as directed to afected area.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Multiple Trauma:
Respiratory failure
Pneumonia
Right hip fracture (subacute)
Left sacral ala fracture
T10 vertebral body fracture (unstable)
Multiple rib fractures (indeterminate ages)
Discharge Condition:
Hemodynamically stable
Followup Instructions:
Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**], Orthoepdic Spine Surgery, in 4
weeks, call [**Telephone/Fax (1) 1228**] for an appointment.
Follow up in [**Hospital 5498**] clinic in 4 weeks, call [**Telephone/Fax (1) 1228**]
for an appointment.
The following appointments were made prior to your reent
hospitalization:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2139-8-28**]
1:30
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2139-9-9**]
2:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2139-9-9**]
3:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2139-8-13**]
|
[
"805.2",
"599.0",
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"332.0",
"041.6",
"805.6",
"564.00",
"707.14",
"518.81",
"E888.8",
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"E879.8",
"E849.7",
"723.4",
"263.9",
"820.8",
"482.41",
"V45.02",
"999.31",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"38.93",
"96.72",
"33.24",
"31.1",
"96.07",
"96.04",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
15779, 15850
|
12079, 13704
|
280, 383
|
16083, 16108
|
1969, 12056
|
16131, 17012
|
1204, 1277
|
13839, 15756
|
15871, 16062
|
13730, 13816
|
1292, 1294
|
228, 242
|
411, 630
|
1309, 1950
|
652, 963
|
979, 1188
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,341
| 158,856
|
13123
|
Discharge summary
|
report
|
Admission Date: [**2103-1-17**] Discharge Date: [**2103-1-19**]
Date of Birth: [**2024-10-21**] Sex: F
Service: MEDICINE
Allergies:
Ibuprofen / Colchicine / Probenecid
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac cath [**2103-1-18**], no intervention
History of Present Illness:
Ms. [**Known lastname **] is a 78yo woman w/hx of CAD s/p 4V CABG [**2088**] and
multiple PCIs who presented to [**Hospital3 8834**] with
chest pain. She reports intermittent chest pain over past 4
days with constant chest pain since awakening at 3:45am this
morning. Pain described as a tightness/pressure in center of
chest with heaviness in the arms bilaterally. She has
associated SOB but no nausea/vomiting/diaphoresis. She states
that over the past 2 weeks she has had intermittent chest pain
with climbing stairs and performing household activities. Prior
to this she denies chest pain since her prior catheterization.
She does not take nitroglycerine at home due to headache. Of
note, she states that she missed 2 days of her aspirin and
plavix around [**Holiday **] because she forgot to take them.
.
She initially went to [**Hospital3 8834**] where she was
started on a heparin gtt, given SL NTG X 3, Morphine 2mg X 1,
aspirin and plavix. She was then transferred to [**Hospital1 18**]. In the
ED, initial vitals were 97.1 88 113/75 18 100% on RA. She had
10/10 chest pain and was started on a nitro gtt which lowered
her chest pain to [**5-21**]. ECG was unchanged and cardiac enzymes
were negative. She was then admitted to the CCU.
.
On arrival, she reports that she has not been chest pain free
since awakening this morning. Currently pain is [**5-21**] and has
been waxing and [**Doctor Last Name 688**]. She has associated shortness of breath
but otherwise ROS is negative.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
1) CAD s/p CABG (SVG->Diagonal; SVG->RPDA; SVG->OM1; SVG->LAD)
in [**2088**]
PCI Summary:
[**2098-6-3**]: 3 cypher stents placed to SVG-D1
[**2098-10-2**]: 3 taxus stents placed to SVG-D1 for in-stent
restenosis, 1
Taxus stent placed to SVG-OM1
[**2099-4-3**]: 1 cypher stent placed to SVG-OM1
[**2099-4-7**]: returned to cath lab where recent DES to SVG-OM was
occluded
[**2099-11-10**]: 1 cypher stent placed to SVG-D1 for in-stent
restenosis
[**2100-5-20**]: 1 cypher stent placed to SVG-D1
[**2100-11-24**]: 1 cypher stent placed to SVG-D1 for in-stent
restenosis
[**2101-7-22**]: cath without intervention
2) HTN
3) Dyslipidemia
4) Diverticulosis
5) COPD
Social History:
-Tobacco history: smoker 1ppd x 30 years, quit 6 years ago
-ETOH: denies
-Illicit drugs: denies
Family History:
Mother and father with hx of MI in their 40s. Brother with MI
at age 80. Son with atrial fibrillation.
Physical Exam:
VS: T= 98.9 BP= 111/68 HR= 81 RR= 14 O2 sat= 98% 2L
GENERAL: Thin, elderly woman, NAD. Appears calm. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with flat JVP.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP, PT dopplerable
Pertinent Results:
ADMISSION LABS:
[**2103-1-17**] 02:00PM BLOOD WBC-8.0 RBC-4.34# Hgb-13.3# Hct-40.2
MCV-93 MCH-30.6 MCHC-33.0 RDW-14.9 Plt Ct-250
[**2103-1-17**] 02:00PM BLOOD Neuts-47.0* Lymphs-48.1* Monos-2.9
Eos-1.6 Baso-0.4
[**2103-1-17**] 02:00PM BLOOD PT-13.8* PTT-79.5* INR(PT)-1.2*
[**2103-1-17**] 02:00PM BLOOD Glucose-100 UreaN-27* Creat-1.0 Na-141
K-4.0 Cl-106 HCO3-25 AnGap-14
[**2103-1-17**] 02:00PM BLOOD CK(CPK)-56
[**2103-1-17**] 08:03PM BLOOD CK(CPK)-72
[**2103-1-18**] 04:18AM BLOOD CK(CPK)-69
[**2103-1-17**] 02:00PM BLOOD cTropnT-<0.01
[**2103-1-17**] 08:03PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2103-1-18**] 04:18AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2103-1-17**] 02:00PM BLOOD Calcium-10.6* Phos-3.1 Mg-1.9
---------------
DISCHARGE LABS:
[**2103-1-18**] 04:18AM BLOOD WBC-8.3 RBC-3.64* Hgb-11.2* Hct-33.2*
MCV-91 MCH-30.7 MCHC-33.7 RDW-14.7 Plt Ct-216
[**2103-1-18**] 04:18AM BLOOD PT-14.5* PTT-92.0* INR(PT)-1.3*
[**2103-1-18**] 04:18AM BLOOD Glucose-105* UreaN-23* Creat-1.0 Na-140
K-4.0 Cl-108 HCO3-21* AnGap-15
[**2103-1-18**] 04:18AM BLOOD Mg-1.8 Cholest-127
[**2103-1-18**] 04:18AM BLOOD Triglyc-130 HDL-48 CHOL/HD-2.6 LDLcalc-53
---------------
STUDIES:
EKG ON ADMISSION: NSR at 81. Left axis deviation. Normal PR
interval. Prolongation of QRS with RBBB pattern. Normal QTC
interval. T wave inversions in V1, V2, V3. Q waves in II, AVL,
V2, V3. No ST changes.
.
CXR ([**2103-1-17**]): No acute cardiopulmonary process. Hyperexpansion
of lungs
suggestive of chronic obstructive pulmonary disease.
.
CARDIAC CATH ([**2103-1-18**]):
1. Selective coronary angiography in this right dominant system
revealed three vessel disease. The LMCA had a 50% mid vessel
stenosis. The LAD had a 100% proximal total occlusion. The Cx
had diffuse mild plaquing throughout. The RCA was not engaged as
it was known to be totally occluded.
2. Arterial conduit angiography revealed the SVG-OM1 to have a
proximal total occlusion. The SVG-LAD was widely patent and
unchanged from prior. The SVG-D1 had multiple stents proximally
with 50 in stent restenosis that is unchanged from prior. The
SVG-RCA was widely patent to the RPDA. There is a 90% stenosis
in the RPLV that is at a 180 degree bend point and not amenable
to intervention.
3. Limited resting hemodynamics revealed a central aortic
pressure of 106/51 mmHg.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
Brief Hospital Course:
SUMMARY
Ms. [**Known lastname **] is a 78 year old woman with a history of extensive CAD
who presents with chest pain and a story typical for unstable
angina. A coronary catherization revealed stable disease.
Patient discharged home with optimal medical therapy and a trial
of GERD treatment
BY PROBLEM
Possible GERD/Chest pain: Patient with h/o ACS s/p CABG &
multiple PCI's for 3VD presented with chest pain which was
typical for unstable angina as it has an escalating quality over
the past 2 weeks and more recently in past 4 days. No ECG
changes and enzymes are flat. Patient was given nitro gtt which
did not completely relieve the pain, and morphine seemed to be
more effective in pain control. Patient was put on heparin gtt,
continued on plavix, aspirin and beta-blocker overnight. She
was taken to the cath lab the next day, which showed stable
three vessel coronary diseae, no intervention was done. Patient
continued to experience intermittent chest pain, relieved by
morphine, and it is thought that the symptoms are not cardiac in
nature given no EKG changes, flat enzymes and no changes in
coronary blockage. Patient was discharged home to continue
optimal medical management (ace, bb, statin, plavix, aspirin)
and start a trial of GERD therapy
SUMMARY: Despite her unstable anginal symptoms, her cath was
unchanged. Her chest pain will be best managed medically and
with a trial of GERD therapy
Mild Systolic Dysfunction:
Patient had no evidence of heart failure during this hospital
stay. Her SOB was related to chest pain. Last echo in [**2099**]
with EF 45-50%. Patient will need a repeat TTE as outpatient.
Hypertension:
Her blood pressure was borderline hypotensive on nitro gtt, so
ramipril was held. It was restarted on discharge.
Anxiety/Insomnia:
Patient takes restoril and xanax at home, which were continued
during this admission.
Medications on Admission:
Xanax 0.5mg [**Hospital1 **] PRN
Carvedilol 12.5 (pt unsure of dose)
Plavix 75mg PO BID
Imdur 30mg PO BID
Ramipril 10mg PO BID
Ranolazine 500mg PO BID
Temazepam 30mg PO qHS
ASA 325mg PO qday
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
non-cardiac chest pain
CAD
Secondary diagnoses:
Hypertension
COPD
Discharge Condition:
Has persistent non-cardiac chest pain, relieved by morphine.
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Followup Instructions:
Please follow up with your cardiologist, Dr. [**Last Name (STitle) 2912**] ([**Telephone/Fax (1) 40063**], within one week after discharge.
|
[
"V45.81",
"401.9",
"300.00",
"272.4",
"414.01",
"414.2",
"780.52",
"562.10",
"V45.82",
"496",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.22",
"88.57"
] |
icd9pcs
|
[
[
[]
]
] |
8745, 8751
|
6628, 8504
|
308, 355
|
8881, 8942
|
4233, 4233
|
9086, 9229
|
3203, 3309
|
8772, 8819
|
8530, 8722
|
6562, 6605
|
4980, 5407
|
3324, 4214
|
8840, 8860
|
258, 270
|
383, 2387
|
4249, 4964
|
5421, 6545
|
8956, 9063
|
2409, 3072
|
3088, 3187
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,708
| 194,503
|
52319
|
Discharge summary
|
report
|
Admission Date: [**2179-10-23**] Discharge Date: [**2179-10-26**]
Date of Birth: [**2120-6-4**] Sex: M
CHIEF COMPLAINT: Mental status changes.
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old
gentleman with multiple medical problems including human
chronic obstructive pulmonary disease (on home oxygen) who
has had multiple admissions in the past for mental status
changes and hypercarbic respiratory failure.
He came to the Emergency Department on [**10-23**] after a fall.
He had refused to go to dialysis early in the week.
poor historian and could not answer questions.
The patient denied all pain. On presentation, his potassium
was 8.7. Arterial blood gas revealed 6.99/92/64 on 6 liters
nasal cannula. The initial electrocardiogram was notable for
peaked T waves in V1 to V6 with possible peaked T waves in
leads I and II. The patient was given intravenous calcium
gluconate, bicarbonate, and 60 mg of oral Kayexalate.
The Renal Service was called and recommended dialysis the
following morning. A repeat arterial blood gas on 4 liters
was 7.03/87/61. Per primary care physician, [**Name10 (NameIs) **] patient's
baseline pH is 7.2. The patient was admitted to the Medical
Intensive Care Unit for administration of BiPAP for treatment
of his hypercarbia. He also was administered 1 g of
ceftriaxone and 500 mg of azithromycin in the Emergency
Department for a possible right lower lobe infiltrate.
PAST MEDICAL HISTORY:
1. Human immunodeficiency virus/acquired immunodeficiency
syndrome; CD4 count of 137 and a viral load of 46,000.
2. Chronic obstructive pulmonary disease (on [**2-27**] liters/min
oxygen at home).
3. End-stage renal disease (on hemodialysis). End-stage
renal disease believed to be due to IgA nephropathy vs MPGN.
4. Pulmonary embolism/deep venous thrombosis. The patient
is now on Coumadin.
5. Hepatitis C.
6. Hepatitis B.
7. Encephalopathy.
8. h/o Intravenous drug abuse; on methadone.
9. Obstructive sleep apnea.
10. Lower gastrointestinal bleed secondary to hemorrhoids.
11. Cardiomyopathy/carditis secondary to human
immunodeficiency virus. The patient has a history of
elevated troponins in the 1.3 range.
12. Sustained Ventricular tachycardia; status post ablation.
13. Open reduction/internal fixation of the left hip.
14. Benign prostatic hypertrophy.
15. Methicillin-resistant Staphylococcus aureus.
16. Anxiety.
17. Depression.
18. Poor nutrition.
ALLERGIES: HALDOL, TRENIZINE, CODEINE, STELAZINE,
DIDANOSINE, H2 BLOCKERS, and CLINDAMYCIN.
MEDICATIONS ON ADMISSION:
1. Olanzapine 2.5 mg. p.o. as needed.
2. Zoloft 75 mg p.o. q.d.
3. Levoxyl 100 mg p.o. q.d.
4. Sevelamer 2400 mg p.o. t.i.d.
5. Coumadin 2 mg p.o. q.d.
6. Bactrim one double-strength tablet p.o. q.o.d.
7. Amiodarone 200 mg p.o. q.d.
8. Nephrocaps one tablet p.o. q.d.
9. Lactulose 30 cc p.o. q.i.d.
10. Methadone 40 mg p.o. q.d.
11. Albuterol inhaler q.4-6h. as needed.
12. Atrovent inhaler q.6h.
13. Folate one tablet p.o. q.d.
14. Protonix 40 mg p.o. q.d.
15. Oxycodone 5 mg p.o. q.4-6h. as needed.
16. Midodrine 2.5 mg at hemodialysis.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed vital signs with a temperature of 98.2, heart rate
was 96, blood pressure was 124/100, respiratory rate was 22,
oxygen saturation was 91% on 6 liters nasal cannula. In
general, a thin and emaciated Caucasian male sitting in bed,
in no apparent distress. Head, eyes, ears, nose, and throat
examination revealed pupils were equal, round, and reactive
to light. Extraocular movements were intact. The oropharynx
was clear. Mucous membranes were slightly dry. Heart
revealed a regular rate and rhythm. No murmurs, rubs, or
gallops. Normal first heart sound and second heart sound.
Lungs revealed bronchial breath sounds in the right base.
Could not auscultate due to position. Otherwise, clear to
auscultation. The abdomen revealed normal active bowel
sounds. Nontender and nondistended. No masses. Extremities
revealed no clubbing, cyanosis, or edema. Good dorsalis
pedis and posterior tibialis pulses. Neurologically, alert
and oriented times two. The patient was oriented to person
and place. Thought the month was [**Month (only) 205**]. He perseverates. He
moved all four extremities. He had a resting right upper
extremity tremor. No asterixis.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory data
on admission revealed white blood cell count was 4,
hematocrit was 41.4, and platelet count was 77. Differential
revealed 86% neutrophils, 9% lymphocytes, 3% monocytes, and
2% eosinophils. PT was 16.8, PTT was 36.6, INR was 1.9.
Chemistry-7 disclosed sodium was 141, potassium was 8.7,
chloride was 107, bicarbonate was 20, blood urea nitrogen was
88, creatinine was 10, and blood glucose was 139. Calcium
was 10.6, magnesium was 2.4, phosphate was 7.5, Ammonia
level was 69. Arterial blood gas at 2:24 a.m. was
6.99/92/64. Arterial blood gas at 3:44 a.m. was 7.03/87/61.
RADIOLOGY/IMAGING: A chest x-ray disclosed large lung
volumes, increased opacity in the right lower lung field.
Electrocardiogram at 2:08 a.m. showed questionable P-R
elongation, QRS elongation to 172 milliseconds, peaked T
waves in V1 through V6, I, and II.
Electrocardiogram at 3:06 a.m. showed a normal sinus rhythm,
normal P-R interval, QRS interval was 50 milliseconds, peaked
T waves in V1 through V6 persisted as well and were
consistent with prior electrocardiograms in [**Month (only) 359**] and
[**2179-9-24**].
IMPRESSION: This is a 59-year-old male with a complicated
past medical history which included human immunodeficiency
virus/acquired immunodeficiency syndrome, chronic obstructive
pulmonary disease (on home oxygen), and end-stage renal
disease (on hemodialysis) who presented with hypercarbic
respiratory failure and change in
mental status, and hyperkalemia secondary to noncompliance
with dialysis regimen.
HOSPITAL COURSE: The patient was initially admitted to the
Medical Intensive Care Unit so that he could be administered
BiPAP for his hypercarbia.
His potassium improved with the administration of
bicarbonate, calcium gluconate, and insulin. In addition, he
was administered albuterol and Atrovent nebulizers q.3-4h.
He was treated empirically for a community-acquired pneumonia
with ceftriaxone and azithromycin. On [**10-24**], he
underwent dialysis.
The patient had persistent episodes of hypoglycemia for which
he required the administration of D-50. It was hypothesized
that his hypoglycemia may have been due to adrenal
insufficiency, so a free cortisol level was sent. Previous
evaluation had ruled out adrenal insufficiency in a work up of
hypotension.
The patient's mental status continued to improve, and he was
transferred to the [**Location (un) **] Service on [**10-24**]. He was
administered Zyprexa 2.5 mg p.o. q.d. A repeat ammonia level
was 24. He underwent dialysis on [**10-25**].
He was judged medically stable for discharge home. The patient
was to complete his course of azithromycin. He spoke at length
with his PCP and the renal service regarding the imperative of
complying with hemodialysis treatment and the possible fatal
consequences of failure to comply.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: The patient was to be discharged to home
with [**Hospital6 407**].
DISCHARGE FOLLOWUP:
1. The patient was to undergo hemodialysis four times per
week. The patient was to undergo dialysis on [**10-27**].
2. The patient was to follow up with his primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
3. Visiting nurses were to check his complete blood count on
[**10-29**].
DISCHARGE DIAGNOSES:
1. Human immunodeficiency virus/acquired immunodeficiency
syndrome.
2. Hyperkalemia.
3. End-stage renal disease (on hemodialysis).
4. Chronic obstructive pulmonary disease (on 4 liters home
oxygen).
5. Hepatitis C.
6. Hepatitis B.
7. Intravenous drug abuse.
8. Depression.
9. Anxiety.
MEDICATIONS ON DISCHARGE:
1. Olanzapine 2.5 mg p.o. q.d. (the patient to take
standing olanzapine)
2. Zoloft 100 mg p.o. q.d.
3. Levoxyl 100 mg p.o. q.d.
4. Sevelamer 2400 mg p.o. t.i.d.
5. Coumadin 2 mg p.o. q.d.
6. Bactrim one double-strength tablet p.o. q.o.d.
7. Amiodarone 200 mg p.o. q.d.
8. Nephrocaps one tablet p.o. q.d.
9. Lactulose 30 cc p.o. q.i.d.
10. Methadone 40 mg p.o. q.d.
11. Albuterol inhaler q.4-6h. as needed.
12. Atrovent inhaler q.6h.
13. Folate one tablet p.o. q.d.
14. Protonix 40 mg p.o. q.d.
15. Oxycodone 5 mg p.o. q.4-6h. as needed.
16. Midodrine 2.5 mg at hemodialysis.
17. Sodium bicarbonate tablets two tablets with water each
day.
[**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. [**MD Number(1) 7551**]
Dictated By:[**Last Name (NamePattern4) 16972**]
MEDQUIST36
D: [**2179-10-26**] 14:21
T: [**2179-10-28**] 11:08
JOB#: [**Job Number 108162**]
|
[
"070.32",
"042",
"518.81",
"585",
"496",
"425.4",
"486",
"276.7",
"070.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7741, 8036
|
8063, 9014
|
2579, 5958
|
5977, 7269
|
7284, 7380
|
137, 161
|
7400, 7720
|
190, 1446
|
1469, 2552
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,051
| 190,445
|
36804
|
Discharge summary
|
report
|
Admission Date: [**2162-8-15**] Discharge Date: [**2162-9-3**]
Date of Birth: [**2103-11-26**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
abdominal pain necrotizing pancreatitis
Major Surgical or Invasive Procedure:
PICC line [**2162-9-1**]
PICC line [**2162-8-16**]
History of Present Illness:
58 year-old female presents as transfer from OSH for necrotizing
pancreatitis. She was initially admitted to [**Hospital3 **] Hospital
on [**2162-8-11**] with severe abdominal pain located in mid-epigastric
region and LUQ. Pain was [**10-9**] at the time and associated with
N/V. In ED, patient was HD stable. WBC was 10.1,
lipase was >3000. She had a CT scan of her abd/pelvis that
revealed enlarged and hyperemic pancreas with surrounding fat
stranding and associated retroperitoneal effusion without a
well-defined pseudocyst. CBD was 1 cm. She was admitted to [**Hospital 28985**] [**Hospital **] Hospital and kept NPO on IVF for severe pancreatitis.
Over the course of this past week, the patient has been treated
conservatively for her pancreatitis. Pancreas enzymes have been
trending down, and her lipase this AM was 139. MRCP obtained on
[**8-12**] showed contracted GB, gallstones, and possible
choledochocele. Patient was still complaining of pain this AM.
Repeat CT scan obtained and showed persistent peripancreatic
stranding and fluid. Pancreatic body has necrosis, while tail,
uncinate process and head continue to enhance. Patient was
transferred to [**Hospital1 18**] for mgmt of severe pancreatic necrosis.
Upon arrival to SICU, patient is confused and is beginning to
display signs of DTs. She is HD stable and reports persistent
LUQ pain.
Past Medical History:
PMHx: HTN, ETOH abuse, depression
[**Doctor First Name **] Hx: Multiple foot surgeries, Tubal ligation
Social History:
Most recently was having [**7-7**] drinks ETOH/night, no tobacco use
Family History:
Non contributory
Physical Exam:
On admission:
VS: T 98.8, HR 91, BP 132/76, RR 16, 98% sats 2L
GEN: NAD, A&O x 3
HEENT: no scleral icterus
LUNGS: Clear at apices, slight decreased BS at bases
CV: RRR, nl S1 and S2
ABD: Soft, TTP in midepigastric and LUQ region, ND, no
guarding/rebound, no hernias, no discoloration
EXT: 2+ edema of LE B/L
Pertinent Results:
[**2162-8-15**] 12:38AM WBC-10.3 RBC-3.15* HGB-10.0* HCT-32.0*
MCV-102* MCH-31.8 MCHC-31.3 RDW-13.4
[**2162-8-15**] 12:38AM PLT COUNT-200
[**2162-8-15**] 12:38AM GLUCOSE-78 UREA N-14 CREAT-0.4 SODIUM-148*
POTASSIUM-3.5 CHLORIDE-114* TOTAL CO2-23 ANION GAP-15
[**2162-8-15**] 12:38AM ALT(SGPT)-66* AST(SGOT)-61* LD(LDH)-588* ALK
PHOS-70 AMYLASE-127* TOT BILI-0.6
[**2162-8-15**] 12:38AM LIPASE-65*
[**2162-8-18**] CTA chest : IMPRESSION:
1. No pulmonary embolism.
2. Moderate bilateral pleural effusion and atelectasis of the
lower lobes.
3. Small ascites and peripancreatic fluid collection are
compatible with the
patient's known history of pancreatic necro
[**2162-8-18**] Abd CT :
1. Pancreatitis with large peripancreatic fluid collection
tracking around
the liver, pericolic gutters, and mesentery.
2. Edematous gallbladder.
3. Bilateral pleural effusions.
[**2162-8-22**] Chest/ Abd CT :
1. No evidence of pulmonary embolus.
2. Decrease in size of bilateral basal pleural effusions.
Extensive
atelectasis in the basilar segments of both lower lobes as
before, but
superimposed consolidation cannot be excluded.
3. Extensive peripancreatic fluid shows no significant change
since prior CT.
Areas of non-enhancement in the pancreatic body consistent with
necrosis.
Preserved enhancement of parenchyma in the pancreatic head,
uncinate process
and tail.
[**2162-8-31**] Abdominal CT :
IMPRESSION:
1. Findings consistent with necrotizing pancreatitis in the body
and medial tail. The extent of inflammation surrounding the
pancreas has improved but the large peripancreatic fluid
collection is unchanged in size when compared to prior CT of
[**2162-8-18**]. No duct dilation or mass evident. Markedly
attenuated but patent splenic vein.
2. Resolution of bilateral pleural effusions.
3. Continued edematous gallbladder wall without pericholecystic
abnormality.
4. Small 17 x 8 mm fluid collection within the pelvis posterior
to the uterus
is likely resolving loculated fluid.
Brief Hospital Course:
The patient was admitted to the ICU for close monitoring and non
surgical management of pancreatitis. Her diet was NPO, IVF for
hydration, foley catheter in place, CIWA scale in place.
[**8-16**] - [**8-17**] - PICC line placed, TPN started, continued NPO,
supportive management
[**8-18**] - The patient had an episode of desaturation, CT scan
performed demonstrating pancreatitis with large peripancreatic
fluid collection tracking around the liver, pericolic gutters,
and mesentery. Continued supportive care with NPO, TPN
[**8-19**] diet advanced to sips, PO home meds started, continued TPN,
foley catheter removed and the patient voided. She spiked a
temperature and was started empirically on vancomycin and
meropenem. She underwent a RUQ ultrasound which demonstrated
gallstones, minimal fluid around the gallbladder, no evidence of
cholecystitis.
[**8-20**] - continued antibiotics, TPN, supportive care in the ICU
due to continued confusion and agitation
[**8-21**] - transferred to the floor for continued monitoring,
continued on vancomycin, meropenem, TPN
[**8-22**] - the patient was tachypneic with O2 requirement and was
transferred back to the ICU. Due to her confusion, the patient
needed to be intubated so a central line and arterial line were
placed. A CTA chest was performed which did not demonstrate a
pulmonary embolus. Following these interventions, she was
extubated without difficulty. She had blood cultures and a
urine culture done at this time. The blood cultures were
positive for enterobacter and the urine culture was positive for
EColi. She remainded on Meropenum and Vancomycin.
[**8-23**] continued ICU monitoring, antibiotics, TPN
[**8-24**] 2 units RBC given for Hct 22, responded appropriately, cont
meropenem, TPN, discontinued vancomycin.
[**8-25**] - LFTs slowly rising, ultrasound performed again
demonstrating fluid around the gallbladder and stones, but no
evidence of cholecystitis, transferred to the floor on
antibiotics, NPO, TPN.
Once on floor, patient's clinical exam improved. Abdomen soft,
non-tender, non-distended. Patient advanced from sips to clears
diet on [**8-30**], which was well-tolerated. On [**8-31**] Patient
transitioned to full liquids diet, well tolerated. Her TPN was
eventually discontinued as she was tolerating a regular low fat
diet.
While on Meropenem she had another temperature spike to 102
prompting removal of her PICC line and blood and urine cultures
were done again. Currently the blood cultures remain negative,
The PICC line tip is negativa as is a urine culture. She
underwent a repeat abdominal CT which was essentially unchanged.
She has been afebrile for 48 hours and she is tolerating a
regular low fat diet.
Due to the fact that she will need antibiotics through [**2162-9-8**]
she has another PICC line placed and to simplify drug therapy at
home she was switched from Meropenem to Ertapenem 1 Gm. IV
Daily. The PICC line will be removed after her last antibiotic
dose by the [**Month/Day/Year 269**].
On [**2162-9-3**] she was discharged home with follow up instructions to
see Dr. [**Last Name (STitle) **] in 2 weeks and prior to the visit she will have
an abdominal CT.
Medications on Admission:
Triazolam [**1-1**] pill qhs, Buproprion 150 mg qd, Cymbalta 30 mg
qd, Lisinopril 10 mg qd, Ativan 0.5 mg po q8hrs prn, HCTZ 25 mg
po qd
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Bupropion HCl 100 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
5. Amylase-Lipase-Protease 60,000-12,000- 38,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
Disp:*100 Cap(s)* Refills:*2*
6. Ertapenem 1 gram Recon Soln Sig: One (1) gram Intravenous
daily () as needed for bacteremia: thru [**2162-9-7**].
Disp:*4 gram* Refills:*0*
7. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*10 ML(s)* Refills:*1*
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Therapies
Discharge Diagnosis:
Necrotizing pancreatitis
Hypertension
Depression
Alcohol abuse
Discharge Condition:
Good
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 [**5-9**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
PICC Line:
*Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse
practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is
significantly soiled for further instructions.
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2162-9-24**] 10:00
You must report to [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] [**Location (un) **] at 9AM
Nothing to eat or drink after 11PM on [**2162-9-23**] the night before
the test
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 2833**]
Date/Time:[**2162-9-24**] 11:15
Call [**Telephone/Fax (1) 250**] to arrange for a primary care physician and
appointment
Completed by:[**2162-9-8**]
|
[
"780.52",
"511.9",
"599.0",
"789.59",
"296.25",
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"574.00",
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"276.3",
"293.0",
"995.91",
"303.91",
"401.9",
"518.0",
"291.0",
"787.91",
"038.40",
"574.10",
"785.0"
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icd9cm
|
[
[
[]
]
] |
[
"99.15",
"96.71",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8757, 8826
|
4420, 7614
|
353, 406
|
8933, 8940
|
2396, 4397
|
11114, 11677
|
2034, 2052
|
7802, 8734
|
8847, 8912
|
7640, 7779
|
8964, 11091
|
2067, 2067
|
274, 315
|
434, 1805
|
2081, 2377
|
1827, 1932
|
1948, 2018
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,722
| 104,583
|
49504
|
Discharge summary
|
report
|
Admission Date: [**2132-12-14**] Discharge Date: [**2132-12-30**]
Date of Birth: [**2066-5-26**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Augmentin
Attending:[**First Name3 (LF) 983**]
Chief Complaint:
dyspnea, anemia
Major Surgical or Invasive Procedure:
EGD
Colonscopy
Capsule endoscopy
History of Present Illness:
Mrs [**Known lastname 103573**] is a pleasant 66F with history of COPD, afib, mitral
valve replacement presenting from group home with worsening
dyspnea on exertion x 3 days. She denies chest pain, cough,
shortness of breath, lower extremity swelling, headache, nausea,
vomiting, or fever. She has orthopnea at rest and sleeps with 2
pillows at baseline, this has not worsened recently.
.
In the ED, she was noted to be hypotensive to the 70s, however
manual BP was 100/70 and pt was mentating well. Physical exam
was notable for loud murmur not previously documented. EKG was
done and notable for hypertrophy and ST depressions, unchanged
from prior. Labs were notable for mildly elevated lactate of
2.4, hyponatremia to 132, elevated creatinine to 2.4 (baseline
2.0), mildly elevated BNP, and crit of 21.5, down from a
baseline of 30. Pt was guiac negative on exam. CXR showed
retrocardiac opacity, possibly pleural effussion.
.
On the floor, pt is comfortable without any complaints. She
states that she feels improved since she arrived in the
hospital, with improvement in her weakness.
.
Review of systems:
(+) Per HPI. Pt states she has 1 BM daily, no blood recently
however did have blood in stools 1 wk prior which she attributed
to her hemorrhoids. + lightheadedness.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
-Rheumatic heart disease s/p mitral & aortic valve replacement
-COPD
-Asthma
-Hypothyroid
-CRI, baseline creatinine 2.0
-urinary incontinence
-Anxiety
-Depression
-Afib
-psychoaffective disorder
-hx ascending aortic anuerysm 5.4x 4.9 cm [**6-/2132**], appropriate
for resection
Social History:
Lives in group home. No tobacco/No Etoh, very unstable family
life according to PCP
Family History:
Mother and father with CAD, dad died of MI
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T:98.2 BP:100/46 P:63 R:17 O2:98%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, conjunctiva
pale
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Irregular rate, 2/6 SEM, mechanical s1, s2
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
Neuro: aaox3, CNs [**3-22**] intact, strength and sensation grossly
nl.
.
DISCHARGE PHYSICAL EXAM
VS: 97.3, 77, 103/52, 16, 96% on RA
GEN: A&OX3
HEENT: MM dry, oropharynx clear, anicteric conjunctiva
NECK: supple, JVP not elevated, no LAD
HEART: irregularly irregular rhythm, high pitched S1, S2, [**3-16**]
systolic murmur best heart at LUSB
LUNG: CTA Bl
ABD: soft, NT/ND, positive BS, no rebound/guarding
EXT: warm, no pitting edema, nontender over left MTP
Pertinent Results:
ADMISSION LABS
[**2132-12-14**] 02:50PM WBC-9.5 RBC-2.34*# HGB-6.9*# HCT-21.5*#
MCV-92# MCH-29.6 MCHC-32.2 RDW-20.5*
[**2132-12-14**] 02:50PM NEUTS-84.1* BANDS-0 LYMPHS-9.8* MONOS-5.3
EOS-0.7 BASOS-0.1
[**2132-12-14**] 02:50PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-OCCASIONAL
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-OCCASIONAL
STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL
[**2132-12-14**] 02:50PM PLT SMR-NORMAL PLT COUNT-273
[**2132-12-14**] 02:50PM PT-33.2* PTT-77.7* INR(PT)-3.3*
[**2132-12-14**] 02:50PM proBNP-2838*
[**2132-12-14**] 02:50PM GLUCOSE-100 UREA N-69* CREAT-2.4* SODIUM-132*
POTASSIUM-3.5 CHLORIDE-91* TOTAL CO2-28 ANION GAP-17
[**2132-12-14**] 02:50PM cTropnT-0.02*
[**2132-12-14**] 03:00PM LACTATE-2.4* K+-3.5
[**2132-12-14**] 05:35PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2132-12-14**] 05:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2132-12-14**] 11:34PM HCT-23.3*
[**2132-12-14**] 11:34PM CK-MB-2 cTropnT-0.01
[**2132-12-14**] 11:34PM CK(CPK)-24*
.
DISCHARGE LABS
[**2132-12-30**] 07:05AM BLOOD WBC-2.9* RBC-3.06* Hgb-8.8* Hct-27.1*
MCV-89 MCH-28.9 MCHC-32.6 RDW-17.0* Plt Ct-146*
[**2132-12-30**] 07:05AM BLOOD PT-28.0* INR(PT)-2.7*
[**2132-12-30**] 07:05AM BLOOD Glucose-96 UreaN-13 Creat-1.4* Na-141
K-4.2 Cl-105 HCO3-28 AnGap-12
[**2132-12-30**] 07:05AM BLOOD ALT-31 AST-24 AlkPhos-21* TotBili-0.4
[**2132-12-30**] 07:05AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.1
.
PERTINENT LABS
[**2132-12-14**] 02:50PM BLOOD proBNP-2838*
[**2132-12-15**] 04:52AM BLOOD calTIBC-369 Hapto-33 Ferritn-23 TRF-284
[**2132-12-19**] 07:25AM BLOOD VitB12-455 Folate-19.4
.
Beta-2-Glycoprotein 1 Antibodies IgG
Test Result Reference
Range/Units
B2 GLYCOPROTEIN I (IGG)AB <9 <=20 SGU
.
[**2132-12-16**] 07:30AM BLOOD tTG-IgA 1
[**2132-12-20**] 07:00AM BLOOD Inh Screening POS
[**2132-12-20**] 07:00AM BLOOD Lupus anti-coagulant POS
[**2132-12-22**] 07:05AM BLOOD ACA IgG-2.2 ACA IgM-7.2
Anticardiolipin Antibody IgG 2.2 0 - 15 GPL
0-15 GPL: NEGATIVE;15-20 GPL: INDETERMINATE; >20 GPL: POSITIVE
Anticardiolipin Antibody IgM 7.2 0 - 12.5 MPL
.
PERTINENT STUDIES
[**12-14**] CT chest/abd/pelvis
IMPRESSION:
1. Stable appearance of thoracic aortic aneurysm without
evidence of hematoma in the chest, abdomen, or pelvis, as
questioned.
2. Splenomegaly and prominence of the left hepatic lobe,
findings that
suggest the possibility of background liver disease. Correlation
with LFTs is recommended.
3. Biapical and left lower lobe nodular pulmonary densities, for
which
followup with chest CT is recommended in one year if there are
risk factors for lung cancer.
4. Aortic and mitral valve replacement with biatrial enlargement
and findings again consistent with pulmonary artery
hypertension.
5. Fat-containing umbilical and left inguinal hernias.
.
[**12-16**] EGD
[**Doctor First Name **]-[**Doctor Last Name **] tear
Blood in the body of stomach
Erythema in the stomach
Normal mucosa in the duodenum (biopsy)
Otherwise normal EGD to third part of the duodenum
.
[**12-16**] Colonoscopy
Melanosis coli in the colon
Polyp in the colon
.
[**12-16**] Duodenal biopsy
Duodenum, biopsy (A): Duodenal mucosa within normal limits.
.
[**12-24**] CXR
FINDINGS: In comparison with the study of [**12-14**], there is
continued
enlargement of the cardiac silhouette in a patient with aortic
and mitral
valve replacement and CABG procedure. Opacification at the base
posteriorly is consistent with pleural effusion, more prominent
on the left. Volume loss is again seen in the region of the left
lower lobe. No evidence of acute focal pneumonia.
.
[**12-26**] single ballon enteroscopy
Normal esophagus.
Normal stomach.
Normal duodenum.
There was one small area with active bleeding seen in the
proximal jejunum. The base of the bleeding was not able to be
well visualized because of the active bleeding and clots. It is
suspicious for AVM or Dieulafoy lesion. It was first treated
with cauterization with a gold probe. Then it was injected with
1:10,000 epinephrine. Three hemoclips were placed successfully
with good hemostasis.
SPOT tattoo was applied on either side of the bleeding area for
future localization
.
[**12-29**] KUB
IMPRESSION: Single focally dilated loop of small bowel with wall
thickening and two clips within the lumen, which likely
represents a focal ileus in the area of the recent AVM clipping.
Brief Hospital Course:
66 yo woman with h/o rheumatoid heart disease s/p MVR and AVR,
A-fib on coumadin, admitted for DOE, found to have new anemia.
.
ACTIVE ISSUES:
# Jejunal AVM: Pt presented with 10 pt crit drop. There was no
evidence of hemolysis or BM suppression. She was treated with
PPI gtt. Her EGD revealed [**Doctor First Name 329**] [**Doctor Last Name **] tear, but no active
source of bleeding. Her colonoscopy showed benign polyp and
melanosis coli . However, capsule endoscopy showed jejunal AVM.
Pt was treated medically with blood transfusion, while awaiting
optimization of anticoagulation status. She received endoscopic
cauterization on [**12-26**]. She was hemodynamically stable
afterwards. We discontinued her aspirin given she is already on
warfarin. WE continued her homedose omeprazole given there is
no evidence gastric ulcer disease.
.
# Coagulation abnormality: Pt has chronically elevated PTT.
Current workup is notable for positive mixing test, inhibitor
screening, and lupus anticoagulant. The test was done > 48 hrs
after cessation of heparin, therefore unlikely false positive
from presence of heparin. Her anti-cardiolipin and
beta2-glycoprotein were negative. The clinical suspicion for
anti-phospholipid syndrome was high, however, pt does not
formally meet the diagnostic criteria for antiphospholipid
syndrome, and she is already on anti-coagulation treatment. A
FOLLOW UP APPOINTMENT WITH HEMATOLOGY ON [**2132-3-6**] WITH DR. [**First Name (STitle) **]
HAS BEEN MADE FOR FURTHER WORKUP AND MANAGEMENT.
.
# Ileus: Pt complained of abdominal bloating and mild discomfort
on the last few days of this admission. She tolerated food
intake well with no nausea/vomiting. Her abdominal exam was
always reassuring. She did not have bowel movement for three
days. KUB showed evidence of ileus likely in the location of
AVM clipping.
.
# Hx prosthetic valve: Pt has documented h/o MVR and AVR
secondary to rheumatic heart disease. We kept her INR at goal
of 2.5 - 3.5 with heparin gtt for procedure. No thromboembolic
events were observed during this admission. She was discharged
with INR 2.7.
.
# Gout: Pt developed left MTP pain. The location and nature of
pain is concerning for gout. She was empirically treated with
low dose colchicine once, and her symptoms improved
significantly in the following days.
.
# [**Last Name (un) **]: Pt presented with acute kidney injury in the setting of
significant GIB. Her creatinine improved after correcting her
anemia.
.
# CHF: Pt has a documented history of diastolic CHF. We held
her diuretics temporarily in the setting of hypovolemia. An the
time of discharge, pt tolerated half dose of her lasix well. We
recommend restarting spiralactone and half dose of her potassium
supplement, and titrating up as tolerated.
.
CHRONIC ISSUES
# A-fib: Pt has documented a-fib. She was in a-fib rhythm
throughout this hospitalization. We started her diltiazem after
the procedure, and she tolerated well. Pt was anticoagulated
throughout this hospitalization.
.
# Psychoaffective disorder/depression: We continued her home
medication.
.
# COPD: Pt has documented history of COPD. She did well on her
home medication Spiriva and Advair.
.
# Hyperlipidemia: We continued her home dose statin.
.
TRANSITIONAL ISSUES
# CODE STATUS: Full code
# COMMUNICATION: [**Doctor First Name **] at group home [**Telephone/Fax (1) 103574**] (pt
designated person of contact), daugher is official HCP, but not
in [**Name (NI) 86**].
# PENDING STUDIES AT DISCHARGE: none
# MEDICATION CHANGES:
- STOPPED aspirin in the setting of GIB. Will consider
restarting after stabilization, as there are evidence that
aspirin and coumadin is superior than coumadin monotherapy in
mortality of patients with mechanical valves.
- RESTARTED furosemide at half dose.
- STOPPED Metolazone.
- CONTINUED at home dose with alternating 5 mg and 4.5 mg.
- RESTARTED half dose of potassium supplement
# FOLLOWUP:
- Will need early follow-up with PCP/Cardiology
- Recommend follow-up with hematology
- Recommend maintenance treatment for gout as outpatient.
Medications on Admission:
Priloesec 20 mg qam
diltiazem 240 mg q am
spiriva 1 cap inh qhs
aspirin 81 mg daily
pramipexole 1 mg PO qhs
bupropion 150 mg po qam
zocor 10 mg po qhs
iron sulfate 325 po q am
aldactone 25 mg po qam
nephrocaps 1 cap po q day
advair 5/500 puff inh [**Hospital1 **]
senna 2 tabs PO bid
colace 100 mg PO BID
albuterol nebs 1 vial neb q 4hr prn sob
tylenol 650 mg po q 6h
procrit 40,000 un sc q month, hold for hgb 12
levothyroxine 125 mcg po qam
zaroxolyn 1 tab 2.5 po mon/wed/fri 1/2 hr prior to lasix
kcl 20 mcg po bid
lasix 40 mg PO bid
coumadin 4.5 alternating with 5 mg
MoM 30 mL po prn constipation
Discharge Medications:
1. pramipexole 1 mg Tablet Sig: One (1) Tablet PO qHS ().
2. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO DAILY (Daily).
3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
4. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Diltia XT 240 mg Capsule,Ext Release Degradable Sig: One (1)
Capsule,Ext Release Degradable PO once a day.
8. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. albuterol sulfate 2.5 mg/0.5 mL Solution for Nebulization
Sig: One (1) neb treatment Inhalation q4h prn as needed for
shortness of breath or wheezing.
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
14. Procrit 40,000 unit/mL Solution Sig: One (1) injection
Injection once a month: Hold for Hgb > 12.
15. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: alternate 4.5mg and 5mg doses every other day.
17. FerrouSul 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO
once a day.
18. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) cc
PO once a day as needed for constipation.
19. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
20. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
21. potassium chloride 20 mEq Packet Sig: One (1) PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 2251**] Nursing and Rehabilitation - [**Location (un) 2251**]
Discharge Diagnosis:
Primary Diagnosis
- A-V malformation in jejunum
Secondary Diagnosis
- Atrial fibrillation
- Asthma
- anti-phospholipid syndrome (high suspicion)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 103573**],
You came to our hospital for shortness of breath, and was found
to have a significant drop in blood count, concerning for
bleeding from your gut. You were initially treated in the MICU,
and received multiple units of blood products. You underwent
upper and lower endoscopy, as well as a capsule endoscopy. We
found that you have a large malformed vessel in your small
intestine. Our gastroenterologist corrected that bleeding
vessel through endoscopy. During this hospitalization, we also
found that you have an unusual blood clotting pattern, that will
require further followup. You had a small gout flare, that has
largely resolved.
.
Please note that the following medication has changed:
- Please STOP taking aspirin, until further instruction by your
PCP.
[**Name Initial (NameIs) **] Please TAKE a reduced dose of furosemide at 20 mg tablet, one
tablet by mouth twice a day. Please remind your doctor that
this is half of your previous dose, and should be increased if
needed.
- Please STOP taking Metolazone until further notice by your
PCP.
[**Name Initial (NameIs) **] Please CONTINUE to take warfarin 5 mg daily and have your INR
checked regularly.
- There is no further changes to your medication.
INR monitoring will be extremely important moving forward due to
the propensity of your blood to clot.
We have arranged followup with your PCP/Cardiologist Dr. [**Last Name (STitle) **],
and with our hematologist. Please make sure that you make to
these appointments.
It has been a pleasure taking care of you here at [**Hospital1 18**]. We
wish you a speedy recovery.
Followup Instructions:
Name: [**Last Name (LF) 7726**],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE/CARDIOLOGY
Address: [**Street Address(2) 7727**],2ND FL, [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 7728**]
Appointment: THURSDAY [**1-29**] AT 2PM
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2133-3-6**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 5056**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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7,242
| 143,109
|
15755
|
Discharge summary
|
report
|
Admission Date: [**2144-7-1**] Discharge Date: [**2144-7-16**]
Date of Birth: [**2077-5-9**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
SDH, rigidity
Major Surgical or Invasive Procedure:
Right frontoparietal occipital craniotomy for acute subdural
hematoma.
History of Present Illness:
67 y/o male transferred from [**Hospital **] [**Hospital 45374**] Hospital after
being admitted there on [**6-29**] after wife noticed he was rigid and
leaning forward and drooling at a restaurant. Pt remembers being
dizzy prior to episode then does not remember anything until
several seconds later when wife was talking with him. Pt is an
alcoholic and does not remember drinking any more or less than
usual before this happened. He has been admitted here in [**Month (only) **]
O5 for a similar episode and was to follow up with a
neurologist. He was admitted to [**Hospital6 8283**] for
observation. He had a CT on admission that showed no hemorrhage.
He had one witnessed seizure while hospitalized. According to
notes on [**6-29**] he fell out of bed and sustained a small
laceration on his
posterior head. He became more aggitated was transferred to
the ICU and CIWA protocol was followed on On morning of [**7-1**]
staff noticed a right eye droop and a head CT showed a Right
subdural hematoma approx 1.3cm with 6mm of shift. He was then
transferred to our facility for neurosurg consult.
Past Medical History:
Alcohol Abuse
History of a possible seizure on a cruise ship 1.5 years ago
Gout
Hypertension
Status post appendectomy in [**2101**].
Social History:
The patient is married with no children and lives with his wife.
His wife is a breast cancer survivor, currently undergoing
treatment for recurrence, and the pair are very active with a
summer home in [**Location (un) **] that they frequent often.
The patient quit tobacco use four years ago. He smoked less than
a pack a day for approximately 35 years. He states that he
drinks 5 glasses of scotch per day, 5x's per week. His wife
implies that this is quite an underestimate.
He is a retired counselor/psychotherapist and used to work in
schools with troubled teens.
Family History:
One sister is healthy. Another sister was diagnosed with gout
at the age of 40. Another brother is healthy. The patient's
mother died around the age of 77 of heart failure.
She had some amputations secondary to vascular disease.
The patient's father died in his early 80's of heart failure as
well.
Physical Exam:
O: T:99.4 BP:144/98 HR:90 R 28 O2Sats 100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 2mm min reactive
Neck: Supple no point tenderness.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, prefers
eyes closed .
Orientation: Oriented to person, place, and date unsure of month
knew day was 28th
Language: Speech slightly slurred with good comprehension.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-8**] throughout.
Has left sided pronator drift
Sensation: Intact to light touch
Reflexes: B T Br Pa Ac
Right decreased to absent
Left decreased to absent
Toes down bilaterally
Pertinent Results:
[**2144-7-1**] 11:47PM TYPE-ART PO2-150* PCO2-35 PH-7.41 TOTAL
CO2-23 BASE XS--1 INTUBATED-INTUBATED VENT-CONTROLLED
[**2144-7-1**] 11:47PM GLUCOSE-126* LACTATE-1.4 NA+-140 K+-3.0*
CL--107
[**2144-7-1**] 11:47PM HGB-8.3* calcHCT-25
[**2144-7-1**] 11:47PM freeCa-0.97*
Brief Hospital Course:
67 yo man admitted to neurosugery service for evacuation of
Right SDH after sustaining a fall. Patient initial head CT
revealed 1.5 cm r SDH at a largest width with 1cm subfalcine
herniation. Patient taken to OR on [**2144-7-1**] for evacuation of
SDH hematoma and subdural hemovac drain under general anesthesia
without intraoperative complications. Estimated blood loss was
500cc. Patient extubated successfully after the procedure. He
was tranferred to neuro ICU after surgery for close neurologic
and hemodynamic monitoring. His Cervical spine CT did not show
any fracture, and cleared clinically.
Patient placed on a lorazepam drip for known long Etoh use to
prevent withdrawal. His postoperative neurologic exam was:
follows commands, open his eyes to stimuli, pupils equal
reactive about 2mm, motor strenght antigravity on post op day
one. On post op day two he was delirius, mumbling psychiatry
consulted to manage delirium and DT. His drain removed on postop
day two, without any complications. His vitals remained wnl.
Per psych rec he was changed from lorazepam to valium 10mg PO
q1h.
On POD3 he was slightly less oriented on neuro exam and had a
fever up to 101.7. He was pan cultured and got a chest Xray,
which showed atelectasis. He was started on empiric antibiotics
and neuro checks were increased to q2hours. He completed his
valium course and it was discontinued.
On POD4 he was lethargic but following commands. His vital
signs remained stable. He was switched from dilantin to Keppra
1000 [**Hospital1 **]. His labs remained stable.
On POD5 he was alert and oriented x2, followed commands, did not
open eyes. He spiked a temp to 102.7 and had a CXR that was
wnl. He had long periods of tachycardia up to 120 and tachypnea
to 25. He got a head CT and a sinus CT. The sinus CT showed
minimal mucosal thickening and the head CT showed a rebleeding
into the subdural hematoma, not an unexpected postoperative
finding.
On POD6 the patient was transfered to neuro stepdown. His
neuro exam remained stable and he was afebrile. His Keppra was
titrated to 1500 [**Hospital1 **].
On POD7 he was tachycardic and tachypnic overnight and had
another CXR in the morning that showed right side pneumonia. He
was started on levofloxacin and flagyl. He was also
pancultured. He was alert and oriented x3, followed commands
and had full strength. He failed a speech and swallow eval and
was converted to IV medications.
On POD8 he was febrile again to 101.7. An abd Xray showed no
sign of obstruction or dilation. His neuro exam remained
stable. He passed the video swallow and was resumed on PO meds.
He did intermittently continue to have fevers and blood cultures
from [**7-11**] grew out gram positive cocci and he was begun on
antibiotics but the final read on the cultures was only 1 out of
4 bottles positive and this was felt to be a contaminant by ID
and the vancomycin was ultimately dc'd.. He did receive 2 units
of PRBC on [**7-11**] which had his hematocrit rise from 22 to 27 and
he appeared a bit more active and alert. PT worked with him
throughout his hospital stay but did recommend him for rehab
hospital. He continued to have loose stools though somewhat
resolving and c. diff cultures were negative x3. He did become
afebrile. His INR was found to be slowly rising - he was seen by
hematology who felt this was related to vitamin K deficiency
(antibiotic related vs poor nutrition) and/or consumption of
factor VII due to previous hematoma and recommended oral vitamin
K. His WBC count was followed and did slowly decrease but then
slight increase (from 17.7 ([**7-15**]) to 18.3 ([**7-16**])). In light of
being afebrile, negative cultures,MRI head that showed no
evidence of infection, decreasing loose stools and improved
clinical status of pt, no further action was taken. He should
continue to have WBC count and INR followed at rehab. If has
fever or WBC count rises, he should go to ER for evaluation.
Medications on Admission:
Atenolol 50 mg QD
Loratidine 10mg QD
Zantac 150mg QD
MVI 1 mg PO QD
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours): dc [**7-22**].
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): dc [**7-22**].
9. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
10. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
11. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Right sided subdural hematoma
Discharge Condition:
Stable
Discharge Instructions:
WBC count and INR should be followed at rehab.
Continue your usual home medications.
You will be antiseizure medication until discussed with your
neurosurgeon, please discuss at the time of follow up.
Followup Instructions:
Follow up with Dr [**Last Name (STitle) 548**] in 6 weeks. Call for an appointment at
[**Telephone/Fax (1) 1669**].
Completed by:[**2144-7-16**]
|
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21,693
| 113,485
|
22279+22280
|
Discharge summary
|
report+report
|
Admission Date: [**2169-9-23**] Discharge Date:
Date of Birth: [**2117-12-21**] Sex: M
Service: NSU
HISTORY OF PRESENT ILLNESS: This 51-year-old man with a
newly diagnosed GBM status post resection on [**2169-9-8**] with
residual right hemiparesis was discharged to rehabilitation
but was noted to have increased word finding difficulties on
[**2169-9-23**]. He had been at [**Hospital6 310**]
from [**2169-9-12**] until [**2169-9-23**]. Per his wife, she first
noticed increased word finding difficulties on the Saturday
prior to admission. On Sunday, the day of admission, he was
unable to articulate three word sentences which was his
baseline at [**Hospital1 **].
PAST MEDICAL HISTORY: Significant for GBM diagnosed in
[**9-/2169**], resected on [**2169-9-8**], with a plan to have
radiation therapy done. History of inflammatory bowel disease
status post resection with ileostomy in [**2143**]. Hyperlipidemia,
gastroesophageal reflux disease and steroid-induced diabetes
mellitus.
MEDICATIONS ON ADMISSION:
1. Decadron 2 mg p.o. b.i.d.
2. Hydrochlorothiazide 25 mg q day.
3. Lopressor 12.5 mg b.i.d.
4. Lipitor 10 mg q day.
5. Insulin.
6. Tylenol.
SOCIAL HISTORY: He transferred from [**Hospital3 7**]. No
tobacco. No ETOH. Married. Works as a consultant. Has two
children.
FAMILY HISTORY: Significant for breast cancer for mother and
father with coronary artery disease.
PHYSICAL EXAMINATION: On admission, vital signs:
Temperature 100.0, blood pressure 157/77, heart rate 82,
respirations 18, O2 is 95 percent. General: He was agitated.
HEENT: Ruddy complexion baseline per wife, pupils equal,
round and reactive to light and accommodation, extraocular
movements were full. Cardiac: Regular rate and rhythm. Lungs
are clear bilaterally. Abdomen: Soft, nontender,
nondistended. Extremities: No edema. He was awake, alert and
completely aphasic but able to follow commands such as "close
your eyes" and able to repeat "no ifs, ands or buts about
it". Cranial nerves II-XII are grossly intact except for a
right facial droop with decreased labial fold and tongue
deviation to the right. Strength was five out of five on the
left. Unable to assist on the right due to neglect. Reflexes
were three plus on the right and two plus on the left.
LABORATORY DATA: White blood cell count 18.7, hematocrit
37.7, platelets 226, sodium 133, potassium 4.6, 93/25 and 29
for BUN, 0.8 for creatinine, 234 for glucose, calcium 8.9,
alkaline phosphatase 4.6, magnesium 2.1. Urinalysis was
within normal limits. ALT was noted to be at 131. AST was 26.
LDH 243, lipase 224, CK were within normal limits. Head CT
showed air and blood products in the subdural space along the
left convexity and surgical resection site and in the left
cortex/basal ganglia with surrounding hypo-attenuation into
the left caudate nucleus and internal capsule and thalamus.
Normal ventricles. No midline shift. Chest x-ray showed a
retrocardiac opacity in the left lower lobe likely
atelectasis. Electrocardiogram showed atrial bigeminy at a
rate of 78. Blood cultures on [**2169-9-23**] on both anaerobic
and aerobic were positive for GPC pairs and clusters.
HOSPITAL COURSE: The patient was admitted to the Oncology
service where he underwent a fever workup. He had reported
fevers at [**Hospital1 **]. Also is part of the fever workup they
obtained lower extremity Dopplers, which showed a clot in his
left peroneal vein. He also was started on Dilantin to rule
out seizures given his change in mental status and he was
given a dose of 10 mg intravenous and changed to 6 mg q six
hours. It was noted that his incision site on his head from
his previous surgery was fluctuant with what was felt to be a
fluid collection underneath. Blood cultures from [**2169-9-23**] and
[**2169-9-24**] showed
coag positive staphylococcus aureus methicillin
sensitive. The blood culture results were indicative of high-
grade MSSA bacteremia. An Infectious Disease consultation was
obtained and the patient was started on oxacillin 2 gm
intravenously q four hours with a recommendation for six
weeks. For empiric coverage prior to starting the oxacillin,
he was started on vancomycin and cefepime. Those were
discontinued on [**2169-9-26**] and as mentioned he was started on
the oxacillin. Infectious Disease also recommended an
echocardiogram be done to rule out endocarditis. No
vegetation was seen via echocardiogram that was completed on
[**2169-9-26**].
On [**2169-9-25**], [**Name6 (MD) **] [**Name8 (MD) 739**], M.D. aspirated 80 cc
of purulent fluid from his wound site which showed Gram
positive cocci in pairs and clusters and grew out
staphylococcus aureus coagulopathy positive. Regarding the
patient's deep venous thrombosis, Dr. [**Last Name (STitle) 739**] did not
want to anticoagulate but follow with serial ultrasounds to
see if the clot propagated. On [**2169-9-25**], the patient
underwent a left-sided craniotomy for wound debridement and
evacuation of subdural intracranial empyema. On [**2169-9-25**],
the patient had an upper extremity ultrasound to rule out a
deep venous thrombosis in his right arm and that was negative
for any deep venous thrombosis. Postoperatively, he was sent
to the Intensive Care Unit where he was monitored with close
neurological checks. He was awake and alert and aphasic with
right-sided hemiplegia. While in the Intensive Care Unit, it
was noted that his platelets dropped to as low as 85. His
subcutaneous heparin was discontinued and a heparin panel was
sent off. Also, his sodium at that time started to fall to
the 133 range. He was started on sodium p.o. The HIT panel
was positive for heparin-induced thrombocytopenia. His liver
function tests were monitored closely while continuing to
receive oxacillin.
He was transferred to the surgical floor on [**2169-9-27**] where
he remained awake, alert and aphasic. The patient expressed
extreme need to be discharged home along with his wife. They
did not want to go back to any rehabilitation facility and
were adamant that he be discharged home as soon as possible.
The discharge planning process was begun. Home physical
therapy, occupational therapy, necessary medical equipment
were ordered. Also, home visiting nurse service was set up
due to the fact that he would need continuous infusion of
oxacillin.
On [**2169-9-28**], a repeat ultrasound was performed of the
patient's right lower extremity which showed propagation of
deep venous thrombosis to the popliteal vein and distal
superficial femoral vein. Given that new finding,
Interventional Radiology was contact[**Name (NI) **] and an inferior vena
cava filter was placed. The patient had no complications from
his inferior vena cava filter placement. On [**2169-9-29**], a
PICC line was inserted into the patient's left median vein
without complication. Also, a psychiatry consultation was
obtained also on [**2169-9-29**] given the patient's depression,
periods of confusion, agitation and then occasional treatment
opposition. Their recommendation was to avoid benzodiazapine,
use Haldol for acute agitation and have psychiatric follow-up
as needed at home. Social Work also saw the family and
offered services as needed. On [**2169-9-30**], it was noted that
the patient's HIT panel was positive. At that time,
Hematology/Oncology was consulted who recommended starting
argatroban. They recommended avoiding all heparin and
continuing argatroban only until it is clear that the
platelets had normalized. Further recommendations on
[**2169-10-2**] from Hematology/Oncology was to discontinue the
argatroban and to start a fondaparinux 7.5 mg subcutaneously
q day and introduce Coumadin in the next 4-5 days continuing
on the fondaparinux until his INR level was at 2.0, and he
should continue on Coumadin therapy for four weeks.
On [**2169-10-3**], the day of discharge, it was noted that his
hematocrit was 26.8. Dr. [**Last Name (STitle) 739**] recommended
transfusing one unit of packed red blood cells and starting
on iron. Also, on [**2169-10-3**], his platelet count had
recovered to 245. His sodium had recovered to 137. At this
time, the patient and his family again expressed a profound
interest to be discharged home. They are acutely aware of the
amount of services that will be needed at home and the 24
hour supervision that the patient's care will entail. They
once again were offered the option of
DICTATION ENDED
[**Name6 (MD) **] [**Name8 (MD) 739**], MD [**MD Number(2) 2930**]
Dictated By:[**Last Name (NamePattern1) 8633**]
MEDQUIST36
D: [**2169-10-3**] 14:39:58
T: [**2169-10-3**] 15:20:54
Job#: [**Job Number 58060**]
Admission Date: [**2169-9-23**] Discharge Date: [**2169-10-3**]
Date of Birth: [**2117-12-21**] Sex: M
Service: NSU
ADDENDUM: This is a continuation of a Discharge Summary
dictated earlier.
DISCHARGE INSTRUCTIONS:
1. Report any redness, swelling, or drainage of incision, or
fever immediately to Dr.[**Name (NI) 4674**] office.
2. He needs to continue on the fondaparinux until the INR is
2 or greater.
3. He needs to start on Coumadin on [**Last Name (LF) 1017**], [**10-8**], and
have his INR checked on [**10-10**] with the results sent
to Dr.[**Name (NI) 4674**] office. Those results should be
called into telephone number [**Telephone/Fax (1) 1669**].
4. He needs weekly complete blood count, liver function
tests, creatinine, and blood urea nitrogen checks. Those
results need to be sent to Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 977**] (telephone
number [**Telephone/Fax (1) 11959**].
5. He needs to follow up with Dr. [**First Name (STitle) **] [**Name (STitle) 739**] on
[**2169-10-16**] at 11:00 o'clock for suture removal.
MEDICATIONS ON DISCHARGE:
1. Hydrochlorothiazide 25 mg by mouth once per day.
2. Atorvastatin calcium 10 mg by mouth once per day.
3. Metoprolol 25-mg tablets 0.5 tablet by mouth twice per
day.
4. Dilantin 100 mg by mouth three times per day.
5. Sodium chloride tablets two tablets by mouth three times
per day (for two days) and then 2 grams twice per day (for
two days) and then 1 gram by mouth twice per day (for two
days).
6. Normal saline flushes.
7. Decadron taper down to 2 mg by mouth once per day.
8. Senna 8.6 mg one by mouth twice per day.
9. Famotidine 20 mg by mouth twice per day.
10. Oxycodone/acetaminophen 5/325-mg tablets one to two
tablets by mouth q.4-6h.
11. Metoprolol 25-mg tablets 0.5 tablet by mouth twice
per day.
12. Regular and Humulin insulin.
13. Fondaparinux 2.5 mg - three injections of 2.5 mg to
total 7.5 mg by mouth once per day (until his INR is 2 or
greater once he is on Coumadin).
14. Ferrous sulfate tablets one tablet by mouth twice
per day.
15. Oxacillin 2 grams 1 IV q.4.h.
16. Colace 100 mg by mouth twice per day.
17. Coumadin 5 mg by mouth once per day (starting on
[**Last Name (LF) 1017**], [**10-8**]).
FINAL DISCHARGE DIAGNOSES:
1. GBM.
2. Incision infection.
3. Deep venous thrombosis.
4. Type 1 diabetes (induced by steroids).
5. Hypertension.
6. Hyponatremia.
CONDITION ON DISCHARGE: Mr. [**Known lastname 58058**] was discharged
neurologically intact.
[**Name6 (MD) **] [**Name8 (MD) 739**], MD [**MD Number(2) 2930**]
Dictated By:[**Last Name (NamePattern1) 8633**]
MEDQUIST36
D: [**2169-10-3**] 14:55:50
T: [**2169-10-3**] 16:13:45
Job#: [**Job Number 58061**]
|
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"453.8",
"287.5",
"276.1",
"790.7",
"191.9",
"251.8",
"530.81",
"998.59",
"324.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.23",
"38.7",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
1326, 1409
|
9819, 11017
|
1038, 1181
|
3184, 8858
|
8882, 9793
|
1432, 3166
|
11044, 11180
|
150, 691
|
714, 1012
|
1198, 1309
|
11205, 11516
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,098
| 106,393
|
50733
|
Discharge summary
|
report
|
Admission Date: [**2114-2-14**] Discharge Date: [**2114-2-23**]
Date of Birth: [**2067-3-6**] Sex: F
Service: MEDICINE
Allergies:
Latex / Penicillins
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Intubation
Central venous catheterization
History of Present Illness:
Ms. [**Known lastname 60258**] is a 46 year-old woman with history of advanced
interstitial lung disease, likely NSIP, chronic diastolic CHF,
DM, and chronic pain s/p MVA who presents with respiratory
failure. Patient unable to provide history, so HPI gathered from
OMR and sign-out. Patient was presumably in USOH on home O2 and
began to feel unwell over the past 7 days, with increased home
O2 requirement, fever, cough and sputum production. She saw her
PCP who treated her for presumed asthma exacerbation and started
the patient on a steroid taper (unclear dose). The patient did
not improve with this treatment regimen. At home, patient's
respiratory distress worsened and she called EMS who took her to
OSH ED. At OSH she was found to be hypoxic to 60-70's on RA, she
was treated with 750 mg levaquin, 125 mg solumedrol, 4 mg
morphine, duonebs and 12.5 mg benadryl, and transfered to [**Hospital1 18**]
for further care.
.
In the ED, initial vs were: T AFeb P 116 BP 118/69 R 30 O2 sat.
85% 7L. Patient was given etomidate, succinylcholine and
vecuronium for intubation and sedated with propofol. She was [**Last Name (un) **]
given 1g IV ceftriaxone, 100 ucg fentanyl, and albuterol nebs.
Even on the ventilator, her O2 Sats were still in the 80's with
ABG 7.07/91/78 on 100% FiO2. After optimization of her
ventilator settings with low RR and high Vt, the patient's O2
sats improved to 90's. On the floor, the patient was intbuated
and sedated. IV access was challenging to obtain and a central
line was placed. Her vitals were HR 121 BP 128/59 RR 20 O2 Sat
98% on 100% FiO2.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Non-specific interstitial pneumonitis (possibly idiopathic
pulmonary hemosiderosis?)
- s/p lung biopsy by VATS [**2109**] at [**Hospital1 **], lost to follow-up until
[**2112**]
- followed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], perhaps started prednisone course
[**2114-1-30**]
- Home O2 requirement of ~4L
- [**2114-1-2**] PFTs: DLCO 40% predicted, TLC 58% predicted, FEV1 54%
- Overall consistent with restrictive lung disease
CHF with recent hospitalization (per OMR)
Diabetes
Depression
Chronic pain status post MVA
?Cardiomegaly
TTE with ?rheumatic MV disease
CAD s/p MI (normal MIBI in [**2109**])
Cervical dysplasia
Colonic polyps s/p multiple polypectomies
Hiatal hernia
Migraines
PSH:
TAH-BSO
Cervical cone bx
Mediastinoscopy & L VATS [**2109**]
Social History:
She lives in [**Location **]. She is currently widowed. She has been
disabled after a motor vehicle accident which happened several
years ago.
- Tobacco: ~25 pack year history
- Alcohol: denies
- Illicits: h/o illicit drug use in youth
Family History:
She has two children. She has several relatives who have had
lung problems and has died from complications related lung
disease. Her mother had COPD, died of respiratory failure,
father with cardiovascular disease. She had a sister
who died after a lung biopsy was performed. She states that
several of her family members may have had asbestos exposure
including the patient.
Physical Exam:
ON ADMISSION:
Vitals: AFeb HR 121 BP 128/59 RR 20 O2 Sat 98% on 100% FiO2
General: Intubated, mildly sedated, in mild distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, difficult to assess JVP due to short, thick neck
Lungs: Tubular, coarse breath sounds anteriorly with occasional
expiratory squeaks
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
ON DISCHARGE:
Vitals: 97.5 HR 58 BP 100/66 RR 20 O2 Sat 98% on 6L NC
General: NAD, comfortable
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, no JVP
Lungs: Symmetric chest rise, no increased resp effort, dew
scattered crackles. No wheezes/rales/rhonchi.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Pertinent Results:
ADMISSION LABS:
[**2114-2-13**] 11:40PM WBC-10.6 RBC-4.06* HGB-11.3* HCT-32.9*
MCV-81* MCH-27.9 MCHC-34.5 RDW-15.1
[**2114-2-13**] 11:40PM NEUTS-89.4* LYMPHS-7.4* MONOS-2.3 EOS-0.5
BASOS-0.3
[**2114-2-13**] 11:40PM PLT COUNT-198
[**2114-2-13**] 11:40PM GLUCOSE-227* UREA N-10 CREAT-0.9 SODIUM-133
POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-21* ANION GAP-18
[**2114-2-13**] 11:54PM LACTATE-2.3* K+-4.0
[**2114-2-13**] 11:40PM PT-14.8* PTT-35.6* INR(PT)-1.3*
[**2114-2-13**] 11:40PM proBNP-1023*
[**2114-2-13**] 11:40PM cTropnT-<0.01
MICRO:
[**2114-2-13**] BLOOD CULTURE X2 - NGTD (PENDING)
[**2114-2-14**] 10:30 am Influenza A/B by DFA
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2114-2-14**]):
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2114-2-14**]):
Negative for Influenza B.
[**2114-2-14**] 11:07 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2114-2-14**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2114-2-16**]):
Commensal Respiratory Flora Absent.
YEAST. RARE GROWTH.
[**2114-2-15**] 10:37 am URINE Source: Catheter.
URINE CULTURE (Final [**2114-2-16**]): NO GROWTH.
[**2114-2-15**] 12:05 pm SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
GRAM STAIN (Final [**2114-2-15**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Preliminary):
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
[**2114-2-15**] BLOOD CULTURE - NGTD (PENDING)
STUDIES:
[**2114-2-13**] CXR: Interval recurrence or progression of diffuse
alveolar
opacification in setting of known chronic interstitial lung
disease (NSIP/ILD leading diagnostic considerations per OMR).
This could be pulmonary edema or widespread pneumonia or
hemorrhage. Given the course consideration should also be given
to drug or toxin exposure exacerbating a preexisting reaction.
[**2114-2-14**] TTE: Suboptimal image quality. Right ventricular cavity
enlargement with free wall hypokinesis. Normal left ventricular
cavity size and regional/global systolic function. Mild mitral
stenosis.
Compared with the prior study (images reviewed) of [**2110-4-9**],
the right ventricular findings are new and suggestive of
myocardial contusion. The severity of mitral stenosis has
increased. The severity of mitral regurgitation has declined
(may be due to tachycardia and suboptimal image quality).
[**2114-2-15**] EKG: Sinus rhythm and increase in rate as compared to
the previous tracing of [**2110-4-9**]. There is right axis deviation
and low limb lead voltage. There is now ST segment elevation in
leads V1-V3 with biphasic to inverted T waves in leads V1-V5,
more prominent as compared to the previous tracing of [**2110-4-9**].
The rate is increased. These findings are consistent with active
anterolateral ischemic process. Followup and clinical
correlation are suggested.
CTA Wet read [**2114-2-23**]:
No PE. Some consolidations/septal thickening suggestive of fluid
vs infection. Enlarged pulm artery suggestive of pulmonary HTN.
Brief Hospital Course:
Ms. [**Known lastname 60258**] is a 46 year-old woman with history of advanced
interstitial lung disease, likely NSIP, CHF, DM, and chronic
pain s/p MVA who presents with respiratory failure.
ICU Course:
Patient was intubated in the ED secondary to respiratory
distress and oxygen saturations in the 80s. She was admitted to
the MICU were a CVL was placed. She was treated initially
empirically with levofloxacin and broadened to
vancomycin/cefepime/azithromycin for empiric coverage of HCAP.
She was also given IV steroids, then transitioned to prednisone
40 mg daily, for an ILD flare per her outpatient pulmonologist,
Dr. [**Last Name (STitle) **]. Influenza swab was sent and returned negative. Sputum
cultures grew commensal respiratory flora and yeast. She was
also diuresed with IV lasix given an elevated BNP of 1023 over
her baseline of 363 from [**10-1**] and overload on CXR. IV Lasix
40mg IV was effective and diuresis. Echocardiogram showed
findings of RV free wall hypokinesis c/w contusion related to
MVA as well as mild MS and MR. [**Name14 (STitle) 2287**] cardiology recommended
further evaluation with TEE as this valvular disease may be
contributing to her heart failure. She was extubated on [**2-16**]
with return to her baseline home oxygen requirement. Just prior
to transfer to the floor patient was started on morphine
60mg/30mg/60mg PO TID for her chronic fibromyalgia neck and
shoulder pain.
*ACTIVE ISSUES*
# Acute on chronic diastolic heart failure: The patient is on
daily lasix 60 mg at home and has a history of chronic diastolic
heart failure secondary to rheumatic heart disease (echo in [**2109**]
showed EF>55%, mild-mod MV regurg). Her dyspnea was thought to
be due to volume retention in the setting of starting steroids
for baseline lung disease. In the MICU she was started on IV
lasix 40 mg with good response. On the floor her lung exam was
notable for bibasilar crackles and high-pitched inspiratory
squeaks, as well as bipedal pitting edema. She was therefore
continued on IV lasix with resolution of dyspnea and improved
lung exam. Her oxgen requirement was lowered to her baseline of
6L NC. A repeat CXR on [**2-21**] showed substantial improvement in
pulmonary edema compared to the prior study of [**2-17**]. To
evaluate the role of mitral valve dysfunction on CHF
exacerbation, she also underwent a repeat echo given poor window
of bedside TTE in the MICU. The echo was largely unchanged from
her prior in [**2109**], with preserved EF 70% and mild resting left
ventricular outflow tract obstruction. Rheumatic mitral valve
deformity was noted along with mild MV stenosis. Cardiology
recommended starting the patient on low-dose metoprolol due to
concern for CHF exacerbation from tachycardia/decreased filling
time in the setting of the patient's MR/MS. [**First Name (Titles) **] [**Last Name (Titles) 8337**]
metoprolol succinate 12.5mg daily well. The patient was
transitioned to po lasix 40 mg, and on this low dose continued
to produce output 3-4L daily. She appeared consistently
euvolemic on this dose. Her Cr remained stable throughout this
period. On discharge her weight was 100.2 kg, compared to her
baseline weight of 101.2 kg ([**2114-1-2**]). The CTA on day of
discharge revealed signs of some fluid overload and decision was
made to send her home on 60mg daily (her usual home dose) and to
likely taper down to 40mg daily if appropriate when she sees her
primary care physician. [**Name10 (NameIs) **] was discharged on lasix 60mg daily
and metoprolol 12.5 mg daily. Pt was satting in the mid-high 90s
on 6L at time of discharge.
# ILD: The patient has advanced interstitial lung disease with
tissue diagnosis of fibrotic NSIP in [**2109**]. She is on baseline 6L
O2 at home and is followed closely by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. While
inhouse it was thought that her lung disease was contributing to
her dyspnea and acute presentation. She was therefore continued
on prednisone 40 mg po daily. The patient was seen by Dr. [**Last Name (STitle) **]
who recommended a slow steroid taper over 1-2 months with
possible outpatient transition to azathioprine. Given her
continuation of steroids, she was started on a PPI. She was also
started on PCP prophylaxis with bactrim and discharged on
Cal/VitD.
# Diabetes mellitus: The patient had poor glycemic control
during her stay, with post-meal FSBG levels consistently >400.
A HgA1c was 9.2. Her lantus was increased to 24 from baseline
20 with good effect. She was started on a novolog sliding scale
with frequent adjustment. [**Last Name (un) **] saw the patient while inhouse
for elevated sugars. The decision was made to STOP metformin
given her CHF, and the patient was instructed not to resume this
outpatient. She was discharged on lantus 24 U qhs and novolog
sliding scale (Starting breakfast and lunch at 12 for BG
100-150, increase by 2; dinner at 8 Units for BG 100-150,
increase by 2; bedtime at 4 for BG 151-200, increase by 2).
# Chronic pain s/p MVA: Baseline chronic back pain was
controlled with her home morphine dose 60mg/30mg/60mg PO TID
which was started in the MICU. She had adequate pain control
during her hospitalization.
*INACTIVE ISSUES:*
# Anemia: The patient is chronically anemic and remained so
with Hcts ranging from 27.9-31.9. This is consistent with her
baseline.
# Hypertension: Patient's aldactone was held given diuresis and
relatively low BPs on the floor. Because she was started on
metoprolol, her aldactone was discontinued.
# Depression/anxiety: The patient was continued on her home
doses of sertraline 200 mg daily and diazepam 5 mg q6 prn.
Labs/Studies Pending at Discharge:
- CTA final read ([**2114-2-23**])
Transitional Care Issues:
- Patient will need electrolytes checked on Friday [**3-2**].
VNA has been arranged and PCP [**Name Initial (PRE) 13109**].
-Aldactone was held during admission. [**Month (only) 116**] be resumed outpatient
if patient tolerates metoprolol.
-Started metoprolol 12.5mg succinate daily. Reccomend continued
monitoring outpatient as she might benefit from higher dose.
Medications on Admission:
Diazepam 5mg q6-8h PRN anxiety
Lasix 60mg daily
Lantus 20u daily
Metformin 1000mg [**Hospital1 **]
Morphine 60/30/60 mg PO qAM/afternoon/PM
Oxycodone 5mg PO BID (between morphine doses)
Sertraline 200mg daily
Diovan 80mg daily
Various vitamins: D2, B6, B12, fish oil
(per [**Location (un) 2274**] records, additionally)
Fioricet 2 tablets q4h PRN severe HA
Spironolactone 25mg daily
Hydroxyzine 50mg qAM/PM
Discharge Medications:
1. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
Continue until you see Dr. [**Last Name (STitle) **].
Disp:*60 Tablet(s)* Refills:*1*
3. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation every 4-6 hours as needed for wheeze.
Disp:*1 inh* Refills:*0*
6. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. dextromethorphan-guaifenesin 10-100 mg/5 mL Liquid Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
Disp:*40 ML(s)* Refills:*0*
8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
9. morphine 30 mg Tablet Extended Release Sig: Two (2) Tablet
Extended Release PO Q12H (every 12 hours) as needed for
neck/shoulder pain.
10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for pain.
11. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO NOON (At Noon).
12. diazepam 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for anxiety.
13. Outpatient Lab Work
Please draw chem 7 on [**2114-2-27**] and fax to:[**Telephone/Fax (1) 6808**] attn: Dr
[**First Name8 (NamePattern2) 4320**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
14. insulin glargine 100 unit/mL Solution Sig: Twenty Four (24)
Subcutaneous at bedtime.
Disp:*1 month's supply* Refills:*2*
15. insulin Novolog Sig: One (1) four times a day: Follow
Sliding Scale.
Disp:*1 month's supply* Refills:*2*
16. Insulin Syringe MicroFine 0.3 mL 28 x [**12-24**] Syringe Sig: One
(1) Miscellaneous four times a day.
Disp:*1 month's supply* Refills:*2*
17. Lasix 40 mg Tablet Sig: 1 and [**12-24**] Tablet PO once a day: take
total of 60mg (1.5 tablets) a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company **] [**Location (un) **]
Discharge Diagnosis:
Primary diagnoses:
Acute on Chronic Diastolic Congestive Heart Failure
Interstitial Lung Disease
Congestive Heart Failure
Secondary diagnoses:
Diabetes Mellitus
Coronary Artery Disease
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 60258**],
You were admitted to the hospital for shortness of breath. We
believe this was most likely due to extra fluid in your lungs.
When you first arrived to our Emergency Department, a tube was
placed in your throat to help you breathe (intubation). You
were admitted to the intensive care unit, where you were given a
medication (Lasix) to help decrease the fluid in your lungs.
You were treated with steroids to decrease possible inflammation
in your lungs. You also received antibiotics to cover the
bacteria that cause lung infections. You responded well to these
treatments and your breathing tube was eventually removed.
In the ICU, you had an ultrasound of your heart (Echo) which
showed slightly worsened disease of one of your heart valves
(from rheumatic heart disease). Your heart function is
otherwise unchanged from your last echo in [**2109**].
You were then transferred to the medicine floor, where you
completed the course of antibiotics. You were continued on
steroids. Your IV Lasix was transitioned to Lasix by mouth, and
you continued to put out a considerable amount of extra fluid
which helped your oxygenation. Your oxygen requirements
decreased to your home oxygen of 6 Liters. You were able to
ambulate on your own without issue. You will go home on lasix
60mg daily. This dose might be lowered to 40mg daily after you
see your primary care doctor next week if she feels it is
appropriate.
Your sugars were found to be elevated, especially after starting
prednisone. We had diabetes specialists see you who helped to
titrate your insulin. You will go home on Insulin Sliding Scale
regimen that was reviewed with you in the hospital. Please
follow the attached Sliding Scale regimen.
On the day of discharge you had some chest pain with breathing.
We obtained a CT scan of your lungs and it showed there is no
clot in your lungs, this is good news.
Remember to check daily weights. If your weight goes up by 3
pounds, please call Dr [**Last Name (STitle) **], you might need a higher dose of
your lasix. This is VERY important. If you can not get through
to Dr [**Last Name (STitle) **], please call your primary care doctor.
The following changes were made to your medications:
STOP Metformin. Do not take this medication any more. It should
not be taken by patients with heart failure.
STOP Aldactone. You may resume this if your PCP agrees and if
your blood pressure tolerates. We started you on metoprolol and
decided to stop the aldactone for now.
START insulin sliding scale with Novolog, see the attached form
for an explanation.
CHANGED lantus from 20->24 U every evening
START: Bactrim, take 1 tab daily to prevent pneumonia while on
steroids.
START: Pantoprazole 40mg daily, take this while on steroids
START Prednisone 40 mg daily. You will be on this medication
until further discussion with your pulmonologist Dr. [**Last Name (STitle) **].
START Metoprolol 12.5mg daily. Please take [**12-24**] pill of the 25mg
daily. This will protect your heart from future heart failure
episodes.
CONTINUE: Lasix 60mg daily to help remove fluid from your lungs
No other medication changes were made. Please continue to take
them as you have been doing.
Follow-up appointments have been made for you. Please see the
details below.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: [**Location (un) 2274**]-[**Location (un) **]
Address: 111 [**Doctor Last Name **] DR, [**Location (un) **],[**Numeric Identifier 17464**]
Phone: [**Telephone/Fax (1) 105541**]
Appointment: Friday [**3-2**] at 1:45PM
Department: PULMONARY FUNCTION LAB
When: MONDAY [**2114-3-12**] at 8:10 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: MONDAY [**2114-3-12**] at 8:30 AM
Department: MEDICAL SPECIALTIES
When: MONDAY [**2114-3-12**] at 8:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) 611**], M.D. [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2114-3-22**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"250.00",
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"724.5",
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"518.81",
"276.3",
"285.9"
] |
icd9cm
|
[
[
[]
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[
"96.04",
"96.6",
"38.97",
"96.71"
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icd9pcs
|
[
[
[]
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17069, 17135
|
8248, 13481
|
287, 330
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17378, 17378
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5023, 5023
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14022, 14389
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3238, 3476
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,165
| 131,060
|
50411
|
Discharge summary
|
report
|
Admission Date: [**2159-6-2**] Discharge Date: [**2159-6-6**]
Date of Birth: [**2091-8-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
gangrenous scrotum
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
67yo M h/o ESRD, ESLD, CAD who presents with scrotal rash.
Initially presented to pcp who prescribed lamisil. The next day
he re-presented to [**Hospital3 **] where he was diagnosed with
fourniers gangrene. Patient was given Clindamycin and Zosyn. A
CT abdomen reportedly showed no free air and the patient was
lethargic but they spoke to his neice who wanted a further
workup and he was sent here for urology.
.
In the ED, initial vs were: T 97.4 52 100/46 14 99. He was A+OX1
and unable to give a history. He was noted to have crepitus and
a gangrenous scrotum on exam. The OSH CT scan was read here as
having evidence of free air by our radiologists but then they
decided there was not free air actually it was just the
decompressed bladder with foley balloon tenting it up. Urology
consult and Surgery consult both thought that he was too sick to
be a surgical candidate and recommended admit to MICU for
unclear reasons. Blood and urine cultures were sent and he was
given vanc/gent here per urology recs. He was also given
thiamine for alcoholism and encephalopathy and 3L NS. While he
was in the ED his neice was [**Name (NI) 653**]. She said he would not
want surgery but would want antibiotics and other treatment. She
also faxed over DNR paperwork, however the patient reportedly
said he would be willing to be intubated. Family was called in
and will be here around 9pm from out of town. Ground work laid
to be CMO later tonight. Renal aware that he's here but since
DNR/DNI but may need HD at some point. (Normally does not get HD
as an outpatient). Two PIVs in for access.
.
Vital signs prior to transfer: HR: 45-50 sinus bradycardia, BP:
111/60 RR 14 98% RA.
.
On the floor, patient had no pain. Said the rash had been there
for a year. No other complaints except that he has "Flat lined"
and sick of medical care.
Past Medical History:
ESLD
Afib
Diabetes
Bypass surgery
HTN
ESRD not on HD yet
Gastric bypass
ETOH abuse
Social History:
Lives in [**Hospital3 **] and is a former accountant. Heavy ETOH abuse
for 7 years per niece and wife after gastric bypass he started
drinking instead of eating. Stopped smoking several years ago.
Family History:
unknown
Physical Exam:
Vitals: T:97 BP:102/59 P:55 R:16 O2: 100% RA
General: Alert, oriented to person only, no acute distress
HEENT: Sclera anicteric, very dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: distended, non-tender, bowel sounds present, no
rebound tenderness or guarding,
GU: foley in place with crepitus in scrotum and left side of
groin along inguinal ligament. Two patches of necrotic tissue
(about 2cm in diameter) on scrotum with candidal rash overlying
it in groin
Ext: warm, well perfused, anasarca
Pertinent Results:
[**2159-6-2**] 05:20PM BLOOD WBC-11.4* RBC-3.03* Hgb-9.1* Hct-27.4*
MCV-90 MCH-30.1 MCHC-33.3 RDW-15.0 Plt Ct-198
[**2159-6-2**] 05:20PM BLOOD Neuts-83.8* Lymphs-11.5* Monos-3.8
Eos-0.7 Baso-0.2
[**2159-6-2**] 05:20PM BLOOD PT-15.6* PTT-37.2* INR(PT)-1.4*
[**2159-6-2**] 05:20PM BLOOD Glucose-98 UreaN-73* Creat-5.7* Na-143
K-4.0 Cl-116* HCO3-11* AnGap-20
[**2159-6-2**] 05:20PM BLOOD ALT-6 AST-10 CK(CPK)-16* AlkPhos-79
TotBili-0.5
[**2159-6-2**] 05:20PM BLOOD Albumin-2.1* Calcium-8.2* Phos-6.1*
Mg-3.0*
[**2159-6-2**] 05:29PM BLOOD Lactate-2.2*
[**2159-6-5**] 07:35AM BLOOD WBC-9.6 RBC-2.89* Hgb-8.8* Hct-25.2*
MCV-87 MCH-30.5 MCHC-35.0 RDW-15.0 Plt Ct-163
[**2159-6-5**] 07:35AM BLOOD PT-16.1* INR(PT)-1.4*
[**2159-6-5**] 07:35AM BLOOD Glucose-40* UreaN-70* Creat-5.7* Na-145
K-3.2* Cl-115* HCO3-13* AnGap-20
[**2159-6-5**] 07:35AM BLOOD Calcium-7.3* Phos-5.1* Mg-2.5
[**2159-6-3**] Radiology SCROTAL U.S.
1. No evidence of abscess.
2. Massive scrotal edema consistent with stated diagnosis of
cellulitis.
3. Small right hydrocele otherwise normal testes and
epididymides
bilaterally.
[**2159-6-3**] Radiology CHEST (PORTABLE AP)
Lungs are well aerated, without consolidation or effusion. Heart
size,
mediastinal contours, and pulmonary vascular markings are within
normal
limits.
[**2159-6-3**] Radiology CT ABDOMEN/PELVIS W/O CONTRAST
1. No evidence of air within the scrotum or subcutaneous
tissues.
2. Large amount of ascites. Small nodular liver consistent with
history of
chronic liver disease.
3. Diffuse anasarca and bilateral hydroceles.
Brief Hospital Course:
67yo M with h/o ESLD, ESRD, CAD admitted with scrotal cellulitis
and worsening hepatic and renal failure.
Patient evaluated by urology and surgery in the ED who felt pts
scrotum not true fournier's, just a scrotal cellulitis. Scrotal
ultrasound was obtained and did not show evidence of deep tissue
fluid collections or gas. Broad abx coverage initiated with
vanc/zosyn. Discussed with family and pt who agreed that he
would not want surgical management even if indicated.
Similarly, despite worsening renal failure (creatinine to 5.7
from ?baseline 1.7) and poor urine output, patient and family
declined dialysis despite electrolyte abnormalities and
metabolic acidosis attributed to anuria. He was managed
medically with pain control, antibiotics, and IV bicarbonate.
His renal function did not improve. Lactulose was continued for
his liver disease. Palliative care was very involved regarding
goals of care with patient and his family. Patient had been ill
for a very long time and did not want aggressive care. On the
day prior to discharge patient was made CMO with treatment with
oral antibiotics, symptom control, lactulose, and comfort
feeding. He was discharged [**Last Name (un) **] with hospice.
Medications on Admission:
Paxil 30mg daily
lactulose 30mL QID
Os-cal with vit D daily
Folate 1mg daily
Levothyroxine 150mcg daily
MVI
FeSo4 325mg daily
Nadolol 20mg daily
PRN APAP QD
Ativan 0.5 mg daily
Discharge Medications:
1. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q24H (every 24 hours) for 9 days.
Disp:*9 Tablet(s)* Refills:*0*
2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
3. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Dilaudid-5 1 mg/mL Liquid Sig: [**2-22**] mL PO every four (4) hours
as needed for pain.
Disp:*250 mL* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Hospice of [**Hospital3 **]
Discharge Diagnosis:
Health Care Proxy has been invoked.
Primary Diagnosis:
1. Scrotum Cellulitis
2. End Stage Renal Disease
3. End Stage Kidney Disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with infection of your scrotum. You were
initially in the ICU and treated with IV antibiotics. You have
end state kidney and liver disease, and your health care proxy
decided to focus on comfort care only. You are going home with
hospice services.
Please continue all medications as prescribed.
You will complete Augmentin for another 9 days for your scrotal
infection.
Please contact your hospice services for any questions or
concerns.
Followup Instructions:
Please follow up all concerns with hospice and your new PCP.
Completed by:[**2159-6-7**]
|
[
"303.91",
"276.2",
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"348.30",
"403.91",
"414.01",
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"427.31",
"572.8"
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icd9cm
|
[
[
[]
]
] |
[
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
6780, 6838
|
4828, 6049
|
331, 339
|
7015, 7015
|
3241, 4805
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2535, 2544
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6075, 6253
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367, 2198
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,648
| 116,090
|
19920+19921+19922
|
Discharge summary
|
report+report+report
|
Admission Date: [**2191-1-12**] Discharge Date: [**2191-1-17**]
Date of Birth: Sex:
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 86 year old
male with persistent cough found to have left upper lobe mass
on chest x-ray. Chest CT on [**2190-11-9**] confirmed the presence
of a 6 cm cavitary left upper lobe mass and right hilar
lymphadenopathy. The patient has lost about 30 pounds in the
past six weeks. Fatigued on standing. Persistent cough.
Right shoulder pain for the past six weeks with certain
movements. No headaches.
PAST MEDICAL HISTORY: Status post XRT eight years ago for
prostate cancer. Mild hypertension. Pedal edema. AAA 2.4
cm in [**5-9**].
PAST SURGICAL HISTORY: None.
ALLERGIES: None.
MEDICATIONS: Aspirin 81 mg twice weekly.
PHYSICAL EXAMINATION: The patient was a well appearing
normal in no acute distress. HEENT pupils equally round and
reactive to light. No scleral icterus. Lungs clear to
auscultation bilaterally. Heart regular rate and rhythm, no
murmurs. Abdomen negative. Extremities no cyanosis,
clubbing or edema. Neuro no focal deficits.
LABORATORY DATA: CAT scan on [**2190-11-9**] showed a 6 cm large
cavitary left upper lobe mass and 2 cm right hilar mass. PET
scan reported no peripheral mets, but question mediastinal
involvement.
HOSPITAL COURSE: The patient was admitted on [**2191-1-12**] and was
taken directly to the operating room where left upper lobe
resection and ribs two, three and four resections were
performed. The patient did all right postoperatively and was
transferred to the surgical ICU postoperatively, intubated.
On transfer the patient didn't have any problems
postoperatively. This was particularly important because the
patient was an extremely difficult intubation. The patient
had an epidural in place for pain. He received Kefzol
perioperatively. He did have some postoperative oliguria
requiring periodic fluid boluses. Chest tubes were in place
and to suction.
On postoperative day one the patient was successfully
extubated. He had his diet advanced successfully and was
heplocked. He was transferred to the floor. He stayed on
the floor for another three days secondary to high chest tube
output. On [**2191-1-17**] the chest tubes were removed
successfully. His epidural was removed and the patient was
changed to p.o. pain medication. He is doing well and will
be discharged in the morning to a rehab facility.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern4) 12487**]
MEDQUIST36
D: [**2191-1-17**] 16:05
T: [**2191-1-17**] 17:09
JOB#: [**Job Number 53753**]
Admission Date: [**2191-1-12**] Discharge Date: [**2191-1-18**]
Service: Thoracic Surgery
HISTORY OF PRESENT ILLNESS: This is an 86 year old male who
presented with persistent cough and right shoulder pain and
was found to have a left upper lobe on chest x-ray. A
computerized tomography scan on [**2190-11-9**], confirmed
the presence of a 6 cm cavitary left upper lobe mass and
there was also question of a right hilar lymph node. On
[**2190-12-22**], he underwent a mediastinoscopy after which
he was found to have a resectable left lung tumor. At this
time he was admitted for resection of the left upper lobe
mass.
PAST MEDICAL HISTORY: Status post radiation therapy eight
years ago for prostate cancer, mild hypertension, 2.4 cm
abdominal aortic aneurysm.
PAST SURGICAL HISTORY: None.
ALLERGIES: No known drug allergies.
MEDICATIONS: Aspirin 81 mg twice weekly.
SOCIAL HISTORY: Married, retired with 30 year history of
smoking two packs per day, quit 30 years ago.
PHYSICAL EXAMINATION: On admission, well-appearing in no
apparent distress. Chest clear to auscultation bilaterally.
Heart, regular rate and rhythm. Abdomen, soft, nontender,
nondistended. Extremities, no cyanosis, clubbing or edema.
Neurologically intact.
HOSPITAL COURSE: On the day of this admission, he underwent
a left upper lobectomy and resection of the chest wall
overlying the tumor which included segments of ribs 2, 3 and
4. He tolerated the procedure well, but secondary to a very
difficult intubation he was kept intubated over night
immediately postoperatively and was therefore in the
Intensive Care Unit for 24 hours. The next morning he
extubated with no difficulty and after that his course is
summarized as follows.
1. Neurological - His pain was initially controlled with an
epidural and then was well controlled on p.o. pain
medication. He did present with slight confusion early
postoperatively but was back to his baseline mental status
with no neurological deficits thereafter and this was
attributed to postoperative delirium and narcotics.
2. Cardiovascular - He remained stable postoperatively and
required no additional medications. Due to slight
bradycardia early postoperatively, he was not started on any
beta blockade perioperatively.
3. Respiratory - He remained stable with good saturations
initially with some oxygen later on room air. Chest tubes
were removed on postoperative day #5. Chest x-ray
demonstrated good inflation of the remaining segment of the
left lung with a small residual space. Prior to discharge he
is comfortable and his saturations were 97% on room air.
4. Gastrointestinal - His diet was advanced as tolerated and
he tolerated that with no difficulty.
5. Genitourinary - His urine output was good at all times
and renal function was maintained. He had no difficulty
voiding after the Foley catheter was removed.
6. Heme - He remained stable and required no blood products
during the hospitalization. His hematocrit on [**2191-1-14**], postoperatively was 32.9.
7. Infectious disease - There were no active issues. He was
covered with Cefazolin perioperatively which was continued
for a few days after surgery and he will stop with discharge.
He remained afebrile with a normal white count and his wound
was healing well.
8. Musculoskeletal - Activity was gradually advanced with
the assistance of physical therapy. It was felt that he will
benefit from a short stay in a rehabilitation facility to
assist him to get back to baseline activities.
He is discharged in stable condition to a rehabilitation
facility with the following recommendations:
1. Follow up with Dr. [**Last Name (STitle) 952**] as scheduled, see discharge
sheet.
2. Continue current medications, again as summarized in the
discharge sheet and including Percocet prn for pain, Colace
100 mg p.o. b.i.d. as long as taking pain medications,
Albuterol inhaler 2 puffs every 6 hours prn.
DISCHARGE DIAGNOSIS: Left lung tumor, status post left upper
lobectomy with chest wall resection.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2191-1-17**] 08:04
T: [**2191-1-18**] 08:34
JOB#: [**Job Number 53754**]
Admission Date: [**2191-1-12**] Discharge Date: [**2191-1-18**]
Service: Thoracic Surgery
HISTORY OF PRESENT ILLNESS: This is an 86 year old male who
presented with persistent cough and right shoulder pain and
was found to have a left upper lobe on chest x-ray. A
computerized tomography scan on [**2190-11-9**], confirmed
the presence of a 6 cm cavitary left upper lobe mass and
there was also question of a right hilar lymph node. On
[**2190-12-22**], he underwent a mediastinoscopy after which
he was found to have a resectable left lung tumor. At this
time he was admitted for resection of the left upper lobe
mass.
PAST MEDICAL HISTORY: Status post radiation therapy eight
years ago for prostate cancer, mild hypertension, 2.4 cm
abdominal aortic aneurysm.
PAST SURGICAL HISTORY: None.
ALLERGIES: No known drug allergies.
MEDICATIONS: Aspirin 81 mg twice weekly.
SOCIAL HISTORY: Married, retired with 30 year history of
smoking two packs per day, quit 30 years ago.
PHYSICAL EXAMINATION: On admission, well-appearing in no
apparent distress. Chest clear to auscultation bilaterally.
Heart, regular rate and rhythm. Abdomen, soft, nontender,
nondistended. Extremities, no cyanosis, clubbing or edema.
Neurologically intact.
HOSPITAL COURSE: On the day of this admission, he underwent
a left upper lobectomy and resection of the chest wall
overlying the tumor which included segments of ribs 2, 3 and
4. He tolerated the procedure well, but secondary to a very
difficult intubation he was kept intubated over night
immediately postoperatively and was therefore in the
Intensive Care Unit for 24 hours. The next morning he
extubated with no difficulty and after that his course is
summarized as follows.
1. Neurological - His pain was initially controlled with an
epidural and then was well controlled on p.o. pain
medication. He did present with slight confusion early
postoperatively but was back to his baseline mental status
with no neurological deficits thereafter and this was
attributed to postoperative delirium and narcotics.
2. Cardiovascular - He remained stable postoperatively and
required no additional medications. Due to slight
bradycardia early postoperatively, he was not started on any
beta blockade perioperatively.
3. Respiratory - He remained stable with good saturations
initially with some oxygen later on room air. Chest tubes
were removed on postoperative day #5. Chest x-ray
demonstrated good inflation of the remaining segment of the
left lung with a small residual space. Prior to discharge he
is comfortable and his saturations were 97% on room air.
4. Gastrointestinal - His diet was advanced as tolerated and
he tolerated that with no difficulty.
5. Genitourinary - His urine output was good at all times
and renal function was maintained. He had no difficulty
voiding after the Foley catheter was removed.
6. Heme - He remained stable and required no blood products
during the hospitalization. His hematocrit on [**2191-1-14**], postoperatively was 32.9.
7. Infectious disease - There were no active issues. He was
covered with Cefazolin perioperatively which was continued
for a few days after surgery and he will stop with discharge.
He remained afebrile with a normal white count and his wound
was healing well.
8. Musculoskeletal - Activity was gradually advanced with
the assistance of physical therapy. It was felt that he will
benefit from a short stay in a rehabilitation facility to
assist him to get back to baseline activities.
He is discharged in stable condition to a rehabilitation
facility with the following recommendations:
1. Follow up with Dr. [**Last Name (STitle) 952**] as scheduled, see discharge
sheet.
2. Continue current medications, again as summarized in the
discharge sheet and including Percocet prn for pain, Colace
100 mg p.o. b.i.d. as long as taking pain medications,
Albuterol inhaler 2 puffs every 6 hours prn.
DISCHARGE DIAGNOSIS: Left lung tumor, status post left upper
lobectomy with chest wall resection.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2191-1-18**] 08:04
T: [**2191-1-18**] 08:34
JOB#: [**Job Number 53754**]
|
[
"196.1",
"V10.46",
"293.0",
"401.9",
"198.89",
"198.5",
"162.3",
"441.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.4",
"32.4"
] |
icd9pcs
|
[
[
[]
]
] |
11028, 11369
|
8337, 11006
|
7864, 7952
|
8080, 8319
|
7190, 7696
|
7719, 7840
|
7969, 8057
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,596
| 135,002
|
13155
|
Discharge summary
|
report
|
Admission Date: [**2162-1-27**] Discharge Date: [**2162-2-11**]
Date of Birth: [**2112-10-13**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
dry cough, congestion and generalizaed malaise, plus increased
jaundice from his baseline status
Major Surgical or Invasive Procedure:
EGD/EUS
PICC line placement
History of Present Illness:
HPI from [**Hospital Unit Name 153**]: 49M vasculopath w/ chronic mesenteric ischemia
s/p multiple abdominal surgeries including near total
enterectomy, severe malnutrition, TPN dependent (does own TPN at
home), and h/o multiple fungemia episodes who orginally
presented to [**Location (un) **] ED on [**1-18**] with dry cough, congestion and
generalizaed malaise, plus increased jaundice from his baseline
status. Upon presentation to the ED, the pt had a temp of 100.0
and was found to be in afib per report. Of note, the patient
recently stopped his chronic iv caspo tx for chronic fungemia on
[**2162-1-11**] since he was doing well (ID at [**Hospital1 18**] dc'd caspo). His
TEE at [**Hospital1 18**] on [**2162-1-5**] showed no vegetations.
.
ON admisisons to [**Location (un) **], the patient denied any CP, HA, nausea,
vomiting, diarrhea. +fevera nd chills at home, + dry cought, no
hemoptysis or hematemeisis. No nightsweats. Denies gaining or
losing [**First Name8 (NamePattern2) 691**] [**Last Name (un) 14836**]. He was found to have bilateral pleural
effusions and admitted to general medicine service. There was a
q of infiltrate on cxr, unasyn was started [**2162-1-19**]. Hct found to
hve 24.5, xfused 2 u PRBCs. Blood cx sent, [**5-5**] grew yeast,
speciation pending. Repeat Cx drawn [**1-23**], [**1-30**] yeast. ID
consultation was obtained, and the patient was started on IV
caspo [**1-20**] and IV fluc [**1-26**], given his previous infections with
cadindia (sensitive to Cipro). R sided [**Female First Name (un) 576**] was done [**1-23**] and
[**1-26**] with 1L transudative fluid out both times. L pleural
effusion persisted. CT scan was done noting paraesophageal mass,
false lumen was suspected. Barium swallow was done, negative for
false lumen. Request was made to xfer pt to [**Hospital1 18**] for tissue dx
of this mass. Patient was maintained on present dose of TPN. It
is not clear from records, but on [**1-26**], pt spiked to 103.5, with
BP 81/48. He was given fluids, IV abx, xferred to [**Location (un) **] ICU.
Abx were continued and xfer to [**Hospital1 18**] ICU vs [**Hospital1 18**] floor was
requested. He was given 3L of IVF at [**Location (un) **] ICU with
improvement of SBP to 100s. He was transiently on levophed, but
unclear duration. His PICC was changed on [**2162-1-26**]. Through all
of this, the patient decided to be DNR/DNI. Of note, pt still
has multiple abdominal vascular grafts present.
.
admitted [**Location (un) **] [**1-20**] fever
xfused 2 u prbcs [**2162-1-19**].
was on levo, unasyn/vanc initially: [**1-19**], changed to
vanc 1g qd [**1-24**]
caspo 50 qd [**1-20**]
unasyn [**1-19**]
fluc 400 iv q24 [**1-26**]
.
[**Hospital Unit Name 13533**]: Upon arrival to [**Hospital1 18**], the patient was stable,
though septic. No resp distress, pt's own home TPN running (he
was never changed over to [**Location (un) **] TPN) at ~230cc's/hr. On [**1-27**]:
Contact[**Name (NI) **] ID, thoracics, vascular [**Doctor First Name **]. [**1-28**]: TTE showed no
vegetation. ID consulted, rec ophtho & liver c/s and TEE. [**1-29**]:
CT chest with ?paraesphageal abscess and large bilat pleural
effusions. Guaiac +ve ostomy output. [**1-30**]: TPN via PICC.
Thoracics-no surgical intervention (too morbid). Liver rec
ursodiol 300 TID. ID rec change cefepime to meropenem for better
anaerobe coverage. [**1-31**]: Began to have some bleeding in ostomy
output. Hct dropped 27 to 21. Transfused 2 units PRBC. FFP
ordered for morning to reverse coagulopathy in advance of
EGD/EUS. [**2-1**]: EGD/EUS: Blood in stomach, no active bleeding site
identified. Thick stomach mucosa with cystic appearence, 2 cc of
fluid removed from para-esophogeal cystic mass and sent to
micro. Patient desatted post-procedure, responded well to
non-rebreather.
[**2-2**]: Weaning O2. D/c'd TEE due to positive culture from EUS
biopsy. Transfused 1 U PRBC for volume. Given LR for
hypotension. [**2-3**]: More blood in ostomy drainage. Hct stable.
Thoracics consulted for ? drainage of fungal abscess. [**2-4**]:
Cultures from para-esophageal cystic mass growing yeast, MRSA,
and Enterococcus. SSRI started.
[**2-5**]: PICC line D/C'd. Meropenem D/C'd.
Past Medical History:
-chronic mesenteric ishcemia
-s/p aortobifemoral artery bypass [**2144**]
-occluded SMA and celiac arteries
-s/p abdminal stents x2 ([**2157**], [**2159**])
-hypercholesterolemia
-s/p splenectomy [**12/2159**]
-reflux
-emphysema
Social History:
Tobacco smoker - quit; ~60 pack year history; occasional EtOH,
no IVDU
Family History:
Non-contributary
Physical Exam:
VS: Tc 98.8; BP 98/56, RR 15; 98%2l
GEN: very cachectic, icteric male, older than stated age.
HEENT: +scleral icterus. PERRLA
RESP: decreased breath sounds Right and left base otherwise
clear
CV: RR, S1 and S2 wnl, [**1-5**] sys murmur at apex, no rubs or
gallops
ABD: scaphoid, multiple scars, ostomy in place, draining dark
brown liquid. + bilateral femeoral bruits and thrill on right
EXT: cachectic, no edema.
SKIN: very dry, icteric.
NEURO: AAOx3.
Pertinent Results:
labs [**1-27**]
wbc 11.3
hct 29.0
plt 136
5 bands
61 neuts
.
na 149
k 4.2
cl 123
co2 20
bun 29
cr 0.7
gluc 133
[**1-19**] pre-alb 3.4 (LOW)
.
INR 2.1
.
UA: large bil, otherwise, negative
.
[**2162-1-20**]:
pleural fluid
ph 7.53
wbc 80
rbc 11K
neut 36
Lymp 42
mono 19
ldh 114
tot prot < 3.0
.
[**2162-1-27**] LFTs
Tbili 8.6
AST 159
ALT 136
TBili 8.6
ALP 167
.
micro data: [**1-19**], [**1-20**], [**1-23**]
BLOOD:+yeast 6/6 bottles
GR stain: budding yeast
.
Pleural fluid: [**2162-1-26**]
gr stain
no wbcs
no orgs
no growth after 3 days (from [**2162-1-23**])
.
Previous micro data:
Blood cultures:
[**5-22**], [**5-24**], [**5-27**]: C. [**Month/Year (2) 563**]
[**5-28**], [**6-2**]: CNS
[**10-19**], [**10-20**]: C. [**Month/Year (2) 563**]
(MIC to fluc 32; Caspo 1, Vori 0.5, amphoB 0.5)
[**10-31**], 12/4x2, [**11-3**]: negative
.
[**2162-1-5**] TEE:
Conclusions:
No thrombus/mass is seen in the body of the left atrium. No mass
or thrombus is seen in the right atrium or right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. There are simple atheroma in the aortic arch.
The aortic valve leaflets (3) are mildly thickened. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is
seen.
No vegetations seen on any cardiac valve.
.
Imaging: .
.
CXR today: diffuse bilateral haziness, patchy opacities R>L.
prominent R heart border, wide mediastinum.
.
[**2162-1-21**] Barium swallow:
? false lumen on ct
-small hiatal hernia
-no false passage or false tract and the esophagus distends
normally
-+sumbumucosal edema (increasing in size compared to old, ?
lymphoma
-no false lumen no obstruction
-exact cause of the mediastinal fluid and thickening along the
[**Last Name (un) 40139**] curvature of the stomach on the CT scan on [**1-18**] adn [**1-20**]
is unclear. endoscopic ultrasound suggested for eval.
.
[**2162-1-20**] CT chest
-large L and R pleural effusion.
-severe copd
-density to the right of esophagus. contains a central area of
decreased attenuation and is surrounded by some increased
attenuation material. it is most likely in the mediastinum and
adjacent to the esophagus. NEW from [**7-/2161**] CT. ? false lumen
from prior instrumentation or encrotic LN ? abscess
-fatty infiltration of the liver
-aortic stent
-sma stent
-thrombosed celiac axis
.
[**2162-1-18**]: LENIs: no DVT
CT scan [**11-4**]
CT SCAN ABD AND PELVIS
No intra or extrahepatic biliary dilatation
1. No evidence of septic emboli.
2. Mild emphysema.
3. Resolution of previously noted liver lesion.
4. Unchanged right adrenal lesion, incompletely characterized
but
statistically probably representing an adenoma.
5. Patent aortobifemoral graft. Unchanged appearance of the
occluded graft
from the left iliac limb of the aortobifemoral bypass to the
superior
mesenteric artery compared to [**2161-5-28**].
6. Evidence of extensive bowel
resection is noted. The remaining bowel loops appear
unremarkable
Brief Hospital Course:
49 year old man with chronic mesenteric ischemia s/p multiple
surgeries including near total enterctomy and h/o recurrent C.
[**Month/Day/Year 563**] infections presents to OSH 5 days after stopping caspo
with fungal sepsis. Transferred on [**1-27**] to [**Hospital Unit Name 153**] for sepsis,
paraesophegeal fluid collection which showed MRSA and yeast.
Sepsis/fungemia initially resolved in the [**Hospital Unit Name 153**] with baseline BPs
in the 90s, WBC decreasing. Cause was likely fungemia ([**5-5**]
cultures reportedly positive for [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 40140**] from OSH).
There also appeared to be a new pneumonia on OSH CXR. PICC dced
on [**2-5**]. Ophtho consult with no evidence fungal eye infection,
noted to have bilat intraretinal hemorrhages [**1-1**] TPN vs. HTN. Pt
also had paraesophageal collection that EUS aspiration grew
yeast, MRSA, and lactobacillus. Patient started on vancomycin
and ambisome and meropenem to cover for above. Patient also had
intermittent blood in stool/melena and blood was noted in
stomach on endoscopy without active bleeding found. Transfused
on [**2-2**] with appopriate response initially. Repeat transfusion
on [**2-9**] done when Hct trended down again. Pt noted also to have
chronic hyperbilirubinemia, likely secondary to TPN and fatty
liver. Started on ursodiol. Bilirubinemia continued to worsen.
On [**2-8**] pt's blood pressures again started to trend down with
rising Cr. Discussed with family and patient worsening
condition and need to transfer back to ICU. Overall outlook
grave and patient without many more options, as poor surgical
candidate with likely infected hardward +/- fluid collections.
In discussion decision made to have pt be DNR/DNI. Comfort
measures started and antibiotics stopped. Patient died on [**2-11**]
with family at bedside.
Medications on Admission:
TPN
recently finished 12 weeks of caspo for [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**]
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"530.19",
"285.9",
"579.3",
"578.1",
"286.9",
"486",
"276.0",
"511.9",
"112.5",
"557.1",
"263.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"45.13",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
10689, 10698
|
8624, 10493
|
373, 402
|
10749, 10758
|
5481, 8601
|
10814, 10824
|
4974, 4992
|
10657, 10666
|
10719, 10728
|
10519, 10634
|
10782, 10791
|
5007, 5462
|
237, 335
|
430, 4616
|
4638, 4869
|
4885, 4958
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,734
| 115,176
|
29195
|
Discharge summary
|
report
|
Admission Date: [**2129-3-18**] Discharge Date: [**2129-3-26**]
Date of Birth: [**2076-12-31**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
[**3-19**]: Right superficial bronchial artery embolized with
embospheres and 4 coils. Rt inferior bronchial artery embolized
with PVAs. Angioseal deployed.
[**3-20**]: Had another episode of bleeding which required DL ETT
placement. Bronch showed active bleeding from same site of
emoblization. Patient hemodynamically stable but did not respond
to 1U PRBC. No further intervention.
Intubation
History of Present Illness:
This is a 52 year old male with PMH of morbid obesity with
resultant lymphedema, depression, Afib on Coumadin, OSA on CPAP,
and h/o LLL pulmonary hemorrhage secondary to an AVM requiring
rigid bronchoscopy and APC to cauterize area of bleeding
presenting for further evaluation of repeat hemoptysis. He
reportedly coughed up some bright red blood at home this evening
and was initially stable upon arrival to the ED until he was
witnessed coughing up a pint and a half of blood. Of note, he
developed a UTI about a week ago and received ceftriaxone
followed by a po cephalosporin, which likely interfered with his
Coumadin levels.
In the ED, initial VS were: 98, 130, 128/75, 16, 97%
Non-Rebreather. He arrived with normal mental status and a
patent airway, but began coughing in the ED which was productive
of bright red blood. Over the next couple minutes, the
significant bleeding continued and he was intubated for airway
protection him. Before intubation, he was noted to have about
200-300 mL of bright red bloody hemoptysis. Peripheral IV access
was obtained and 4 units of FFP were given in addition to 10mg
of IV vitamin K since his INR was supratherapeutic at 6.1 on
Coumadin. Interventional radiology, interventional pulmonology,
and cardiothoracic surgery were consulted in the ED. After
intubation, the ventilator kept alarming due to elevated
pressures likely secondary to blood clot obstruction. He
therefore required manual bagging to maintain his sats and his
resistance improved once placed in the left lateral decub
position to a point where he could be placed back on the vent.
Of note his HR was consistently in the 130s probably from Afib
RVR.
.
On arrival to the MICU, he could not be placed on the ventilator
due to the high resistance in his airways from the blood and
clots in his lungs. He required manual bagging at times to
maintain his sats as well as paralysis with cisatracurium. A
central line was placed in his right IJ to continue infusion of
blood products. A bedside flexible bronchoscopy revealed massive
hemoptysis and clotting of his bilateral bronchi. IP was
contact[**Name (NI) **] and the patient was immediately taken to the OR for
rigid bronchoscopy in an attempt to clean out the clots and find
the site of bleeding in order to cauterize it.
.
Review of systems:
unable to obtain
Past Medical History:
- hemoptysis ([**2123**]) - IP LLL
- major depression
- obstructive sleep apnea: on CPAP at home
- morbid obesity
- lymphedema
- psoriasis
- atrial fibrillation s/p cardioversion in [**4-/2128**]
- dilated cardiomyopathy (EF 35-40%)
Social History:
Has not left his house in >1 year due to
depression and now worsening obesity; lives with his sister.
Formerly smoked 1 ppd up until 5 yrs ago. Was a binge drinker in
his 20s, but no longer drinks. Distant marijuana and intranasal
cocaine use. Denies IVDU.
Family History:
Father with 2 [**Name2 (NI) **] in his 50s but still living in
his 70s currently. Mother with schizophrenia.
Physical Exam:
Admission physical exam:
Vitals: T: afebrile, BP: 100s-110s/60s-70s, P: 110s, R: 22, O2:
99% RA
General: intubated/sedated, bloody secretions in ET tube
requiring
HEENT: Sclera anicteric, MMM, ET tube in place, PERRL
Neck: supple
CV: Irregularly irregular, tachycardic
Lungs: Diminished breath sounds bilaterally
Abdomen: soft, large pannus, non-tender, bowel sounds present
GU: Foley in place
Ext: warm, well perfused, bilateral lower extremity lymphedema
and venous stasis changes
Neuro: intubated/sedated
Pertinent Results:
[**2129-3-18**] 09:33PM BLOOD WBC-7.2 RBC-4.24* Hgb-13.4* Hct-38.8*
MCV-92 MCH-31.6 MCHC-34.5 RDW-13.0 Plt Ct-269#
[**2129-3-19**] 10:50AM BLOOD WBC-17.5* RBC-3.53* Hgb-11.5* Hct-32.4*
MCV-92 MCH-32.5* MCHC-35.4* RDW-13.4 Plt Ct-257
[**2129-3-20**] 02:20PM BLOOD Hct-28.9*
[**2129-3-18**] 09:33PM BLOOD PT-61.1* PTT-51.4* INR(PT)-6.1*
[**2129-3-19**] 06:27AM BLOOD PT-16.0* PTT-31.6 INR(PT)-1.5*
[**2129-3-20**] 03:56AM BLOOD PT-14.3* PTT-29.5 INR(PT)-1.3*
[**2129-3-18**] 09:33PM BLOOD Glucose-140* UreaN-12 Creat-0.9 Na-139
K-4.1 Cl-103 HCO3-26 AnGap-14
[**2129-3-20**] 03:56AM BLOOD Glucose-104* UreaN-12 Creat-0.7 Na-142
K-3.9 Cl-106 HCO3-29 AnGap-11
Brochial angiogram ([**2129-3-19**]): Two arteries of possible bleed
in the right lung from the right superior and Preliminary
Reportinferior bronchial arteries which were successfully
embolized with
Preliminary ReportEmbospheres, PVAs and four coils.
CT head [**3-23**]:
IMPRESSION: Compared to study of [**2129-3-14**], there are new regions
of subtle
hypodensity involving both the [**Doctor Last Name 352**] and white matter in the
right temporal, right occipital, and left parieto-occipital
regions. These are suspicious for cytotoxic edema related to
acute embolic infarction. Recommend MR [**First Name (Titles) 151**] [**Last Name (Titles) **] of the brain for
better evaluation.
.
Echo [**3-23**]:
IMPRESSION: poor technical quality due to patient's body
habitus. Left ventricular function is probably normal, a focal
wall motion abnormality cannot be fully excluded. There is mild
right ventricular dilatation and global free wall hypokinesis.
No pathologic valvular abnormality seen. Pulmonary artery
systolic pressure could not be determined.
.
Bilateral LENIs [**3-22**]:
IMPRESSION:
No evidence of deep venous thrombosis in visualized portions of
bilateral
lower extremities. Suboptimal exam due to patient's body
habitus.
.
CTA chest [**2128-3-20**]:
IMPRESSION:
1. Multiple bilateral segmental and subsegmental lower lung
pulmonary emboli.
2. Bilateral peribronchovascular opacifications consistent with
provided
history of pulmonary hemorrhage or edema.
3. Dual channel endotracheal, distal chamber ends in left main
bronchus,
proximal channel ends in distal trachea. No apparent means of
right bronchial
obturation.
4. Possible right retrohilar hematoma.
Brief Hospital Course:
This is a 52 year old male with PMH of morbid obesity with
resultant lymphedema, depression, dilated cardiomyopathy with an
EF=35-40%, Afib on Coumadin, OSA on CPAP, and h/o LLL pulmonary
hemorrhage secondary to an AVM requiring rigid bronchoscopy and
APC to cauterize area of bleeding presenting for further
evaluation of repeat hemoptysis.
#. Hemoptysis/respiratory failure. He presented to the ED with
massive hemoptysis requiring intubation for airway protection
and ventilatory support to maintain his sats. Flexible
bronchoscopy on admission in MICU showed fresh hemorrhage in
right lung. He was taken to OR for rigid bronchoscopy whose
course was complicated by persistent hypoxia and hypotension. He
was taken to IR suite where they embolized superior bronchial
artery embospheres and 4 coils while right inferior bronchial
artery was embolized with PVAs. Coagulopathy was reversed with 8
units of FFP and vitamin K while coumadin was stopped and given
3 units of PRBC.
On [**2129-3-20**] he was noted to have opacification of the right
lung. IP's bronchoscopy showed fresh bleeding. He was given 1
unit of PrBC. Double lumen ET tube was placed and plan is to
take him for rigid bronchoscopy tomorrow.
After some brief progress was made at lowering the patient's
oxygenation requirements, the patient had increasing oxygen
requirements that resulted in a CTA chest, which ended up
showing bilateral pulmonary embolism. In addition, the patient's
chest X-ray suggested some left infiltrate and he was started on
treatment for ventilator-associated pneumonia. It was also noted
at this time that his pupils were not as responsive, though he
was sedated so a neurological exam was not fully possible. A
head CT was obtained that showed three areas concerning for
embolic stroke. The patient's respiratory status showed no
improvement and by [**3-24**], he was back to requiring pressors. The
family was brought in for a series of discussions, during which
the patient's poor progress and prognosis were discussed, along
with the damage to three organ systems (lungs, heart, brain).
The patient's father and health care proxy decided to make the
patient [**Name (NI) 9036**] Measures Only. Fifteen minutes after the pressor
was stopped, the patient died.
#. Atrial fibrillation with RVR. Patient has h/o of Afib at
home on warfarin and metoprolol as well as sotalol for
rate/rhythm control. Coumadin held while INR reversed as above.
Sotalol and metoprolol held. The patient was restarted on his
sotalol following his embolization and spent more than two days
in sinus rhythm following spontaneous conversion, which also
allowed his blood pressure to recover. His then went back to
atrial fibrillation and required pressors to support his blood
pressure. A Cardiology consult was called and recommendations
made, but these recommendations were superceded by the patient's
deteriorating clinical status and decision to be made [**Name (NI) 9036**]
Measures Only.
#. Dilated cardiomyopathy. Most recent ECHO in [**2-/2129**] shows
biatrial enlargement, mild symmetric left ventricular
hypertrophy, and normal left and right ventricular function with
normal valvular function. ASA, lisinopril and Lasix are held in
setting of massive hemoptysis.
# Likely embolic stroke: CT head showed three areas of
hypodensity, most likely to be secondary to embolic stroke per
radiology. Given that patient has AVM, it is possible the AVM
was the source of paradoxical emboli. LENIs negative. Patient
was made [**Year (4 digits) **] measures only.
Medications on Admission:
-ammonium lactate 12 % Lotion Apply to affected area twice a day
-clobetasol 0.05 % Cream Apply to affected area twice a day
-furosemide 40 mg by mouth once a day
-lisinopril 2.5 mg by mouth once a day
-lorazepam 0.5-1 mg by mouth twice a day as needed for anxiety
-metoprolol tartrate 12.5 mg by mouth three times a day
-polyethylene glycol 3350 17 gram by mouth daily as needed for
constipation
-sotalol 120 mg by mouth twice a day
-trazodone 25 mg by mouth at bedtime
-venlafaxine 225 mg Tablet Extended Rel 24 hr by mouth once a
day
-warfarin 2.5 mg Tablet 1.5 Tablet(s) by mouth once a day as
directed Fridays 5mg
-aspirin 81 mg by mouth once a day
-cholecalciferol 2,000 unit by mouth once a day
-cod liver oil by mouth once a day
-docusate sodium 100 mg by mouth twice a day
-fish oil-dha-epa 1,200 mg-144 mg Capsule by mouth once a day
-multivitamin with minerals by mouth daily
-sennosides 8.6 mg; 2 tablets by mouth daily
Discharge Medications:
None. Patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired.
Discharge Condition:
Expired.
Discharge Instructions:
Expired.
Followup Instructions:
Expired.
|
[
"457.1",
"278.01",
"E879.8",
"434.11",
"747.32",
"415.11",
"786.30",
"276.2",
"427.31",
"428.0",
"997.31",
"348.5",
"V85.45",
"327.23",
"599.0",
"041.04",
"518.89",
"428.30",
"V58.61",
"428.31",
"427.5",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"33.23",
"96.72",
"88.43",
"39.79",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11214, 11223
|
6628, 10182
|
317, 713
|
11275, 11285
|
4272, 6605
|
11342, 11353
|
3618, 3728
|
11167, 11191
|
11244, 11254
|
10208, 11144
|
11309, 11319
|
3768, 4253
|
3050, 3069
|
266, 279
|
741, 3031
|
3091, 3325
|
3341, 3602
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,805
| 111,508
|
18053
|
Discharge summary
|
report
|
Admission Date: [**2157-5-30**] Discharge Date: [**2157-5-31**]
Date of Birth: [**2117-6-6**] Sex: M
Service:
CHIEF COMPLAINT: Hypotension.
HISTORY OF PRESENT ILLNESS: The patient is a 39 year old
male with a history of cirrhosis and portal hypotension
secondary to alcohol use who was admitted to the Medical
Intensive Care Unit status post TIPS procedure. The patient
has had ascites for approximately one year and has had
Clostridium difficile in the past with accompanying
hepatic-renal syndrome. The patient had come in to the
hospital for an outpatient TIPS procedure the morning of
admission. His arterial blood gases prior to the procedure
revealed an acidosis with pH of 7.28, pCO2 of 27, and pO2 of
102 to 120% O2. The patient received Versed and
succinylcholine for anesthesia. He also was given fresh
frozen plasma for his INR of 1.6 for paracentesis, liver
biopsy and TIPS placement. He had no obvious bleeding during
this procedure and two liters of fluid were removed.
The patient became hypotensive approximately one hour later.
Intravenous fluids were given aggressively and phenylephrine
was begun. The patient also continued to trail downward on
this level of phenylephrine, therefore epinephrine was added.
Hydrocort was given and the patient was sent up to the
Medical Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Cirrhosis.
2. Portal hypertension.
3. Alcoholism.
4. Chronic ascites.
5. Hepatorenal syndrome with a baseline creatinine of 2.0.
MEDICATIONS ON ADMISSION:
1. Protonix 40 mg p.o. q. day.
2. Lasix 20 mg p.o. q. day.
3. Ciprofloxacin 750 mg p.o. q. Wednesday.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient continues to drink. He is
married and lives with his wife. [**Name (NI) **] smokes half a pack per
day.
PHYSICAL EXAMINATION: Vital signs are 115; 105/70; 98% and
14. General appearance: Intubated flushed male in no
apparent distress. HEENT: Pupils are equal, round and
reactive to light and accommodation, intubated. Neck:
Bilateral internal jugular lines in place; no bleeding.
Cardiac: Tachycardic, no murmurs, rubs or gallops;
hyperdynamic. Pulmonary: Bilaterally clear to auscultation
anteriorly. Abdomen: Positive bowel sounds, mildly
distended. Liver edge palpable below the inferior margin.
Extremities with no cyanosis, clubbing or edema. Weak
pulses, warm.
LABORATORY: White blood cell count 23.9, hematocrit 31.6,
platelets 355, coags 15.9, 52.3 and 1.7. Electrolytes are
135, 3.9, and 109, 12, 37, 1.6, 7.1, 7.8 and 1.1. Albumin
was 2.7. Alkaline phosphatase 208. ALT 23, AST 26. Total
bilirubin 1.5. Ethanol was negative. Lactic acid was 1.5
and an arterial blood gas revealed 7.32, 26 and 90.
HOSPITAL COURSE: Given the above, the patient was brought
to the Medical Intensive Care Unit. In terms of his
hypotension this was thought to be secondary to fluid shift
secondary to his paracentesis. Other etiologies considered
were transfusion reaction from the fresh frozen plasma given,
possible hypotension as a result of the benzodiazepines and
succinylcholine that he had received, or possible sepsis
versus a bleed from the procedure.
Therefore, the patient was initially continued on epinephrine
and phenylephrine, however, these were weaned within one to
two hours. The patient had been given Hydrocort,
epinephrine, therefore he was monitored for further signs of
a transfusion reaction. Enough time had passed for other
drugs such as benzodiazepine and succinylcholine to wear off.
He was cultured for possible sepsis with blood cultures
which were negative and urinalysis and urine culture which
were negative, and a chest x-ray which showed no signs of
infection.
Paracentesis fluid had already been discarded, therefore,
this could not be cultured. The patient had serial
hematocrits to rule out bleeding and a right upper quadrant
ultrasound to assess flow through the TIPS and to insure that
there had been no bleeding around the site of the TIPS. This
was all intact.
In terms of his pulmonary status, the patient was intubated
when he first came to the floor, however, he was extubated
within one to two hours as well and his repeat arterial blood
gas showed a similar acidosis. This was thought to be
secondary to his hepatorenal syndrome or possibly secondary
to alcohol, however, his alcohol level was negative while in
the hospital. He was also taking Lactulose immediately
afterwards and it was thought that the patient may have an
acidosis secondary to chronic diarrhea.
Otherwise, the patient was continued on Protonix,
pneumoboots. He was on a CIWA scale so that he would not go
into withdrawal and he had good intravenous access while in
the hospital.
The patient also had a chest x-ray done which revealed
congestive heart failure most likely secondary to the
aggressive intravenous hydration that he received after his
episode of hypotension. A repeat chest x-ray was performed
the next day which showed improvement in the congestive heart
failure. The patient was kept on a fluid restriction and a
low salt diet at this point.
As per the patient's request and once he was medically
stable, he was discharged from the Intensive Care Unit with
instructions to follow-up with Dr. [**Last Name (STitle) 497**].
[**Known firstname **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5587**]
Dictated By:[**Name8 (MD) 234**]
MEDQUIST36
D: [**2157-6-4**] 20:25
T: [**2157-6-4**] 21:22
JOB#: [**Job Number 49956**]
|
[
"572.3",
"303.90",
"305.1",
"458.2",
"572.4",
"276.2",
"571.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"38.93",
"39.1",
"50.11"
] |
icd9pcs
|
[
[
[]
]
] |
1532, 1677
|
2759, 5575
|
1838, 2740
|
149, 163
|
193, 1346
|
1368, 1506
|
1695, 1814
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,847
| 171,054
|
44632
|
Discharge summary
|
report
|
Admission Date: [**2155-11-24**] Discharge Date: [**2155-11-27**]
Date of Birth: [**2072-12-31**] Sex: F
Service: MEDICINE
Allergies:
Ambien
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 82 y/o female with grade II diastolic CHF, CAD, atrial
fibrillation who presents with increasing shortness of breath.
She reports that in the middle of night to early morning she
began to notice she could not longer lie flat in bed. Her
breathing was becoming more labored. Denies any chest pain,
palpitations, nausea, vomiting. No cough recently, no fevers,
chills. She lives in [**Hospital3 **], but no known sick contacts
around recently that she is aware of. She has chronic lower
extremity edema but does not feel it has been worse recently.
.
EMS noted her oxygen saturation was in the high 80s on a NRB.
They gave her 2 NTG SL and 80mg IV lasix. In the ED, her vital
signs were T 99.6, HR 119, BP 198/92, RR 34, O2sat 60% on NRB.
She was placed on BIPAP and her saturation improved to 92%. She
was placed on a nitro gtt. CXR suggested pulmonary edema. Prior
to coming to the floor she was taken off BIPAP and placed on 6L
NC as her respiratory status improved.
.
Currently, pt reports marked improvement in her breathing.
Denies CP, palpitations, nausea/vomiting. +constipation. No
dysuria, hematuria. +chronic bilateral lower extremity pain but
no change recently.
Past Medical History:
1. CAD: h/o MI [**2139**], had PCI at [**Hospital1 112**]
2. diastolic CHF with grade II dysfunction and normal to
hyperdynamic EF
3. atrial fibrillation on coumadin
4. HTN
5. Cystic carcinoma: s/p resection, cystoscopy [**7-12**] shows no
recurrence
6. Basal cell CA: left nasal ala, s/p Mohs' resection
7. Anxiety
8. COPD
Social History:
Lives in senior housing in [**Location (un) 3146**] (independent living) has 2
children; smoked >60 pack-years, quit 2 years ago; denies any
alcohol or drug use
Family History:
CAD: father died of MI at 62yo; mother had MI.
Physical Exam:
VS: BP 156/83, HR 105, RR 32, O2sat 93% on 6L NC
GEN: Elderly female, resting comfortably in bed, tachypnic but
not in acute distress.
HEENT: NC/AT, EOMI, PERRL, O/P clear no oral lesions, MMM
Neck: JVP ~10cm
CV: Irregularly irregular, no murmurs appreciated
PULM: Crackles 2/3 up from the base, no wheezing
ABD: Soft, NT, ND +BS
EXT: trace LE edema right greater than left. no clubbing or
cyanosis
PULSES: 2+ DP/PT pulses bilaterally
NEURO: A&O x3, CN III-XII intact, sensation in tact to light
touch throughout. Toes mute bilaterally. Bicep, brachioradialis
reflexes normal. Could not elicit patellar reflexes. Did not
assess gait currently.
Pertinent Results:
ADMISSION LABS:
.
[**2155-11-24**] 08:32AM BLOOD WBC-28.3*# RBC-5.04 Hgb-14.3 Hct-43.4
MCV-86 MCH-28.3 MCHC-32.9 RDW-14.9 Plt Ct-380
[**2155-11-24**] 08:32AM BLOOD Neuts-49.4* Lymphs-47.2* Monos-2.5
Eos-0.7 Baso-0.2
[**2155-11-24**] 08:32AM BLOOD PT-28.1* PTT-29.7 INR(PT)-2.8*
[**2155-11-24**] 08:32AM BLOOD Glucose-246* UreaN-18 Creat-0.9 Na-142
K-3.7 Cl-103 HCO3-28 AnGap-15
[**2155-11-24**] 08:32AM BLOOD CK-MB-NotDone proBNP-1853*
[**2155-11-24**] 08:32AM BLOOD cTropnT-<0.01
[**2155-11-24**] 03:14PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2155-11-24**] 10:19PM BLOOD CK-MB-NotDone cTropnT-<0.01
.
.
PERTINENT LABS/STUDIES:
.
Hct: 43.4 -> 36.1 -> 34.0 -> 35.8
WBC: 28.3 -> 11.4 -> 9.3 -> 10.2
INR: 2.8 -> 3.4 -> 2.0
BNP: 1853
Troponin: <0.01 x4
Lactate: 2.6
.
U/A: Small blood, 500 protein, negative leukocytes
.
[**2155-11-24**] 8:30 am URINE Site: CATHETER
**FINAL REPORT [**2155-11-25**]**
URINE CULTURE (Final [**2155-11-25**]):
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
.
CXR [**2155-11-24**]: Worsening CHF with increased asymmetric opacity at
the right mid to lower lung raising concern for pneumonia.
Possible atelectasis versus pneumonia at the left lung base.
.
.
DISCHARGE LABS:
.
[**2155-11-27**] 04:55AM BLOOD WBC-10.2 RBC-4.33 Hgb-12.4 Hct-35.8*
MCV-83 MCH-28.6 MCHC-34.6 RDW-14.9 Plt Ct-265
[**2155-11-27**] 04:55AM BLOOD Plt Ct-265
[**2155-11-27**] 04:55AM BLOOD PT-21.6* PTT-32.1 INR(PT)-2.0*
[**2155-11-27**] 04:55AM BLOOD Glucose-101 UreaN-18 Creat-0.8 Na-139
K-4.1 Cl-101 HCO3-30 AnGap-12
[**2155-11-27**] 04:55AM BLOOD Calcium-9.3 Phos-3.5 Mg-1.9
Brief Hospital Course:
ASSESSMENT AND PLAN: Patient is a 82 yo female with a h/o
diastolic CHF, AFib, CAD who presents with progressive SOB and
found to have a CHF exacerbation likely secondary to AFib with
RVR.
.
# Dyspnea: History and presentation suggests that she likely had
flash pulmonary edema causing her respiratory distress. Patient
was transferred to the MICU on arrival, where she was placed on
BIPAP. The patient was placed on a nitroglycerine drip and was
given Lasix. The patient diuresed significantly, and her O2
requirement decreased to 2L. The patient was thus transferred
to the floor. She was placed back on her home dose of Lasix 40
mg PO daily, and her O2 requirement decreased. The patient was
ruled out for influenza, and her blood cultures did not show any
growth. It was thought that the etiology of this patient's
flash pulmonary edema was AFib with RVR. The patient was rate
controlled for this condition and did not have any further
episodes of dyspnea.
.
# Leukocytosis: The patient had a leukocytosis of 28.3 on
admission. Blood cultures, urine cultures, sputum cultures, and
influenza cultures were drawn, which did not show any obvious
source of underlying infection. It was thought that this
leukocytosis was a stress reaction; thus, the patient was not
started on antibiotics. Her leukocytosis decreased with
oxygenation and adequate diuresis, and the patient remained
afebrile during this admission.
.
# Atrial Fibrillation: Patient was found to be in AFib with RVR
on admission. She was continued on her home dose of beta
blocker and verapamil, and her pulse decreased appropriately.
The patient continued to be adequately beta-blocked on this
admission. She was monitored on telemetry, and her Coumadin
was continued, and did not have any acute events during this
admission.
.
# Coronary Artery Disease: The patient has a h/o MI. She denies
any chest pain on this admission, but it was thought that
cardiac ischemia may have been the etiology of her flash
pulmonary edema. The patient's cardiac troponins were checked,
and they were negative x4. She was continued on her home doses
of Metoprolol, Statin, ACE inhibitor, and ASA.
.
# COPD: The patient was continued on her home dose of
Fluticasone, Spiriva, and nebulizations as needed.
.
# Anxiety: The patient was continued on her home dose of
Alprazolam as needed.
.
# Urinary Tract Infection: The patient's U/A on admission
showed small blood and 500+ protein. The patient's urine
culture grew out Gram positive bacteria, consistent with
Lactobacillus or alpha streptococcus. The patient was not
started on antibiotics for her asymptomatic bacteriuria.
.
# Code: DNR/DNI per patient.
.
Medications on Admission:
1. Metoprolol Tartrate 100 mg PO BID
2. Verapamil 80 mg PO TID
3. Alprazolam 0.25 mg PO once a day as needed for anxiety
4. Warfarin 2.5 mg PO Q4PM
5. Lasix 40 mg PO once a day
6. Quinapril 20 mg PO BID
7. Aspirin 325 mg PO once a day
8. Atorvastatin 40 mg PO DAILY
9. Fluticasone two puffs [**Hospital1 **]
10. Tiotropium Bromide one cap IH daily
11. Xopenex PRN
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Verapamil 80 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
3. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed.
4. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Quinapril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
8. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
11. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
Three (3) ML Inhalation q4hrs prn () as needed for wheezing.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
Pulmonary Edema
Diastolic Congestive Heart Failure
Atrial Fibrillation with Rapid Ventricular Response
Secondary:
Coronary Artery Disease
Chronic Obstructive Pulmonary Disease
Discharge Condition:
Good. Patient's vital signs are all stable, and she is able to
ambulate on room air.
Discharge Instructions:
You were admitted to the hospital because you had increased
shortness of breath on Sunday night. You were found to be in
flash pulmonary edema, which means that there was quite a lot of
fluid in your lungs. You were admitted to the MICU, and you
were given Lasix to remove the fluid. Your oxygen saturation
improved, and you were able to ambulate comfortably on room air.
While you were here, we made the following changes to your
medications:
1. We decreased your Metoprolol to 50 mg [**Hospital1 **], as your heart
rate had decreased to 38.
Please take all medicatiosn as prescribed.
Please keep all previously scheduled appointments.
Please return to the ED or your healthcare provider if you
experience chest pain, shortness of breath, abdominal pain,
fevers, chills, or any other concerning symptoms. Please weigh
yourself every morning, and [**Name8 (MD) 138**] MD if weight > 3 lbs. Please
adhere to a 2 gm sodium diet
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in [**1-8**] weeks.
Completed by:[**2155-12-1**]
|
[
"414.01",
"496",
"V10.83",
"288.60",
"428.33",
"412",
"427.31",
"518.81",
"428.0",
"V58.61",
"300.00",
"402.91",
"791.9",
"276.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8514, 8571
|
4512, 7186
|
278, 284
|
8801, 8889
|
2759, 2759
|
9874, 9977
|
2032, 2080
|
7600, 8491
|
8592, 8780
|
7212, 7577
|
8913, 9851
|
4110, 4489
|
2095, 2740
|
231, 240
|
312, 1491
|
2775, 4094
|
1513, 1838
|
1854, 2016
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,184
| 142,311
|
35787
|
Discharge summary
|
report
|
Admission Date: [**2147-7-24**] Discharge Date: [**2147-7-31**]
Date of Birth: [**2088-8-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Left upper lobe mass with history of Stage IV NSCLC for
pericardial involvement three years ago.
Major Surgical or Invasive Procedure:
[**2147-7-24**]:
OPERATIONS:
1. Left thoracotomy/left pneumonectomy.
2. Buttressing of bronchial stump with intercostal muscle.
History of Present Illness:
The patient is a 58-year-old male with a large left upper lobe
tumor. He presented in [**2144**] with a malignant pericardial
effusion and received palliative
chemotherapy and radiation therapy. Surprisingly, he has done
well for 3 years and has no evidence of disease outside of the
left upper lobe. Given this and his good performance status and
pulmonary function, we brought him to the operating room today
for possible resection.
Past Medical History:
Stage 4 Non-small cell lung cancer (due to pericardial
involvement), CVA in
[**2140**] with left sided weakness, HTN, hypercholesterolemia, DM II
Social History:
He is married and has no children. He
previously worked in construction before his diagnosis. He is
originally from [**Country 6257**]. He
previously smoked 1-2 packs per day x 42 years, quitting in
[**2144**].
He drinks 3 bottles of wine per week.
Family History:
No family history of lung cancer. His father had
a history of strokes. His mother had type 2 diabetes. He has
no
children.
Physical Exam:
Discharge Vital Signs:
T 98.4, BP 132/84, HR 86, RR 18, O2 sats 100% RA, Blood sugars
149-245
Discharge Physical Exam:
Gen: pleasant in NAD
Lungs: diminished over left lung fields, clear on right upper
and lower.
left thoracotomy incisions C/D/I
CV: RRR S1, S2, no MRG or JVD
Abd: soft, NT, ND
Ext: warm without edema
Pertinent Results:
[**2147-7-31**] 06:32AM BLOOD WBC-6.2 RBC-3.49* Hgb-9.5* Hct-29.7*
MCV-85 MCH-27.2 MCHC-32.0 RDW-15.0 Plt Ct-313
[**2147-7-31**] 06:32AM BLOOD Glucose-125* UreaN-24* Creat-0.8 Na-138
K-3.8 Cl-99 HCO3-30 AnGap-13
[**2147-7-25**] 08:57PM BLOOD Glucose-180* UreaN-49* Creat-2.6* Na-136
K-5.4* Cl-102 HCO3-22 AnGap-17
[**2147-7-24**] 02:14PM BLOOD Glucose-202* UreaN-29* Creat-1.3* Na-138
K-5.1 Cl-103 HCO3-23 AnGap-17
[**2147-7-28**] 09:50AM BLOOD cTropnT-<0.01
[**2147-7-28**] 02:30AM BLOOD CK-MB-3 cTropnT-<0.01
[**2147-7-27**] 06:29PM BLOOD CK-MB-4 cTropnT-<0.01
[**2147-7-26**] 02:32AM BLOOD CK-MB-8 cTropnT-<0.01
[**2147-7-31**] 06:32AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.0
[**2147-7-27**] 07:53PM BLOOD Type-ART pO2-92 pCO2-39 pH-7.42
calTCO2-26 Base XS-0
[**2147-7-31**] Discharge CXR:
FINDINGS: In comparison with the study of [**7-30**], there is no
change in the
postoperative appearance with a large air-fluid level and
substantial filling of the left hemithorax with fluid. Elevation
of the left hemidiaphragmatic contour and shift of the trachea
to the left are again seen. The right lung is essentially clear.
[**2147-7-28**] KUB:
IMPRESSION:
1. Increased gaseous distension of the colon, consistent with
post-operative ileus.
2. Distention of the stomach with air and fluid should be
correlated
clinically, as this patient may benefit from placement of an NG
tube.
[**2147-7-26**] Echo:
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy small/normal cavity size and preserved
global biventricular systolic function. Dilated aortic sinus.
Compared with the prior study (images reviewed) of [**2145-1-28**],
then findings are similar (prior study image quality was
superior).
[**2147-7-25**] Renal US:
IMPRESSION: No evidence of tardus parvus waveforms bilaterally
in the right or the left kidney. No evidence of hydronephrosis.
Exam limited due to the patient's body habitus.
Brief Hospital Course:
Mr. [**Known lastname 32665**] was brought into the operating room by Dr. [**First Name (STitle) **] on
[**2147-7-24**] where he underwent left thoracotomy/left pneumonectomy,
and buttressing of the bronchial stump with intercostal muscle.
He recovered in the ICU postop with left chest tube to water
seal. He was hypotensive requiring multiple albumin boluses and
IV fluids, along with neosynephrine POD 1.
POD 1 he developed acute kidney injury. Renal consult was
obtained and he was felt to be prerenal. Renal US was a poor
study due to body habitus but did not show abnormality. His left
chest tube was discontinued.
Echo was done POD 2 and normal. On POD 2 he was volume
overloaded and lasix gtt was started which he responded to.
POD 3 he developed afib which quiesced after diltiazem gtt. This
was nicely transitioned to oral ditiazem without any more afib.
POD 4 he was transfused 1 unit of PRBC's for low hct and to
assist in oxygenation and blood pressure. His diet was advanced
but his abdomen was quite distended prompting KUB which was
positive for ileus. Suppositories and stool softeners were
continued and he had a bowel movements without nausea vomiting
and less abd distention thereafter. Methylnaltrexone was given.
POD 5 he transfered to the floor. PT evaluated him and he was
not found to have home PT needs. He was deemed stable for
discharge on [**2147-7-31**] with VNA. Foley was dc'd [**2147-7-30**] with good
urine output.
CXR's were serially watched without evidence of stump leak. Pain
was initially controlled with dilaudid and bupivicaine epidural,
which was split postop for hypotension. He titrated off epidural
and PCA early on and tolerated po dilaudid for effective pain
control along with tylenol.
Medications on Admission:
ERLOTINIB [TARCEVA] - (Prescribed by Other Provider) - 150 mg
Tablet - 1 Tablet(s) by mouth daily
FOLIC ACID - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth daily
GLIMEPIRIDE - (Prescribed by Other Provider) - 2 mg Tablet - 1
Tablet(s) by mouth daily
LISINOPRIL-HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider)
- 20 mg-12.5 mg Tablet - 1 Tablet(s) by mouth daily
SIMVASTATIN - (Prescribed by Other Provider) - 80 mg Tablet - 1
Tablet(s) by mouth daily
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Delayed
Release (E.C.) - 1 Tablet(s) by mouth daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
Disp:*60 Capsule(s)* Refills:*2*
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily). Tablet, Chewable(s)
3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours as needed for pain.
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
6. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
Disp:*30 Capsule, Extended Release(s)* Refills:*2*
7. glimepiride 2 mg Tablet Sig: One (1) Tablet PO once a day.
8. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
9. lisinopril-hydrochlorothiazide 20-12.5 mg Tablet Sig: One (1)
Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
Community Nurse [**First Name (Titles) **] [**Last Name (Titles) **] Care,Inc
Discharge Diagnosis:
Non-small cell lung cancer s/p left pneumonectomy
Acute kidney injury now resolved, dc creatinine 0.8
Postoperative atrial fibrillation resolved on diltiazem
Hyponatremia resolved
Postoperative ileus resolving
HTN
HL
DM II
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office at [**Telephone/Fax (1) 2348**] if you have fevers
greater than 101.5, worsening cough, chest pain, shortness of
breath.
Call if your left thoracotomy incision opens, drains or becomes
red.
Call if fast irregular heartbeat.
Call if you have abdominal pain or ongoing constipation, nausea
or vomiting.
Activity:
Walk often. Use the incentive spirometer.
You may shower. Do not tub bathe or submerge in water for [**7-19**]
weeks.
Pain:
Take tylenol around the clock and dilaudid as needed. While on
dilaudid do not drive. Take stool softeners to prevent
constipation.
We have added diltiazem to your medications. This is a once a
day pill which should control your heart rate. You had a day of
postoperative atrial fibrillation which went away after starting
this medication.
Do not resume erlotnib (tarceva) until advised by your
oncologist.
Followup Instructions:
Followup with:
Name: [**Last Name (LF) 8034**],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Location (un) **] FAMILY MEDICINE
Address: [**Street Address(2) 81386**], [**Location (un) **],[**Numeric Identifier 28653**]
Phone: [**Telephone/Fax (1) 81387**]
Fax: [**Telephone/Fax (1) 81388**]
Date/time [**2147-8-7**] at 8:30am
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**]
Date/Time:[**2147-8-10**] 2:30 [**Hospital Ward Name 23**] [**Location (un) **], [**Hospital Ward Name **]
Get a chest xray 30 minutes prior to your appointment on the [**Location (un) **] radiology.
Followup with your oncologist regarding when to resume Tarceva.
Name: [**Last Name (un) **],[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] MD
Location: [**Hospital3 **] HOSPITAL
Address: [**Street Address(2) 81389**], [**Location (un) **],[**Numeric Identifier 17178**]
Phone: [**Telephone/Fax (1) 81390**]
Fax: [**Telephone/Fax (1) 81391**]
We tried to make an appointment but was unable to reach the
office. Please call to make a followup appointment.
Completed by:[**2147-8-1**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,610
| 142,728
|
7839
|
Discharge summary
|
report
|
Admission Date: [**2172-6-6**] Discharge Date: [**2172-6-15**]
Date of Birth: [**2121-12-11**] Sex: F
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Levofloxacin / Ciprofloxacin /
Zithromax / Nortriptyline
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Chest pain/STEMI
Major Surgical or Invasive Procedure:
Cardiac catheterization with BMS to LAD
History of Present Illness:
50 y/o F with hx of [**Hospital **] transfered from OSH. Pt was admitted
to OSH on [**5-27**] with c/o chest pain. Pt had rise in Troponin and
EKG changes with STE and anterolateral Q waves. Pt also
diagnoses with LLL and RLL pneumonia.
In [**Hospital1 18**] CCU, pt with ongoing SSCP, [**5-19**]. Sbp 124/80, hr 100,
96% 8l, a/ox3, +respiratory distress, crackles bil, 2pIV, (+)
foley, (-) heparin gtt, (+) nitro gtt. EKG with STE v2, v3, v4,
v5, I, st-depressions III, NSR (unchanged from [**6-4**] EKG from
OSH). Given 80mg iv lasix, nitro gtt increased to 12mcg, placed
on NRB, CXR showing +pulmonary edema. Received asa 325mg, plavix
300mg, atorvastatin 10mg at OSH, heparin gtt started at OSH but
DC'ed prior to transfer. Heparin gtt restarted for 45mins then
discontinued in preparation for cath lab. Hx of dye allergy (LLE
swelling with dye 20yrs ago), given 60mg methylprednisone, 20mg
famotidine, 25mg benadryl. ABG 7/27/38/94, electively intubated
(anesthesia performed, etomidate) as would have difficulty lying
flat for cath lab table, started on low dose versed for
sedation. Given atorvastatin 80mg down NGT prior to cath.
In cath lab, lmca 20% ostial, lcx 70%, rca mild dz, LAD total
occlusion first septal, thrombectomy performed, 3.5 by 15mm
BMS-vision stent deployed.
.
Cardiac review of systems is notable for + CP x2 days duration,
(-) dyspnea on exertion, (-)paroxysmal nocturnal dyspnea,
(-)orthopnea, (-)ankle edema, (-)palpitations, (-)syncope or
presyncope.
Past Medical History:
1. SLE - complicated by nephritis, DVT, pericarditis, on
steroids since [**61**] (+ anticardiolipin).
2. Diabetes Mellitus - on lantus, retinopathy
3. DVT hx - on coumadin
4. CKD [**1-11**] lupus nephritis - on predisone 40mg qd, bl cr 2-2.5
5. Dyslipidemia - on atorvastatin
6. Diabetes mellitus type 2 times ten years with
retinopathy.
7. Acute pancreatitis, complicated by methicillin -
resistant Staphylococcus aureus peritonitis, vancomycin
resistant enterococcus bacteremia, Serratia bacteremia in
[**2164-7-10**].
8. Asthma.
9. Hypertriglyceridemia.
10. Chronic anemia with baseline hematocrit of 30.
11. Leukopenia with white blood cell count 1.4 to 8.5.
12. Steroid induced myopathy.
13. Hx methicillin - resistant Staphylococcus aureus abscess in
lower extremity in [**2163-11-9**].
14. Pulmonary embolism, status post withdrawal of Coumadin in
[**2164-2-8**].
Social History:
significant for absence of current tobacco use, past user for
'years.' No hx etoh use, +intermittent ingestion. No apparent hx
premature coronary artery disease or sudden death. Pt lives
alone, functional, former hospital cafeteria employee,
unemployed for years given lupus diagnosis. No other apparent
IVDU or illicit drug use. ' Brother and father (divorced) do not
get along well, pt has identified two friends as care givers,
with [**Name (NI) **] (friend) as HCP.
Family History:
Mother deceased in 'old age,' had dementia, pt's friend doubt
mother had lupus. Father alive, element of 'dementia.
Physical Exam:
VS: T 98.8, BP 117/87, HR 110, RR 24, 97% 8L
Gen - female in NAD, +tachypnea, +accessory muscle use. Oriented
x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa, markedly dry
mucosa.
Neck: Supple with JVP of 10 cm in upright position.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis.
+crackles, no wheeze, no rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
[**2172-6-6**] 01:25PM WBC-4.2 RBC-4.34 HGB-12.0 HCT-36.5 MCV-84
MCH-27.5 MCHC-32.8 RDW-18.6*
[**2172-6-6**] 01:25PM PT-39.0* PTT-38.5* INR(PT)-4.2*
[**2172-6-6**] 01:25PM GLUCOSE-111* UREA N-53* CREAT-3.2*#
SODIUM-142 POTASSIUM-4.8 CHLORIDE-113* TOTAL CO2-18* ANION
GAP-16
.
[**2172-6-15**] 12:45PM BLOOD WBC-2.9* RBC-3.54* Hgb-10.0* Hct-29.9*
MCV-84 MCH-28.3 MCHC-33.6 RDW-16.6* Plt Ct-353
[**2172-6-15**] 12:45PM BLOOD Glucose-195* UreaN-57* Creat-2.2* Na-136
K-5.0 Cl-103 HCO3-23 AnGap-15
[**2172-6-15**] 12:45PM BLOOD PT-35.9* PTT-79.6* INR(PT)-3.8*
.
[**2172-6-6**] 01:25PM BLOOD CK-MB-192* MB Indx-25.9* cTropnT-4.06*
[**2172-6-6**] 08:53PM BLOOD CK-MB-235* MB Indx-22.0*
[**2172-6-7**] 03:27AM BLOOD CK-MB-139* MB Indx-25.5*
[**2172-6-9**] 05:49AM BLOOD CK-MB-9 cTropnT-10.75*
[**2172-6-9**] 10:40AM BLOOD CK-MB-NotDone cTropnT-10.1*
[**2172-6-6**] 01:25PM BLOOD CK(CPK)-741*
[**2172-6-6**] 08:53PM BLOOD CK(CPK)-1069*
[**2172-6-7**] 03:27AM BLOOD CK(CPK)-546*
[**2172-6-9**] 05:49AM BLOOD CK(CPK)-68
[**2172-6-9**] 10:40AM BLOOD CK(CPK)-75
.
[**2172-6-10**] 05:43AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-OCCASIONAL Microcy-1+ Polychr-1+ Ovalocy-OCCASIONAL Tear
Dr[**Last Name (STitle) 833**]
[**2172-6-11**] 05:39AM BLOOD calTIBC-163* VitB12-533 Folate-6.7
Hapto-281* Ferritn-1303* TRF-125*
[**2172-6-11**] 05:39AM BLOOD TSH-1.2
[**2172-6-8**] 03:10AM BLOOD dsDNA-NEGATIVE
[**2172-6-8**] 03:10AM BLOOD C3-66* C4-7*
.
EKG demonstrated - NSR, nl intervals, q-waves v2-v3,
st-elevation v2, v3, v4, I, avL.
.
[**2172-6-6**] cardiac cath
1. Selective coronary angiography of this right dominant system
demonstrated two (2) vessel coronary artery disease. The left
main
demonstrated a 20% lesion. The left anterior descending artery
demonstrated a total occlusion just distal to the first septal
branch.
The left circumflex demonstrated a 70% lesion distally. The
right
demonstrated only minimal non obstructive disease.
2. LV ventriuculography was deferred due to her decreased renal
function. Visipaque contrast used.
3. Successful PTCA, thrombectomy and stenting of the mid left
anterior descending artery with a Vision (3.5x15mm) bare metal
stent.
Final angiography demostrated no angiographically apparent
dissection,
no residual stenosis and TIMI III flow throughout the vessel
(See PTCA
comments).
4. Successful closure of the right femoral arteritomy site with
a 6F
Mynx closure device.
1. Two vessel coronary artery disease.
2. Anterior myocardial infarction managed by thrombectomy and
stenting
with a bare metal stent to mid left anterior descending artery.
.
[**2172-6-8**] Echo
Extentive regional left ventricular systolic dysfunction with
apical aneurysm c/w CAD (mid-LAD infarction pattern). Moderate
to severe mitral regurgitation. Mild-moderate pulmonary artery
systolic hypertension.
If clinically indicated, a cardiac MRI ([**Telephone/Fax (1) 9559**]) with late
gadolinium contrast is more definitive for the presence of an LV
thrombus in this condition. Compared with the prior report
(images unavailable for review) of [**2164-7-3**]), the left
ventricular dysfunction is new and the severity of mitral
regurgitation and pulmonary artery systolic hypertension are
increased. LVEF 25%.
Brief Hospital Course:
50yoF with hyperlipidemia, DMII, lupus nephritis presents from
OSH with ST elevation myocardial infarction, no s/p bare metal
stent.
.
CAD/Ischemia
EKG showed ST elevation MI. Cardiac cath showed LMCA 20%, LCX
70%, LAD total occlusion first septal. Bare metal stent placed
to LAD. Started on Aspirin 81mg, Plavix 75mg, Atorvastatin 80mg.
Beta blocker started after catheterization - discharged on
Toprol XL 150mg QD. Discharged with goal INR 2.5-3.5. INR 3.8
at discharge.
.
LV systolic dysfunction
Exhibited signs of CHF, with significant lower extremity edema
and bilateral crackles throughout lung fields. Transthoracic
echocardiography [**2172-6-8**] showed EF 25% with extensive LV
regional systolic dysfunction with apical aneurysm consistent
with CAD, moderate/severe MR, mild/moderate PA systolic HTN.
Diuresed with varying doses of Lasix IV. Treated with
hydralazine in varying doses. Discharged on hydralazine 25mg
TID as rising creatinine prohibited the resumption of [**Last Name (un) **] that
pt was taking at home. Appointment made with Dr. [**Last Name (STitle) **] for
defibrillator placement. Appointment made for echocardiogram
prior to appointment with Dr. [**Last Name (STitle) **].
.
Rate/Rhythm
Initially tachycardic upon presentation to floor. Treated with
increasing doses of metoprolol, with good control of heart rate.
Discharged on Toprol XL 150mg. EKG during hospital course
gradually improved, showing no changes consistent with further
infarction or ischemia.
.
Respiratory failure
Was previously being treated for pneumonia at OSH - appears
patient received total of 10 days leveo and zosyn ([**5-27**] to
[**6-6**]). Sputum gram stain and culture both negative.
Respiratory failure thought to be due to CHF in setting of
STEMI. Respiratory failure resolved with diuresis with Lasix.
.
DMII
Is on lantus at home. Here in hospital, managed with insulin
sliding scale and Lantus. Had episodes of low blood sugars,
leading to decrease in Lantus dosage.
.
SLE
On admission, she was on a dose of 40mg QD prednisone.
Rheumatology was consulted and felt that she did not require
such a high dosage of prednisone. Her prednisone dosage was
decreased to 15mg QD.
.
Renal failure
History of chronic renal insufficiency due to lupus nephritis.
Received dye load during cardiac catheterization. This led to
concern about high susceptibility to acute on chronic renal
failure, especially given dye load. Creatinine increased from
3.2 on presentation up to 3.6 two days later, but subsequently
decreased to a low of 2.1 at discharge.
.
Anemia
She has a long standing baseline anemia. Hematocrit was
initially 36.5 on admission, she had an initial hematocrit drop
during cardiac catheterization, then consequently continued to
trend down, reaching a hematocrit of 21.8, at which point she
was transfused with 1 unit of PRBCs, to a hematocrit of 28.9.
Hematology was consulted. Anemia was thought to be likely
multifactorial, including kidney disease, chronic inflammation,
and possibly an underlying sideroblastic process. A smear
showed nucleated RBCs with basophilic stippling suspicious for
an underlying sideroblastic anemia. Hematology felt that if her
anemia worsened in the future, it might be reasonable to
consider a bone marrow biopsy for further evaluation. However,
it was felt that this was not currently necessary in the setting
of other active medical issues. Hct 29.9 on discharge.
.
Leukopenia
She has a long standing baseline leukopenia. Here, her WBC
count was as low as 1.1. However, when blood drawn off a fresh
stick (versus line), WBC increased to 2.1, so likely artifact
although may be related to lupus, as per Hematology. WBC 2.9 on
discharge.
Medications on Admission:
1. Oxycontin 40 mg daily
2. Dilaudid 2 mg q4h IV
3. Vicodin for breakthrough pain
4. Coumadin 5 mg PO daily
5. Prednisone 40 mg PO daily
6. Insulin Lantus 40 QH, plus RISS
7. Levaquin 250 mg PO daily x7 days (unsure if received, called
[**Hospital1 46**], cannot find documentation).
8. Zosyn 2.2 mg [**Hospital1 **] x7 days
9. Nifedipine XL 60 mg daily
10. Metoprolol XL 100 mg daily
11. Temazepam 30 mg daily
12. Colace 100 mg daily
13. Gabapentin 100 mg tid
14. Atorvastatin 10 mg daily
15. Fluticasone 100 2 puffs [**Hospital1 **]
16. Latanoprost 1 drop L eye daily
17. Pantoprazole 40 mg daily
18. Procrit - 20,000 units every other week
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
Disp:*1 one* Refills:*0*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*1 1* Refills:*0*
7. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Tablet, Delayed Release (E.C.)(s)
9. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
Take one pill under your tongue 5 minutes apart. If you have any
chest pain after 3 tablets, call 911.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
10. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
12. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous three times a day: per sliding scale.
13. Latanoprost 0.005 % Drops Sig: One (1) Drop(s)left eye
Ophthalmic HS (at bedtime).
14. Cosopt 2-0.5 % Drops Sig: One (1) drop both eyes Ophthalmic
at bedtime.
15. Temazepam 30 mg Capsule Sig: One (1) Capsule PO at bedtime
as needed for insomnia.
16. Epoetin Alfa 20,000 unit/mL Solution Sig: One (1) injection
Injection every other week.
17. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: Three
(3) Tablet Sustained Release 24 hr PO once a day.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
18. PhosLo 667 mg Capsule Sig: One (1) Capsule PO three times a
day.
19. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO three times
a day.
Disp:*90 Tablet(s)* Refills:*2*
20. Outpatient Lab Work
Please draw PT/INR, Potassium, BUN and Creatinine on [**6-17**]
and forward results to Dr. [**Last Name (STitle) 18998**].
21. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day:
please adjust as instructed by your coumadin clinic.
22. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
23. Vitamin D-3 400 unit Tablet Sig: Two (2) Tablet PO once a
day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
vna [**Hospital3 635**]
Discharge Diagnosis:
Primary Diagnosis:
ST elevation myocardial infarction s/p bare metal stent to LAD
Acute systolic heart failure
Acute renal failure
Anemia s/p transfusion
.
Secondary Diagnosis:
SLE w/ anticardiolipin antibody
Leukopenia
DM-2
Hypertension
Discharge Condition:
Stable vital signs with appropriate follow-up.
Discharge Instructions:
You were admitted to [**Hospital1 69**] with a
myocardial infarction (commonly known as a heart attack). The
clogged artery was opened up and a metal stent was placed to
keep the artery open.
.
Because you had a heart attack, you were started on Aspirin
81mg, Plavix 75mg, and Atorvastatin 80mg. Please continue
taking these every day unless otherwise instructed by your
cardiologist.
.
Following your heart attack, your heart was not pumping well,
leading to swelling in your legs and difficulty breathing. You
were treated with doses of Lasix. An echocardiogram was done,
which showed that your heart was not contracting as well as it
normally does. You were started on a number of medications for
this. We would like you to continue taking the following
medications: Lasix 80mg twice a day, Imdur 60mg once a day,
Hydralazine 25mg three times a day, Toprol XL 150mg once a day.
You will continue taking Coumadin with a goal INR of 2.5 to 3.5.
.
We made some changes to the medications that you take.
- your prednisone dosage was decreased to 15mg per day
- your Toprol XL was increased to 150mg per day
- your Lasix dosage was increased to 80mg twice a day
- your Lipitor was increased to 80mg daily
- you were started on hydralazine, 25mg three times a day
- you were started on aspirin, 81mg per day
- you were started on Plavix (clopidogrel) 75mg per day
- your Procardia was STOPPED
.
Please follow these instructions:
- Weigh yourself every morning and call your physician if your
weight increases more than 3 lbs.
- Adhere to 2 gm sodium diet.
- You will need have follow up labs drawn on Wednesday morning
to check your INR and also to check some electrolytes.
- DO NOT take any Coumadin Monday night and you can resume
Coumadin 2mg on Tuesday. Please tell your [**Hospital 197**] clinic that
your INR was 3.8 on Monday [**6-15**].
.
If you develop any chest pain, shortness of breath, worsening of
condition, or any other concerning symptoms, please go to the
nearest emergency room.
Followup Instructions:
We made an appointment for you with your primary doctor, Dr.
[**Last Name (STitle) 18998**]: Monday, [**7-6**] at 3pm. Call [**Telephone/Fax (1) 20264**] with any
questions.
We made an appointment for you with a cardiologist, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 5310**], on [**6-24**] at 10:40 PM. Please call his office
at [**Telephone/Fax (1) 5315**] after you return home to confirm this
appointment. Please bring a copy of your medical records to
this appointment.
We made an appointment for an ECHOCARDIOGRAM on [**2172-7-21**] at 11:00 on [**Hospital Ward Name 2104**] 4, near main entrance of [**Hospital1 18**] [**Hospital Ward Name **]. Phone: [**Telephone/Fax (1) 62**]
We made an appointment with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] on [**2172-7-21**] at 1:00PM. Phone:[**Telephone/Fax (1) 285**]
|
[
"583.81",
"584.9",
"285.9",
"710.0",
"V58.61",
"250.00",
"414.01",
"288.50",
"410.11",
"V12.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"36.06",
"00.45",
"00.40",
"00.66",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
14642, 14696
|
7513, 11225
|
361, 403
|
14978, 15027
|
4248, 7489
|
17078, 17992
|
3315, 3432
|
11918, 14619
|
14717, 14717
|
11251, 11895
|
15051, 17055
|
3447, 4229
|
305, 323
|
431, 1917
|
14894, 14957
|
14736, 14873
|
1939, 2812
|
2828, 3299
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,414
| 167,603
|
17352
|
Discharge summary
|
report
|
Admission Date: [**2186-5-30**] Discharge Date: [**2186-6-4**]
Date of Birth: [**2138-12-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Amoxicillin
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Unstable angina
Major Surgical or Invasive Procedure:
s/p CABGx2 (LIMA-LAD, SVG-PDA) [**5-30**]
History of Present Illness:
This is a 47 year old man s/p cardiac cath who presented with
unstable angina. He was refered to us for possible operative
treatment of his 3 vessel disease
Past Medical History:
1. CAD s/p LAD stent
.
2. Anterolateral STEMI [**4-4**]
.
3. Cardiac cath [**2184-4-27**]
- 3-vessel CAD.
- LMCA free of obstructions.
- LAD 100% mid-vessel occlusion with moderate diffuse disease
distally.
- S1 90% origin stenosis.
- LCX 60% proximal stenosis, 80% stenosis of large OM2.
- 70% PDA origin stenosis, 90% stenosis of the mid PL branch.
* mid-LAD stented.
.
4. TTE [**2184-4-28**]
- EF 35-40%
- distal anteroseptal akinesis and apical akinesis/dyskinesis
Social History:
Married, toxicologist.
-No tobacco
-6 drinks per week of EtOH
-No recreational drugs
Family History:
Father, MI at 37 yo
Physical Exam:
98.0 150/88 20 99%RA
NAD
Neuro: grossly intact
HEENT: PERRLA, EOMI, MMM
Resp: CTA bilat
CV: RRR, S1,S2 nl
Abdomen: soft, obese, NT
Pulses 2+ throughout
Pertinent Results:
[**2186-5-29**] 01:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2186-5-29**] 01:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2186-5-29**] 01:00PM PT-12.7 PTT-26.6 INR(PT)-1.1
[**2186-5-29**] 01:00PM PLT COUNT-256
[**2186-5-29**] 01:00PM WBC-8.1 RBC-4.50* HGB-15.2 HCT-44.1 MCV-98
MCH-33.7* MCHC-34.4 RDW-12.7
[**2186-5-30**] 02:09PM UREA N-11 CREAT-0.8 CHLORIDE-110* TOTAL
CO2-21*
[**2186-5-30**] 04:45PM K+-4.0
Brief Hospital Course:
Pt was admitted to the CSRU after uneventful CABGx2. He was
initially on pressor support. He was started on plavix for poor
target vessels. His chest tubes were d/c'ed on POD1. His swan
and foley came out on POD2. Multiple cxr were serially normal.
His trauma line was changed out for a standard double lumen
catheter. This was done on POD 2 and was uneventful. His lytes
were repleted PRN and he was sent to the floor on POD 2. His
course on the floor was unremarkable and he was sent home on POD
5.
Medications on Admission:
ASA
lipitor 80
lisinopril 5',
plavix75,
allopurinol 300'
metoprolol 25"
colchicine
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
8. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*0*
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
12. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
CAD
s/p CABG
gout
hyperlipidemia
Discharge Condition:
good
Discharge Instructions:
you may take a shower and wash your incision with mild soap and
water
do not swim or take a bath for 1 month
do not drive for 1 month
do not lift anything heavier than 10 pounds for 1 month
do not apply lotions, creams, ointments or powders to your
incisions
Followup Instructions:
follow up with Dr. [**Last Name (STitle) **] in [**12-4**] weeks
follow up with Dr. [**Last Name (STitle) 911**] in [**12-4**] weeks
follow up with Dr. [**Last Name (STitle) **] in [**2-3**] weeks
Completed by:[**2186-6-4**]
|
[
"272.4",
"412",
"414.01",
"V17.3",
"V45.82",
"274.9",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.11",
"39.61",
"89.60"
] |
icd9pcs
|
[
[
[]
]
] |
4235, 4286
|
1934, 2444
|
308, 351
|
4362, 4368
|
1387, 1911
|
4675, 4901
|
1176, 1197
|
2577, 4212
|
4307, 4341
|
2470, 2554
|
4392, 4652
|
1212, 1368
|
253, 270
|
379, 538
|
560, 1057
|
1073, 1160
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,602
| 190,692
|
39233
|
Discharge summary
|
report
|
Admission Date: [**2151-1-11**] Discharge Date: [**2151-1-15**]
Date of Birth: [**2078-5-30**] Sex: F
Service: MEDICINE
Allergies:
Vancomycin / Benadryl / Morphine
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Chest pressure.
Major Surgical or Invasive Procedure:
cardiac catheterization with no intervention
History of Present Illness:
Ms [**Known lastname 10680**] is a 72 year-old female with pmh of hypertension, HL,
depression, and GERD who was admitted to the MICU on [**1-11**] due to
hypotension after she developed chest pressure in the ED. She
describes being under a lot of stress as she came to the ED with
husband who was in a traumatic traffic accident after having a
stroke. She describes this her chest pressure as a band across
the chest below her left breast and into her back. Upon further
history she endorses URI symptoms and similar chest pressure
dating back 7-14 days. She says that pressure is unrelated to
activity, but is accompanied by some shortness of breath. She
denies relationship to food. She also endorses having
occassional dark stool 1x/week. She had an episode of non-bloody
emesis in the ER. Her EKGs in the ED did not show any ischemic
changes and her CK was normal, however her trop was elevated to
0.45. She was hypotensive with SBPs in the 70's to 80's. She was
given 4 L IVF and started on zosyn, flagyl, and clindamycin. A
central line was placed and she was also started on neo. A CT
torso and abdominal US showed gallbladder wall edema and
pericholecystic fluid. Surgery was consulted and they did not
feel it was acute cholecystitis. Patient was started on Zosyn,
Flagyl, Clindamycin. This morning because of the persistently
elevated troponin and TWI in V4-V6, patient was sent to cath
lab. Catheterization demonstrated normal LMCA, LAD, LCX, and RCA
coronary arteries as well as moderate elevation of R/L heart
filling pressures. Echo demonstrated apical hypokinesis with
severe MR [**First Name (Titles) **] [**Last Name (Titles) **] leaflet. CO 3.55, CI 2.12. Patient was
transferred to CCU without intervention. Patient endorses
continued chest pressure.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, abdominal pain. She denies recent fevers. Last
hospitalization 10 years ago.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
syncope or presyncope.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
Hypertension
Hyperlipidemia
Gastroesophageal reflux
Depression
S/p surgery for endometriosis
Strep endocarditis (hospitalized 10 yrs ago)
Mitral Valve Prolapse/Regurg, which predates Strep endocarditis
Hiatal hernia and diverticula by CT.
Social History:
SOCIAL HISTORY: Retired administrative assistant from [**State 1727**].
-Tobacco history: smoked 15-70yo x0.5 pk/d (23pkyrs)
-ETOH: glass of wine/day
-Husband died on [**2151-1-13**]. Pt was able to see him after death
here in hospital.
Family History:
FAMILY HISTORY:
Father died of vascular disease. Mother died of [**Name (NI) **] CA.
No family history of early MI, several uncles had heart attacks
>60yo. No other history of cardiac disease. No FHX of DM, other
cardiac disease.
Physical Exam:
Exam on admission:
VS: T=95.9...BP=94/61...HR=88...RR=22...O2 sat=96-99% on
non-rebreather.
GENERAL: WDWN women in NAD. Orientedx3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. No pallor or
cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 13 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. II/VI apical systolic murmur. No r/g.
No thrills, lifts. No S3 or S4. Mild chest wall tenderness.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Lung fields were
auscultated anteriorly only: CTAB, no crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. Abd aorta not enlarged by palpation. No
abdominial bruits. Nml BS.
EXTREMITIES: WWP. No c/c/e. R fem insertion site without
hematoma, bruit, or visible echymosis. Clean bandage without
pain.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
By discharge patient was stable with SpO2 96% on RA and only
minimal bibasilar crackles.
Pertinent Results:
labs on admission:
[**2151-1-11**] 09:15PM ALT(SGPT)-19 AST(SGOT)-27 CK(CPK)-98 ALK
PHOS-80 TOT BILI-0.2
[**2151-1-11**] 09:15PM LIPASE-31
[**2151-1-11**] 09:15PM cTropnT-0.56*
[**2151-1-11**] 05:50PM GLUCOSE-121* UREA N-15 CREAT-1.3* SODIUM-139
POTASSIUM-4.8 CHLORIDE-106 TOTAL CO2-17* ANION GAP-21*
[**2151-1-11**] 05:50PM CK(CPK)-104
[**2151-1-11**] 05:50PM cTropnT-0.45*
[**2151-1-11**] 05:50PM CK-MB-7
[**2151-1-11**] 05:50PM WBC-17.5* RBC-4.35 HGB-13.3 HCT-39.1 MCV-90
MCH-30.5 MCHC-33.9 RDW-13.2
.
Labs at discharge:
[**2151-1-15**] 05:47AM BLOOD WBC-7.6 RBC-3.20* Hgb-9.6* Hct-28.9*
MCV-90 MCH-29.9 MCHC-33.1 RDW-13.3 Plt Ct-166
[**2151-1-15**] 05:47AM BLOOD Plt Ct-166 LPlt-1+
[**2151-1-15**] 05:47AM BLOOD Glucose-121* UreaN-12 Creat-1.0 Na-142
K-3.8 Cl-107 HCO3-28 AnGap-11
[**2151-1-12**] 10:15AM BLOOD Cortsol-45.7*
Peak CK: 104, Peak Troponin: .54
.
ECHO [**2151-1-12**]:
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is moderate
regional left ventricular systolic dysfunction with focal
hypokinesis to akinesis of the mid to distal anterior wall,
septum, apex, and mid to distal inferior and inferolateral
walls. 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 aortic
valve leaflets are mildly thickened (?#). There is no aortic
valve stenosis. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There appears to be partial
mitral leaflet [**Month/Day/Year **] of the posterior leaflet. An eccentric,
anteriorly directed jet of moderate to severe (3+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is mild pulmonary artery systolic hypertension. There is
an anterior space which most likely represents a fat pad.
IMPRESSION: Suboptimal image quality. Extensive regional
systolic dysfunction c/w multivessel CAD or extensive
cardiomyopathy. Possible posterior leaflet partial mitral
leaflet [**Month/Day/Year **] with an eccentric, anteriorly directed jet of
moderate to severe mitral regurgitation. Mild pulmonary
hypertension.
.
Cardiac catheterization:
COMMENTS:
1. Coronary angiography in this right dominant system
demonstrated no
evidence of obstructive coronary artery disease. The LMCA, LAD,
LCx, and
RCA were all patent.
2. Resting hemodynamics revealed elevated left and right sided
filling
pressures with an RVEDP of 16 mmHg and an LVEDP of 25 mmHg.
There was
moderate pulmonary artery systolic hypertension with a PASP of
44 mmHg.
The cardiac index was preserved at 2.3 L/min/m2. Systemic blood
pressures were normal.
3. There was no evidence of aortic stenosis on left heart
pullback.
.
CT Chest:
IMPRESSION:
1. No evidence of pulmonary embolism or aortic dissection.
2. Mildly distended gallbladder, with a large amount of wall
edema and/or
pericholecystic fluid as well as stranding within the porta
hepatis.
Correlation with right upper quadrant symptoms, LFT levels, and
lipase/amylase
is suggested. If clinically indicated, this can be further
evaluated with a
right upper quadrant ultrasound.
3. Patchy opacities throughout the lungs, with interlobular
septal thickening
and thickening of the bronchovascular interstitium, likely
reflective of
pulmonary edema.
Brief Hospital Course:
Mrs. [**Known lastname 10680**] is a 72 year old woman who presented to the ED with
chest pressure consistent with ischemia in the setting of
positive cardiac biomakers and TWI. Echo demonstrated apical
akinesis and question of [**Last Name (un) **]-Tsubo cardiomyopathy vs cardiac
ischemia.
# Takotsubo stress-related cardiomyopathy. Patient developed
chest pressure while visiting the emergency room where her
husband had been taken following a traumatic MVA following a
stroke. Her husband was transferred to the SICU where he
expired 2 days later. The patient was seen in the ED where she
was found to have abdominal pain, hypotension, and some
difficulty breathing. She was initially treated for infection
with broad spectrum antibiotics, norepinephrine, and IVF. Of
note IV vancomycin was discontinued after she developed a rash.
Patient remained afebrile throughout hospitalization and
antibiotics were discontinued on the floor. Later her cardiac
biomarkers came back as elevated and her EKG the next morning
showed T wave abnormalities concerning for cardiac etiology.
Cardiac catheterization demonstrated normal coronary vessels,
but a transesophageal echocardiogram demonstrated decreased EF
of 35-40%, apical akinesis, and a [**Last Name (un) **] mitral leaflet. The
patient was transferred to the coronary care unit where she was
diuresed with IV lasix and gradually weaned off of oxygen.
Because of the apical a/hypokinesis she was started on
anti-coagulation with IV heparin followed by warfarin and a LMWH
bridge. Her INR was 1.1 at the time of discharge, her INR should
be checked on [**1-18**].
The patient's blood pressure did not tolerate an ACEi or beta
blocker during her admission while being diuresed. She was
restarted on a low dose ace inhibitor with lisinopril 2.5 mg
daily prior to discharge. The patient will require repeat
echocardiogram as an outpatinet to assess for improvement of her
depressed cardiac function. She is being discharged on lasix
20mg daily for continued [**Month/Year (2) **]. She should have her
electrolytes and renal function checked at her outpatient follow
up.
#Mitral Regurgitation by phsyical exam and echo. Patient has
history of disease, which may have been related to past
endocarditis. [**Month/Year (2) 26058**] leaflet seen on echo required close
hemodynamic monitoring. Her hemodynamics stabilized after
[**Month/Year (2) **] so surgical evaluation was not urgently required. She
will require repeat echocardiogram as an outpatient to assess
for improvement of her MR [**First Name (Titles) **] [**Last Name (Titles) **].
#Anemia. Patient's hematocrit declined from 39 at admission to
29 at discharge. Some of the initial decline was likely due to
hemodilution and then blood loss during catheterization. Patient
endorsed history of dark stools, but guaiac was negative.
#Abdominal pain. Likely constipation, would also consider
hiatal hernia on imaging. Given severe abdominal aorta
atherosclerotic disease and SMA stenosis would also consider
abdominal angina. Patient was treated with a bowel regimen.
#Dyslipidemia. Patient treated with statin per home regimen.
#GERD. Patient treated with proton pump inhibitor throughout
hospitalization.
#Depression and anxiety. Patient was continued on wellbutrin
and lorazepam per her home regimen. Patient was given trazadone
on several occasions for difficulty sleeping.
Medications on Admission:
(patient does not recall doses of medications)
Lisinopril 10 mg daily
Simvastatin 40 mg daily
Aspirin 325 mg PO Daily
Pantoprazole 40mg QD
Wellbutrin 75mg PO BID
Lorazepam 0.5mg HS/PRN anxiety
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
[**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0*
4. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day:
Take 2 tablets daily at same time, approx 4pm. Discuss dose
changes with your physician.
[**Name Initial (NameIs) **]:*90 Tablet(s)* Refills:*2*
5. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO twice a
day.
6. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) syringe
Subcutaneous [**Hospital1 **] (2 times a day): Inject every 12 hours per
instructions.
[**Hospital1 **]:*8 syringe* Refills:*2*
7. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
8. Outpatient Lab Work
Please check INR on Monday [**1-18**] and call results to
Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 79348**]
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
[**Telephone/Fax (1) **]:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Takotsubo cardiomyopathy
Hypertension
Dyslipidemia
Depression
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You had a very stressful event and had some heart damage that we
think is Takotsubo cardiomyopathy. You had a cardiac
catheterization that was did not show any blockages that needed
to be fixed. Your heart is weak right now but we expect your
heart to get stronger over the next month or so. You will need
to take coumadin for at least 1-2 months to prevent blood clots.
Your goal coumadin level (INR) is 2.0-3.0. Please start taking 5
mg coumadin at home at 4pm and get your coumadin level checked
on Monday at [**Hospital3 **]. Dr. [**Last Name (STitle) 9897**] will tell you how much
coumadin to take from then on.
.
Medication changes:
1. Take Lovenox injection twice a day. Dr. [**Last Name (STitle) 9897**] will tell you
when to stop taking this medicine
2. Start Coumadin to prevent blood clots.
3. Decrease Lisinopril to 2.5 mg daily
4. Start furosemide 20 mg daily
.
5. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs in 1 day or 6 pounds in 3 days.
Followup Instructions:
Cardiology:
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 79081**] Phone: [**Telephone/Fax (1) **] Date/time: Monday 22 at
11:30 am. Main hospital.
.
Primary Care:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9897**] Phone: [**Telephone/Fax (1) 79348**] Date/Time: [**Doctor First Name **] will make
an appt for you. Fax [**Telephone/Fax (1) 86829**]
|
[
"300.4",
"276.2",
"693.0",
"440.0",
"401.9",
"424.0",
"794.9",
"429.83",
"E930.8",
"564.00",
"428.0",
"428.21",
"285.9",
"530.81",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"38.93",
"88.72",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
12936, 13011
|
8029, 11435
|
308, 355
|
13117, 13117
|
4581, 4586
|
14285, 14707
|
3262, 3478
|
11678, 12913
|
13032, 13096
|
11461, 11655
|
13262, 13882
|
3493, 3498
|
2647, 2705
|
13902, 14262
|
253, 270
|
5122, 8006
|
383, 2531
|
4600, 5102
|
13131, 13238
|
2736, 2976
|
2575, 2627
|
3008, 3230
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,839
| 173,811
|
21515
|
Discharge summary
|
report
|
Admission Date: [**2204-3-28**] Discharge Date: [**2204-4-3**]
Date of Birth: [**2136-12-23**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
[**2204-3-28**]: Placement of percutaneous cholecystostomy tube.
History of Present Illness:
Patient is a 67-years-old male was presented in [**Hospital1 **] [**Location (un) 620**] with
c/c abdominal pain on [**2204-3-28**]. CT abdomen revealed likely
cholecystitis vs. cholangitis. Patient was started on
Ceftriaxone and Flagyl and was transferred to [**Hospital1 18**] for further
w/u and management.
Past Medical History:
1. Hypertension
2. Hypercholesterolemia
3. Diabetes
4. Peripheral vascular disease
5. CVA with R hemiparesis and right facial palsy
6. Anemia
7. BPH
8. Hypomagnesemia
9. Right femur fracture
10. Depression
Social History:
Resident in skilled nursing facility. Toxic habits not known.
Family History:
Unknown
Physical Exam:
On Discharge:
VS: T 97.4, HR 74, BP 124/66, RR 18, O2 Sat 94%
GEN: Awake and alert, Confused, NAD
HEENT: PERRL, Right gaze preference, right facial palsy
HEART: RRR, no m/r/g
LUNGS: Coarse b/l
ABD: Soft, nontender, right PCT w/dressing c/d/i
EXT: Right hemiparesis, left - normal muscle tone, follows all
commands.
Pertinent Results:
[**2204-3-28**] 06:43AM GLUCOSE-264* LACTATE-3.3* NA+-135 K+-4.5
CL--93* TCO2-26
[**2204-3-28**] 06:30AM GLUCOSE-263* UREA N-22* CREAT-0.8 SODIUM-133
POTASSIUM-4.4 CHLORIDE-93* TOTAL CO2-27 ANION GAP-17
[**2204-3-28**] 06:30AM ALT(SGPT)-76* AST(SGOT)-94* CK(CPK)-43* ALK
PHOS-134* TOT BILI-1.8*
[**2204-3-28**] 06:30AM LIPASE-16
[**2204-3-28**] 06:30AM WBC-28.2*# RBC-4.52*# HGB-13.9*# HCT-40.0#
MCV-88 MCH-30.6 MCHC-34.7 RDW-13.3
[**2204-3-28**] 06:30AM NEUTS-90.3* LYMPHS-4.1* MONOS-5.4 EOS-0.1
BASOS-0.2
[**2204-3-28**] 06:30AM PLT COUNT-316
[**2204-3-28**] 06:30AM PT-15.1* PTT-26.9 INR(PT)-1.3*
[**2204-3-28**] 07:15AM URINE BLOOD-SM NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-8* PH-7.0 LEUK-MOD
[**2204-3-28**] 8:41 am MRSA SCREEN Source: Nasal swab.
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
[**2204-3-28**] 7:15 am URINE
URINE CULTURE (Final [**2204-3-29**]): YEAST. >100,000
ORGANISMS/ML..
[**2204-3-30**] BEDSIDE SWALLOWING EVALUATION:
RECOMMENDATIONS:
1. PO diet: ground solids, nectar thick liquids
2. Meds crushed in puree
3. TID oral care
4. Assist with meals as needed to assist with self-feeding and
maintain standard aspiration precautions.
[**2204-4-2**] CHOLANGIOGRAM:
IMPRESSION: Persistent obstruction at the level of the cystic
duct.
Indwelling cholecystostomy tube in adequate position.
Cholelithiasis.
[**2204-3-30**] 06:00AM BLOOD ALT-24 AST-28 AlkPhos-93 TotBili-0.5
[**2204-3-30**] 06:00AM BLOOD WBC-10.1# RBC-2.99* Hgb-9.2* Hct-26.6*
MCV-89 MCH-30.7 MCHC-34.5 RDW-13.3 Plt Ct-215
[**2204-3-30**] 06:00AM BLOOD Glucose-81 UreaN-33* Creat-0.6 Na-136
K-3.6 Cl-102 HCO3-26 AnGap-12
Brief Hospital Course:
The patient was admitted in SICU to the General Surgical Service
for evaluation of the aforementioned problem. On [**2204-3-28**], the
patient underwent IR guided placement of cholecystostomy tube
with drainage catheter, which went well without complication
(reader referred to the Procedure Note for details). Patient was
continue on IV antibiotics with Flagyl, Levofloxacin and
Fluconazole. Patient was continue to have IV fluid for hydration
with boluses for low urine output and tachycardia. ON [**3-29**] NG
tube was clamped and patient was advanced to clears with PO home
meds.The patient was hemodynamically stable and was transferred
on the floor. On [**2204-3-30**] patient was neurologically stable,
afebrile with stable vital signs. Swallowing evaluation was
performed and patient was advanced to his baseline of soft
solids and nectar thick liquids with meds crushed in puree once
he is reunited with his dentures. Patient was ordered to have
diagnostic cholangiogram. On [**3-31**] and [**4-1**] patient was afebrile,
with stable vital signs, neurologically stable. On [**2204-4-2**]
patient underwent diagnostic cholangiogram, which revealed
continued cystic duct obstruction, adequate position of the
cholecystostomy tube within the gallbladder, and Cholelithiasis.
On [**2204-4-3**] patient was discharged back in Nursing Home with
instruction to continue antibiotics for another 3 days. Patient
will have a follow up appointment with Dr. [**Last Name (STitle) **] in one month
after discharge.
.
During this hospitalization, patient was neurologically on his
baseline. He is awake and alert, baseline confused. He continue
to have right sided hemiparesis s/t CVA, he follows simple
commands on left side. The patient received subcutaneous
heparin and venodyne boots were used during this stay. The
patient's blood sugar was monitored regularly throughout the
stay; sliding scale insulin was administered when indicated.
Labwork was routinely followed; electrolytes were repleted when
indicated.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a soft
solids diet with nectar thick liquids, voiding without
assistance, and pain was well controlled. The patient was
discharged in his skilled nursing facility with detailed
discharge and follow-up instructions.
Medications on Admission:
1. Novolin (80U qam, 22U qpm, novolin SS)
2. Norvasc 5 mg PO qday
3. Lisinopril 10 mg PO qday
4. Metoprolol 25 mg Po bid
5. ASA 81 mg PO qday
6. Seroquel 25 mg PO qhs and 25 mg PO prn
7. Depakoate 500 mg PO tid
8. Cymbalta 60 mg PO qday
9. Flomax 0.4 mg PO daily
10. Trazadone 25 mg PO prn
11. Percocet 5/325 mg PO prn
12. Combivent nebs prn
13. Senna 2 tabs PO qday
14. Colace 100 mg PO bid
15. MOM 30 ml PO prn
16. Bisacody l0 mg PR prn
17. Fleet enema prn
18. Tylenol prn, MVI
19. MVI qday
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for agitation.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every four (4) hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-14**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
11. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for agitation.
13. Divalproex 125 mg Capsule, Sprinkle Sig: Four (4) Capsule,
Sprinkle PO TID (3 times a day).
14. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
15. Levaquin 750 mg Tablet Sig: One (1) Tablet PO once a day for
3 days.
Disp:*3 Tablet(s)* Refills:*0*
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed) as needed for groin irritation.
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for constipation.
18. Novolin N 100 unit/mL Suspension Sig: Eighty (80) units
units Subcutaneous qam and 22 units SC qpm.
19. Novolin R 100 unit/mL Solution Sig: [**3-7**] sliding scale units
Injection sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
1. Acute cholecystitis
2. Vascular dementia
3. Right hemiparesis
Discharge Condition:
Mental Status: Confused - always
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
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 [**5-21**] 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.
.
General 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).
*If the drain is connected to a collection container, please
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.
*Wash the area gently with warm, soapy water or 1/2 strength
hydrogen peroxide followed by saline rinse, pat dry, and place a
drain sponge. Change daily and as needed.
*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:
1.Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**]
Date/Time:[**2204-5-11**] 10:00. Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**]
.
Please call ([**Telephone/Fax (1) 56735**] to arrange a follow-up appointment
with Dr. [**Last Name (STitle) 31**] in [**2-15**] weeks.
Completed by:[**2204-4-3**]
|
[
"285.9",
"438.20",
"272.0",
"250.00",
"290.40",
"401.9",
"574.01",
"600.00",
"443.9",
"437.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.54",
"51.01"
] |
icd9pcs
|
[
[
[]
]
] |
7835, 7919
|
3114, 5460
|
328, 395
|
8028, 8028
|
1420, 3091
|
10013, 10407
|
1060, 1069
|
6003, 7812
|
7940, 8007
|
5486, 5980
|
8200, 8200
|
8824, 9990
|
1084, 1084
|
1098, 1401
|
8232, 8809
|
274, 290
|
423, 735
|
8043, 8176
|
757, 964
|
980, 1044
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,864
| 186,500
|
26755
|
Discharge summary
|
report
|
Admission Date: [**2148-1-22**] Discharge Date: [**2148-1-27**]
Date of Birth: [**2093-2-24**] Sex: M
Service: MEDICINE
Allergies:
Lipitor / Amiodarone
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
cc: weakness on left side, double vision
Major Surgical or Invasive Procedure:
Pulmonary vein isolation
History of Present Illness:
HPI: 54 yo M with hx of DM, CAD s/p CABG in [**2139**], AF, HL s/p
elective ablation for AF p/w chest pain, L-sided weakness and
double vision. With his AF, he describes symptoms of fatigue,
SOB, chest tightness and anxiety, and has symptoms almost every
other day with rates > 100. He has had multiple admissions with
lopressor treatment, and undergone catheterization 8-10 times
for his chest tightness, most recently in [**2145**] at MWH, which
were reportedly clear. He received a cardiac MR on [**1-18**] in
preparation for pulmonary vein isolation, which showed a normal
EF and mild biatrial enlargement. He subsequently was admitted
on [**1-22**] for elective pulmonary vein isolation under general
anesthesia and was doing well post-operatively when he suddenly
stopped responding to questions at ~3:30 PM. He reported
burning chest pain with R shoulder soreness. Repeat EKGs showed
no acute ST changes. Received SL NTG x1 without improvement.
He received a dose of morphine 4mg for this and during the
infusion became sleepy, difficult to arouse and not moving his
extemities at all. He was given 0.4 mg Narcan and was noted to
be weak in his L arm and leg with double vision in his L eye by
the neurology stroke team. He was taken for emergent CTA which
showed no evidence of arterial occlusion. A subsequent MRI
showed no evidence of acute stroke. Neurology felt that this
could medication effect vs seizure. He was transferred to the
CCU for further monitoring.
.
ROS: (-) TIA (-) CVA (-) melana/GIB
Past Medical History:
Afib
high cholesterol
DM
CABG [**6-/2140**] (LIMA-LAD, SVG-RCA, SVG-OM)
[**6-21**] cardiac catheterization - occluded LAD, OM and RCA. Patent
LIMA, and SVG-OM/RCA. Preserved LV function.
bilateral shoulder surgeries
bilateral knee surgeries
appy
.
Social History:
Social History: Married for 4 years with one child. His wife
will drive him to and from the procedure.
Family History:
Family History: (+) [**Name (NI) 41900**] CAD Uncle died of MI at 54 yo. Paternal
grandparents died in early 60's from heart failure.
Physical Exam:
Tm 98.9 Tc 98.6 HR 84 BP 126/65 RR 23 99% on 4 L NC
Gen: mildly obese man lying in bed with audible upper
respiratory breath sounds responding slowly to questions
HEENT: PERRL, does not track finger with eye movements - able to
move eyes to R, not to L, does not open mouth very widely, able
to stick out tongue, no gag reflex,
Neck: JVP flat
CV: RRR, nl s1, s2, no m/g/r
Lungs: coarse breath shouds from chest
Abd: BS+, soft, NT, ND
Ext: chronic venous stasis changes, 1+ BL LE edema
Neuro: CN 2, (3,4,6 on R eye), (3 on L eye), 7, 8, 9,10 (able to
swallow, but no gag), 11 (SCM), 12 intact. 2+ biceps and
brachioradialis BL, [**1-20**]+ L patellar, [**11-20**]+ R patellar, downgoing
toes on L, upgoing on R. fair squeeze on L, 1/5 strength on L
biceps, [**2-21**] biceps on R, 1/5 strength in L IP on L, [**2-21**] IP on
R.
Pertinent Results:
Studies:
[**2148-1-18**] Cardiac MR
1. Mild concentric left ventricular hypertrophy with normal
cavity size and systolic function. The LVEF was normal at 66%.
2. Normal right ventricular cavity size and function. The RVEF
was normal at 55%.
3. The diameters of the ascending aorta and arch were normal.
The diameter of the descending thoracic aorta was mildly
increased. The main pulmonary artery diameter was also mildly
increased.
4. Mild biatrial enlargement. (L atrium - 48 mm parasternal long
axis, R atrium - 52 mm)
5. Normal size and orientation of the pulmonary veins without
CMR evidence of anomalous pulmonary venous return or pulmonary
vein stenosis.
6. Normal coronary artery origins with no evidence of anomalous
coronary arteries.
MR HEAD W/O CONTRAST [**2148-1-22**] 5:30 PM
MR HEAD W/O CONTRAST
Reason: Evaluate for CVA
[**Hospital 93**] MEDICAL CONDITION:
54 year old man with h/o AF s/p Ablation p/w new neuro deficits.
REASON FOR THIS EXAMINATION:
Evaluate for CVA
MRI EXAM OF THE BRAIN
CLINICAL INDICATION: Neurologic deficit, evaluate for CVA.
Patient has undergone ablation for atrial fibrillation.
Multiplanar T1- and T2-weighted images of the brain was
obtained. The study is significantly degraded by motion
artifact. No prior exams were available for comparison.
There is minimally increased signal seen on diffusion images
involving the lower aspect of the medulla. This could be
artifactual in nature or related to possible small infarction.
FLAIR images were significantly degraded by motion artifact and
could not confirm the suspicion of this finding. The ventricular
system is symmetrical without hydrocephalus. There is no midline
shift. Signal flow voids are noted along the intracranial
portions of the carotid arteries.
IMPRESSION: Significantly limited exam by motion artifact. No
cerebral infarcts were seen. There was however suspicion for a
tiny area of restricted diffusion involving the left aspect of
the lower medulla. This might be artifactual in nature or
related to a small subacute infarct. Further followup is
suggested by obtaining repeat diffusion images and conventional
images of the brain preferably after sedation if possible.
CTA HEAD W&W/O C & RECONS [**2148-1-22**] 3:55 PM
CTA HEAD W&W/O C & RECONS; CT 150CC NONIONIC CONTRAST
Reason: change in mental status, r/o new CVA, or hemorrhage
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
54 year old man with question of acute bleed or stroke
REASON FOR THIS EXAMINATION:
change in mental status, r/o new CVA, or hemorrhage
CONTRAINDICATIONS for IV CONTRAST: None.
CT CEREBRAL ANGIOGRAM:
CLINICAL INFORMATION: ? acute bleed or stroke. Change in mental
status.
TECHNIQUE: Pre- and post-contrast multislice CT from skull base
to vertex during arterial phase of contrast enhancement with
multiplanar MIP and 3D reformats.
FINDINGS: There is moderate arterial wall calcification at the
cavernous portions of the internal carotid arteries bilaterally,
without significant luminal narrowing. The circle of [**Location (un) 431**] and
its principal tributaries otherwise demonstrate normal caliber
and tapering. No critical stenosis, aneurysm, or vascular
malformation can be seen within the scanned volume.
There is minor opacification involving the ethmoidal air cells,
sphenoid, and left maxillary sinus, likely to be
infective/inflammatory in origin.
CONCLUSION: Minor arterial wall calcification at the cavernous
portions of the internal carotid arteries bilaterally, without
significant luminal narrowing. No other significant
abnormalities.
MR HEAD W/O CONTRAST [**2148-1-23**] 1:33 PM
MR HEAD W/O CONTRAST
Reason: Per neurology, PLEASE DO DWI ONLY, do NOT need to do
MRA. T
[**Hospital 93**] MEDICAL CONDITION:
54 year old man with L sided weakness after EP procedure
REASON FOR THIS EXAMINATION:
Per neurology, PLEASE DO DWI ONLY, do NOT need to do MRA. Thank
you.
INDICATION: Left-sided weakness after EP procedure. Evaluate for
infarction.
COMPARISON: Motion limited MR of the head of [**2148-1-22**].
TECHNIQUE: Sagittal T1, axial T2, FLAIR and susceptibility
images were obtained, in addition to diffusion-weighted images
of the brain.
FINDINGS: There are no areas of restricted diffusion on today's
exam to suggest acute infarction. There is no shift of normally
midline structures. The ventricles and cisterns are normal.
There is a small focus of susceptibility within the left
occipital lobe. As there is no hyperdense region in this locale
on recent CT scan of [**2148-1-22**], the finding likely represents an
old hemorrhagic residue. Otherwise, the signal of the brain
parenchyma is normal. Normal flow voids are seen within major
circle of [**Location (un) 431**] tributaries.
A lipoma is noted within the left parotid gland, and is
partially imaged.
IMPRESSION: No definite areas of restricted diffusion on today's
exam to suggest acute infarction. See above report.
CHEST (PA & LAT) [**2148-1-25**] 3:54 PM
CHEST (PA & LAT)
Reason: Evaluate for pneumonia vs. atelectasis.
[**Hospital 93**] MEDICAL CONDITION:
54 year old man with recent NG tube and aspiration vs. pna seen
on previous chest x-ray.
REASON FOR THIS EXAMINATION:
Evaluate for pneumonia vs. atelectasis.
2 view chest [**2148-1-25**].
COMPARISON: [**2148-1-23**].
INDICATION: Possible pneumonia.
The patient is status post median sternotomy and coronary artery
bypass surgery. There has been interval removal of a nasogastric
tube. There has been interval clearing of a previously reported
bibasilar opacities. There are no pleural effusions. Skeletal
structures reveal evidence of prior sternotomy.
IMPRESSION: Interval resolution of bibasilar opacities.
Brief Hospital Course:
54 yo M with hx of DM, CAD s/p CABG in [**2139**], AF, HL s/p elective
ablation for AF p/w chest pain, L-sided weakness and double
vision without clear neurological cause.
.
#. Altered mental status, Left sided weakness - Following
transfer of the patient from the cath lab to the PACU, he became
acutely confused with left sided weakness and double vision in
his left eye. A CTA and MRI were negative by neurology's read
for acute change, without evidence of arterial occlusion, bleed
or CVA. The patient was initially admitted to the CCU and his
blood pressures were kept at 140-160 and he was started on
heparin in case a CVA was missed and ASA was administered
rectally as he had loss of his gag reflex. A final read of the
MRI showed "suspicion of a tiny area of restricted diffusion
involving the left aspect of the lower medulla. This might be
artifactual in nature or related to a small subacute infarct."
Neurology felt that the site of the restricted diffusion would
not correlate with his deficits, and recommended a repeat
diffusion weighted MRI. A repeat scan showed no evidence of
CVA. An NG tube was placed so that the patient could receive
oral medications, and his blood pressure was normalized with a
beta-blocker and ACE-I. Patient reported h/o of Left sided
deficits similar to those on admission after severe assault in
[**6-22**]. This is most likely a reappearance of his old deficits
following anesthesia and his procedure. Neuro was felt that his
exam was inconsistent and that this was most likely a medication
effect versus conversion disorder, as his MRI showed no evidence
of anatomic pathology. All opiates and benzodiazepines were
withheld from the patient. Over the course of his
hospitalization, his strength greatly improved (5-/5 in upper
extremities and 4+/5 in lower extremities) as he worked with
physical therapy and his vision gradually improved. Physical
therapy felt that he was safe for discharge home after [**12-22**]
in-house treatment sessions. He was evaluated by speech
pathology when his gag reflex returned, and he was cleared for a
regular diet.
.
#. Chest pain - The patient developed chest pain following his
pulmonary vein isolation. Repeated EKGs showed diffuse ST
changes unchanged from prior to procedure. EP felt that this
was a result of the induced myocardial damage from the procedure
vs. pericarditis. After a brief period of atrial fibrillation
in the PACU, his heart remained in sinus rhythm. His pain waxed
and waned, and he was started on ketorolac for his pain.
Cardiac enzymes were trended with a troponin leak peak of 1.79
(normal 0-0.01) and peak CK of 336 on morning following
procedure. His chest pain resolved on POD3, and he remained
without chest pain for the remainder of his hospital course.
.
#. Coronary Artery Disease - patient with long history of CAD
s/p CABG with all grafts reportedly patent from last cath in
[**2145**]. His cardiac enzymes were trended with a troponin leak of
1.79 and peak CK of 336 (expected post procedure). His lipid
panel was found to be LDL 113, Trig 207, HDL 51. He was started
on crestor, which is associated with less myalgias than the
other statins, without elevation in his LFTs or new muscle
pains. He was continued on aspirin, metoprolol and lisinopril.
.
#. Pump: A TTE showed a normal EF, mild MR [**First Name (Titles) **] [**Last Name (Titles) **]. On
admission, he appeared dehydrated, and he was started on 120
cc/hr NS. However, he became hypervolemic and required
diuresis. At time of discharge he was felt to be euvolemic. He
was continued on metoprolol and lisinopril.
.
#. Atrial Fibrillation - The patient remained in NSR on
transfer. He was started a heparin drip initially for question
of stroke and then as a bridge to reaching a therapeutic INR.
Medications on Admission:
metoprolol 50mg [**Hospital1 **]
niaspan 500mg [**Hospital1 **]
metformin 1000mg [**Hospital1 **] (last dose [**1-21**] am)
coumadin last dose 2/28
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Succinate 200 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
6. 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*
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Insulin Regular Human 100 unit/mL Solution Sig: see sliding
scale Injection ASDIR (AS DIRECTED).
9. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Lovenox 100 mg/mL Syringe Sig: One (1) injection
Subcutaneous twice a day: Will be instructed when to discontinue
by Dr. [**First Name (STitle) 1075**] once your INR level is therapeutic with your
coumadin dose.
Disp:*50 injections* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
Primary:
Atrial Fibrillation
Neurological deficits of uncertain cause
Secondary:
Coronary Artery Disease
Hyperlipidemia
Discharge Condition:
Stable. Patient walking and eating without difficulty. Is
being sent home with services for medication teaching with
lovenox injections.
Discharge Instructions:
1. Please take all medications as prescribed.
2. Please keep all follow-up appointments.
3. Please seek medical attention if you develop fevers, chills,
shortness of breath, chest pain or have any other concerning
symptoms.
4. No heavy lifting for within the next 2-4 weeks. No driving
for the next 1-2 weeks or until you have consulted with your
primary care doctor.
Followup Instructions:
1. Please follow up in 1 month with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] at
[**Telephone/Fax (1) 7332**].
2. Please make a follow up appointment with your cardiologist,
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] at [**Telephone/Fax (1) 6256**], for within the next 2-4 weeks.
3. Please follow up with your primary care doctor, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 8049**] at [**Telephone/Fax (1) 14935**], within the next 1-2 weeks.
***You will need to get your blood drawn at Dr.[**Name (NI) 16071**] office on
Monday morning ([**2148-1-29**]) for a 'PT, PTT and INR' to adjust your
coumadin dose***
Completed by:[**2148-1-27**]
|
[
"342.90",
"293.0",
"250.00",
"427.31",
"784.5",
"414.00",
"V45.81",
"428.0",
"781.99",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.27",
"37.26",
"37.34"
] |
icd9pcs
|
[
[
[]
]
] |
14379, 14441
|
9029, 12835
|
322, 349
|
14606, 14747
|
3315, 4158
|
15165, 15880
|
2331, 2450
|
13034, 14356
|
8391, 8480
|
14462, 14585
|
12861, 13011
|
14771, 15142
|
2465, 3296
|
242, 284
|
8509, 9006
|
377, 1908
|
1930, 2179
|
2211, 2299
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,004
| 109,969
|
36649
|
Discharge summary
|
report
|
Admission Date: [**2132-12-7**] Discharge Date: [**2132-12-19**]
Date of Birth: [**2064-2-9**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Keflex
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
malaise, fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 68 year-old man with a history of T cell lymphoma
s/p five cycles of CHOP (last dose [**2132-11-28**]) and recently
admitted for pneumonia/sepsis and Capnocytophaga bacteremia
([**2132-11-13**] - [**2132-11-26**], [**Hospital Unit Name 153**] admission) and abdominal pain
([**2132-12-1**] - [**2132-12-3**], no etiology identified) who presents with
malaise and fevers. He was in his USOH after his last discharge
until this morning when he awoke with malaise and fever to 100.7
at home, along with some worsening of his chronic abdominal pain
associated with antibiotic ingestion (levo and clinda for
capnocytophagia bacteremia) and right flank pain. He denied
cough, dyspnea, nausea, vomiting, and loose stools. After
consultation with his oncologist, he presented to the ED.
.
In the ED, vital signs were initially: 99.6 90 115/66 18 90%ra.
He was given vancomycin, levoflox, doxy, and clinda for presumed
infection/recurrence of his capnocytophagia bacteremia and a
chest/abdominal CT demonstrated increased bibasilar
consolidation in the lung bases concerning for progressive
lymphoma vs pneumonia, but no acute findings in the abdomen.
Labs were notable for lactate of 3. He was initially signed out
to BMT but then became hypotensive to SBPs in the 80s. He also
spiked to 101.6. His pressures responded to 4L IVFs and he was
transferred to the [**Hospital Unit Name 153**] for further management. Of note that he
completed courses of levoflox and clinda on [**12-3**].
.
REVIEW OF SYSTEMS:
(+) as above. No chest pain, shortness of breath, nausea,
vomiting, diarrhea.
Past Medical History:
1. Melanoma, right arm excised in [**2129**].
2. Question of history of histoplasmosis.
3. Right shoulder surgery for fracture and dislocation [**2129**].
4. Kidney stones 40 years ago.
Oncologic History:
Mr. [**Known lastname **] developed left inguinal swelling in [**5-17**] while in
[**Country 4194**], where it was attributed to a hernia. Upon his return to
the US in early [**Month (only) 216**], his PCP suspected left inguinal
lymphadenopathy and arranged for excisional biopsy of a part of
a lymph node. This revealed reactive changes. He was admitted to
the [**Hospital1 18**] on [**2132-9-7**]
with worsening left groin swelling and pain related to worsening
lymphadenopathy, abdominal pain and nausea. Laboratory data
remarkable for elevated LDH and significant eosinophilia (as
high as 30%.) CT imaging demonstrated bilateral basilar
pulmonary nodules and significant lymphadenopathy involving the
retroperitoneal, pelvic, and left iliac chains. Infectious
disease work-up was unremarkable. The CT findings, along with
elevated LDH, raised concern about a lymphoproliferative
disorder. SPEP revealed monoclonal gammopathy, which was
comprised of IgG lambda and constituted 1600 mg/dl. PET scan
demonstrated intensely FDG avid in the left cervical (SUV 18),
right axillary (SUV 5), left supraclavicular (SUV 17), left
paratracheal (SUV 13), retroperitoneal (SUV 22,) and left
inguinal (SUV 25) lymph node groups.
Mr. [**Known lastname **] [**Last Name (Titles) 1834**] repeat excisional biopsy of an FDG-avid
inguinal lymph node on [**9-13**]. Flow cytometry revealed atypical
lymphohistiocytic infiltrate highly suggestive of peripheral
T-cell lymphoma NOS. On histological examination, the lymph node
architecture was completely effaced with a background of
epithelioid histiocyte granulomatoid aggregates. Intermingled
was an atypical lymphoid population that stained positive for
CD2, 3, and 5 with dual loss of CD4 and CD8 and loss CD7. The
combined morphologic and immunophenotypic picture was most
consistent with peripheral T-cell lymphoma, NOS. [**Last Name (un) **] staining
was negative. IgH gene rearrangement failed to show
monoclonality. TCR rearrangement, on the other hand, was
monoclonal. On further review of BM, he was found to have 5-10%
plasma cells in BM c/w plasma cell dyscrasia.
Social History:
Typically splits his time between [**First Name9 (NamePattern2) 82914**] [**Last Name (un) **], [**Country 4194**] and
[**Last Name (un) 51768**]. Spent the majority of the past five years in
[**Country 4194**] where his wife of several years works as a physician. [**Name10 (NameIs) **]
frequently traveled to [**Country 4194**] over the past 25 years. Patient
also has a strong social support network of friends in [**Name (NI) 108**].
Patient has traveled to Western Europe; used to smoke a pipe, 5
bowls per day x30 years. Currently living with his son and
[**Name2 (NI) 41859**] in law plus their children here in [**State 350**]. He
used to be an alcoholic but has been sober since [**2098**]. He is a
retired school teacher and used to teach in [**Last Name (un) 51768**],
[**State 108**]. He has one healthy pet dog.
Family History:
Breast cancer in mother, throat cancer in father,
and coronary artery disease in brothers.
Physical Exam:
VS: 101.6 94/54 83 96%2l 20
GEN:The patient is in no distress and appears comfortable
SKIN:No rashes or skin changes noted
HEENT:No JVD, neck supple, No lymphadenopathy in cervical,
posterior, or supraclavicular chains noted.
CHEST:Lungs are clear without wheeze, rales, or rhonchi.
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.
ABDOMEN: No apparent scars. Non-distended, and soft without
tenderness
EXTREMITIES:no peripheral edema, warm without cyanosis
NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE
[**5-13**], and BLE [**5-13**] both proximally and distally. No pronator
drift. Reflexes were symmetric. Downward going toes.
Pertinent Results:
CT Abd/pelv [**2132-12-7**]:
1. Interval progression of the bibasilar consolidation, with new
involvement of the right middle lobe and lingula. Given the
relative long time course and slowly progressing disease from
foci of centrilobular nodules to frank enlarging consolidation
over several months, the likelihood of an acute infectious
process (in this immuncompromised patient) seems less likely.
Therefore, progression of malignant disease is favored. However,
superimposed infectious process cannot be entirely excluded.
2. No renal calculus or hydroureteronephrosis. No acute
intra-abdominal
process. Interval decrease of inguinal lymphadenopathy.
.
CXR PA and LAT [**2132-12-7**]:
Bilateral basilar opacities, given chronicity question if
possibly indicative of progression of underlying known
malignancy over
infectious process. However, given slight increase in opacities
in
retrocardiac left lower lobe, a coincident pneumonia cannot be
excluded.
CT chest ([**2132-12-9**]): Improved mediastinal lymphadenopathy,
persistent bronchiectasis, small nodules have improved in the
lingula and right middle lobe. Also there has been improvement
in bibasilar consolidation. No areas of acute abnormalities.
1. Marked improvement of bilateral lower lobe opacities.
2. Grossly stable mediastinal lymph nodes with minimal
enlargement of AP
window lymph node, which measures up to 9 mm, previously
measured 7 mm.
3. Probable left renal cyst, stable.
4. Moderate centrilobular emphysema.
CT sinus ([**2132-12-11**]): Minimal sinus disease as described above
TTE ([**2132-12-11**]): Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF 70%). There is no ventricular
septal defect. The right ventricular cavity is mildly dilated
with borderline normal free wall function. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion. There are no echocardiographic signs of
tamponade.
Brief Hospital Course:
Mr. [**Known lastname **] is a 68 year-old man with T cell lymphoma s/p five
cycles of CHOP (last dose [**2132-11-28**]) and recently admitted for
pneumonia/sepsis and Capnocytophaga bacteremia
([**Date range (1) 82915**]) who presented with malaise, progressive
fatigue and fevers and was initially admitted to [**Hospital Unit Name 153**] for
hypotension.
Sepsis/Hypotension: The patient initially met SIRS criteria with
hypotension, fever and leukocytosis. Tamiflu was initially
started but stopped when nasopharyngeal swab for influenza came
back negative. Blood and urine cultures did not yield any
organisms. Antibiotic treatment with Vancomycin, Aztreonam and
Levaquin was initated. IV fluid boluses were provided as needed
for MAP>60. TSH was wnl. The patient remained hemodynamically
stable and did not require pressors. He was called out of the
ICU the following day. CT abdomen/pelvis on admission revealed
interval progression of the bibasilar consolidation, with new
involvement
of the right middle lobe and lingula. After 5 days of empiric
coverage with Vancomycin, Aztreonam and Levaquin despite
continually negative culutres did not improve daily febile
episodes, they were discontinued. Given the credible story of
prior acute Histoplasmosis, we initiated empiric treatment with
Ambisome for re-activated chronic Histoplasmosis on [**2132-12-13**].
This resulted in resolution of febrile episodes. The patient
reported significant symptomatic improvement. CT chest was
performed and revealed marked improvement of bilateral lower
lobe opacities, grossly stable mediastinal lymph nodes. The
patient was discharge home with the plan to complete a 14 day
course of Ambisome, followed by a PO course of Itraconazole to
complete treatment for Histaplasmosis.
T cell lymphoma: The next cycle of CHOP therapy was not
initiated during this admission due to concern for active
infectious process. The patient will follow up with his
oncologists Dr. [**Last Name (STitle) 4613**] and Dr. [**First Name (STitle) **] for further management of
his T cell lymphoma upon discharge. PCP Prophylaxis was
continued.
Chronic epgastric abdominal pain: the patient had several months
of chronic abdominal epigastric pain. He was seen by GI service
on admission and [**First Name (STitle) 1834**] EGD, which did not reveal any
abnormalities in his esophagus, stomach or duodenum. The
patient was started on Carafate and Mylanta prior to his
discharge with some improvement in his symptoms.
DVT: The patient with a history of a provoked DVT being
anticoagulated with Levenox as outpatient. The patient was
Lovenox was held trasiently given possibility of invasive
diagnostic procedure, but was re-started once all procedures
were complete. The patient will continue on Lovenox for
anticoagulation upon discharge.
Medications on Admission:
MEDICATIONS AT HOME (per last discharge summary):
1. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous DAILY
2. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO QHS (once a day (at bedtime))
prn
3. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H prn
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H prn
5. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet Q6H
prn
6. Tamsulosin 0.4 mg Capsule, SR 1 tab po qhs
7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
8. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for
nausea/vomiting.
9. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours for 5 days: Last day: Monday, [**12-8**].
10. Protonix 40 mg Tablet, Delayed Release (E.C.) One (1) tab
[**Hospital1 **]
11. Maalox/Diphenhydramine/Lidocaine, Sig: [**5-23**] mL qid prn
Discharge Medications:
1. Enoxaparin 100 mg/mL Syringe Sig: One (1) syringe
Subcutaneous Q24H (every 24 hours).
2. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for epigastic pain.
3. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
7. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO QHS (once a day (at bedtime)).
8. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
9. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
10. AmBisome 50 mg Suspension for Reconstitution Sig: Two
Hundred (200) mg Intravenous once a day for 7 days.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Peripheral T-cell lymphoma, Acute pulmonary infectious
process, likely Histoplasmosis, Epigastric Abdominal Pain
Secondary: None
Discharge Condition:
Afebrile, vitals stable, able to ambulate without difficulty.
Discharge Instructions:
You were admitted to the hospital because you developed fevers
and progressive weakness and shortness of breath. You were
admitted to Intensive Care Unit because there was a concern
about your blood pressure. You received a 5 day course of oral
antibiotics, which were discontinued because they did not seem
to help with fevers. Because of the history of suspected
infection with Histoplasmosis, and your immunocompromised state,
you were started on treatment for chronic Histoplasmosis
infection. After initiation of treatment, your symptoms have
improved and your fevers resolved. You also had an endoscopy to
evaluate your chronic abdominal pain. Your esophagus, stomach
and first part of small intestine looked normal. You were
prescribed Carafate and Mylanta to help with abdominal
discomfort.
You need to continue to receive daily IV antibiotic medication
Ambisome for the next week. After that, you will be switched to
an oral medication called Itraconazole. We set up daily
appointments for you to come to the clinic to receive Ambisome
as well as Lovenox (see below).
You have follow-up appointment with Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) 4613**] next
week (see below). You will also be called with an appointment
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] (infectious diseases).
1. Carafate 1gram 4 times a day
2. Mylanta 15-20ml every 4 times a day as needed for abdominal
pain
3. Ambisome 200mg IV daily for 7 days (in clinic), after which
you will be switched to oral medicine for Histoplasmosis
You should continue to take all your other medications as
previously prescribed.
Followup Instructions:
You have an appointment to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4613**] on Wednesday, [**2132-12-24**] at 1:30 pm at
[**Hospital Ward Name 23**] [**Location (un) 436**] clinic.
You will follow up with infectious disease specialist Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**]. You will be called with an appointment on Monday.
If you do not hear back by Tuesday, please call [**Doctor First Name 43395**] at
[**Telephone/Fax (1) 31305**].
You will need to come in daily to 7 [**Hospital Ward Name 1826**] outpatient clinic
or [**Hospital Ward Name 23**] [**Location (un) 436**] clinic for administration of Ambisome (IV
antibiotic) and Lovenox for the next week.
Your appointments are as follows:
7 [**Hospital Ward Name **] Date/Time: Saturday, [**2132-12-20**] at 11:00 am
7 [**Hospital Ward Name **] Date/Time:Sunday, [**2132-12-21**] at 11:00 am
[**Hospital Ward Name **] 7 CLINIC Date/Time:Monday, [**2132-12-22**] at 1:00 pm
[**Hospital Ward Name **] 7 CLINIC Date/Time:Tuesday, [**2132-12-23**] at 2:00 pm
[**Hospital Ward Name **] 7 CLINIC Date/Time:Wednesday, [**2132-12-24**] at 1:00 pm
[**Hospital Ward Name **] 7 CLINIC Date/Time:Thursday, [**2132-12-25**] at 12:00pm
[**Hospital Ward Name **] 7 CLINIC Date/Time:Friday, [**2132-12-26**] at 12:00 pm
Completed by:[**2133-2-13**]
|
[
"V12.51",
"V10.82",
"276.1",
"202.78",
"789.06",
"995.91",
"038.9",
"054.9",
"115.05",
"494.0",
"V49.83",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
13114, 13120
|
8219, 11050
|
305, 311
|
13303, 13367
|
5930, 8196
|
15081, 16526
|
5146, 5239
|
12060, 13091
|
13141, 13282
|
11076, 12037
|
13391, 15058
|
5254, 5911
|
1868, 1948
|
250, 267
|
339, 1849
|
1970, 4288
|
4304, 5130
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,822
| 163,807
|
9282
|
Discharge summary
|
report
|
Admission Date: [**2197-4-6**] Discharge Date: [**2197-4-14**]
Date of Birth: [**2128-1-30**] Sex: F
Service: C-MED
ID: A 69-year-old female status post syncopal episode.
HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old
female with a past medical history significant for coronary
artery disease, status post coronary artery bypass graft x4
in [**2180**], congestive heart failure (diastolic), diabetes
mellitus type II, chronic renal insufficiency with a
creatinine baseline of 2, renal artery stenosis, status post
stent placement in [**2197-2-3**], paroxysmal atrial fibrillation
status post cardioversion in [**2196-12-6**], pulmonary
hypertension, hypercholesterolemia who presents status post
syncopal episode at approximately 12 noon the day of
admission. The patient reports "not feeling well" about one
hour after taking all her medications that morning with some
nausea and dry heaving, as well as unsteadiness, but no
shortness of breath, lightheadedness, chest pain, fevers or
chills. Sometime before noon, the patient's visiting
caregiver arrived and then witnessed her syncopal episode.
She was sitting in a chair and then just loss consciousness.
The patient denies any warning signs. She denies any
palpitations, loss of bowel or bladder control or shaking
limbs. They are unsure of how long she was unconscious.
The patient was then taken to [**Hospital6 2910**]
with electrocardiogram showing atrial fibrillation/flutter
with a heart rate in the 50s and a blood pressure in the 90s.
The patient had sustained a chin laceration which was
sutured. The patient was then transferred to [**Hospital6 1760**] due to lack of telemetry beds
at [**Hospital6 2910**]. Chest x-ray there had shown
some congestive heart failure. In the [**Hospital1 **]
Emergency Department, the patient felt fatigued, but denied
any other symptoms at that time.
The day prior to her admission at [**Hospital6 649**], the patient was at [**Hospital6 1322**] in the Emergency Room for urinary incontinence and
started on Detrol. The Monday prior to the patient's
admission, she was discharged from the [**First Name5 (NamePattern1) 46**] [**Last Name (NamePattern1) **] at [**Hospital6 14475**] for a six week stay for
rehabilitation.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post coronary artery
bypass graft x4 in [**2180**]
2. Congestive heart failure
3. Diabetes mellitus type II
4. Chronic renal insufficiency
5. Renal artery stenosis status post stent
6. Paroxysmal atrial fibrillation, status post cardioversion
in [**2196-12-6**]
7. Pulmonary hypertension
8. Hypothyroidism
9. Hypercholesterolemia
10. Urinary retention
ALLERGIES: No known drug allergies.
MEDICATIONS (home):
1. Plavix
2. Amiodarone
3. NPH/Humalog
4. Lipitor
5. Enteric coated aspirin
6. Hydralazine
7. Atrovent
8. Ambien
9. Detrol
10. Allopurinol
11. Serevent
12. Levofloxacin
13. Epogen
14. Neurontin
15. Lasix 80 mg po bid
16. Vicodin
17. Xanax
18. Lopressor
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 127/55, heart rate 65 and
regular, respiratory rate 18, O2 saturation 97% 3 liters
nasal cannula at baseline.
GENERAL APPEARANCE: No acute distress, speaking full
sentences, no shortness of breath, obese.
HEAD, EARS, EYES, NOSE AND THROAT: Normocephalic, atraumatic
head. Supple neck, no jugular venous distention, no
hepatojugular reflux. Sutured chin with 2 cm laceration
right frontal bruise.
CARDIOVASCULAR: Regular rate and rhythm, normal S1 and S2
with no murmurs, rubs or gallops appreciated.
LUNGS: Quiet breath sounds, rales bilaterally at the base up
to [**12-8**] in all lung fields.
ABDOMEN: Obese, nondistended, nontender, soft, normoactive
bowel sounds.
EXTREMITIES: 2+ pitting edema bilaterally, lower extremities
nontender, warm.
NEUROLOGIC: Cranial nerves II through XII intact, nonfocal.
LABORATORY DATA: White blood cells 9.1, hematocrit 33.6,
platelets 220. Sodium 135, potassium 5.4, chloride 95, HCO3
28, BUN 95, creatinine 2.8, glucose 144. Calcium 9.4,
phosphate 4.6, magnesium 2.4, albumin 3.8. PT 14.4, INR 1.4,
PTT 29.6. CK #1 60, troponin less than 0.3, CK #2 47, CK #3
49.
IMAGING: Electrocardiogram revealed atrial fibrillation with
slow ventricular response, normal axis, no acute ST or T-wave
changes, compared with [**2197-3-10**] which showed atrial
fibrillation with normal ventricular response. Chest x-ray
([**Hospital6 **] [**4-6**]) revealed some congestive heart
failure. Head CT revealed no acute bleed or abnormal
pathology.
SUMMARY OF HOSPITAL COURSE: The patient is a 69-year-old
female with a past medical history of coronary artery disease
status post coronary artery bypass graft in [**2180**], congestive
heart failure, paroxysmal atrial fibrillation status post
cardioversion in [**2196-12-6**], diabetes mellitus type II,
chronic renal insufficiency, renal artery stenosis, status
post stent and hypertension who presents status post syncopal
episode transferred from [**Hospital6 2910**] for
telemetry observation. It was thought that her syncopal
episode was likely cardiac in origin given her history and
possibly related to her antihypertensive medical regimen of
Lopressor and hydralazine. The patient ruled out for
myocardial infarction by serial CKs.
The patient was found to be in congestive heart failure on
chest x-ray at [**Hospital6 **] and on exam. The patient
was gently diuresed. Her creatinine was elevated at 2.8.
The patient currently appeared to have total body fluid
overload, but was intravascularly dry. The patient's
telemetry also revealed atrial flutter with variable AV
block. The initial plan involved discontinuing her
hydralazine, continuing her Lopressor and starting an
amiodarone load. In addition, anticoagulation with heparin
and Coumadin was started given the patient's atrial
fibrillation/flutter.
On the night of [**4-8**], the patient had an episode of
bradycardia/hypotension with heart rate in the 40s and
systolic blood pressure in the 80s requiring 1 mg of Atropine
x2 and then returning to baseline stable condition, but with
sinus bradycardia. Then, on the morning of [**4-9**],
approximately 7:30 a.m., the patient had another episode of
bradycardia and hypotension with a heart rate as low as 26
and a systolic blood pressure in the 80s requiring 1 mg of
atropine. The patient was then in sinus bradycardia in the
40s to 50s. Her blood pressure at the time was in the 110s.
In addition, the patient had vomited dark black
vomitus/coffee ground emesis x1. In addition, the stool was
trace heme positive. It was also noted that the patient's
mental status was somewhat changed and she was somewhat
lethargic. Her telemetry the night before had recorded a
three second pause. The patient's morning hematocrit at that
time was 25.8 down from 28.3. The day prior, her hematocrit
was 33. The patient then began a 2 unit packed red blood
cell transfusion.
The CCU team came to evaluate the patient for her episodes of
bradycardia/hypotension and it was decided that the patient
would be closely observed while on the floor. It was thought
that her hypotension and bradycardia was likely due to her
initial amiodarone load and the amiodarone and Lopressor were
discontinued. The EP fellow was also notified and a
temporary pacing wire or a pacemaker at this time was not
deemed necessary given that her bradycardia responded to
atropine. The patient's heparin and Coumadin had been
stopped given the patient's coffee ground emesis that a.m.
The patient's INR was 2.0 and 10 mg subcutaneous vitamin K
was given as well as 1 unit of fresh frozen plasma.
Gastrointestinal was consulted and agreed on holding any
nasogastric lavage given vagal stimulation may result in
further bradycardia. Protonix 40 mg [**Hospital1 **] was started and they
agreed with reversing the anticoagulation. Any further
gastrointestinal work up including esophagogastroduodenoscopy
will be held off until patient stable from a cardiac
standpoint.
In addition, that morning, the patient's mental status had
changed. In order to rule out possible intracranial bleed,
head CT was performed which was negative. Mental status
change may also be explained by the patient receiving Xanax
and Vicodin that morning as well as possible uremia with a
BUN of 148 and a creatinine of 3.5. Given the patient's
multiple active issues, the patient was transferred to the
Medical Intensive Care Unit for further evaluation and closer
observation.
While in the Medical Intensive Care Unit, the patient
received an additional 2 units of packed red blood cells and
hematocrit remained stable thereafter. The patient was
eventually restarted on amiodarone 200 mg q od. Her renal
function returned to baseline. The patient was found to have
a urinary tract infection and was started on levofloxacin for
a total of seven days. On [**4-12**], the patient was stable for
return to the floor.
Gastrointestinal service was consulted while the patient was
on the floor and the patient at this time was refusing
esophagogastroduodenoscopy. This is a reasonable request
given her bleeding had occurred on heparin, Coumadin, aspirin
and Plavix in the setting of nausea and vomiting and she had
no evidence of further bleeding for the previous 72 hours.
Protonix 40 mg po bid will be continued for the next eight
weeks and then switched to qd. Plavix will be restarted
given patient status post stent for renal artery stenosis.
The patient is aware that if there is any further evidence of
bleeding on antiplatelet [**Doctor Last Name 360**] that an
esophagogastroduodenoscopy will be pursued. The patient's
hematocrit was stable at 28 to 29.
The patient's coronary artery disease is stable at this time
with an ejection fraction of approximately 50%. The patient
will eventually need follow up echocardiogram and MIBI as an
outpatient. The patient also has a history of pulmonary
hypertension and will eventually need further pulmonary work
up as an outpatient with possible sleep study and/or chest
CT.
While the patient was in the Medical Intensive Care Unit,
renal team was consulted. The patient had acute renal
failure most likely secondary to hypertension, now resolved.
Creatinine returned back to baseline and on [**4-12**] was 1.6. The
patient had renal artery stenosis without hyponatremia in the
post ATN setting. Normal Lasix home po dose was resumed on
discharge.
Physical therapy was consulted. The patient was screened for
rehabilitation. The patient was requesting for [**First Name9 (NamePattern2) **] [**Hospital1 46**] at
[**Hospital6 **].
DISCHARGE CONDITION: Stable
DISCHARGE STATUS: To rehabilitation facility.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass graft
2. Congestive heart failure
3. Paroxysmal atrial fibrillation
4. Diabetes mellitus type II
5. Chronic renal insufficiency
6. Renal artery stenosis, assess with stent
7. Hypertension
8. Hypercholesterolemia
9. Gastrointestinal bleed
DISCHARGE MEDICATIONS:
1. Amiodarone 200 mg po q od
2. Plavix 75 mg po qd
3. Protonix 40 mg po bid x8 weeks, then 40 mg po qd
4. Lipitor 40 mg po qd
5. Levothyroxine 100 mcg po qd
6. Allopurinol 100 mg po qd
7. Levofloxacin 250 mg po qd (until [**2197-4-15**])
8. Neurontin 300 mg po bid
9. Atrovent 2 puffs metered dose inhaler qid
10. Salmeterol 2 puffs metered dose inhaler [**Hospital1 **]
11. Lasix 80 mg po bid
12. Xanax 0.25 mg po tid prn
13. Colace 100 mg po bid
14. Senna 2 tablets po bid prn
15. Ambien 5 mg po q hs prn
16. Regular insulin sliding scale
17. NPH 22 units subcutaneous q a.m., 20 units subcutaneous q
p.m.
18. Humalog 10 units subcutaneous q a.m., 15 units
subcutaneous q p.m.
19. Epogen 40,000 units subcutaneous q Friday
20. Vicodin 1 to 2 tablets po q 4 to 6 hours prn
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 21980**]
Dictated By:[**Last Name (NamePattern1) 1183**]
MEDQUIST36
D: [**2197-4-13**] 11:16
T: [**2197-4-13**] 11:26
JOB#: [**Job Number 31813**]
|
[
"416.8",
"427.31",
"584.9",
"428.0",
"440.1",
"250.00",
"V45.81",
"593.9",
"458.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10638, 10694
|
10715, 11026
|
11049, 12075
|
4572, 10616
|
3027, 4543
|
223, 2265
|
2287, 3005
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,467
| 160,687
|
32906
|
Discharge summary
|
report
|
Admission Date: [**2106-11-23**] Discharge Date: [**2106-12-2**]
Date of Birth: [**2041-12-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
jaw pain with exertion
Major Surgical or Invasive Procedure:
CABGx4(LIMA-LAD,SVG-OM1,SVG-OM3,SVG-Pda)[**11-25**]
History of Present Illness:
64 yo M with 6 months of jaw pain and DOE. Cath showed 3 vd.
Past Medical History:
HTN, ^ chol, DM type 2, ETOH 2-3d
Social History:
manages sporting goods store
3 cigars/day for 40 years, quit 4 years ago
[**1-9**] etoh/day
Family History:
NC
Physical Exam:
HR 53 RR 18 BP 148/74
NAD
EOMI PERRLA
Lungs CTAB
Heart RRR
Abdomen Benign, obese
Extrem 1+ edema, 1+ dp/pt pulses
Pertinent Results:
[**2106-12-1**] 09:15AM BLOOD WBC-8.2 RBC-2.51* Hgb-8.4* Hct-24.7*
MCV-99* MCH-33.6* MCHC-34.1 RDW-15.3 Plt Ct-237
[**2106-12-1**] 09:15AM BLOOD Plt Ct-237
[**2106-11-29**] 06:15AM BLOOD PT-12.5 PTT-25.6 INR(PT)-1.1
[**2106-12-1**] 09:15AM BLOOD Glucose-208* UreaN-65* Creat-2.0* Na-137
K-3.5 Cl-97 HCO3-31 AnGap-13
[**2106-11-29**] 06:15AM BLOOD Glucose-138* UreaN-66* Creat-2.1* Na-142
K-4.0 Cl-101 HCO3-27 AnGap-18
[**11-23**] TYPE-ART PO2-52* PCO2-45 PH-7.46* TOTAL CO2-33* BASE XS-6
CHEST (PORTABLE AP) [**2106-11-29**] 7:52 AM
CHEST (PORTABLE AP)
Reason: evaluate effusion
[**Hospital 93**] MEDICAL CONDITION:
64 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
evaluate effusion
REASON FOR EXAMINATION: Followup of a patient after CABG.
Portable AP chest radiograph compared to [**2106-11-26**].
The cardiomediastinal silhouette is unchanged. The sternal wires
are unremarkable. The bibasilar areas of atelectasis are present
slightly improved since the previous study. There is no
appreciable pleural effusion or pneumothorax.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 76588**] (Complete)
Done [**2106-11-25**] at 1:14:15 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2041-12-11**]
Age (years): 64 M Hgt (in): 73
BP (mm Hg): / Wgt (lb): 250
HR (bpm): BSA (m2): 2.37 m2
Indication: Intra-op TEE for CABG
ICD-9 Codes: 786.51, 440.0
Test Information
Date/Time: [**2106-11-25**] at 13:14 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW02-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.4 cm <= 4.0 cm
Left Ventricle - Diastolic Dimension: 5.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% >= 55%
Aorta - Annulus: 2.5 cm <= 3.0 cm
Aorta - Sinus Level: *4.2 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 3.0 cm <= 3.0 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aorta - Arch: 2.6 cm <= 3.0 cm
Aorta - Descending Thoracic: *2.7 cm <= 2.5 cm
Findings
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dynamic interatrial septum. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Low
normal LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Moderately dilated aortic sinus. Normal ascending aorta
diameter. Normal aortic arch diameter. Mildly dilated descending
aorta. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. No AS. No AR.
MITRAL VALVE: No MS. Mild (1+) MR.
TRICUSPID VALVE: Physiologic TR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
Conclusions
PRE-BYPASS:
1. The left atrium is moderately dilated. No atrial septal
defect is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is low normal (LVEF
50-55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. The aortic root is moderately dilated at the sinus level. The
descending thoracic aorta is mildly dilated. There are simple
atheroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. There is no aortic
valve stenosis. No aortic regurgitation is seen.
6. Mild (1+) mitral regurgitation is seen.
POST-BYPASS: Pt is on an infusion of phenylephrine and is being
A paced
1. [**Hospital1 **]-ventricular function is uncahnged.
2. Aorta is intact post decannulation
3. Other findings are unchanged
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to cardiac surgery. Preoperatively he was
87% saturated on room air. He was seen and followed by renal
preop and postop. He was taken to the operating room on [**11-25**]
where he underwent a CABG x 4. He was transferred to the ICU on
propofol and neo. He was given 48 hours of periop vancomycin as
he was in the hospital preoperatively. He was extubated on POD
#1, and transferred to the floor on POD #2. He did well
postoperatively, and was ready for discharge home on POD #7.Pt.
is to make all followup appts. as per discharge instructions.
Medications on Admission:
NPH insulin 34", humalog SS, Glucosamine and chondrotin, fish
oil 1200', cozaar 50 qam, 100 qpm, lasix 80", clonidine 0.1",
lovastatin 80', allopurinol 150", gabapentin 300 qam, 3pm, 900
qhs
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
7. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Ferrous Gluconate 300 mg (35 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
11. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty
Four (34) units Subcutaneous twice a day.
Disp:*QS 1 month* Refills:*0*
13. Insulin Lispro 100 unit/mL Solution Sig: sliding scale
Subcutaneous twice a day.
Disp:*qs 1 month* Refills:*0*
14. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
15. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO twice a day.
Disp:*30 Tablet(s)* Refills:*0*
16. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
Disp:*60 Capsule(s)* Refills:*0*
17. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
CAD now s/p CABG
HTN, ^ chol, DM type 2, CRI
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) 32496**] 2 weeks
Dr. [**Last Name (STitle) 8579**] 2 weeks
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] at the end of [**Month (only) 404**] - call [**Telephone/Fax (1) 3637**] for
appointment
Completed by:[**2106-12-2**]
|
[
"585.3",
"414.01",
"272.0",
"276.6",
"403.90",
"250.40",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7921, 7970
|
5199, 5783
|
346, 400
|
8059, 8067
|
825, 1409
|
8366, 8671
|
672, 676
|
6024, 7898
|
1446, 1476
|
7991, 8038
|
5809, 6001
|
8091, 8343
|
691, 806
|
284, 308
|
1505, 5176
|
428, 490
|
512, 547
|
563, 656
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,944
| 193,440
|
18245
|
Discharge summary
|
report
|
Admission Date: [**2138-3-20**] Discharge Date: [**2138-3-23**]
Date of Birth: [**2086-2-22**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
52 y.o. male transferred from [**Hospital3 417**] where he presented
with hematemesis. He has a history of upper GI bleeding and was
recently discharged from [**Hospital3 417**] 1 day prior to this
admssion for upper GI bleed. He has a h/o Dieulafoy lesion in
the cardia and peptic ulcer disease. He underwent EGD ([**2138-3-14**])
which revealed a small Dieulafoy in the cardia of the stomach,
which was injected with epinephrine, resulting in vigorous
bleeding. He underwent multiple transfusions, and was
stabilized. Repeat EGD [**3-17**] revealed no active bleeding. He
was transferred the the medical floor at [**Hospital3 417**] [**3-18**],
but the following day had massive hematemesis again. He was
transfused 5 units PRBCs, and transferred to [**Hospital1 18**] for further
management.
.
Initially admitted to the MICU, the patient was seen by GI in
consult. He was hemodynamically stable with no further
hematemesis, and underwent repeat EGD here on [**2138-3-20**], revealing
clips and clots, but no active bleeding. He is called out to
the floor [**2138-3-21**].
Past Medical History:
Morbid Obesity
Hypertension
Hypercholesterolemia
Non-insulin dependent diabetes mellitus
Renal insufficiency
- baseline cr 1.7-1.8
Coronary artery disease
- PTCA in [**2135-8-26**] c/b spiral dissection of RCA successfully
stented
- 50% mid LAD
- diffuse 80% mid LCx
- 80% proximal OM2
- 90% ostial rPDA
Congestive heart falure
- EF 30%
s/p pacemaker implant in [**2129**] for sick sinus
previous alcoholic w/ h\o DTs at least twice, last ~ 25 yrs ago
COPD
Obesity hypoventilation
Chronic low back pain
Depression
s/p fractured skull in childhood
Social History:
Patient is married, lives with his wife in [**Name (NI) 1474**]. Has 2
children. Current 1 PPD smoker x 30 years. Previous alcoholic
with h/o DT's, current EtOH 2-3 beers/day. Now disabled, former
construction worker.
Family History:
Mother alive with h/o CVA; [**Name (NI) 50362**] father also alive.
Maternal grandfather died of an MI in his 60s.
Physical Exam:
Upon admission to the medical floor:
Vitals: T 98.8 BP 147/85 HR 84 RR 18 99% RA, FS 160
General: morbidly obese, comfortable, NAD
HEENT: PERRL, EOMI, MMM, OP clear
Neck: JVD difficult to assess given body habitus,
Heart: distant HS, but RRR and w/o murs
Lungs: distant lung sounds, but CTAB, no wheezes or rhonchi
Abdomen: obese, NABS, soft, NT/ND; no stigmata of liver disease
Extremities: L arm with 2+ bilat lower extremity pitting edema
Neuro: A&Ox3, strength 5/5, no focal defecits
Pertinent Results:
[**2138-3-20**] 02:11PM PT-12.6 PTT-25.1 INR(PT)-1.1
[**2138-3-20**] 02:11PM PLT SMR-LOW PLT COUNT-95*#
[**2138-3-20**] 02:11PM NEUTS-93.5* BANDS-0 LYMPHS-5.1* MONOS-1.2*
EOS-0.3 BASOS-0
[**2138-3-20**] 02:11PM WBC-9.4 RBC-3.63* HGB-11.3* HCT-31.7* MCV-87
MCH-31.0 MCHC-35.5* RDW-15.8*
[**2138-3-20**] 02:11PM HCV Ab-NEGATIVE
[**2138-3-20**] 02:11PM HBsAg-NEGATIVE HBs Ab-POSITIVE HBc
Ab-NEGATIVE
[**2138-3-20**] 02:11PM ALBUMIN-2.4* CALCIUM-7.2* PHOSPHATE-4.8*
MAGNESIUM-1.5*
[**2138-3-20**] 02:11PM LIPASE-161*
[**2138-3-20**] 02:11PM ALT(SGPT)-57* AST(SGOT)-47* LD(LDH)-317* ALK
PHOS-41 AMYLASE-108* TOT BILI-0.6
[**2138-3-20**] 02:11PM GLUCOSE-183* UREA N-67* CREAT-1.6* SODIUM-134
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-21* ANION GAP-13
[**2138-3-20**] 03:18PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2138-3-20**] 03:18PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2138-3-20**] 10:09PM HCT-29.4*
.
EGD [**2138-3-20**]:
Blood in the fundus
Two clips in the fundus
Ulcer in the duodenal bulb
Otherwise normal EGD to second part of the duodenum
Recommendations: No active bleeding or sites of bleeding seen on
this exam.
.
pCXR [**2138-3-20**]:
Portable AP, without comparison, demonstrates pacemaker leads
within right atrium and right ventricle on single view. Lungs
are clear. Costophrenic sulci are sharp. Heart, mediastinal
contours, and pleural surfaces are unremarkable, given
technique.
IMPRESSION: No cardiopulmonary process. .
.
Abd u/s [**2138-3-21**]:
1. Echogenic liver consistent with fatty infiltration, however,
other forms of liver disease including significant hepatic
fibrosis and cirrhosis cannot be excluded on the basis of this
exam.
2. No ascites.
3. Cholelithiasis without evidence of cholecystitis.
4. Normal appearance of the kidneys.
.
L upper extremity u/s [**3-21**]: L cephalic vein DVT
Bilat Leg Venous Ultrasound (OSH [**3-14**]): No evidence of deep
venous thrombosis.
.
ECG ([**2138-3-20**] 18:53)
RRR @ 77, nl axis, intervals, no ST/T changes (no change [**Last Name (un) 834**]
[**2134-8-25**]
Brief Hospital Course:
52 y.o. male with h/o Dieulafoy lesion and PUD p/w hematemesis.
.
# Hematemasis - The patient has a h/o peptic ulcer disease, as
well as Dieulafoy's lesion. He had EGD at the outside hospital
with hemostatis achieved. He then rebled requiring multiple more
blood transfusions and underwent EGD on [**3-20**] at [**Hospital1 18**] with no
evidence of active bleeding. He was given protonix [**Hospital1 **]. His Hct
remained stable. We considered the possibility of bleeding
varices given his ETOH history, but liver U/S w/o evidence of
portal hypertension, showing only fatty liver. No varices were
noted on multiple EGDs. His diet was advanced to regular and
tolerated well. He will f/u with his PCP.
.
# L Cephalic Vein clot: The pt had a PICC line placed at [**Hospital 6451**] hospital in his L arm, and was found to have a L
Cephalic vein clot by u/s, which was persued to investigate UE
swelling. The PICC was removed, but no anticoaggulation given
due to recent GI bleeding. This is a peripheral vein clot and
was treated with removal of the offending line.
.
# Thrombocytopenia - unclear etiology, likely due to alcohol
use/fatty liver disease, but more likely consumptive in setting
of recent bleeding. HIT was considered low probability as Plts
remained stable.
.
# Elevated LFTs: Hepatitis serologies indicate immunity to HBV,
but no active infection. Abdominal u/s was performed and
revealed fatty liver, but no evidence of portal hypertension or
cirrhosis. NASH or Alcoholic hepatitis are possible diagnoses.
In addition, the patient reported he was recently started on a
statin, so this may be the cause. His Zocor and Tricor were
held. He was instructed to follow up with his PCP for repeat
LFTs, and referral to Hepatology if they remain elevated.
.
# CAD: The patient has known 3vd, but no evidence of active
ischemia> His ASA was stopped to due GI bleeding, and should be
restarted by his PCP when appropriate. After he was stabilized
for >48 hours, his b-blocker was re-started, which he tolerated
well. He will be discharged on Toprol XL, and his PCP can
titrate the dose as needed.
.
# CHF: EF 30% by report. His diuretics and b-blocker were held
in the ICU for possiblity of hemodynamic instabiltiy with recent
bleeding. Upon transfer to the medical floor, the pt was volume
overloaded on exam. His Lasix and B-blocker were restarted and
doses should be titrated by his primary care physician.
.
# COPD: Advair & nebulizers were continued.
.
# Renal failure: Etiology is unknown, presumed from hypertension
vs diabetes. According to OSH records, he is near his baseline
(Cr 1.6) His Nephrocaps and Phoslo were restarted.
.
# Chronic back pain: Morphine initially, then Percocet prn.
.
FEN: Regular, monitor lytes
.
Proph: No heparin given GI bleed; Pneumoboots, [**Hospital1 **] PPI
.
FULL CODE
Medications on Admission:
Advair 250/50 [**Hospital1 **]
Rocaltrol 0.25 PO QD
PhosLo 667 PO BID
Prozac 40 PO QD
Trazodone 100 PO QHS prn insomnia
Nephrocaps 1 PO QD
Zocor 40 PO QD
TriCor 145 PO QD
Lasix 80mg QAM, 40mg QPM
Omeprazole 20 PO BID
Toprol XL 150mg daily
Discharge Medications:
1. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Capsule(s)* Refills:*2*
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. Lasix 20 mg Tablet Sig: Three (3) Tablet PO twice a day.
5. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain for 7 days.
Disp:*20 Tablet(s)* Refills:*0*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed.
12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
prn as needed for shortness of breath or wheezing.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Upper GI bleeding
2. Upper extremity cephalic clot secondary to PICC
3. Transaminitis
Discharge Condition:
Stable, Hct stable, no signs of bleeding
Discharge Instructions:
* Take medications as prescribed. Several medications were
held, and you should discuss restarting any other medications
with your primary care physician.
* Do not take aspirin until directed by your primary care
physician.
* Call your doctor if you have blood in your vomit or stool,
light-headedness, or any other concerning symptom.
* Please note that you have elevated liver enzymes. This may be
due to your cholesterol medication, alcohol, or fat infiltration
of your liver. You must follow up with your primary care
physician and seek referral to a Liver specialist if this does
not resolve.
Followup Instructions:
Please call your doctor, Dr. [**Last Name (STitle) 20426**] ([**Telephone/Fax (1) **]) for an
appointment in the next week. He needs to monitor your
hematocrit and should check your liver enzymes and if they
remain elevated, refer you to a Liver specialist.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
Completed by:[**2138-3-23**]
|
[
"V45.82",
"428.0",
"401.9",
"453.8",
"996.74",
"278.01",
"272.0",
"250.00",
"414.01",
"584.9",
"578.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
9592, 9598
|
5047, 7889
|
279, 285
|
9731, 9774
|
2863, 5024
|
10423, 10834
|
2220, 2336
|
8178, 9569
|
9619, 9710
|
7915, 8155
|
9798, 10400
|
2351, 2844
|
228, 241
|
313, 1398
|
1420, 1969
|
1985, 2204
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,054
| 106,938
|
44839
|
Discharge summary
|
report
|
Admission Date: [**2176-7-31**] Discharge Date: [**2176-8-6**]
Date of Birth: [**2119-5-12**] Sex: M
Service: MEDICINE
Allergies:
Naprosyn / Aspirin / Nylon 12 / Spironolactone
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Attempted biventricular upgrade of ICD
History of Present Illness:
57 year old male with CAD s/p MIx4, CABG, DM2, HLD, HTN, CHF,
CVA p/w with chief complaint of substernal chest & back pain
with diaphoresis which occurred around 10am in [**Hospital Ward Name 23**] lobby.
Pt. took 2 sl NTG AT 10:15AM & again 10:30 AM (O.6MG). Came up
to [**Hospital Ward Name **] 7 for cardiology appt with more substernal/back pain
withdiaphoresis. Given 2 more sl NTG at 11am with relief. Dr.
[**First Name (STitle) 437**] evaluated pt. EKG LBBB morphology which is wider, SR.
BP122/80 [**Last Name (un) **]/STANDING, AFTER NTG 114/80, HR 86-90. No N/V/SOB.
Feels some indigestion. Dr. [**First Name4 (NamePattern1) 437**] [**Last Name (NamePattern1) 95937**] requested CTA to
rule out aortic dissection & PE, ? cath.
.
In the ED, he had no further chest pain (initially). A CXR with
No ACP and no mediastinal widening. Per ED, it was discussed
with Dr. [**First Name (STitle) 437**] and he was put into Obs for two sets and a
stress. He ruled in on the second set with a trop of 0.13. He
received ? 1-2L of NS for unclear reasons and an amiodarone
bolus for 5 beat run of NSVT. The ED then found him c/o chespt
pain with radiation to back and tachycardic and believed that he
was in Afib with RVR. He developed a new O2 requirement with 91%
on 5L and a CXR was apparently c/w pulmonary edema. He received
0.125 mg Digoxin, zofranm large doses of morphine,was placed on
bipap, ntg drip, heparin drip with resolution of his chest pain.
His EKG was c/w SR with apcs and vpcs. After CCU admission was
requested, he then received 5 mg of IV metoprolol and 50 mg of
Lopressor for HR 130. His rate fell to 80's. He also received 60
mg of IV lasix.
.
On review of systems, he denies any prior history of deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. He denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CHF (last echo [**12-19**], EF 20-25%)
-Coronary artery disease, status post myocardial infarction
times four; last one in [**2166-7-11**]. Status post 3x coronary
artery bypass grafting in [**2155**]. Stented in '[**60**], but had
re-stenosis within 6 months. Had 3-vessel disease on cath in
[**2-20**].
3. OTHER PAST MEDICAL HISTORY:
-History of left middle cerebral artery stroke in [**2166-7-11**]
with residual Broca aphasia.
-History of seizure disorder with last seizure in [**Month (only) 404**] of
[**2167**].
-Type 2 diabetes mellitus; most recent hemoglobin A1c of 7.3.
-Gastroesophageal reflux disease.
-Peptic ulcer disease.
-History of upper gastrointestinal bleeds.
-Bilateral CEA
Social History:
Canadian. The patient is married. His wife was recently
discharged from the hospital with a new diagnosis of Alzheimer's
disease. He is responsible for most of the chores at home. He
has a 70 pack-year tobacco history. He quit two years ago.
Sometimes he would smoke up to four packs per day. He denies
alcohol or drug abuse. He was previously an ombudsman in [**Country 6607**]
and was a handyman in the United States. He notes financial
struggles.
Family History:
The patient's father died of a myocardial infarction at age 50.
His mother has a history of CAD, DM2, and bladder cancer. The
patient has multiple siblings who have had heart attacks in
their 40s.
Physical Exam:
On admission:
BP: 119/73 Pulse: 85 RR: 21 O2: 99%
General Appearance: Well nourished, No acute distress,
Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), S3
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)
Dullness : ), (Breath Sounds: Crackles : bibasilar)
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace, No(t) Cyanosis, No(t) Clubbing
Skin: Not assessed, No(t) Rash:
Neurologic: Attentive, Responds to: Not assessed, Oriented (to):
x3, Movement: Not assessed, Tone: Not assessed
On discharge:
T: 98.2 HR: 62 BP 125/60 RR 18 O2: 95% RA
Gen: NAD
CV: irregularly irregular, normal S1/s2
Resp: CTAB
Abd: soft, NT/ND
Ext: no lower ext edema
Skin: warm, dry
Pertinent Results:
CBC:
[**2176-7-31**] WBC-8.6 Hgb-13.1* Hct-39.8* MCV-92 Plt Ct-275
[**2176-8-6**] WBC-8.7 Hgb-10.6* Hct-31.3* MCV-92 Plt Ct-234
BMP:
[**2176-7-31**] BG-214* UreaN-17 Creat-1.4* Na-138 K-4.3 Cl-98 HCO3-33*
AnGap-11
Calcium-10.0 Phos-3.6 Mg-1.7
[**2176-8-6**] BG-107* UreaN-27* Creat-1.3* Na-136 K-4.1 Cl-94* HCO3-32
AnGap-14
Calcium-8.7 Phos-3.6 Mg-1.8
Coags:
[**2176-7-31**] PT-14.2* PTT-25.2 INR(PT)-1.2*
[**2176-8-2**] PT-15.8* PTT-60.5* INR(PT)-1.4*
Cardiac Enzymes:
[**2176-7-31**] 12:00PM BLOOD cTropnT-0.03*
[**2176-7-31**] 06:40PM BLOOD cTropnT-0.13*
[**2176-8-1**] CK-MB-107* MB Indx-10.4* cTropnT-1.40*
[**2176-8-1**] CK-MB-51* MB Indx-6.8* cTropnT-2.39*
[**2176-8-2**] CK-MB-20* cTropnT-2.46*
[**2176-8-1**] 03:22AM BLOOD ALT-30 AST-133*
[**2176-8-1**] BLOOD CK(CPK)-1024*, CK(CPK)-755*,
Lipid Pannel
[**2176-8-1**] Triglyc-101 HDL-42 CHOL/HD-3.8 LDLcalc-99
Blood Digoxin Level
[**2176-8-2**] Digoxin-1.3
Other Studies
- ECG: SR at 120 with APC and VPC, LBBB
.
- ECHO [**2176-7-31**]:
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is severely dilated.
There is severe global left ventricular hypokinesis (LVEF <20
%). The estimated cardiac index is borderline low
(2.0-2.5L/min/m2). The right ventricular cavity is mildly
dilated with moderate global free wall hypokinesis. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**2-11**]+) mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Severe left ventricular dilation with severe global
left ventricular hypokinesis. Mildly dilated right ventricle
with moderate global hypokinesis. Mild to moderate mitral
regurgitation.
.
CXR [**2176-7-31**]
Stable chest x-ray examination with no acute pulmonary process
identified. The tracheal deviation in the course of the
contiguous [**Month/Day/Year 26418**] lead is in keeping with a large left thyroid
lobe which grossly is stable.
CXR [**2176-7-31**]
1. New mild pulmonary edema.
2. Intact [**Month/Day/Year 26418**]/pacemaker lead in standard position.
3. Stable rightward tracheal deviation due to known thyroid
mass.
Brief Hospital Course:
57 year old male with CAD s/p MIx4, CHF, CVA p/w with chief
complaint of substernal chest & back pain found to have NSTEMI
who was not a candidate for interventional therapy so received
medical management.
.
ACTIVE ISSUES:
# NSTEMI: Pt presented with CP and found to have NSTEMI by
enzymes. Previous cath suggested pt would benefit best from
medical management. Started on nitroglycerin drip, heparin gtt x
48 hrs, [**Month/Day/Year **] (allergy was previous GI bleed) and [**Month/Day/Year 4532**]. Nitro
drip d/c'ed on [**8-1**] and pt re-started on home imdur. Pt
experienced another episode of CP while undergoing PT, though no
EKG changes were noted. Amlodipine 10mg was added to help
improve pt's CP. Max dose of Crestor was added in place of
atorvastatin for suboptimal lipid control. Also started on [**Month/Year (2) **].
Pt was not started on an ACEI during this admission as it had
been noted in the chart that he had developed hyperkalemia when
on ACEIs in the past.
.
# RHYTHM: Pt's rhythm is underlying sinus though marked by
considerable ectopy. Pt is s/p ICD from a previous admission. To
improve functional status, pt was upgraded to BiV pacing on [**8-5**]
though the ventricular lead could not be positioned, so an
epicardial lead may have to be placed at a later date. During
the procedure, the patient had an episode of Afib/flutter which
converted back to sinus with APC and VPC. Pt's home metoprolol
and amiodarone were continued.
.
CHRONIC ISSUES:
# Chronic Systolic CHF: Per prior Echo, pt's EF is 20% and had
evidence of dyskinesis for reason why CRT was pursued and should
continue to be followed as an outpatient. Pt's BPs were in the
low 100s throughout most of the hospitalization so his home
torsemide was introduced as pt's BP could tolerate. Pt's home
digoxin was continued.
.
# HLD Pt's LDL (99) is above his goal given his recent cardiac
event. Pt was switched from atorva 80 to Crestor 40 to better
optimize his lipid levels.
.
# DIABETES TYPE 2: Pt's blood sugars were in the 300s while on
sliding scale insulin but improved upon resumption of pt's home
regimen of 40u lantus [**Hospital1 **].
.
# CKD: Pt's Cr was at his new baseline of 1.6. Meds were renally
dosed and nephrotoxins avoided.
.
# GOITER/HYPERTHYROIDISM: Continued pt's home methimazole
.
# s/p LMCA CVA: Stable. He has chronic Broca's aphasia at
baseline. In addition to his home [**Last Name (LF) 4532**], [**First Name3 (LF) **] was started this
admission as pt's allergy was a hx of GI bleed.
.
# SEIZURE DISORDER: Stable. Continued pt's home keppra.
.
# GASTROESOPHAGEAL REFULX DISEASE/PEPTIC ULCER DISEASE: Stable.
Continued pt's home ranitidine.
.
# ASTHMA: Stable. Continued home advair and albuterol prn
.
TRANSITIONAL ISSUES:
1. BiV placement was unsuccessful. Will need follow up with CT
surgery for evalution for placement of epicardial lead.
2. Blood pressure: Consider adding [**First Name8 (NamePattern2) **] [**Last Name (un) **] as an outpatient. It
was deferred in the hospital because pressures were tenuous in
the setting of uptitrating of other medications.
3. diuretics: Patient was also very sensitive to his home dose
of torsemide while in the hospital perhaps because of effective
salt restriction. Please reevaluation kidney function and weight
in next clinic visits.
4. Aflutter: Patient was found to have Aflutter during his EP
procedure, otherwise in sinus. Deferred the question of
anticoagulation to his outpatient physicians.
Medications on Admission:
ALBUTEROL SULFATE - prn
AMIODARONE - 200 mg Tablet daily
ATORVASTATIN - 80 mg Tablet daily
AZELASTINE [ASTELIN] - 137 mcg qd
CLOPIDOGREL - 75 mg Tablet - qd
DIGOXIN - 125 mcg Tablet - qd
FLUOCINOLONE - 0.025 % Ointment - [**Hospital1 **] for Eczema
FLUTICASONE [FLONASE] - 50 mcg Spray - 2 sprays qd
FLUTICASONE-SALMETEROL 500 mcg-50 mcg/Dose [**Hospital1 **]
GLUCAGON EMERGENCY KIT - 1MG Kit
INSULIN GLARGINE [LANTUS] - 40 twice a day
INSULIN LISPRO [HUMALOG] - QID SS
ISOSORBIDE MONONITRATE - 60 mg qd
LEVETIRACETAM [KEPPRA] - 500 mg Tablet - 3 in AM and 2 in PM
METHIMAZOLE - 20 mg daily
METOPROLOL SUCCINATE - 50mg [**Hospital1 **]
NITROGLYCERIN - 0.6 mg prn
OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet q4-6 prn
POTASSIUM CHLORIDE 20meq qd
RANITIDINE HCL - 150 mg Tablet [**Hospital1 **]
TORSEMIDE - 20 mg Tablet - 4 Tablet(s) by mouth in the morning
once goes up to 258 lbs or higher
Discharge Medications:
1. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
2. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. methimazole 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
10. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
Disp:*1 bottle* Refills:*0*
11. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO QAM
(once a day (in the morning)).
12. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QPM (once
a day (in the evening)).
13. torsemide 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
14. amlodipine 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
15. insulin glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous twice a day.
16. insulin lispro 100 unit/mL Solution Sig: 1-12 units
Subcutaneous as per home sliding scale.
17. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
18. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
19. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
20. Astelin 137 mcg Aerosol, Spray Sig: One (1) spray Nasal once
a day.
21. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Non ST Elevation Myocardial infarction
Acute on Chronic Systolic congestive heart failure: no ACE/[**Last Name (un) **]
because of low blood pressures.
Secondary diagnosis:
Diabetes Mellitus Type 2
Gastro esophageal reflux disease
Discharge Condition:
Mental Status: Clear and coherent with baseline expressive
aphasia s/p CVA.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory with cane
Discharge Instructions:
It was a pleasure taking care of you here at [**Hospital1 771**]. You were admitted because you had
chest pain and were found to have a mild heart attack. We
treated your heart attack medically and did not perform a
cardiac catheterization. We attempted to upgrade your ICD to a
type that paces both ventricles to help with your heart failure.
We were not able to do this and you may need to return to have
this done surgically. You have an appt with Dr. [**Last Name (STitle) **] to
discuss this. In the meantime, please take all of your medicines
and weigh yourself daily in the morning. Call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] if
weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days.
Take all your home medications as directed EXCEPT for the
following medication changes or additions that were made during
your hospital stay:
1. We want you to start taking Aspirin 325mg by mouth daily to
help prevent another heart attack. Your allergy is listed as a
prior GI bleed which is not considered a true allergy.
2. We want you to stop taking atorvastatin 80mg by mouth daily
and instead start taking Rosuvastatin Calcium 40mg PO to control
your high cholesterol.
3. We want you to start taking Nitroglycerin 0.3mg under the
tongue as needed for chest pain instead of Nitroglycerin 0.6mg.
You can also try taking an antacid such as mylanta to see if
this helps with the pain.
4. We want you to start taking Amlodipine 10 mg by mouth daily
to help relieve your chest pain.
5. Start taking Cephalexin for one week to prevent an infection
at the ICD site
6. Change the Metoprolol tartrate to metoprolol succinate to
treat your heart disease. This once a day formulation is better
for your heart failure
7. Continue to hold your valsartan because of your low blood
pressure. Dr. [**Last Name (STitle) 7790**] can consider adding this medicine back
on if your blood pressure is a little higher.
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2176-8-14**] at 11:00 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: THURSDAY [**2176-8-15**] at 9:00 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: Gz [**Hospital Ward Name 2104**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST Best Parking: Main Garage
Department: CARDIAC SERVICES
When: MONDAY [**2176-8-19**] at 9:15 AM
With: ICD CALL TRANSMISSIONS [**Telephone/Fax (1) 59**]
Building: None None
Campus: AT HOME SERVICE Best Parking: None
Department: [**Hospital1 18**] [**Location (un) 2352**]
When: TUESDAY [**2176-8-13**] at 11:10 AM
With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
We are working on a follow up appointment in Cardiology with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] within 2 weeks. The office will contact you at
home with an appointment. If you have not heard within 2
business days or have any questions please call [**Telephone/Fax (1) 62**].
Completed by:[**2176-8-6**]
|
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71,296
| 163,584
|
3529
|
Discharge summary
|
report
|
Admission Date: [**2158-5-12**] Discharge Date: [**2158-5-26**]
Date of Birth: [**2083-6-19**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Cold, pulseless left foot
Major Surgical or Invasive Procedure:
left groin cut-down with open thrombectomy
History of Present Illness:
74-y.o. female p/w left lower extremity pain x 3 days,
worsening,
affecting thigh, calf, and foot. Prior to this, last week, she
had been seen in the ED for left leg shooting pains, which was
diagnosed as sciatica. She has also had similar symptoms in her
right leg. Before a week ago, she had been able to ambulate
without difficulty, no distance limitations, no claudication, no
rest pain. Mild decreased sensation in left foot.
She was diagnosed with atrial fibrillation earlier this month,
prescribed coumadin but not taking any anticoagulant.
Past Medical History:
HTN, HLD, a-fib, borderline hypothyroidism, osteoporosis,
arthritis, h/o pancreatitis as a child.
PSH: RF ablation of left greater saphenous vein [**8-/2157**], remote
appendectomy, orthopedic surgeries to bilateral lower legs.
Social History:
Denies h/o tobacco use, denies EtOH consumption, and denies
recreational drug use. Married.
Family History:
Denies family history of diabetes mellitus and vascular disease.
Positive for heart disease.
Physical Exam:
EXAM ON TRANSFER TO MEDICINE
VS - Temp 98.9F, BP 131/60 , HR 82 , R 20 , O2-sat 97% RA
GENERAL - well-appearing female in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - Decreased BS at bilateral bases
HEART - PMI non-displaced, irreg. irreg, no MRG, nl S1-S2
ABDOMEN - NABS, mild TTP epigastically, no rebound or guarding
EXTREMITIES - 2+ pitting edmea to mid thigh bilaterally L> R.
LLE wound site with clean dry bandage in place. Erythema
extending to the lower abdmonem, regressed from previous
marking. LLE cool to the touch with 1+ PT, DP not palpated. RLE
warm with 1+ DP, PT pulses.
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**6-17**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric at knees and biceps, cerebellar exam intact, gait not
assessed
.
DISCHARGE EXAM
Pertinent Results:
ADMISSION LABS
[**2158-5-12**] 11:25AM BLOOD WBC-6.0 RBC-4.16* Hgb-11.2* Hct-36.7
MCV-88 MCH-27.0 MCHC-30.5* RDW-14.0 Plt Ct-225
[**2158-5-12**] 11:25AM BLOOD Neuts-73.2* Lymphs-19.5 Monos-5.3 Eos-1.5
Baso-0.6
[**2158-5-12**] 11:25AM BLOOD Glucose-102* UreaN-19 Creat-1.1 Na-139
K-4.2 Cl-106 HCO3-24 AnGap-13
[**2158-5-12**] 05:32PM BLOOD ALT-12 AST-19 LD(LDH)-188 CK(CPK)-35
AlkPhos-64 TotBili-0.2
[**2158-5-12**] 05:32PM BLOOD CK-MB-2 cTropnT-<0.01
[**2158-5-13**] 02:46AM BLOOD CK-MB-3 cTropnT-<0.01
[**2158-5-14**] 07:25AM BLOOD %HbA1c-5.9 eAG-123
[**2158-5-14**] 07:25AM BLOOD Triglyc-62 HDL-54 CHOL/HD-2.4 LDLcalc-66
.
DISCHARGE LABS
[**2158-5-25**] 05:57AM BLOOD WBC-7.0 RBC-3.95* Hgb-10.6* Hct-35.0*
MCV-89 MCH-26.7* MCHC-30.2* RDW-14.2 Plt Ct-249
[**2158-5-26**] 05:59AM BLOOD PT-18.2* PTT-29.1 INR(PT)-1.7*
[**2158-5-25**] 05:57AM BLOOD Glucose-103* UreaN-12 Creat-0.9 Na-140
K-3.8 Cl-101 HCO3-35* AnGap-8
.
INR
[**2158-5-12**] 11:25AM BLOOD PT-11.9 PTT-27.4 INR(PT)-1.1
[**2158-5-12**] 08:25PM BLOOD PT-13.2* PTT-150* INR(PT)-1.2*
[**2158-5-15**] 06:33AM BLOOD PT-26.6* PTT-150* INR(PT)-2.6*
[**2158-5-16**] 07:50AM BLOOD PT-45.6* INR(PT)-4.5*
[**2158-5-17**] 11:00AM BLOOD PT-51.4* PTT-42.1* INR(PT)-5.1*
[**2158-5-20**] 04:51AM BLOOD PT-29.1* INR(PT)-2.8*
[**2158-5-24**] 01:10PM BLOOD PT-22.4* INR(PT)-2.1*
[**2158-5-26**] 05:59AM BLOOD PT-18.2* PTT-29.1 INR(PT)-1.7*
.
URINE STUDIES
[**2158-5-12**] 06:20PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.042*
[**2158-5-12**] 06:20PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2158-5-12**] 06:20PM URINE RBC-10* WBC-1 Bacteri-NONE Yeast-NONE
Epi-0 TransE-<1
.
MICROBIOLOGY
C. difficile DNA amplification assay (Final [**2158-5-20**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
.
IMAGING
Lumborsacral Spine [**2158-5-12**]
IMPRESSION: Grade 2 anterolisthesis of L5 on S1 with no acute
fractures
identified.
.
EKG
[**2158-5-13**]
Atrial fibrillation. Compared to the previous tracing of [**2158-5-4**]
no change
.
4/1/12Atrial fibrillation with borderline controlled ventricular
response rate.Non-specific ST segment changes in the
inferolateral leads. Compared to the previous tracing of [**2158-5-13**]
the ventricular response rate is faster.
.
[**2158-5-15**]
Atrial fibrillation with borderline rapid ventricular response
rate.
Early R wave transition. Non-specific ST segment changes in the
lateral
and high lateral leads. Compared to the previous tracing of
[**2158-5-14**] the
findings are similar.
.
[**2158-5-23**]
Atrial fibrillation with controlled ventricular response. ST-T
wave
abnormalities. Since the previous tracing of [**2158-5-15**] the rate is
slower.
R wave progression is now earlier and may be related to lead
position.
.
CTA CHEST ABDOMEN [**2158-5-12**]
1. Occlusion of the mid superficial femoral and proximal deep
femoral
arteries, as well as the tibioperoneal trunk on the left. The
distal left
superficial femoral artery and left popliteal artery are
stenotic and thready although these fills via collaterals. More
distally, however, the left peroneal and anterior tibial
arteries appear stenotic. A long occlusion of the right superior
femoral artery is also present but overall disease is worse in
the left leg.
2. Short occlusion of the superior mesenteric artery with patent
distal flow via collaterals.
3. Few very small pulmonary nodules. If underlying risk is low,
the no
followup is needed. Otherwise, however, if the patient is at
elevated risk
for malignancy, for example with a history of smoking or known
prior
malignancy, then follow-up chest CT surveillance is recommended
in one year.
.
CTA Chest [**2158-5-14**]
1. No evidence of pulmonary embolism.
2. Trace bilateral pleural effusions and dependent atelectasis.
3. Multiple subcentimeter pulmonary nodules, the largest
measuring 4 mm in
the right middle lobe. As stated on CT of [**5-12**], if this
patient is felt
to be at low risk for primary lung cancer, no followup is
needed. If the
patient does have a history of smoking or other risk factors, a
followup chest CT in one year is recommended.
.
CTA BRAIN [**2158-5-13**]
1. Non-contrast head CT of the head without evidence of acute
findings.
2. CT perfusion with no evidence of acute stroke.
3. No major vascular occlusion is detected.
4. Left thyroid nodule, correlation with non-urgent ultrasound
is
recommended.
.
Brain perfusion study [**2158-5-16**]
Completed infarction in left ACA distribution with left
parasagittal frontal lobe hypodensity, elevated MTT, and reduced
BF and BV.
Findings were communicated via page to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16193**], who
confirmed that the primary team was already aware of these
findings.
.
TTE [**2158-5-16**]
The left atrium is mildly dilated. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). No
atrial septal defect or patent foramen ovale is suggested on
intravenous saline injection at rest and with cough (suboptimal
image quality). . There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function. Pulmonary artery hypertension.
Mild mitral regurgitation.
.
Lower extremity doppler [**2158-5-14**]
1. Deep venous thrombosis within the left common femoral and
superficial
femoral veins.
2. Findings consistent with left groin hematoma. No abnormal
vascular flow
to suggest pseudoaneurysm.
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION
74F HTN, HLD, ?hypothyroidism (NL T4/elevated TSH not on
supplementation) and Afib also with PVD s/p L SFA cut-down w/
thrombectomy [**5-12**] with a complicated post operative course.
.
# LLE Arterial Thrombus- As above the patient presented with
acute onset of pain in her LLE. She was found to have an acute L
SFA occlusion now s/p cut-down w/ thrombectomy on [**5-12**].
Post-operatively she was noted to have absent DP and faint PT
pulses. Her foot was cool but with good capillary refill. She
continued to have significant burning pain that was felt to be
multi-factorial in nature with component of continued ischemia
as well as a neuropathic component. Pain was controlled with
oxycodone and gabapentin. She will follow-up with vascular
surgery regarding the need for further intervention. She further
required lasix 20 mg x 2 with resultant improvement of lower
extremity edema. She was then transitioned to oral lasix 20 mg
daily which was continued on discharge.
.
# Atrial Fibrillation with difficult to control heart rates-
Patient noted to have HR to the 140s in the immediate post
operative period. She patient was given increasing doses of
metoprolol with resulting hypotension and blood pressures in the
80s systolic resulting in TIA (see below). She was transferred
to the CVICU where she was converted to digoxin. Hypotension
continued to be a problem and she required phenylephrine x 1
day. She was weaned from pressor support though she continued
to require intermittent fluid and albumin boluses last on [**5-17**].
HR remained poorly controlled she was given intermittent PRN
doses of IV metoprolol. She was restarted on oral metoprolol
which was carefully titrated upward with maintenance of stable
blood pressures. She was anti-coagulated as below. At the time
of discharge she was on metoprolol succinate 75 mg daily and
digoxin 0.125 mg daily. She will follow-up with cardiology as an
outpatient.
.
#TIA/Acute STROKE-
On POD 1, she had an episode of expressive aphasia and right
sided paralysis. A code stroke was called. The symptoms
resolved on their own with no intervention. She had several
studies, including a CT of the head which initially was read as
normal but on re-read showed occlusion of the L ACA, though this
was not known until several days later. On POD 4, she again had
an episode of expressive aphasia and R sided weakness,
associated with SBP in the high 80s/low 90s. A code stroke was
again called and a CT perfusion scan showed the previously
mentioned blockage in the left ACA as well as relative
hypoperfusion of the L ACA terratory. Per the neuro stroke
team, her goal SBP was set at 120-140. Her hypotension had
resulted from aggressive beta-blockade for her afib. Her beta
blocker was stopped and she was started on digoxin. She was
also started on a neosynepherine drip for her low blood
pressure. Her symptoms began to resolve within ten minutes of
starting the neo. She was transfered to the CVICU for her neo
drip. As above the drip was weaned and pressures stabilized.
Deficits resolved and her neurological exam remained stable for
the remainder of her hospitalization. Her blood pressures were
maintained in a goal range of 120-140 systolic. She was
anti-coagulated as below. The patient will follow-up with
neurology as an outpatient.
.
# DVT- On [**5-14**] the patient was noted to have increased swelling
in thh left leg, and an ultrasound showed a DVT in the L CFV and
SFV as well as a small hematoma over the left SFA. CTA was
negative for PE. She was anti-coagulated intitially with heparin
gtt with conversion to warfarin when INR was therapeutic. INR
was difficult to control. The day of discharge INR was notable
to be subtherapeutic at 1.7 (goal 2.0-3.0). Warfarin was
increased to 2 mg daily. She was started on a lovenox bridge
which should be continued until her INR is therapeutic for 2
days. She will require close INR monitoring while at rehab.
.
# Chest Pain- On [**5-14**] cardiology was consulted for concern for
chest pain. Trops were negative x 6. As above CTA was negative
for PE. Echo bubble study was negative. Ultimately chest pain
was felt to be atypical in nature and recommended stress test as
an outpatient.
.
# LLE Wound Infection- Patient was intiated on vanc/flagyl/cipro
on [**2158-5-15**] for concern for infection of her LLE wound site given
erythema and edema. The patient completed a 10 day course of
antibiotics with improvement in her erythema. She remained
afebrile with a normal white blood cell count.
.
# Diarrhea- Patient has developed loose stools over the past 3
days. She states at last one stool has been red in color. She
denies associated abdominal pain or association with food. C
diff was negative x 1. She was started on loperamide for
symptomatic management.
.
STABLE ISSUES
# HTN- As above patient was continued on digoxin and metoprolol
for rate control. Her home losartan was held in the setting of
hypotension. This medications were held on discharge. The
patient will follow-up with his cardiologist.
.
# Hyperlipidemia- Patient was continued on simvastatin
.
TRANSITIONAL ISSUES
- Full code
- Patient was discharged to [**Hospital 100**] Rehab on [**2158-5-26**]
- INR monitoring and coumadin dose adjustment was transitioned
to the Rehab physician
[**Name Initial (PRE) **] [**Name10 (NameIs) **] is on a lovenox bridge which will need to be continued
until INR is therapeutic (2.0-3.0) for 2 days. She should be
bridged for any INR <1.9 given high risk of embolus
- Multiple subcentimeter pulmonary nodules, the largest
measuring 4 mm in
the right middle lobe. If this patient is felt to be at low risk
for primary lung cancer, no followup is needed. If the patient
does have a history of smoking or other risk factors, a followup
chest CT in one year is recommended
- CT demonstrated left thyroid nodule, correlation with
non-urgent ultrasound is
recommended.
- Patient will follow-up with Cardiology, Neurology and Vascular
surgery.
Medications on Admission:
hydrochlorothiazide 25 mg Tablet 1 Tablet(s) by mouth once a day
(On Hold from [**2158-5-4**] to unknown for diarrhea)
lorazepam
losartan 50 mg Tablet
1 Tablet(s) by mouth once a day
metoprolol succinate 200 mg Tablet Extended Release 24 hr
2 Tablet(s) by mouth once a day (400 mg).
simvastatin 20 mg Tablet
1 Tablet(s) by mouth at bedtime
zolpidem 10 mg Tablet [**2-14**] Tablet(s) by mouth at bedtime
aspirin 325 mg Tablet1 Tablet(s) by mouth once a day
calcium carbonate-vitamin D3 500 mg (1,250 mg)-400 unit Tablet,
Chewable 1 Tablet(s) by mouth twice a day
ibuprofen
brimonidine eyedrops
omeprazole
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for rash.
5. zolpidem 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
7. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
8. loperamide 2 mg Capsule Sig: Two (2) Capsule PO QID (4 times
a day) as needed for diarrhea.
9. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
10. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours): discontinue when INR
therapeutic for 2 days.
11. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Hold for SBP < 120.
12. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain: hold for sedation .
13. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
14. digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day.
15. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
16. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Acute lower extremity arterial thrombus
Atrial fibrillation
Stroke
Wound infection
SECONDARY DIAGNOSIS
Hypertension
Hyperlipidemia
Peripheral vascular disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms [**Known lastname 16194**],
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 pain in your leg. A CT
scan was done which showed a clot in your leg. You had an
operation done to remove this clot. You also have several
narrowings in your arteries and may require another surgery in
the futher. You will need to follow-up with the surgeons in the
future about the need for a further surgery.
.
During your hospitalization your heart rates were hard to
control. You got higher doses of medication which caused your
blood pressure to go low. You also had a stroke, fortunately all
of your symptoms resolved but you will need to follow-up with
the neurologist. You were also felt to have an infection of your
wound site. You were given antibiotics for this infection and
improved. You also had diarrhea. Your stool was negative for
signs of infection so you were given medication to help improve
the diarrhea.
.
We made the following changes to your medications
1. STOP losartan
2. STOP HCTZ
3. START oxycodone 2.5 mg every 4 hours as needed for pain
4. START gabapentin 300 mg three times a day. This is for your
leg pain
5. START Digoxin 0.125 mg daily This is for your atrial
fibrillation
6. START Loperamide as needed for dairrhea
7. START Simethicone as needed for gas
8. START Warfarin 2 mg daily, this dose will be adjusted by the
rehab facility. This is for the clots in your legs.
9. START lasix 20 mg daily
10. DECREASE metoprolol succinate to 75 mg daily
11. DECREASE aspirin to 81 mg daily
You should continue to take all other medications as instructed.
Please feel free to call with any questions or concerns
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 1980**] J.
Location: [**Hospital3 249**]
[**Hospital1 **]/EAST
Address: [**Location (un) **], E/CC-6, [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2010**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Name: [**Last Name (LF) 1391**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **]
Department: Vascular Surgery
Address: [**Doctor First Name **] STE 5C, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 1393**]
Appointment: Wednesday [**2158-5-31**] 10:15am
Name: [**Last Name (LF) 16195**],[**First Name7 (NamePattern1) 1216**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Department: Cardiology
Address: [**Hospital1 993**], [**Location (un) **],[**Numeric Identifier 994**]
Phone: [**Telephone/Fax (1) 16196**]
*We are working on a follow up appointment for your
hospitalization with your cardiologist. You need to be seen
within 2 weeks of discharge. The office will contact you at the
facility with the appointment information. If you have not heard
within 2 business days or have any questions please call the
office at the above number.
Department: NEUROLOGY
When: FRIDAY [**2158-6-30**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD [**Telephone/Fax (1) 2574**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"272.4",
"427.31",
"V12.01",
"E849.7",
"440.20",
"444.22",
"453.41",
"998.12",
"434.11",
"E947.8",
"401.9",
"E878.4",
"458.29",
"733.00",
"998.59",
"786.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.08",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
16694, 16760
|
8511, 14524
|
298, 342
|
16982, 16982
|
2374, 8488
|
18913, 20588
|
1305, 1401
|
15178, 16671
|
16781, 16961
|
14550, 15155
|
17165, 18890
|
1416, 2355
|
233, 260
|
370, 925
|
16997, 17141
|
947, 1178
|
1194, 1289
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,403
| 167,767
|
53964
|
Discharge summary
|
report
|
Admission Date: [**2195-4-25**] Discharge Date: [**2195-4-29**]
Date of Birth: [**2128-1-14**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
esophagoduodenoscopy - [**4-26**]
History of Present Illness:
67 Spanish-speaking female with hx of cirrhosis c/b hepatic
encephalopathy, variceal bleeding, CVA, schizoaffective d/o pw
hematemesis. The patient was in her usual state of health until
2 day prior when she developed small amount of coffee ground
emesis and melena. She presented to the OSH ED and was noted to
have altered mental status which by report is close to her
baseline. Initial vitals were: 97.5, 131/53, 85, 16, 97% RA. She
had hematemesis in the ED and NGT was placed with return of
"bright red blood". Lavage did not clear after 250cc of IVF. GI
was consulted and she had EGD. EGD with no clear source of
bleed, 1+ varices with no stigmata of bleeding, clot in stomach.
She was started on cipro, flagyl, octreotide, pantoprazole and
was given 2u PRBC. For her AMS she had an elevated ammonia and
was given lactulose enema x1 with reported improvement in her
mental status. Other labs included: WBC 9.6, Hb 11.2, Hct 33.9,
Plt 118, INR 1.2, LFTs nl bili, ALT 42, AST 90, BUN 38, Cr 0.88,
CO2 20, ammonia 139.5. Repeat Hct were: 33.9 -> 28.9 -> 33.1 ->
31.1. She had a CT abdomen with no acute intra-abdominal
pathology, cirrhotic liver, subcutaneous foci of air overlying
RLQ, and irregular density within stomach lumen. The patient
seemed HD stable without any evidence of GIB following the EGD.
Given no ICU beds at OSH she was transferred to [**Hospital1 18**] for
further evaluation and management. Vitals at transfer were:
99.1, 103/45, 81, 16, 98% RA and access was 2 18g IVs.
On arrival to the MICU, vitals were: 98.7, 82, 129/50, 23, 96%
RA. Patient was able to answer questions with nodding head yes
and shaking head no. Only able to verbalize "lalala" which per
son is her baseline since stroke years ago. Patient denied any
pain currently.
Past Medical History:
Past Medical History:
- Cirrhosis c/b hepatic encephalopathy, varices: patient
diagosed 2 years ago in setting of variceal bleed. No hx of etoh
- DM2
- Schizoaffective disorder
- Hyperlipidemia
- Seizure d/o
- h/o CVA, muliple CVA has residual right sided weakness, unable
to speak, but can interact.
Social History:
Nursing home due to CVAs. No hx of Etoh/smoking/drug use. Uses
wheelchair.
Family History:
Family hx of stroke, diabetes, CAD
Physical Exam:
ADMISSION EXAM
Vitals: 98.7, 82, 129/50, 23, 96% RA.
General: no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: obese soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
Rectal: Black stool, guiac +
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 4/5 strength upper/lower extremities on
right side full on left, grossly normal sensation, 2+ reflexes
bilaterally, gait deferred. Able to answer only with "lalala"
.
DISCHARGE EXAM:
VS - 98.6, 131/56 BP , 60 HR , 17 R , O2-sat 97% RA
I/O: 24 hr 1696/2425 (1000 stool, 1425 urine)
GENERAL - elderly appearing woman, comfortable, nonsensical
speech
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple
LUNGS - diffusely wheezy with transmitted upper airway noses,
resp unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/ND, no masses or HSM, no rebound/guarding,
very mildly tender to deep palpation
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs); right hand contracted with splint in place, tender to
manipulation; 2x4cm hematoma above left antecubital fossa
SKIN - no rashes or lesions
NEURO - awake, unable to follow commands, mild asterixis
Pertinent Results:
ADMISSION LABS
[**2195-4-25**] 10:30PM WBC-3.8* RBC-3.48* HGB-10.2* HCT-31.0* MCV-89
MCH-29.2 MCHC-32.8 RDW-15.8*
[**2195-4-25**] 10:30PM NEUTS-56.4 LYMPHS-36.5 MONOS-4.2 EOS-2.6
BASOS-0.4
[**2195-4-25**] 10:30PM PLT COUNT-78*
[**2195-4-25**] 10:30PM GLUCOSE-240* UREA N-27* CREAT-0.6 SODIUM-148*
POTASSIUM-3.7 CHLORIDE-112* TOTAL CO2-27 ANION GAP-13
[**2195-4-25**] 10:30PM ALT(SGPT)-42* AST(SGOT)-45* LD(LDH)-212 ALK
PHOS-73 TOT BILI-0.8
[**2195-4-25**] 10:30PM ALBUMIN-3.2* CALCIUM-7.9* PHOSPHATE-2.4*
MAGNESIUM-1.7
[**2195-4-25**] 10:30PM PT-14.4* PTT-23.4* INR(PT)-1.3*
[**2195-4-25**] 10:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-MOD
[**2195-4-25**] 10:10PM URINE RBC-167* WBC-54* BACTERIA-MANY
YEAST-NONE EPI-1
[**2195-4-25**] 10:43PM LACTATE-2.1*
Hct trend:
[**2195-4-25**] 10:30PM BLOOD Hgb-10.2* Hct-31.0*
[**2195-4-26**] 02:56AM BLOOD Hgb-9.8* Hct-30.8*
[**2195-4-26**] 03:08AM BLOOD Hct-33.1*
[**2195-4-26**] 12:40PM BLOOD Hct-31.2*
[**2195-4-26**] 07:50PM BLOOD Hct-32.2*
[**2195-4-27**] 03:32AM BLOOD Hgb-10.1* Hct-31.1*
[**2195-4-28**] 04:10AM BLOOD Hgb-10.6* Hct-32.0*
Critical care:
[**2195-4-27**] 02:08PM BLOOD Type-ART pO2-30* pCO2-57* pH-7.31*
calTCO2-30 Base XS-0
[**2195-4-25**] 10:43PM BLOOD Lactate-2.1*
[**2195-4-26**] 03:50AM BLOOD Lactate-2.0
[**2195-4-27**] 02:08PM BLOOD Lactate-2.6*
DISCHARGE LABS:
[**2195-4-29**] 06:00AM BLOOD WBC-2.0* RBC-3.36* Hgb-9.4* Hct-31.0*
MCV-93 MCH-27.9 MCHC-30.2* RDW-15.7* Plt Ct-66*
[**2195-4-29**] 06:00AM BLOOD PT-14.3* PTT-28.6 INR(PT)-1.3*
[**2195-4-29**] 06:00AM BLOOD Glucose-235* UreaN-11 Creat-0.6 Na-141
K-3.4 Cl-106 HCO3-27 AnGap-11
[**2195-4-29**] 06:00AM BLOOD ALT-52* AST-46* AlkPhos-97 TotBili-0.6
[**2195-4-29**] 06:00AM BLOOD Calcium-8.0* Phos-3.0 Mg-1.6
.
EGD
Findings: Esophagus:
Lumen: A sliding small size hiatal hernia was seen.
Protruding Lesions 2 cords of grade II varices were seen in the
lower third of the esophagus. One of themshowede stigmata of
recent bleeding (red [**Last Name (un) 23199**] sign). 1 band was successfully placed.
Other No evidecen of active bleeding
Stomach:
Mucosa: Localized discontinuous mosaic appearance of the mucosa
with no bleeding was noted in the stomach body. These findings
are compatible with Mild portal gastropathy. Localized
discontinuous erythema of the mucosa with no bleeding was noted
in the antrum.
Protruding Lesions One single large varix was seen in the
fundus. Red blood was identified surrounding the area of the
varix. After irrigation with normal saline no active bleeding
was identified.
Duodenum:
Mucosa: Normal mucosa was noted in the first part of the
duodenum and second part of the duodenum.
Other No evidence of ulcers, polyps or active bleeding
Impression: Varices at the lower third of the esophagus
(ligation)
Small hiatal hernia
No evidecen of active bleeding
Varices at the fundus
Mosaic appearance in the stomach body compatible with Mild
portal gastropathy
Erythema in the antrum
Normal mucosa in the first part of the duodenum and second part
of the duodenum
No evidence of ulcers, polyps or active bleeding
Otherwise normal EGD to third part of the duodenum
Recommendations: 1. Continue Ocreotide gtt
2. Continue PPI gtt
3. Continue IV abx (total of 7 days)
4. Check HCT q6 hrs (transfuse to keep HCT 24-29)
5. If more episodes of bleeding will need emergent TIPS
6. Check RUQ US with dopplers
7. Keep patient NPO until tomorrow
8. Keep patient in the ICU
Abdominal ultrasound with dopplers [**4-27**]:
The liver is coarse and echogenic, denoting hepatic steatosis.
No focal
intrahepatic lesion or intrahepatic bile duct dilation is seen.
The CBD is
not dilated, measuring 3 mm. The gallbladder is surgically
absent. The
spleen is enlarged, measuring 14.0 cm. There is no ascites.
Wall-to-wall color flow is seen within the left, mid, right
hepatic veins,
left, right anterior and posterior portal veins, main portal
vein, and main hepatic artery, all demonstrating appropriate
waveforms and flow direction.
IMPRESSION:
1. Patent hepatic and portal veins, and main hepatic arteries,
demonstrating appropriate waveforms and flow directions.
2. Echogenic liver denotes hepatic steatosis. More advanced
disease such as cirrhosis or fibrosis cannot be excluded with
this technique.
3. Splenomegaly.
TTE [**4-27**]:
The left atrium is mildly dilated. 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. The estimated
cardiac index is normal (>=2.5L/min/m2). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (?#) appear structurally normal with good leaflet
excursion. Trace aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is high normal. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global biventricular systolic
function. Mild mitral regurgitation. High normal pulmonary
artery systolic pressure.
Brief Hospital Course:
67F with hx of cirrhosis and varices, CVA, seizure disorder,
schizoaffective disorder, diabetes admitted with hematemesis and
melena, found to have esophageal varix.
.
ACTIVE ISSUES:
#Upper GI Bleed: Patient with hx of cirrhosis and varices
presented to an OSH following several episodes of melana. An EGD
was performed which did not show clear evidence of bleeding. No
ICU bed was available at the OSH so she was transferred to
[**Hospital1 18**]. She was treated with IV PPI, Octreotide gtt, and
ceftriaxone for a planned 7 day course. An EGD performed at
[**Hospital1 18**] showed a gastric varix and an esophageal varix which
looked like it may have recently bled. One band was placed on
the esophageal varix. She was restarted on her nadolol. Her HCT
remained stable, and octreotide was discontinued. Her
pantoprazole was switched to PO. She was restarted on her home
medications prior to discharge without hypotension or repeat
bleeding. She had a midline placed for antibiotic
administration, but this infiltrated so her antibiotics were
transitioned to cefpodoxime. She developed a large left arm
hematoma from the midline, which should be monitored at the
nursing home. She will need complete a 5 day course of
cefpodoxime.
.
#AMS. Per OSH ED, patient was altered with elevated ammonia.
This improved with lactulose, which is a home medication for the
patient. She also has hx of CVA, schizoaffective disorder, and
seizure disorder though these appear to be controlled. On the
morning of [**4-27**] she was observed to be somnolent with reduced
mental status. Her lactulose was increased and by evening she
returned to her baseline mental status per family observation.
A rectal tube was briefly placed to facilitate care; this was
removed [**4-28**] when her lactulose was reduced to home dosing
schedule.
.
CHRONIC ISSUES:
#Cirrhosis. Etiology of her cirrhosis is unclear. [**Name2 (NI) **] her family
she does not have a history of heavy EtOH use and her viral
hepatitis panel was negative at the OSH. NASH cirrhosis versus
autoimmune etiologies possible. We initially held her
spironolactone, furosemide and nadolol. After she clinically
stabilized we restarted the nadolol and her home diuretics prior
to discharge.
.
#Aspiration: Patient was observed to cough while eating despite
sitting upright. Speech and swallow evaluation was performed
and cleared the patient for soft diet and full liquids. She was
able to take medications safely with apple sauce.
.
#DM: Patient on Lantus at night, 70/30 in AM, metformin, ISS. We
held metformin but continued her insulin. Her metformin was
restarted on discharge.
.
#CVA: Per records from OSH and nursing home not on aspirin or
Plavix, likely due to high bleeding risk. She was continued
Baclofen 20mg PO TID
.
#Schizoaffective Disorder: Stable. We continued her Venlafaxine
150 mg ER PO qAM and Abilify 10mg PO BID.
.
#Seizure: Stable. Continued Keppra 500 mg PO BID
.
TRANSITIONAL ISSUES:
# Pt should be on cefpodoxime for a 5 day course, last dose to
be given [**5-4**].
.
# Pt should be started on pantoprazole 40 mg daily. She should
be monitored for any signs of recurrent bleeding.
.
# Pt developed large left arm hematoma from midline. Please keep
this arm elevated and apply warm compresses until this resolves.
Medications on Admission:
1. Vicodin 5mg/500mg PO qHS
2. Metformin 1000mg PO BID
3. Multivitamin 1 tab PO daily
4. Vitamin D3 50,000 u PO qMonthly
5. Furosemide 40mg PO daily
6. Venlafaxine 150mg ER PO qAM
7. Spironolactone 25mg PO daily
8. Nadolol 20mg PO daily
9. Miralax 17g PO daily
10. Baclofen 20mg PO TID
11. Abilify 10mg PO BID
12. Lactulose 30ml PO BID - [**3-8**] BM per day
13. Calcium/Vitamin D 500mg/200IU PO BID
14. Keppra 500mg PO BID
15. Novolog 70/30 16 units qAM
16. Lantus 10units qHS
17. Bisacodyl 10mg PR daily prn constipation
18. Fleet enema PR q3days prn
19. Trazodone 50mg PO q6H prn agitation
20. Acetaminophen 325mg PO Q4H prn pain
21. Vicodin 5mg/500mg PO q4H prn pain
22. Milk of magnesium 30ml PO daily prn constipation
23. Acetaminophen 650mg PR q4H pain or temp
24. Albuterol 0.083% inhaled q4H prn cough/wheeze
25. Novolin R U-100 insulin sliding scale
Discharge Medications:
1. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO at bedtime as needed for pain.
2. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
3. multivitamin with minerals Capsule Sig: One (1) Capsule
PO once a day.
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Two (2)
Capsule, Ext Release 24 hr PO DAILY (Daily).
6. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Miralax 17 gram/dose Powder Sig: One (1) packet PO once a
day.
9. baclofen 20 mg Tablet Sig: One (1) Tablet PO three times a
day.
10. aripiprazole 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): [**3-8**] BM/day.
12. Calcium 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One
(1) Tablet PO twice a day.
13. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
14. Novolog Mix 70-30 100 unit/mL (70-30) Solution Sig: Sixteen
(16) units Subcutaneous QAM.
15. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous
at bedtime.
16. bisacodyl 10 mg Suppository Sig: One (1) supp Rectal once a
day as needed for constipation.
17. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal
every seventy-two (72) hours as needed for constipation.
18. trazodone 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for Agitation.
19. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every
four (4) hours as needed for pain: no more than 2g/day.
20. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ml
PO once a day as needed for constipation.
21. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every four (4) hours as
needed for sob, wheeze.
22. insulin regular hum U-500 conc 500 unit/mL Solution Sig: One
(1) unit Injection four times a day: per sliding scale.
23. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
24. Vitamin D2 50,000 unit Capsule Sig: One (1) Capsule PO once
a month.
25. cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO twice a day
for 5 days: for 5 days, last dose 4/30.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 110659**] Skilled Nursing & Rehabilitation Center -
[**Hospital1 1559**]
Discharge Diagnosis:
PRIMARY:
esophageal varix s/p banding
cirrhosis
hepatic encephalopathy
.
SECONDARY:
h/o CVA
diabetes
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms [**Known lastname 1794**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were transferred to this hospital from [**First Name8 (NamePattern2) **]
[**Hospital3 6783**] hospital with gastrointestinal bleeding. An endoscopy
showed a varicose vein in your esophagus, which is the likely
cause of this bleeding. This was banded, a procedure which
should reduce the change of future bleeding. After the
procedure you had no further signs of bleeding.
During your stay you became more tired and confused than normal.
Your home lactulose was increased, as this was thought to be
due to your liver disease. With this medication change you
returned to your normal mental status.
We made the following changes to your home medications:
- START pantoprazole daily
- START Cefpodoxime 100 mg every 12 hours for 5 days for UTI
Also, it is important than you use no more than 2 grams of
acetaminophen per day. Note that each Vicodin tablet has 500mg,
so you may use no more than 4 of these per day even if you use
no other Tylenol.
Please see your outpatient hepatologist (liver doctor) in [**1-5**]
weeks for follow up.
Please follow-up with your primary care physician and
gastroenterologist as listed below.
Followup Instructions:
Please follow up with your GI physician and the physicians at
the nursing home. Please see your GI doctor within the next 2
weeks.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
Completed by:[**2195-4-29**]
|
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icd9cm
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20,864
| 186,872
|
5284+5285+55658
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2107-11-25**] Discharge Date:
Service:
CONTINUATION:
HOSPITAL COURSE: The patient was taken to the Operating Room
on hospital day five. There, she had an exploratory
laparotomy, fistula takedown, small bowel resection with
ileocolic anastomosis, and lysis of adhesions.
Postoperatively, the patient was transferred to the Surgical
Intensive Care Unit in stable condition. She stayed in the
Surgical Intensive Care Unit for one day and then was
transferred to the surgical floor in stable condition.
During the postoperative hospital stay, the patient's diet
was advanced to a regular diet. Her bowel function returned
to [**Location 213**]. The patient was being seen by a urology consult
for her past urological procedures. The patient's tube feeds
were started.
Postoperative complications included sun-downing with
narcotics. Therefore, narcotics were discontinued. The
presence of an overnight sitter has helped the patient to be
alert and oriented. The patient's pain was successfully
managed originally with a patient controlled analgesia pump
and subsequently with oral pain medications. The patient was
also postoperatively maintained on ceftriaxone and Diflucan.
DISCHARGE MEDICATIONS:
Vancomycin 500 mg i.v.q.24h. times three days.
Diflucan 200 mg p.o.q.d. times ten days.
Ceftriaxone 1 gm i.v.q.24h. times seven days.
Elavil 100 mg p.o.q.d.
Regular insulin sliding scale.
Heparin 5,000 units s.c.b.i.d.
Synthroid 100 mcg p.o.q.d.
Protonix 40 mg p.o.q.d.
Lopressor 50 mg p.o.b.i.d.
Tylenol 650 mg p.o.p.r.n.
DISPOSITION: The patient is being discharged to the [**Hospital **]
Rehabilitation Center with a follow-up by Dr. [**Last Name (STitle) **] in two
weeks and Dr. [**Last Name (STitle) 365**] of urology in one month. The patient is
being discharged to a rehabilitation in stable condition.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2107-12-6**] 18:21
T: [**2107-12-6**] 19:22
JOB#: [**Job Number **]
Admission Date: [**2107-11-25**] Discharge Date: [**2107-12-7**]
Service: SURGERY
HISTORY OF PRESENT ILLNESS: The patient is an 81 year old
pleasant female with a history of parasternal hernia and
enterocutaneous fistula for which she has been maintained on
TPN via a right subclavian line for the past eight weeks.
The patient now presents from rehabilitation because of line
sepsis and inability to place new central catheter. The
patient has had multiple attempts to heal parasternal hernia
and fistula (last attempt was on [**2107-10-4**], with a rectus
muscle flap. Dr. [**Last Name (STitle) 21555**] was planning to operate on the
patient during this admission.
While in rehabilitation, the patient's temperature was 101.9
for two days and blood cultures were positive for gram
positive cocci and yeast. The urine culture while the
patient was in rehabilitation was positive for VRE.
PAST MEDICAL HISTORY: Bilateral ureteral implants.
Parasternal hernia repair on [**2107-10-4**], as well as left
nephrostomy tube in [**2107-7-24**]. Stenosis of the ureter,
parasternal hernia. Transient silk bladder and cystectomy
with an ileal loop diversion, pancreatic adenoma resected,
status post Whipple, hypothyroidism, short syndrome, and
depression. The patient also had a rectal muscle flap for
attempt to repair parasternal hernia in [**9-24**]. Chronic
diarrhea.
MEDICATIONS ON ADMISSION:
1. Elavil.
2. Somatostatin.
3. Synthroid.
4. Vancomycin.
5. Levaquin.
6. Diflucan.
7. Colace.
8. P.r.n. medications of Dilaudid, Ativan.
PHYSICAL EXAMINATION: On admission, physical examination
revealed an 81 year old female in mild distress. Temperature
was 99.8, pulse 86, blood pressure 83/50, respiratory rate
20, 96% in room air. She was alert and oriented times
three, pleasant, appeared comfortable. The pupils are equal,
round, and reactive to light and accommodation. Sclera
anicteric. The lungs are clear to auscultation bilaterally.
The patient had regular rate and rhythm, no murmurs, rubs or
gallops. The abdomen was soft, nontender, nondistended,
guaiac negative, no masses palpable, enterocutaneous fistula
site, clean, nonerythema and nonfluctuant. The ureteral site
was pink and clean. Extremities were within normal limits.
There was no cyanosis, clubbing or edema.
LABORATORY DATA: On admission, white blood count was 6.9,
hematocrit 27.9, platelets 192,000. Urinalysis on admission
showed between 21 and 50 white blood cells, moderate amount
of bacteria but no nitrites, no ketone, no glucose. Sodium
on admission was 135, potassium 5.0, chloride 98, bicarbonate
28, blood urea nitrogen 33, creatinine 1.6, glucose 124,
anion gap 15. ALT was 45, AST 44, CPK 32, alkaline
phosphatase 189, total bilirubin 0.8, calcium 8.7, phosphate
4.4, magnesium 1.8.
Electrocardiogram showed normal sinus rhythm and borderline
left axis deviation. Q-T prolongation, no acute ST-T wave
changes as compared to the electrocardiogram from [**2107-10-17**].
Her chest x-ray was negative. Namely, there was no
infiltrate or effusion or congestive heart failure. No acute
changes since the previous study.
HOSPITAL COURSE: The patient was admitted to Dr. [**Last Name (STitle) **].
Peripheral intravenous placed and the patient was continued
on Vancomycin, Levofloxacin, Diflucan. Additionally,
Linezolid was added for the treatment of VRE. Follow-up
blood cultures were taken and were negative. The patient was
also transfused one unit of blood. TPN was continued during
hospital stay.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Name8 (MD) 7892**]
MEDQUIST36
D: [**2107-12-6**] 18:12
T: [**2107-12-6**] 19:15
JOB#: [**Job Number 21556**]
Name: [**Known lastname 3590**], [**Known firstname 3591**] Unit No: [**Numeric Identifier 3592**]
Admission Date: [**2107-11-25**] Discharge Date:
Date of Birth: [**2026-1-11**] Sex: F
Service:
PREVIOUS DISCHARGE SUMMARY IS DATED [**2107-11-25**] AND [**2107-12-7**]
FOR DETAILS OF HER PREOPERATIVE COURSE.
HISTORY: Briefly, Ms. [**Known lastname **] was taken to the operating
room on [**2107-11-29**] for takedown of her distal
ileoenterocutaneous fistula. She was noted to have multiple
adhesions. She underwent an exploration with lysis of
adhesions, fistula takedown, and ileocolic resection, as well
as a jejunostomy feeding-tube placement.
Postoperatively, she was admitted to the Surgical Intensive
Care Unit, where she remained intubated overnight. But, she
was weaned and extubated on postoperative day #1. She
remained in the Intensive Care Unit for postoperative day #1,
without any complications. She was transferred to the floor
late in the day on postoperative day #1.
By system, her postoperative course consisted of the
following:
#1. NEUROLOGICAL: The patient was found to have mental
status changes with narcotic medications and so these were
discontinued.
#2. CARDIOVASCULAR: Ms. [**Known lastname **] was continued on
perioperative Lopressor, which was initially intravenous and
then changed to p.o. She had no adverse cardiac events
during the hospitalization.
#3. RESPIRATORY: Similarly, after her extubated,
Ms. [**Known lastname **] remained stable from the respiratory status.
She used the incentive spirometer and had early ambulation.
She never had respiratory complaints.
#4. GASTROINTESTINAL: Initially, Ms. [**Known lastname **] was started
on sips on postoperative day #3. She was started on tube
feeds. She initially had nausea with tube feeds. These were
held and then restarted. She tolerated tube feeds well. She
had return of bowel function with flatus and bowel movements
early in her postoperative course, but then had intermittent
nausea and poor appetite. Given her poor nutritional status,
decision was made to resume TPN, in addition to tube feeds,
to help replete the nutritional status. The TPN was
subsequently discontinued when she was at goal tube feeds and
she was encouraged to take p.o. intake. She intermittently,
however, had nausea. She never had adequate p.o. intake.
She had two episodes during her postoperative course, where
her ileal loop became distended and it was not being
adequately drained by her Foley catheter placed through it.
These episodes culminated in presumed compression of her
gastrojejunostomy resulting in nausea and bilious emesis.
Nasogastric tube was placed with minimal drainage of bilious
fluid. However, once the ileal loop was adequately
catheterized, it drained approximately 1900 cc on the first
episode and approximately 1 liter on the second episode.
Drainage completely resolved her symptoms of nausea, left
upper quadrant and back pain.
She is being discharged on tube feeds 60 cc per hour, Impact
with fiber from 6 p.m. to 6 a.m. and p.o. intake ad lib. with
nutritional supplements t.i.d. and as snacks.
#5. GENITOURINARY: As noted above, Ms. [**Known lastname **] had
difficulty with drainage of her pouch. It was thought that
the difficulty was due to mucous plugging of the catheter
placed through her pouch. We continued with t.i.d. flushings
of her Foley catheter in an effort to prevent obstruction.
Attempt was made to remove the catheter and allow the patient
to straight catheterize every four hours as she had done
previous to admission. However, she was found to be too
debilitated to adequately manage this, so decision was made
to leave the catheter in place.
#6. INFECTIOUS DISEASE: Ms. [**Known lastname **] was admitted with
MRSA and yeast-line sepsis. She completed a 14-day course of
Vancomycin, 21-day course of Diflucan, and 14-day course of
Ceftriaxone for E. coli bacteremia subsequent to an episode
of urosepsis previously described.
At the time of discharge the patient has been afebrile for
approximately a week and on no antibiotics. She had history
of VRE positivity in her urine from previous admissions.
#7. HEMATOLOGY: Ms. [**Known lastname **] was maintained on
subcutaneous heparin throughout the hospital stay in an
effort to prevent deep venous thrombosis. The last
hematocrit was 28.7 on [**2107-12-16**]. However, she has been
hemodynamically stable and has not been transfused.
#8. ENDOCRINE: Ms. [**Known lastname **] was maintained on fingersticks
q.i.d. while she was on TPN and never had episodes of
hyperglycemia.
DISPOSITION: Ms. [**Known lastname **] should be discharged to [**Hospital **]
Rehabilitation Facility, returning to the facility that is
close to her home, where she will have more family support.
The Department of Physical Therapy followed Ms. [**Known lastname **]
throughout the hospital stay and are including
recommendations for her rehabilitation period.
On the day of discharge, Ms. [**Known lastname 3593**] physical examination
was benign. Lungs were clear bilaterally. Heart was
regular, without murmurs. Abdomen was soft, nontender, and
nondistended with a well-healing incision. Staples have been
removed on postoperative day #15. Steri Strips were placed
over the incision. She had the jejunostomy tube in the left
lower quadrant. This site is without erythema or discharge.
She has a urostomy with a 14-French Foley catheter placed
through it in the right lower quadrant. She has no edema and
palpable distal pulses.
DISCHARGE MEDICATIONS:
1. Nystatin 5 cc q.6h. swish and swallow.
2. Anusol Hydrocortisone suppositories, one per rectum
b.i.d. as needed.
3. Elavil 100 mg p.o.q.h.s.
4. Heparin 5000 units subcutaneously b.i.d.
5. Synthroid 100 mcg p.o.q.d.
6. Zantac 150 mg p.o.b.i.d.
7. Lopressor 25 mg p.o.b.i.d., hold for heart rate less than
55, systolic pressure of less than 100.
8. Creon 2 tabs p.o.q.i.d. with meals and snacks.
9. Impact with fiber tube feeds 60 cc per hour from 6 p.m.
to 6 a.m.
DISCHARGE INSTRUCTIONS: Ms. [**Known lastname 3593**] Foley catheter
should be flushed with 20 cc normal saline every 8 hours to
avoid mucous plugging.
DIET: Diet is regular as tolerated with nutritional
supplement, such as Boost t.i.d. with meals and as snacks.
Please encourage the patient's p.o. intake. Calorie counts
are recommended to quantitate her p.o. intake and facilitate
transitioning from tube feeds to strictly p.o. intake.
FOLLOW-UP CARE: Ms. [**Known lastname **] should followup with
Dr. [**Last Name (STitle) **] in approximately two weeks time. Office #:
[**Telephone/Fax (1) 3594**]. The patient should followup with Dr. [**Last Name (STitle) 2698**],
Department of Urology, in approximately two weeks' time.
[**First Name11 (Name Pattern1) 389**] [**Last Name (NamePattern1) 3595**], M.D. [**MD Number(1) 3596**]
DICTATED BY:[**Last Name (NamePattern1) 3597**]
MEDQUIST36
D: [**2107-12-21**] 13:19
T: [**2107-12-21**] 13:22
JOB#: [**Job Number 3598**]
|
[
"311",
"244.9",
"292.81",
"038.11",
"569.81",
"569.69",
"V10.51",
"996.62"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.74",
"54.59",
"99.15",
"45.62",
"45.93",
"38.93",
"46.39",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11513, 11988
|
3522, 3668
|
5271, 11490
|
12013, 13005
|
3691, 5254
|
2231, 3016
|
3039, 3496
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,615
| 161,089
|
51715
|
Discharge summary
|
report
|
Admission Date: [**2136-12-10**] Discharge Date: [**2136-12-17**]
Date of Birth: [**2052-10-4**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Raloxifene / Morphine / Fosamax / Donepezil Hcl /
Ace Inhibitors
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
lightheadedness, fatigue
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
History of Present Illness:
Ms. [**Known lastname 22951**] is an 84 year old woman with a hx of CAD, HTN,
arthritis who presents with symptomatic bradycardia. The patient
awoke this morning feeling at 4am feeling unwell with nausea,
dizziness and lightheadedness. She denies chest pain,
palpitations, shortness of braeth, chest pressure/tightness. She
called EMS.
.
Per EMS, BP was 60/p with HR of 38 on arrival. She was given
Atropine 0.5mg IV X 2 with improvement of HR to the 40s and BP
to 80s-100s systolic.
.
In the ED, initial vitals were HR50 BP100/60 RR18 100% on RA.
She was given 1mg Atropine x 1 in the ED. ECG showed junctional
rhythm with retrograde p waves. External pacing was done for 1
minute as BP was low (90s) and rhythm spontaneously converted to
sinus. The patient was also given Glucagon 1mg and Calcium
Gluconate. She was given Fentanyl 25mcg while being externally
paced. On rectal exam she was noted to have dark guaiac positive
stool. She was given 40mg IV protonix and GI was consulted. She
was typed and crossed for 2 units.
.
On arrival to the floor, she denies any symptoms of dizziness,
lightheadedness, chest pain, palpitations, abdominal pain. She
had an episode of diarrhea a few days ago. She occasionally has
red/brown stools, the last time was a few weeks ago and she
denies any currently. She does not know why she is on Cipro or
Cephalexin. She is somewhat confused due to Fentanyl given to
her in the ED. She states that she may occasionally make
mistakes regarding her medications. She does not use a pill box.
Per her son, she has been more foregetful lately. The patient
lives alone.
.
Per conversations with her PCP, [**Name10 (NameIs) **] has a history of
gastritis/colitis and was due to have a colonoscopy [**10-31**] which
she did not show for.
.
On review of systems, she denies recent fevers, chills or
rigors. Cardiac review of systems as per HPI. Positive for rash
on the legs and arms which was puritic in nature. All of the
other review of systems were negative.
.
Past Medical History:
TIAs
- [**2131**] TIA
- [**8-1**] TIA after being off plavix for 4 days; MRA head/neck
showed short segment of R PCA stenosis
CAD
- q waves seen on past ECGs
- echo [**2131**] HK in inferolateral wall
- echo [**2135**] AK in basal posterior wall; worsening HK in
inferolateral wall; EF 65%
- [**2136-10-23**] - stress test ischemic ST changes in inferior and
lateral walls
Hyperlipidemia
HTN
total knee replacement
depression
arthritis
iron deficiency anemia; baseline HCT 34 for past 7 months
gastritis s/p gastric ulcers on EGD
? ischemic colitis; was due for colonoscopy [**10-31**] but pt [**Name (NI) 107125**]
Social History:
She is married; her husband lives in a nursing home and the
patient lives alone. She has 1 son who lives in [**Location **] and she
has 1 daughter. She does not smoke cigarettes and drinks a glass
of wine every so often.
Family History:
Mother died of congestive heart failure. Father had bladder
cancer. There is no family history of colon cancer.
Physical Exam:
VS: T=97.4 BP 124/43 HR 60 RR 23 99% on 2L NC
GENERAL: Elderly woman, NAD. Oriented X 1 (knew hospital but not
name, thought date was [**2137-2-6**]).
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 5 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
CXR [**2136-12-10**]:
1. Large hiatal hernia.
2. No acute cardiopulmonary abnormality.
ADMISSION LABS
[**2136-12-10**] 03:00PM BLOOD WBC-8.2# RBC-4.36 Hgb-9.5* Hct-32.9*
MCV-75* MCH-21.7* MCHC-28.8* RDW-17.4* Plt Ct-290
[**2136-12-11**] 02:30AM BLOOD WBC-6.7 RBC-3.38* Hgb-7.5* Hct-25.4*
MCV-75* MCH-22.1* MCHC-29.5* RDW-17.0* Plt Ct-215
[**2136-12-10**] 03:00PM BLOOD PT-11.7 PTT-22.5 INR(PT)-1.0
[**2136-12-11**] 02:30AM BLOOD Glucose-81 UreaN-19 Creat-0.6 Na-142
K-4.0 Cl-111* HCO3-26 AnGap-9
[**2136-12-10**] 03:00PM BLOOD CK(CPK)-144
[**2136-12-10**] 09:02PM BLOOD CK(CPK)-97
[**2136-12-11**] 02:15AM BLOOD CK(CPK)-99
[**2136-12-11**] 02:30AM BLOOD CK(CPK)-89
[**2136-12-10**] 03:00PM BLOOD cTropnT-<0.01
[**2136-12-10**] 09:02PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2136-12-11**] 02:15AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2136-12-11**] 02:30AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2136-12-10**] 03:00PM BLOOD Calcium-9.1 Phos-4.4 Mg-2.4
[**2136-12-10**] 03:00PM BLOOD TSH-3.9
EGD [**12-13**]
Large hiatal hernia
Erythema in the antrum
Multiple erosions in the duodenal bulb compatible with
duodenitis
Normal mucosa in the second part of the duodenum (biopsy)
Otherwise normal EGD to third part of the duodenum
Colonscopy [**12-13**]
Diverticulosis of the throughout the colon
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
Ms. [**Known lastname 22951**] is an 84 year old woman with a hx of TIAs, CAD, HTN,
iron-deficiency anemia who presents with symptomatic
bradycardia.
.
#. BRADYCARDIA: Patient was found to be in a junctional rhythm
on arrival to ED. Her bradycardia was thought to be secondary to
improper dosing of her beta-blocker and Verapamil in the setting
of acute renal failure (hypovolemia, GI bleed). These
medications were held with resulting improvement in her heart
rate, though there may be a component of sinus node dysfuction.
ECG did not show ST segment changes and cardiac enzymes were
negative ruling out an ischemic cause of her symptoms. While in
the CCU, she did not require Atropine or Dopamine. The patients
symptoms resolved and she remained in sinus rhythm at a normal
rate. She was transfered to the floor and started on a low dose
of metoproplol tartate.
.
#. GI BLEED: Patient was guaiac positive on exam and iron
studies c/w severe iron deficiency. She required 2u pRBC's in
the CCU for a Hct of 25.4 in the context of lower blood
pressures. She was continued on Protonix 40mg IV BID and
remained NPO. GI recommended NG lavage, but very worried about
vagal stimulation. The patient received EGD/Colonoscopy that
showed duodenitis and diverticulosis. She will need to be
maintained on protonix [**Hospital1 **] outpatient.
.
# Acute Renal Insufficiency: Patient with Cr of 1.0 on
admission, clinical exam supported poor intravascular status
(poor PO and GI bleed). She was given IVF's with improvement in
her clinical appearance and a repeat Cr of 0.6.
.
#. CORONARY ARTERY DISEASE: Unclear history. Per PCP, [**Name10 (NameIs) **]
has q waves on ECG but no prior caths or stents. She has been on
Plavix as an outpatient for h/o TIAs, but has not been on
Aspirin. In the context of bradycardia, her beta-blocker was
initially held. She was restarted on metoprolol prior to
discharge.
.
#. History of multiple TIAs: Patient to continue on plavix.
.
# ?Dementia: Patient with waxing & [**Doctor Last Name 688**] agitation/confusion
during CCU stay. Patient lives alone and reports being able to
manage her medications and ADL's independently. She has fired
VNA on multiple occasions in the past per PCP. [**Name10 (NameIs) **] saw patient
and recommended rehab that patient refused. OT reccommended 24
hour supervision but recognized that if the patient refuses that
there is a middle ground. Her mental status waxed and waned,
however by HD#3, she was mentating very well. In the ED, she had
received large doses of atropine and fentanyl which could
precipitate delirium. There was a family meeting involving the
patient's daughter and social work for placement for rehab.
.
#. Rash: Patient reportedly placed on PO Prednisone by
Dermatologist for rash after failing topical therapy, but
etiology of rash is unclear and plan for taper unknown. Admitted
on 10mg PO Prednisone, but this was held in the setting of
possible GI bleed. She was started on sarna lotion with good
effect.
.
Medications on Admission:
Benicar 20 mg Tab Oral
Ciprofloxacin 250 mg Tab Oral, [**Hospital1 **] - PCP and patient do not know
indication, pt states she has been taking for years
Prednisone 10 mg Tab Oral - pt states she has been taking for 2
weeks for rash
Cephalexin 500 mg Cap Oral, 1 Capsule(s) Three times daily - pt
does not know indication
Atenolol 12.5 mg Tab Oral
Paroxetine 20 mg Tab Oral
Plavix 75 mg Tab Oral
Pravastatin 40 mg Tab Oral
Verapamil SR 180 mg Tab Oral
Zantac 150mg PO BID
Flonase PRN
Glaucoma eye drop
Discharge Medications:
1. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
2. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1)
Nasal twice a day as needed for allergy symptoms.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours):
please discuss with primary care physician.
[**Name Initial (NameIs) **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Name Initial (NameIs) **]:*60 Capsule(s)* Refills:*0*
9. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for itching.
11. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
12. Benicar 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1687**] - [**Location (un) 745**]
Discharge Diagnosis:
Primary Diagnosis:
1. Symptomatic bradycardia
2. Duodenitis
Secondary Diagnosis:
1. Hypertension
2. Hyperlipidemia
3. Iron deficiency anemia
4. Coronary artery disease
5. History of TIA
6. Depression
Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted for a slow heart rate. You were given
medications to help speed up your heart and had to be externally
paced. It is likely that this happened because you took to many
of your high blood pressure medications at once. Be careful to
take you medications as directed in the future. You were also
found to have some blood in your stool. You had a endoscopy and
colonoscopy to evaluate the site of bleeding. It was found that
you had some irritation of your duodenum. A biopsy was taken but
the results are pending. This will need to be followed by your
primary care physician. [**Name10 (NameIs) **] are being discharged to a rehab
facility.
The following changes were made in your medications:
1. Stop Atenolol
2. Stop Verapamil
3. Stop ciprofloxacin
4. Stop cephalexin
5. START Metoprolol Succinate 25mg by mouth daily
6. START Pantoprazole 40mg by mouth twice a day
7. STOP Zantac 150mg by mouth twice a day
8. START sarna lotion apply as needed for your itch
Followup Instructions:
MD: Dr. [**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) **]
Specialty: PCP
[**Name Initial (PRE) 2897**]/ Time: Wednesday, [**1-2**] at 11:15am
Location: [**Hospital1 93015**], ROUTE 9, [**University/College **],[**Numeric Identifier 3471**]
Phone number: [**Telephone/Fax (1) 18377**]
MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1940**]
Specialty: Gastroenterology
Date/ Time: Thursday, [**1-3**] at 9:15am
Location: [**Last Name (NamePattern1) 439**], [**Hospital Ward Name **] Bldg [**Location (un) 858**], [**Location (un) 86**] MA
Phone number: [**Telephone/Fax (1) 463**]
|
[
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"348.30",
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"578.9",
"782.1",
"V12.54",
"535.60",
"V43.65",
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] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
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] |
icd9pcs
|
[
[
[]
]
] |
10596, 10674
|
5692, 8687
|
366, 383
|
10919, 10919
|
4342, 5669
|
12068, 12693
|
3299, 3412
|
9239, 10573
|
10695, 10695
|
8713, 9216
|
11066, 12045
|
3427, 4323
|
302, 328
|
411, 2405
|
10777, 10898
|
10714, 10756
|
10933, 11042
|
2427, 3045
|
3061, 3283
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,768
| 124,918
|
14116+56505
|
Discharge summary
|
report+addendum
|
Admission Date: [**2118-7-16**] Discharge Date: [**2118-7-24**]
Date of Birth: [**2064-1-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Diagnostic catheterization
History of Present Illness:
54M CAD s/p MI '[**06**], PTCA pLAD '[**08**], PCI LCX and RCA ~'[**15**] @ OSH,
here w/ unstable angina. Had no CP for last two years since
intervention until two weeks ago, developed intermittent 5 min
episodes of CP relieved by rest or SLNTG. CP was both with rest
and exertion - occasionally while sleeping. On [**2118-7-13**],
underwent stress test w/ nuclear which revealed lateral
ischemia, EF36%, then admitted to OSH on [**2118-7-15**] for elective
diagnostic cath.
Cath per handwritten report:
RCA PDA 90%
pLCX 90%, LPLB80%
mLAD 50-60% D1 Stent D2 Stent
CO/CI 5.37/2.7, WP11
At baseline, does have heart failure symptoms - DOE w/ one
flight of stairs, but can walk a block without difficulty.
Occasional PND, baseline LE edema, but denies orthopnea. Occ
palpitations, denies syncope, presyncope, denies claudication.
Denies f/c/ does not know dry weight. Denies cough, wheeze, abd
pain, n/v/d/hematochezia or melena. Denies rashes. Does
occasionally get muscle pain with statin (?). Also states that
his girlfriend notes heavy snoring and occasional apnea at
night.
Past Medical History:
CAD as above
DM II - previously on oral meds, now insulin
Obesity
Social History:
Retired - used to work for Lucent.
Denies tobacco use, drinks 1 beer/day occasionally binge to [**5-1**].
Grew up in NH.
Family History:
Grandmother died of MI age 54
Physical Exam:
VS 98.9 122/82 87 96%RA 87kg
GENERAL: NAD, Hispanic male
HEENT: EOMI, OMMM,
NECK: JVP 7cm, no carotid bruits
CARDIOVASCULAR: S1, S2, reg, no MRG.
LUNGS: CTAB
ABDOMEN: Obese, active bowel sounds, soft, NT, ND, no bruits.
EXTREMITIES: Warm, fem pulse 2+ bilat, no bruits. DP and PT 2+
bilat.
NEURO: A/OX3, CNII-XII intact, strength and sensation intact.
Pertinent Results:
[**2118-7-16**] 02:00PM GLUCOSE-313* UREA N-13 CREAT-1.3* SODIUM-135
POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-25 ANION GAP-16
[**2118-7-16**] 02:00PM ALT(SGPT)-55* AST(SGOT)-63* LD(LDH)-252*
CK(CPK)-237* ALK PHOS-97 TOT BILI-0.7
[**2118-7-16**] 02:00PM CK-MB-3 cTropnT-<0.01
[**2118-7-16**] 02:00PM ALBUMIN-4.1 CALCIUM-9.7 PHOSPHATE-3.0
MAGNESIUM-2.1
[**2118-7-16**] 02:00PM WBC-8.0 RBC-UNABLE TO HGB-15.3 HCT-46
MCV-UNABLE TO MCH-UNABLE TO MCHC-36.4* RDW-UNABLE TO
[**2118-7-16**] 02:00PM NEUTS-72.0* BANDS-0 LYMPHS-21.5 MONOS-3.6
EOS-1.5 BASOS-1.4
[**2118-7-16**] 02:00PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2118-7-16**] 02:00PM PLT SMR-NORMAL PLT COUNT-233
[**2118-7-16**] 02:00PM PT-12.0 PTT-23.0 INR(PT)-1.0
Echo: EF45%-50%, focal hypokinesis of the inferior septum and
inferior walls.
Brief Hospital Course:
54M DMII, obesity, early CAD, here w/ unstable angina.
* Unstable Angina: Pt was initially ruled out for overt
myocardial infarction at OSH and repeat enzymes here were
negative also. Pt was continued on aggressive CAD regimen and
prepared for interventional cath on day 3 of hospitalization.
Pt was easily weaned off nitroglycerin without further angina.
* DMII: Pt was continued on half dose standing humalog and
reduced dose lantus in anticipation of hypoglycemia as a result
of restricted and controlled hospital diet.
*On [**7-20**] Mr. [**Known lastname 1005**] was taken to the OR for a CABG x 4. For
details of the operation please see Dr.[**Name (NI) 5572**] operative
report. Postoperatively he did very well. He was extubated on
POD 0 and weaned of nitroprusside by POD 1. He was transferred
out of the ICU on POD 1. He was tolerating a regular diet and po
pain medication. By POD 4 he was ambulating with physical
therapy and he was discharged home with instructions to
follow-up with Dr. [**Last Name (STitle) **], his PCP, [**Name10 (NameIs) **] his cardiologist.
Medications on Admission:
Lantus 30
Humalog 40AM 40PM
Amlodipine 10
Protonix 40
ASA 325
Toprol XL 200
Lasix 40
Plavix 75
Lipitor 40
Oxaprazin PRN, Diclofenac PRN
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2
hours) as needed.
Disp:*75 Tablet(s)* Refills:*0*
8. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
9. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Medication
Lantus 30 units daily
12. Medication
Humalog 40 units [**Hospital1 **]
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
CAD
DM
Discharge Condition:
Good
Discharge Instructions:
Call your doctor or go to the ER if you experience any of the
following: severe pain, increasing nausea/emesis, shortness of
breath, pus from your wound, or any other concerning symptoms.
Do not drive while taking narcotics.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 29068**] Follow-up appointment
should be in 2 weeks
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 37284**] Follow-up
appointment should be in 2 weeks
Name: [**Known lastname **],[**Known firstname **] V Unit No: [**Numeric Identifier 7590**]
Admission Date: [**2118-7-16**] Discharge Date: [**2118-7-24**]
Date of Birth: [**2064-1-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 741**]
Addendum:
Addendum [**7-25**]:
The following medication changes were made with Mr. [**Known lastname 83**] on
[**7-25**]:
Added: KCl 20 mEq po QD
Sliding scale insulin as per printout given to pt. at
discharge ( lantus and humalog dosing)
Deleted: plavix 75 mg po QD
Discharge Disposition:
Home With Service
Facility:
[**Company 720**]
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2118-7-25**]
|
[
"250.00",
"411.1",
"428.20",
"412",
"V64.1",
"V58.67",
"428.0",
"530.81",
"414.01",
"V45.82",
"278.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"34.04",
"39.64",
"89.64",
"38.91",
"39.61",
"99.05",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
6859, 7030
|
3033, 4118
|
332, 360
|
5438, 5445
|
2134, 3010
|
5718, 6836
|
1715, 1746
|
4305, 5315
|
5408, 5417
|
4144, 4282
|
5469, 5695
|
1761, 2115
|
282, 294
|
388, 1469
|
1491, 1559
|
1575, 1699
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,664
| 131,316
|
44066+58667
|
Discharge summary
|
report+addendum
|
Admission Date: [**2135-5-3**] Discharge Date: [**2135-5-20**]
Date of Birth: [**2064-6-2**] Sex: F
Service: MEDICINE
HISTORY OF THE PRESENT ILLNESS: This is a 70-year-old
African-American female with chronic constipation going back
at least to [**2131**]. She has been disimpacted several times in
the past. She has a history of Parkinson disease and
hypertension. The past workup has included a barium enema,
colon in [**2131**]. Colonoscopy had been advised and repeatedly
deferred by the patient. The patient presents today with two
to three weeks of decreased output and three days of
increased abdominal distention. She had some intermittent
diarrhea, but no blood or mucus. Lactulose and Fleet enemas
were tried at home without success. In the emergency room,
KUB showed massive cecal bolus of stool. The patient was
pain, however, did describe nausea and bilious vomiting over
the past few days.
PAST MEDICAL HISTORY:
1. Parkinson disease followed by Dr. [**Last Name (STitle) 83566**] of the Department
of Neurology.
2. Hypertension.
3. Chronic constipation.
ALLERGIES: None.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg p.o.q.d.
2. Atenolol 25 mg p.o.q.d.
3. Dulcolax 10 mg p.o.b.i.d.
4. Elavil 25 mg p.o.q.h.s.
5. Hydrochlorothiazide 25 mg p.o.q.d.
6. Lactulose 30 cc q.i.d.
7. ....................25 mg p.o.q.d.
8. Sinemet 25/100, one tablet p.o.b.i.d.
SOCIAL HISTORY: The patient denies alcohol or tobacco use.
She lives in an apartment downstairs from her son.
PHYSICAL EXAMINATION: Examination revealed the following:
96.6, heart rate 77, blood pressure 157/80, respiratory rate
28. The patient is nontoxic-appearing. She is an elderly
and pleasant female in no acute distress. HEENT: Temporal
wasting. EOMI. PERRLA. Oropharynx moist. NECK: Supple
without lymphadenopathy. CHEST: Chest was clear anteriorly.
HEART: Regular rate and rhythm with normal S1 and S2.
ABDOMEN: Abdomen is massively distended and firm, but
nontender. She has minimal bowel sounds. RECTAL:
Examination is trace guaiac positive per emergency room.
There is soft stool in the vault.
LABORATORY DATA: Initial labs revealed the sodium of 136,
potassium 3.2, chloride 100, bicarbonate 24, BUN 42,
creatinine 1.1, glucose 142. White blood cell count 10.2,
hematocrit 40.8, platelet count 344,000 (differential 75%
polys, 9% bands, 7% lymphs, 0 eosinophils).
KUB: KUB revealed extensive stool in distended colon, no
free air and no pneumatosis.
HOSPITAL COURSE: This is a 70-year-old woman with
Parkinsonism, who was admitted with obstipation. The patient
was on the medical floor from admission until [**5-7**].
She underwent manual disimpaction several times and received
soapsuds enema but with only modest results. However, she
required transfer to the MICU due to hypotension and depressed
mental status and hypernatremia and hypokalemia. In the ICU, the
hypernatremia and hypokalemia were resolved with free water
boluses and aggressive electrolyte repletion. The mental status
cleared. On [**5-12**], the patient returned to the medical floor.
Repeat KUBs showed that he colon was still full of stool.
The patient required frequent manual rectal stimulation and
frequent enemas (tap water alternating with milk and
molasses), which ultimately decompressed her colon. The
major effective treatment was manual rectal stimulation
which would result in large volumes of liquied stool.
Repeat CT scan of her colon on [**5-15**], showed no obstruction of
the bowel and empty colon, which was felt by the Department of
Radiology to be thick and concerning for Clostridium
difficile. The patient had been treated with broad spectrum
antibiotics in the Medical Intensive Care Unit as she had an
elevated white count and fever concomitant with her
hypotension and there was concern for sepsis. The
antibiotics were discontinued on [**5-16**], after 14 days of
Levofloxacin and Flagyl. Repeat assay for Clostridium
difficile were negative. The patient's bowel motility
improved slowly. She had been maintained on TPN in the MICU
and she was slowly able to advance her diet without
difficulty. She was evaluated by the Speech and Swallow
Departments, who felt that she had no pathology with swallow.
At the time of this dictation, the patient is tolerating a
full liquid diet without difficulty. The Gastrointestinal
Service followed the patient closely and recommended
Erythromycin as a promotility [**Doctor Last Name 360**] as Reglan was
contraindicated in the patient with Parkinsonism. The
patient also was placed on b.i.d. Colace and MiraLax q.d.
Finally, the Movement Disorder Service was consulted on this
patient with Parkinsonism. The Medical Service increased the
dosing of her Sinemet from one tablet b.i.d. to one tablet
q.i.d. with only mild improvement. At the time of this
dictation, Movement Disorder Services consultation is still
pending.
CONDITION ON DISCHARGE: The patient is discharged to an
acute rehabilitation facility in good condition. She will be
followed by Dr. [**Last Name (STitle) 83566**] for her Parkinsonism. She will be
maintained on her current bowel regimen, which should be
titrated to one formed stool q.d. Electrolytes should be
followed to prevent recurrent hyponatremia. She should
followup with her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 94595**] in one
to two weeks.
DISCHARGE DIAGNOSES:
1. Obstipation.
2. Parkinsonism.
3. Hypotension.
DISCHARGE MEDICATIONS: As noted, medications will be added
in an addendum to this discharge summary.
[**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**]
Dictated By:[**Last Name (NamePattern1) 11548**]
MEDQUIST36
D: [**2135-5-19**] 11:52
T: [**2135-5-19**] 12:05
JOB#: [**Job Number 94596**]
Name: [**Known lastname 571**], [**Known firstname 9854**] Unit No: [**Numeric Identifier 14915**]
Admission Date: [**2135-5-3**] Discharge Date: [**2135-5-20**]
Date of Birth: [**2064-6-2**] Sex: F
Service:
ADDENDUM:
This Addendum summarizes the patient's final hospital day:
1. Gastrointestinal: The patient is doing well on
Erythromycin 250 mg p.o. three times a day, Colace 100 mg
p.o. twice a day; Myralact one teaspoon p.o. q. day. She is
tolerating a full soft solid diet. She has daily bowel
movements. Should the constipation recur, cathartic
laxatives can be used on a p.r.n. basis. The patient will
also benefit from manual rectal stimulation.
2. Neurological: The patient was evaluated by the Movement
Disorder Service, who felt that it would be appropriate to
continue on Sinemet 25/100, one tablet p.o. four times a day.
They recommended crushing the tablets and dissolving them in
carbonated liquid for better absorption. They also
recommended Seroquel 12.5 mg p.o. q. h.s. as an adjunct.
She will follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5765**] of the Movement
Disorder Service. His office will call with an appointment
or can be reached at ([**Telephone/Fax (1) 14916**].
CONDITION AT DISCHARGE: The patient is discharged to
[**Hospital **] [**Hospital **] Hospital in good condition.
DISCHARGE INSTRUCTIONS:
1. She will follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5765**] at the [**Hospital1 1294**] Movement [**Hospital 6007**] Clinic as
scheduled.
2. She will also follow-up with her primary care provider,
[**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] or [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Nurse Practitioner, on
[**2135-5-24**], at 03:40 p.m. at the [**Hospital 112**] Clinic.
DISCHARGE DIAGNOSES:
1. Parkinson's Disease.
2. Obstipation.
3. Hypertension.
DISCHARGE MEDICATIONS:
1. Sinemet 25/100, one tablet p.o. four times a day, crushed
and dissolved in carbonated liquid.
2. Colace 100 mg p.o. twice a day.
3. Captopril 25 mg p.o. three times a day.
4. Lopressor 100 mg p.o. three times a day.
5. Erythromycin 250 mg p.o. three times a day.
6. Miralax one teaspoon p.o. q. day dissolved in liquid.
7. Heparin 5000 units subcutaneously twice a day until
ambulatory.
8. Lactulose 30 cc., p.o. three times a day, p.r.n.
constipation.
9. Soft/solid heart low sodium diet.
[**First Name11 (Name Pattern1) 520**] [**Last Name (NamePattern4) 521**], M.D. [**MD Number(1) 522**]
Dictated By:[**Last Name (NamePattern1) 4499**]
MEDQUIST36
D: [**2135-5-20**] 13:55
T: [**2135-5-20**] 16:36
JOB#: [**Job Number 14917**]
|
[
"564.09",
"276.0",
"276.8",
"401.9",
"276.5",
"332.0",
"560.39",
"707.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
7810, 7871
|
7894, 8674
|
1148, 1410
|
2515, 4924
|
7309, 7789
|
1545, 2497
|
7195, 7285
|
957, 1122
|
1427, 1522
|
4949, 5424
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,207
| 120,556
|
47644
|
Discharge summary
|
report
|
Admission Date: [**2200-3-17**] Discharge Date: [**2200-3-25**]
Date of Birth: [**2153-3-3**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Amoxicillin
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
ICU to ICU transfer for CVA
Major Surgical or Invasive Procedure:
extubation
History of Present Illness:
The pt is a 47F yo ? HW with poorly controlled DM HTN, obesity
and cardiomyopathy (EF 20% on recent hospitalization at [**Hospital **]
Hospital, ? ishcemic), who initially presented to [**Hospital **]
Hospital with c/o of headache and
was found to have word-finding difficulty on [**3-13**]. At time of
evaluation, she was noted to have a hypodensity oh head CT
concerning for a
subacute right occipital stroke. Given this she was admitted
for
further stroke w/up, although it was understood that symptoms
did
not match the findings.
She subsequently developed RUE weakness and a repeat HCT showed
a
large, left hemisphere hypodensity concerning for an MCA
infarct.
She was started on heparin gtt at this time. MRI/A of the head
and neck was performed and revealed an acute L Temporoparietal
infarct, subacute right occipital infarct and an occlusion of L
ICA. After the MRI and neurology consultation, heparing gtt was
stopped given the size of the infarct in evolution. Because of
difficulties controlling BPs and evidence of dysrhythmia (? SVT,
wide complex tachycardia) she was transferred to ICU. On [**3-14**]
late evening patient was apparently restarted on heparin gtt for
hours on heparin gtt (duration unclear), pt decompensated:
became
aphasic with right sided hemiparesis. She was thus intubated
for
"airway protection"
Since intubation she has been "stable...she has remained sedated
and intubated, responds to verbal stimuli and moves her Left
side, with right side flaccid." TPN has been started [**3-16**] for
nutritional support.
Initial exam on [**3-12**] was notable for normal mental status
including
language, R hemianopsia, VII mild paresis and right spastic
hemiparesis. Pt. was unable to stand on her own, needed an
assisting device. PP decreased over R side of body. She was
started on Aggrenox per Neurology recommendation and was
recommended to have CTA to look for "residual lumen."
Work up so far included Telemetry (wide complext tachycardia),
TTE on [**3-14**] revealed EF 20-25% (severe global hypokinesis) with
dyskinetic septum, decreaed RVF and pressures in 30-40mmHg
range,
no source of embolus, mild MR [**First Name (Titles) **] [**Last Name (Titles) 1192**] TR w/ biatrial
enlargement. TEE was recommended and showed LVEF as above, but
no source of embolus. There was ? of sarcoidosis given
adenopathy.
EEG on [**3-14**] showed background slowing and lateralization of
slowing to LEFT hemisphere w/ focality and sharp wave
development, no seizure discharge.
Of note, she has been found to have a positive Lyme titer, thus
was treated with IV ABx (MD reporting was unsure of IgG vs
IgM?).
Also of Note, her blood pressures were fluctuating including max
of SBP of 190.
Past Medical History:
- Cardiomyopathy (EF 30%) per c/s at OSH [**2195**] stress w/ evid of
ant/inf infarcts, [**5-30**] ECHO w/ EF of 30% diffuse syst. dysf. but
also hx of CM in mother and grandmother.
- HTN
- HL
- DM (Type II per records)
- Obesity
- ? sleep distubance though negative Sleep study in [**2197**]
- Mediastinal adenopathy by CT scan
- Hx of restrictive pattern PFTs
- Onychocryptosis
Social History:
per OSH records. Single, but has 4 children (age 18-28), all
healthy. Was employed as a nursing assisstant, but is currently
unemployed.
Family History:
[ mother ] HTN
[ - ] HL
[ both parents ] DM
[ - ] CVA/TIA
[ - ] CAD/PVD
[ - ] Cancer
Physical Exam:
Vitals: T:99F P:60-80s R: 20 BP:145/77 SaO2:98% on PSV 50%
FiO2 w/ PSV/PEEP of [**5-28**]
General: Awake, obese cooperative, NAD, intubated off sedation.
HEENT: NC/AT, no scleral icterus noted, MMM, supple.
Pulmonary: rhonchi and rales b/l
Cardiac: RR, nl. S1S2, no M/R appreciated
Abdomen: obese, soft, NT/ND, no masses or organomegaly noted.
Extremities: warm, dry, trace pedal b/l edema
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status:
Alert, unable to respond to orientation questions. Follows
axial
commands but not appendicular commands reproducibly. Mimics.
oriented x 3. Unable to asess attention.
She is unable to utter any words.
Tracks examiner past midline, but is unable to clap (L hand does
not cross midline) suggestive of Right sided neglect. Did not
recognize her own limb.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF impaired to threat on the
right
VF. Spont. eye movements and room exploration is L predominant.
III, IV, VI: EOMI without nystagmus, normal saccades.
V: unable to assess
VII: R facial droop.
VIII: unable to assess.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, decreased tone in RUE.
Unable to assess for drift on R, no drift on L.
Delt Bic Tri WrE FFl FE IO
L 5 5 5 5 5 5 5
R 0 0 0 0 0 0 0
IP Quad Ham TA [**First Name9 (NamePattern2) **] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5
R 4- 5 4 5- 5 5 5
-Sensory:
Light touch - intact in LUE and LLE and RLE. Not in RUE. /not
tested
Cold sensation - intact RUE, Left side
Vibr/Proprioception - unable to assess.
Extinction to DSS on Right.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L tr tr 0 1 1
R 2 2 2 2 1
Plantar response:
RIGHT - extensor
LEFT - flexor
-Coordination: can not assess.
-Gait: unable to assess
Exam at time of discharge notable for:
Pertinent Results:
Labs on admission:
[**2200-3-17**] 10:56PM BLOOD WBC-8.4 RBC-4.86 Hgb-13.1 Hct-41.5 MCV-86
MCH-26.9* MCHC-31.4 RDW-17.9* Plt Ct-336
[**2200-3-17**] 10:56PM BLOOD PT-13.2 PTT-24.1 INR(PT)-1.1
[**2200-3-19**] 02:54AM BLOOD PT-14.4* PTT-59.0* INR(PT)-1.3*
[**2200-3-17**] 10:56PM BLOOD Glucose-132* UreaN-10 Creat-0.6 Na-140
K-3.7 Cl-101 HCO3-31 AnGap-12
[**2200-3-17**] 10:56PM BLOOD ALT-12 AST-24 LD(LDH)-372* AlkPhos-261*
TotBili-0.7
[**2200-3-18**] 04:58AM BLOOD ALT-13 AST-24 AlkPhos-264* TotBili-0.6
[**2200-3-18**] 07:59PM BLOOD CK-MB-1 cTropnT-<0.01
[**2200-3-19**] 02:54AM BLOOD CK-MB-1 cTropnT-<0.01
[**2200-3-19**] 09:14AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2200-3-17**] 10:56PM BLOOD Albumin-2.6* Calcium-8.5 Phos-4.1 Mg-1.9
[**2200-3-19**] 02:54AM BLOOD %HbA1c-9.8* eAG-235*
[**2200-3-19**] 02:54AM BLOOD Triglyc-102 HDL-47 CHOL/HD-3.3 LDLcalc-86
[**2200-3-18**] 04:58AM BLOOD Digoxin-0.5*
Imaging:
CXR: FINDINGS: The patient has been intubated. The tip of the
tube projects 3 to
4 cm above the carina. The tip of the newly inserted right PICC
line projects
over the low SVC. The course of the line is unremarkable. There
is no
evidence of complications, notably no pneumothorax. The course
of the
nasogastric tube is also unremarkable, the tip of the tube is
not visualized
on this film.
There is marked cardiomegaly with perihilar blunting and
dependent opacities.
In combination with a slightly distended azygos vein, the image
suggests
[**Month/Day/Year 1192**] pulmonary edema.
The presence of a small left-sided pleural effusion cannot be
excluded; on the
right, no pleural effusion is seen.
No focal parenchymal opacity suggesting pneumonia.
OSH imaging:
MRI OSH [**3-12**]:
Large wedge shape of restricted DWI in Left pareital lobe. DWI
of bright signal intensity in Right occipital lobe w/ ehnacement
after contrast administration. Few small foci on Flair in b/l
hemispheres.
MRA OSH: Left CCA patent, ICA occluded at origin. [**Country **] and RCCA
are patent. Patent Vertebrals. [**Doctor First Name 3098**] supplied by ACA/ACOM.
Carotid doppler [**Country **] [**3-14**] - no stenosis. [**Doctor First Name 3098**] not complete
obstruction, 99% stenosis range. Anterograde flow in
vertebrals.
CTA [**3-14**] - Limited study. Evolving Right occipital and high
Left
F/P infarct with a thin rim of faint hyperdensity relating to
occipital infarct keeping with a small amount of acute
hemorrhage.
CT HEAD [**2200-3-24**]: Preliminary report:
1. Tiny high density foci along the right PCA infarct may
represent tiny areas
of parenchymal bleeding, without mass effect.
2. No bleeding at left MCA infarct or elsewhere.
3. Evolution of previously noted infarcts without findings of
new infarct.
4. Stable opacification of scattered left mastoid air cells.
Brief Hospital Course:
Mrs. [**Known lastname 100659**] is a 47 woman with poorly controlled diabetes,
hypertension, obesity and cardiomyopathy (EF 20% on recent
hospitalization at [**Hospital **] Hospital) who initially presented to
[**Hospital **] Hospital with complaints of headache and was found to
have word-finding difficulty on [**3-13**] and incidental finding of a
R-occipital subacute "stroke," followed by a left temporal
parietal stroke on MRI, both likely of embolic origin
(proximal), though TEE was unrevealing. She was initially
treated with a heparin gtt, then changed to ASA/Plavix. She was
subsequently intabated for AMS and RUE plegia. EEG showed
spikes but no epileptiform activity in the L hemisphere in
addition to encephalopathy. MRA revealed L ICA occlusion with
99% stenosis range on Doppler US. There was also concern for a
hemorrhagic conversion in R occipital lobe lesion on CTA. She
was taken off heparin, placed on ASA/Plavix and transferred to
[**Hospital1 18**] for further care.
Neuro:
Exam on admission was notable for global aphasia, R neglect and
VF deficit w/ RUE plegia and RLE paresis consistent with above
described infarctions. She was admitted to NEURO ICU. She
likely suffered a cardioembolic infarction given both ant. and
post. distribution strokes in setting of severe CM and [**Doctor First Name 3098**]
occlusion, which was felt to be also due to embolic source.
There was initially a question of a hemorrhagic transformation
in Right occipital lobe, but this was later felt to be due to
contrast leak during CTA imaging in setting of impaired blood
brain barrier during stroke.
Given likely embolic stroke and > 99% occlusion she was started
on heparin gtt with PTT goal of 50-70 to prevent stump emboli.
She was started on coumadin. At the time of discharge, she was
transitioned on a lovenox bridge with an INR of 1.5.
On the night prior to transfer [**2200-3-24**], the patient attempted to
stand and fell forward. Neurological exam remained unchanged
from the exam noted below. CT Head was repeated with preliminary
read of tiny high density foci along the right PCA infarct that
may represent a tiny area of parenchymal bleeding without mass
effect. There was no bleeding at left MCA infarct or elsewhere.
There were no new areas of infart.
Neurologic exam at the time of discharge was notable for a
non-fluent aphasia. She was able to follow commands. There was
a slight right facial droop, right arm with a dense paresis
without any movement of the fingers. The right leg was [**4-28**]
proximally.
NUTRITION:
The patient was cleared by speech and swallow evaluation for a
Pureed (dysphagia) diet with nectar prethickened liquids. She
should continue to be assessed and avanced as she improves.
CARDIO:
The patient had severe cardiomyopathy as per HPI with
biventricular failure, etiology of which was unclear.
Cardiology consultation at OSH felt that likely cause was
ischemic given [**2197**] Stress showing "anterior and inferior
infarction." Patient was volume overloaded on admission and
require IV lasix diuresis. Her weight on arrival was 124.6kg.
LDL was 86, continued on Simvastatin of 80 started at the
[**Hospital **] hospital.
Cardiology consultation was obtained to assess the need for ICD
and cardiac regimen. She was noted to have runs of NSVT on
telemetry [**6-2**] bt in duration. It was felt that she was a
candidate for ICD placement however that medical management
needs to be optimized prior to placement (1mo post
hospitalization and final decision was deferred to patient's
cardiologist Dr. [**Last Name (STitle) 4455**]. Magnesium and potassium where kept
at >2 and >4 respectively. Initally, lisinopril was
discontinued, Diovan was restarted, and digoxin increased to
0.1875mg. Aspirin was recommended for CAD prevention, 81mg
daily. Carvediolol was increased for optimal blood pressure
control to 34.375mg [**Hospital1 **]. This can continue to be uptitrated as
her heart rate tolerates up to a maximum CHF dose of 50mg [**Hospital1 **].
She is scheduled for follow up with Dr. [**Last Name (STitle) 4455**] on [**4-2**].
PULM:
The patient was volume overloaded on admission (see above). She
has a history of a possible sleep distubance though negative
Sleep study in [**2197**], restrictive pattern PFTs and mediastinal
adenopathy by CT scan at [**Hospital **] hospital, though no definitive
diagnosis has been made. She is on home oxygen of 4 L/min. She
was extubated on hospital day 1 and treated with additional
lasix and albuterol as needed to maintain good oxygen
saturation. She was sating well (99%) on 3L at the time of
discharge, though she remained somewhat tachypneic (RR ~20 with
accessory muscle use).
ID:
The patient was afebrile. She underwent a Lyme Ab test at OSH
on initial presentation for unclear reasons which had returned
positive and was started there on ceftriaxone IV. This was
discontinued at [**Hospital1 18**] and W. Blot analysis returned negative.
ENDOCRINE:
The patient had poorly controlled glucose with a hemoglobin A1C
of 9.8. She was initially maintained on ISS and home regimen of
Insulin NPH. [**Last Name (un) **] center diabetes consultation was obtained
and her glargine and ISS scale was adjustments were made.
Glargine was at 28qAM at the time of discharge. Sliding scale
is as follows:
GLUCOSE HUMALOG
71-139 0
140-179 5
180-219 9
220-259 11
260-299 16
300-339 18
340-400 20
Medications on Admission:
Digoxin 125 mcg daily
Diovan 160mg daily
Coreg 6.25mg [**Hospital1 **]
Lasix 80mg daily
Metformin 500mg daily
Lexapro 10mg daily
Humalog 75/25 80U [**Hospital1 **]
Discharge Medications:
1. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Digoxin 125 mcg Tablet Sig: 1-2 Tablets PO DAILY (Daily).
5. Valsartan 160 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
8. Insulin Glargine 100 unit/mL Solution Sig: Twenty Eight (28)
units Subcutaneous once a day: qAM.
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for shortness of breath.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
12. Carvedilol 6.25 mg Tablet Sig: Five (5) Tablet PO BID (2
times a day).
13. Enoxaparin 150 mg/mL Syringe Sig: One (1) Subcutaneous Q12H
(every 12 hours): Until INR >2.
14. Insulin Aspart 100 unit/mL Solution Sig: per sliding scale
units Subcutaneous three times a day: see sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] Hospital at [**Location (un) 4047**]
Discharge Diagnosis:
Bilateral thromboembolic strokes with residual non-fluent
aphasia and right upper extremity paralysis
Left ICA occlusion
Congestive heart Failure, EF 25%
Hypertension
Hyperlipidemia
Diabetes (insulin dependent)
Discharge Condition:
Neurologic exam at the time of discharge was notable for a
non-fluent aphasia. She was able to follow commands. There was
a slight right facial droop, right arm with a dense paresis
without any movement of the fingers. The right leg was [**4-28**]
proximally. She was hemodynamically stable. O2 sat was 99% on
3L.
Discharge Instructions:
You where admitted for evaluation of right sided weakness and
difficulty speaking. You were found to have multiple strokes
which were likely caused by blood clots. You were started on a
medication called coumadin to thin your blood and prevent future
strokes.
You are being discharged to rehabilitation for further
treatment.
You have been scheduled for follow up in the neurology clinic as
well as with your outpatient cardiologist.
Followup Instructions:
NEUROLOGY
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD
Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2200-4-29**] 8:30
CARDIOLOGY:
Dr. [**Last Name (STitle) 4455**]
[**2200-4-2**] 2:15om
PCP
[**Name9 (PRE) 17457**],[**Name9 (PRE) **]
[**Telephone/Fax (1) 17458**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2200-4-2**]
|
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"278.01",
"434.11",
"342.80",
"427.2",
"703.0",
"428.0",
"139.8"
] |
icd9cm
|
[
[
[]
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] |
[
"96.71",
"57.94",
"38.93",
"96.6"
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icd9pcs
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[
[
[]
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15695, 15775
|
8739, 14208
|
314, 326
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16030, 16351
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5910, 5915
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16837, 17273
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3662, 3749
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14423, 15672
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15796, 16009
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14234, 14400
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16375, 16814
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4601, 5891
|
3764, 4209
|
247, 276
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354, 3084
|
5930, 8716
|
4224, 4583
|
3106, 3488
|
3505, 3646
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,028
| 175,499
|
2486
|
Discharge summary
|
report
|
Admission Date: [**2118-10-4**] Discharge Date: [**2118-10-6**]
Date of Birth: [**2043-3-1**] Sex: M
Service: NEUROSURGERY
Allergies:
Percocet / Restoril / Zoloft / simvastatin / Requip / Lasix /
Hydromorphone
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Bilateral SDH/EDH
Major Surgical or Invasive Procedure:
Hemodialysis [**2118-10-5**]
History of Present Illness:
This is a 75 year old man with a history of renal cell carcinoma
s/p left nephrectomy, on dialysis who presented to his PCP [**Name Initial (PRE) **]
2 weeks ago for one week of headache that started gradually. He
describes this is as a [**2117-1-29**] dull head pain that can be
bifrontal or holocephalic, not associated with visual
disturbances, nausea/vomitting, asymmetric weakness/numbness,
dizziness/vertigo
or difficulties sleeping at night. The patient reports that he
has had limited relief with a large aspirin, OTC tylenol or
aleve. At the same time, he prefers to avoid all pain
medications and states that he once took percocet and felt very
ill and would prefer no percocet like agents.
When he presented to his PCP two weeks ago and had a NCHCT done
which was normal. His headache persisted, and his PCP ordered [**Name Initial (PRE) **]
brain MRI to be done this
morning which revealed bilateral SDH and one EDH with concern
for midline shift. He was asked to present to the LGH ED who
transferred him here for a neurosurgical evaluation.
Past Medical History:
- Left sided RCC s/p nephrectomy
- DMII
- ESRD on HD
- Diverticulitis
- History of pericarditis
Social History:
He has a 20 pack year smoking history, occasional drinks, no
drugs. Worked as an airforce engineer, quit 17 years ago.
Family History:
Negative for neurological illness
Physical Exam:
On admission:
Physical Exam:
Vitals: 98,8, 85, 155/57, 12, 100%
General: Well appearing man, awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no masses or lymphadenopathy
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall [**11-29**] at 5 minutes.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1.5 mm and brisk. VFF to confrontation.
III, IV and VI: EOM are intact and full, no nystagmus
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch throughou
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 0 1
R 2 2 2 0 1
Plantar response: Down
-Coordination: No intention tremor, no dysmetria on FTN testing
-Gait: Not tested
Upon Discharge:[**2118-10-6**]
He is neurologically intact.
Pertinent Results:
CXR [**2118-10-4**]
No acute cardiopulmonary abnormality
CT Head [**2118-10-4**]:
Allowing for differences in distribution, there is no
significant
change in bilateral extra-axial collections likely representing
acute-on-chronic subdural hematomas with small amount of
subdural hemorrhage layering along the tentorium.
CT head [**2118-10-5**]:
1.No significant change in the bilateral extra-axial
collections, likely
representing acute-on-chronic subdural hematomas, with no change
in degree of mass effect.
2. Minimal subdural blood layering along the left leaflet of the
tentorium, also unchanged, with no new hemorrhage.
[**2118-10-6**] 04:35AM BLOOD WBC-8.0 RBC-3.41* Hgb-11.1* Hct-34.0*
MCV-100* MCH-32.5* MCHC-32.5 RDW-14.1 Plt Ct-167
[**2118-10-6**] 04:35AM BLOOD Glucose-86 UreaN-28* Creat-4.1*# Na-134
K-4.0 Cl-97 HCO3-27 AnGap-14
[**2118-10-6**] 04:35AM BLOOD Albumin-4.3 Calcium-9.8 Phos-3.5 Mg-2.3
[**2118-10-6**] 04:35AM BLOOD Phenyto-5.7*
Brief Hospital Course:
This is a 75 year old man who was admitted to Neurosurgery in
the ICU for close monitoring. He remained stable overnight and
on [**10-5**] had a repeat Head CT which showed no interval change. He
went to the dialysis unit and suffered form a frontal headache
while in treatment. He was medicated with APAP. He was seen by
Neurosurgery and he was neurologically intact and VS were
stable.
He was transferred to the floor. On [**10-6**] he was seen by
physical and occupational therapy who cleared him for home with
outpatient PT. He was told to resume ASA in one week and
dialysis as previously scheduled. Heparin infusion should be
avoided.
Medications on Admission:
ASA 81mg daily
Epo weekly
Renagel (dose?)
Iron pills
MVI
Chondroitin supplements
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for headaches, T>38.3C: MAX 4g/day.
2. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day).
Disp:*120 Tablet, Chewable(s)* Refills:*2*
3. Outpatient Physical Therapy
RE; Bilateral SDH
Pleave eval gait and safety
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral Subdural Hematomas
Renal Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions
Please continue Dialysis as you are normally scheduled. You
should not have a heparin infusion during dialysis until after
your follow up appointment with Dr. [**Last Name (STitle) 739**]
?????? Take Tylenol for pain control. We did not prescribe you any
narcotics as you expressed a desire to avoid them.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Advil, or Ibuprofen
etc.
?????? You may resume taking Aspirin in one week.
You have been prescribed Dilantin for prevention of seizures.
You should have a Dilantin and albumin level drawn with your PCP
each week. Please call [**Telephone/Fax (1) 1669**] with the results. A
corrected Dialntin level goal is between [**9-15**].
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Please follow-up with Dr [**Last Name (STitle) 739**] in 4 weeks with a Head CT
w/o contrast. Please call Paresa at [**Telephone/Fax (1) 1272**] to make this
appointment.
Please bring the CT head done on [**9-20**] on a CD to your
appointment.
Please follow up with you PCP in the next week to follow up on
your admission and for lab work (mentioned above).
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2118-10-6**]
|
[
"432.0",
"305.1",
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"V45.73",
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] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
6050, 6056
|
4920, 5563
|
357, 388
|
6143, 6143
|
3938, 4897
|
7816, 8302
|
1746, 1782
|
5695, 6027
|
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|
5589, 5672
|
6294, 7793
|
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|
300, 319
|
3872, 3919
|
416, 1473
|
1812, 1812
|
6158, 6270
|
1495, 1593
|
1609, 1730
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,188
| 134,344
|
5756
|
Discharge summary
|
report
|
Admission Date: [**2130-2-19**] Discharge Date: [**2130-3-9**]
Date of Birth: [**2067-10-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
OSH transfer for plasma pharesis evaluation
Major Surgical or Invasive Procedure:
Knee washout, intubation
History of Present Illness:
62-year-old male with history of multiple myeloma/plasma cell
dyscrasia, type I cryoglobulinemia, chronic renal insufficiency,
congestive heart failure, anemia and COPD presents from OSH with
staphylcoccus aureus bacteremia, acute on chronic renal
insufficiency, lower extremity edema for evaluation of plasma
pharesis.
.
Per OSH records, the patient was in his usual state of health
until recently when he received velcade and ecadron on [**1-30**] and
again on [**2-6**] and was admitted for concern of tumor lysis
syndrome. He improved and was discharged home. However, at home
he continued be be very weak and developed progressive lower
extremity edema. He missed his nephrology appointments although
was able to keep an oncology appointment on [**2-10**]. At that time
he was admitted for bilateral leg edema.
.
On admission, he was afebrile, denied dysuria, polyuria,
shortness of breath, cough, or other symptoms other than chronic
pain and fatigue. His labs were significant for a WBC 17.4, Hct
34.0, Plt 108, BUN 86, Cr 4.24 (was 3.25 five days prior), uric
acid 11.6, LDH 230. Nephrology was consulted and thought that
the patient had bilateral edema from acute on chronic renal
failure, likely secondary to cryoglobulinemia. He was given
lasix and steroids. Over the next two days he had improvement of
BUN to 76, creatinine to 2.33 (eventual nadir 2.17) and
worsening of thrombocytopenia (to 27). He developed
hallucinations and had a head CT that was negative. He developed
a bandemia of 15. He was pan cultured and diagnosed with a
urinary tract infection. CXR without evidence of acute
infection. He was started on levofloxacin. He continue to have
altered mental status and deveoped hypotension to 99/63, fevers
to 101F and rising WBC. Blood cultures revealed 4/4 bottles with
staphylcoccus aureus (sensitivities pending) and he was started
on vancomycin. ID was consulted and recommended IV antibiotics
for 4-6 weeks and a TTE. Levofloxacin was discontinued. He
became progressively altered and was transferred to the ICU for
further evaluation and management.
.
In the ICU, head CT was done and was negative. ABG was
7.57/32.9/89. He was noted to have hypoalbuminemia and relative
hypotension. [**Name2 (NI) **] was started on PPN, albumin and given 1 u pRBC.
The day of transfer labs were WBC 5.4, Hct 22.3, Plt 12, BUN
102, Cr 2.22, albumin 1.3. Vitals at time of transfer were T
97.8, BP 108/59 (per report baseline 140s), HR 110, RR 28, SaO2
92% 4L NC. Per signout, although no mention in notes,
nephrologist states that he need dialysis. The reason for
transfer is for evaluation for plasma pharesis. He was given
1uPRBCs prior to transfer to [**Hospital1 18**].
.
On arrival to the [**Hospital Unit Name 153**], he was intermittently responsive to
questions, reports all-over body pain and otherwise difficult to
ascertain as patient not very responsive other than moaning to
movement. He was intubated essentially on arrival for CXR
showing ARDS and poor O2 saturation on 6L NC and facemask. 30
mins s/p intubation patient then dropped his BP to 50's, was
given IVF bolus, CVL was placed in R femoral artery emergently
and patient was given peripheral dopa, then levophed through the
central line, and 0.1mg of epinephrine. His BP went up to 70's,
then steadily increased to 160's, and pressors were weaned down.
His art stick showed acidemia and a lactate that increased from
2.6 to 8.2.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
- Plasma cell dyscrasia (multiple myeloma), s/p 6 cycles of
velcade and decadron in [**2127**] and restarted treatment recently
with Dr. [**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) **], on [**1-30**] and again on [**2-6**]
- Type I cryoglobulinemia (1gG kappa light chain secondary to
plasma cell dyscrasia)
- Cardiomyopathy EF 25-30%
- Restrictive cardiomyopathy from amyloid
- Congestive heart failure
- Chronic renal insufficiency currently Stage 3(with AOCRF in
the setting of velcade tx in [**2127-11-3**] that required a month
of dialysis)
- Anemia
- H/o EtOH abuse
- HTN
- S/p MVC with trauma to the right leg with back flap to right
anterior calf, right radial artery to right leg. On chronic
narcotics including methadone and percocet
- Hyperlipidemia
- COPD
- per pt's girflriend he has bacteremic meningitis 5 years ago
with damage to his heart valves also.
Social History:
He lives alone and has a girlfriend who helps with his care.
History of EtOH abuse, none since [**2116**]. History of tobacco use.
None currently. Motorcycle driver. On disability s/p motor
vehicle accident. No EtOH since [**2116**], but heavy use prior. Prior
marijuana use. Had worked in the iron industry and as a
carpenter.
Family History:
Mother with CHF. Father with lung cancer in 50s. No premature
CAD/sudden death.
Physical Exam:
General: AAOx1, appears in moderate distress, tachypneic
HEENT: Sclera anicteric, mucous membranes dry, no teeth
Neck: supple, JVP difficult to assess [**1-4**] tachypnea and
tachycardia
Lungs: anteriorly moderate rhonchi worse over L anterior lung
field
CV: Regular rate and rhythm, difficult to assess for m/r/g as
rhonchorous breath sounds very prominent over L side
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: R lower leg with chronic skin changes [**1-4**] skin flap, and
with large R pleural
.
DISCHARGE EXAM
General Appearance: anxious, oriented to person, hospital,
year:[**2117**]
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Poor dentition, dried blood in
oropharynx and nasopharynx
Cardiovascular: [**1-8**] blowing systolic murmur at LLSB
Pulm: CTA in anterior fields
Abdominal: Soft, Bowel sounds present, mild ttp, and involuntary
guarding in epigastrium
Neurologic: responding to commands to grasp hands, intermittent
response to questions
Skin: A 30cm x 10cm area of erythemia noted over the lateral
aspect of his left thigh.
Pertinent Results:
Admission Labs:
[**2130-2-19**] 09:20PM BLOOD WBC-5.6 RBC-2.81* Hgb-7.7*# Hct-24.1*
MCV-86 MCH-27.5 MCHC-32.2 RDW-18.4* Plt Ct-15*#
[**2130-2-19**] 09:20PM BLOOD Neuts-87* Bands-3 Lymphs-3* Monos-7 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2130-2-19**] 09:20PM BLOOD PT-14.6* PTT-30.8 INR(PT)-1.3*
[**2130-2-19**] 09:20PM BLOOD Glucose-148* UreaN-109* Creat-1.9*#
Na-144 K-3.9 Cl-109* HCO3-23 AnGap-16
[**2130-2-19**] 09:20PM BLOOD ALT-11 AST-19 LD(LDH)-405* CK(CPK)-28*
AlkPhos-66 TotBili-3.4*
[**2130-2-19**] 09:20PM BLOOD Albumin-2.1* Calcium-7.5* Phos-3.8 Mg-2.5
UricAcd-9.4*
[**2130-2-20**] 02:38AM BLOOD CRP-240.2*
DISCHARGE LABS
[**2130-3-7**] 03:50AM BLOOD WBC-6.1 RBC-3.09* Hgb-9.1* Hct-26.4*
MCV-85 MCH-29.5 MCHC-34.6 RDW-16.9* Plt Ct-109*
[**2130-3-5**] 03:15AM BLOOD Neuts-71.8* Lymphs-17.6* Monos-4.9
Eos-5.1* Baso-0.7
[**2130-3-7**] 03:50AM BLOOD Glucose-116* UreaN-31* Creat-1.1 Na-136
K-3.5 Cl-106 HCO3-25 AnGap-9
Micro:
URINE CULTURE (Final [**2130-2-23**]): STAPH AUREUS COAG +.
10,000-100,000 ORGANISMS/ML.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- 32 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
JOINT FLUID
FLUID CULTURE (Final [**2130-2-25**]): STAPH AUREUS COAG +. MODERATE
GROWTH. STAPH AUREUS COAG +. SPARSE GROWTH. 2ND MORPHOLOGY.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| STAPH AUREUS COAG +
| |
CLINDAMYCIN----------- R R
ERYTHROMYCIN---------- R R
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- =>8 R =>8 R
OXACILLIN------------- 0.5 S 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S <=0.5 S
RESPIRATORY CULTURE (Final [**2130-2-23**]): Commensal Respiratory
Flora Absent.
STAPH AUREUS COAG +. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Imaging:
CT CHEST W/O CONTRAST Study Date of [**2130-2-20**] 11:33 AM
IMPRESSION:
1. Moderately large right acute pneumothorax with associated
mediastinal shift to left and collapse of the right upper lobe.
2. Multifocal predominantly upper lobe severe consolidation, in
light of recent chemotherapy, fungal and viral infections are
considered possible,
although the pattern could also be described in bacterial
pneumonia. Adult respiratory distress syndrome is also
considered possible, but the lack of a gravitational gradient
makes this less likely.
3. Bilateral moderately large pleural effusions.
4. Mild pulmonary edema.
Portable TTE (Complete) Done [**2130-2-21**] at 11:23:41 AM FINAL
Conclusions:
The left atrium is mildly dilated. The left ventricular cavity
is moderately dilated. Overall left ventricular systolic
function is severely depressed with inferior and septal
akinesis/severe hypokinesis with mild to moderate hypokinesis
elsewhere. The basal lateral wall moves best. (LVEF= 25-30 %).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] The
right ventricular cavity is mildly dilated with borderline
normal free wall function. 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. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is a
moderate-sized vegetation on the anterior leaflet of the mitral
valve (1.4 cm x 1 cm). An eccentric, laterally directed jet of
moderate (2+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
.
US left thigh
[**2130-3-6**]
Fluid collection in the left lateral thigh with overlying
inflammatory change.
An infected collection is a concern with the history.
.
MRI SPINE [**2130-3-5**]
CERVICAL SPINE:
1. 2.8 cm rim enhancing fluid collection, suspicious for
abscess, in the right posterior paraspinal soft tissues adjacent
to the right C4-5 facet. Abnormal marrow signal adjacent to the
joint may represent osteomyelitis or marrow edema.
2. Increased STIR signal within the C5-6 disc with adjacent
epidural enhancing material suspicious for osteomyelitis,
discitis with associated epidural phlegmon. This process
combines with underlying degenerative changes to cause moderate
spinal canal narrowing at this level.
.
THORACIC SPINE:
1. Numerous rim-enhancing fluid collections involving the left
shoulder,
partially evaluated, suspicious for abscesses.
2. Ill defined, heterogenously enhancing material in the right
anterior
paraspinal soft tissues at T6-7 suspiucious for phlegmon.
LUMBAR SPINE:
1. Given history of recent septicemia, findings highly
suspicious for
infectious osteomyelitis of the bilateral L3-4 facet joints with
adjacent
abscesses in the posterior paraspinal soft tissues. At L3-L4,
there is a
posterior epidural component, which bows the cauda equina
anteriorly, but does not cause high-grade spinal canal
narrowing.
2. Similar collections in the posterior paraspinal soft tissues
at L4-5 and L5-S1 are also suspicious for abscesses, but with
preserved marrow signal adjacent to these more inferior facet
joints making osseous involvement less likely.
.
ECHO
[**2130-3-6**]
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is severe global
left ventricular hypokinesis (LVEF = 25 %). The mitral valve
leaflets are mildly thickened. There is a moderate-sized
vegetation (1.3 cm) on the mitral valve. Moderate to severe (3+)
mitral regurgitation is suggested. There is no pericardial
effusion.
.
Compared with the prior study (images reviewed) of [**2130-2-27**],
the LVEF is lower and the LV cavity has increased in size. A TEE
would better assess the severity of MR and the mitral
vegetation.
.
MRI HEAD [**2130-3-3**]
IMPRESSION:
1. Two foci of acute infarction in the right anterior centrum
semiovale and right posterior occipital lobe.
.
2. Persistent marked ventriculomegaly, slightly out of
proportion to sulci. This could reflect central atrophy, or
normal pressure hydrocephalus in the correct clinical setting.
.
3. Bilateral mastoid opacification. Please correlate clinically
for evidence of mastoiditis.
Brief Hospital Course:
The patient is a 62 year old male with history of ischemic
cardiomyopathy, plasma cell dysplasia with Kappa light chains
and cryoglobulinemia treated in [**2127**], now s/p relapse and
retreatment [**2130-2-6**] with resultant tumor lysis syndrome, acute on
chronic kidney failure, and hospitalization at [**Hospital 22913**] from [**2130-2-10**] to [**2130-2-19**] complicated by development of
MSSA septicemia, transferred to [**Hospital1 18**] for further management.
He was intubated soon after arrival, and found to have a septic
right knee joint, multiple paraspinal abcesses, mitral valve
endocarditis, and septic shock. After a lengthy and complicated
hospital course, his care was transitioned to comfort measures
only and he was discharged to [**Hospital1 **] health.
.
# Goals of care: given overwhelming sepsis and multiple sources
of infection, goals of care discussion was held with his health
care proxy and his care was transitioned to comfort measures
only. Pain was managed with methadone IV standing and
hydromorphone IV bolus as needed. He was transferred to [**Hospital1 **]
health for hospice care.
# Septic Shock: Secondary to MSSA bacteremia. On admission the
patient was hypotensive requiring 3 pressors and epinephrine
injection for support. He had positive cultures for MSSA in
blood from OSH, as well as urine, knee aspirate, and sputum
cultures at [**Hospital1 18**]. He developed mitral valve endocarditis and
septic arthritis (addressed below). Infectious Disease was
consulted and recommended an extended treatment course with
Nafcillin. His blood pressure and urine output improved and his
need for pressors resolved.
.
# Endocarditis: He had stigmata of endocarditis with [**Last Name (un) 1003**]
lesions on his left hand, and bilateral feet. Echo on [**2130-2-21**]
showed 1.0 x 1.4 cm vegetation on his mitral valve. CT Surgery
was consulted and recommended weekly TTEs to monitor for
interval change. He was treated with Nafcillin extended course
as above. Repeat echo showed that MV vegitation had lessened in
size to 1.3 cm. After goals of care discussion with HCP, care
was transitioned to comfort measures only and antibiotics were
discontinued.
.
# Septic Arthritis: He had a septic right knee with purulent
aspiration with serial bedside washes and OR washout on [**2130-2-23**]
with arthrotomy with debridement, lavage, and synovectomy, as
well as irrigation and debridement of his left elbow bursa.
Given persistent fevers, leukocytosis, and tachycardia he
returned to the OR on [**2130-3-1**] for repeat right knee wash out.
.
# Paraspinal fluid collections: MRI of the spine showed multiple
fluid collections likely representing abcesses in the Cervical
and thoracic spine. Given goals of care, comfort measures only
were provided.
.
# Left thigh fluid collection: A 30cm x 10cm area of erythemia
was noted over the lateral aspect of his left thigh. Ultrasound
was consistent with fluid collection, likely representing an
abcess. Given goals of care, symptomatic management with pain
control was performed.
.
# Mental status: patient had depressed consciousness following
extubation. Mental status waxed an wained throughout
hospitalization. Concern for septic emboli was raised and he was
sent for MRI brain which showed acute infarcts in right anterior
centrum semiovale and right posterior occipital lobe but no
evidence of abcess. Throughout the remainder of his ICU course,
he remained confused though responsive to simple commands,
oriented to person, hospital, year:[**2117**].
.
# Hypoxic Respiratory Failure: Patient was intubated shortly
after arrival. Chest CT on [**2130-2-20**] showed upper lobe
consolidation and his sputum grew MSSA, for which he was
continued on Nafcillin. He was also found to have a right
pneumothorax on CT and a chest tube was placed by IP. His
respiratory status improved and he was extubated on [**2130-2-24**] and
transitioned to supplemental oxygen via nasal cannula. Chest
tube remained in place due to persistent bronchopleural fistula.
Tube was discontinued after goals of care discussion.
.
# Anemia: The patient was noted to have a dropping hematocrit in
the setting of coffee ground particles from his NG lavage, and
blood in his oropharynx likely [**1-4**] trauma from multiple NGT
placements. He was started on an IV PPI and transfused as needed
to maintain a Hct >25 and plts > 50. ENT was consulted and saw
no evidence of active epistaxis. GI was consulted who noted
stable HCT and recommended against EGD and continued medical
management with pantoprazole.
.
# Renal Failure: acute on chronic renal failure. He has Stage
III CKD and recent tumor lysis syndrome from Velcade
chemotherapy. His TLS has since improved, with uric acid at OSH
from high of 11 down to 2.3, however elevated >8 at [**Hospital1 18**]. His
urine output was initially low, but after volume resuscitation
he began to autodiurese with improvement in his UOP to greater
than 100cc/hr. He likely developed some degree of ATN given his
hypotension, which gradually resolved.
.
# Multiple Myeloma/Cryoglobulinemia: Last treatment was [**2130-2-6**],
which resulted in TLS. Total IgG elevated (marginally). His SPEP
showed less than 1% total protein IgG Kappa chains. No
cryoglobulin was detected when checked on [**2130-2-20**] and his serum
viscosity was just below the normal range. He was initially on
stress dose steroids which were tapered off given the
hematologic results.
.
# Pain control: He has been having generalized body pain, likely
due to septic arthritis and endocarditis, possibly with some
contribution from his MM and chronic pain. He was started on
Methadone 20 mg IV Q6H to wean off his Fentanyl and Midazolam
drips.
.
#Communication: girlfriend/HCP [**Telephone/Fax (1) 22914**] (cell) or
[**Telephone/Fax (1) 22915**] (home)
# Code Status:Comfort measures only
Medications on Admission:
Allopurinol 100mg PO daily
Coreg 6.25mg PO BID
Cymbalta 30mg PO BID
Hydralazine 10mg PO BID
Isosorbide dinitrate 10mg PO TID
Methadone 10mg PO up to 7x per day
MS Contin 30mg PO TID
Potassium chloride 10mEq daily
Endocet 10mg PO up to 9x per day
Sodium bicarbonate 650mg PO TID
Calcium carbonate plus D 600mg PO daily
Discharge Medications:
1. methadone 10 mg/mL Solution Sig: Twenty (20) mg Injection Q4H
(every 4 hours): hold for sedation
.
2. hydromorphone 2 mg/mL Syringe Sig: 1-2 mg Injection Q2H
(every 2 hours) as needed for pain: hold for sedation
.
3. lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous
membrane TID (3 times a day) as needed for with mouth care.
4. acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4H (every 4 hours) as needed for fever: Do not exceed
4000mg in 24 hours.
5. pantoprazole 40 mg Recon Soln Sig: Forty (40) mg Intravenous
Q12H (every 12 hours).
6. sodium chloride 0.9 % 0.9 % Parenteral Solution Sig: Ten (10)
ML Intravenous PRN (as needed) as needed for line flush: Flush
with 10mL Normal Saline daily and PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Methicillin sensitive staphylococcus areus sepsis
.
Endocarditis
Multiple abcesses
Acute cerebral infarction
Toxic metabolic encephalitis
Gastrointestinal bleed
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. [**Known lastname 22873**],
You were transferred from an outside hospital to the [**Hospital1 18**]
intensive care unit for further evaluation and treatment of your
infection. After a long discussion with your loved ones, it was
decided to transiton our goals of care to making you as
comfortable as possible by treating your pain and other
symptoms. You are being transferred to another facility where
the focus will be on making you pain free.
Followup Instructions:
None
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
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"275.41",
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icd9cm
|
[
[
[]
]
] |
[
"80.16",
"96.6",
"80.76",
"81.91",
"83.5",
"38.97",
"38.91",
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"34.04",
"96.04",
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icd9pcs
|
[
[
[]
]
] |
20772, 20843
|
13790, 16851
|
356, 382
|
21048, 21048
|
6840, 6840
|
21665, 21809
|
5575, 5657
|
20016, 20749
|
20864, 21027
|
19673, 19993
|
21184, 21642
|
5672, 6821
|
3851, 4299
|
272, 318
|
410, 3832
|
6856, 13767
|
21063, 21160
|
4321, 5213
|
5229, 5559
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,688
| 189,787
|
15244
|
Discharge summary
|
report
|
Admission Date: [**2132-6-3**] Discharge Date: [**2132-6-10**]
Date of Birth: [**2094-7-19**] Sex: F
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: This is a Russian 37 year-old
female woman with a known history of rheumatic heart disease
and mitral valve prolapse who has been experiencing
progressive shortness of breath on exertion with occasional
chest pain for which she underwent echocardiography and
stress test in [**2131-7-22**]. This revealed moderate to
severe mitral regurgitation. The patient at that time was
referred for mitral valve surgery, but she declined and has
since reconsidered and was admitted to the hospital for
mitral valve surgery.
PAST MEDICAL HISTORY: Rheumatic heart disease, mitral valve
prolapse, scoliosis with severe thoracic and spinal deformity
and chronic back pain as a result of that. Varicose veins,
chronic headaches, liver cysts noted on echocardiography,
depression, psoriasis and chronic bronchitis. She is status
post tonsillectomy at age 14. She is also status post
removal of cyst on her tailbone in [**2116**].
PREADMISSION MEDICATIONS:
1. Altace 2.5 mg po q.d.
2. Over the counter medications for headache.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is not employed.
PHYSICAL EXAMINATION ON ADMISSION: Unremarkable.
HOSPITAL COURSE: The patient was admitted the day of surgery
and taken directly to the Operating Room where she underwent
a mitral valve repair with a #28 mm Carbomedics anuloplasty
ring. Postoperatively, she was transferred from the
Operating Room to the Cardiac Surgery recovery unit in stable
condition on Neo-synephrine and intravenous Propofol drips.
Postoperatively, the patient required intravenous insulin for
a short period. She also remained on neo-synephrine due to
some hypotension. She was weaned from mechanical ventilation
and extubated on the day of surgery. Her chest tubes
remained in and were discontinued late in the day on
postoperative day one. On postoperative day two the patient
remained marginally hypotensive requiring neo-synephrine drip
and this prolonged her stay in the Intensive Care Unit. She
was begun on diuretics and had remained in normal sinus
rhythm with a rate anywhere from the 90s to one teens at that
time. On postoperative day two she was ultimately weaned off
neo-synephrine and then transferred from the Cardiac Surgery
Recovery Unit to the Telemetry floor. On postoperative day
three the patient had a blood pressure of 103/68, sinus
rhythm with a heart rate of 108 and room air oxygen
saturation of 97%. She did have bibasilar crackles and she
complained of intermittent shortness of breath and weakness
at that time. She was begun on physical therapy and started
to progress with cardiac rehabilitation.
On postoperative day four the patient continued to progress
with cardiac rehabilitation, increased ambulation, remained
tachycardic in the one teens. Her rhythm was sinus at that
time. Her blood pressure remained 140s/70s at that time and
her oral Lopressor dose had been increased. The patient
remained for the next two days somewhat tachycardic again
about 100 to 120 range. She had a chest x-ray on [**6-8**]
postoperative day five, which showed a left lower lobe
infiltrate possible pneumonia, possible atelectasis and she
was also a bit short of breath at that time. For this reason
with the tachycardia she stayed in the hospital for two more
days. Today [**2132-6-10**] the patient remains tachycardic,
although about 100 to 105 for a rate and sinus tachycardia.
Her blood pressure is 115/72. Her respiratory rate is 20 and
her room air oxygen saturation is 94%. She had a chest x-ray
yesterday [**6-9**], which showed a significant increase in
aeration of both of her lung fields as well as a decrease in
the opacity in her left lower lobe. The patient had a small
amount of erythema on her sternal incision with no drainage
and her sternum is intact and stable. For this she was
started on a five day course of po Keflex.
CONDITION ON DISCHARGE: Good. The patient remains afebrile
with previously stated vital signs. Neurologically she was
alert and oriented. Her breath sounds she has few crackles
in her left base, otherwise her lungs are clear to
auscultation bilaterally. She is in a regular rate and
rhythm, which is sinus. There is slight erythema at the mid
portion of her sternal wound with no drainage. Her abdomen
is soft, nontender, nondistended. She has no peripheral
edema and she is at this time below her preoperative weight.
Therefore diuretics have been discontinued today.
MEDICATIONS ON DISCHARGE:
1. Percocet 5/325 one to two tablets po q 6 hours prn pain.
2. Keflex 500 mg one po q 6 hours for five more days.
3. Lopresor 75 mg po t.i.d.
4. Aspirin 325 mg po q.d.
5. Colace 100 mg po b.i.d.
FOLLOW UP: The patient is to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**]
in approximately four weeks for postoperative check. She is
to follow up with her primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 3357**] in one to two weeks for adjustment of Lopressor
dosing depending on her blood pressure and heart rate at that
time.
DISCHARGE DIAGNOSIS:
Mitral valve prolapse status post mitral valve repair.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2132-6-10**] 07:22
T: [**2132-6-10**] 13:33
JOB#: [**Job Number 44348**]
|
[
"E878.8",
"394.1",
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"998.59",
"458.2",
"785.0",
"682.2",
"745.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"35.71",
"39.65",
"35.33"
] |
icd9pcs
|
[
[
[]
]
] |
5310, 5635
|
4643, 4844
|
1350, 4039
|
1122, 1234
|
4856, 5289
|
175, 691
|
1317, 1332
|
714, 1099
|
1251, 1302
|
4064, 4617
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,733
| 126,186
|
45999
|
Discharge summary
|
report
|
Admission Date: [**2180-11-23**] Discharge Date: [**2180-11-29**]
Date of Birth: [**2116-10-20**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 805**] is a 64y.o. woman h/o COPD (on 2L home O2) and CHF
(most recent EF=55%) presenting from her PCP's office with RA O2
sat of 52-64%. Per the pt's report, she had been feeling in her
usual state of health during her routine visit with her PCP this
morning; she reports that on exam, her O2 sat was low (54-62%
per PCP [**Name Initial (PRE) 626**]) and he asked her to come to the ED. Of note, pt
is normally on 2L O2 at home, but has not used her home O2
x24hrs. The pt reports an ongoing cough productive of yellow
phlegm for the past two months, but denies any hemoptysis or
recent worsening of this cough. She also reports rhinorrhea x1
wk. Pt reports that she previously had one episode of chest
pressure and SOB w/exertion 3 days ago, but that both of these
symptoms improved with OTC Theraflu. Currently, pt denies any
chest pressure, chest pain, radiating pain, pleuritic pain, SOB,
diaphoresis or nausea. Otherwise, she denies any recent
fevers/chills. She denies any PND or sleep orthopnea (1
pillow).
In the ED, initial VS were T 98.6, HR 100, BP 154/86, RR 22, O2
sat 89% 4L Nasal Cannula. Exam notable for bibasilar crackles
greater than wheezes. Labs were notable for WBC 6.9 (66.5 PMN,
27.2 lymph), Hct 44.5, Plt 219. Chem 7 with K 2.8, BUN 24 and
Cr 1.1 (baseline 0.5-0.7). Tnt was negative and proBNP 2873 (BL
479 in 09/[**2180**]). Lactate was 2.0. Blood cx are pending. CXR
notable for persistent moderate enlargement of the cardiac
silhouette with possible minimal pulmonary vascular congestion
but without overt pulmonary edema. Pt was given albuterol nebs
x2, ipratropium nebs x2, furosemide 40 mg IV, KCl 50 mEq PO,
methylprednisode 125mg and started on arithromycin 250mg. She
was placed on NRB, satting in mid-90s. Headed for floor, but
every time she dozed off, O2 sats down to 70s - 80s. Tried BIPAP
and CPAP, but did not tolerate.
.
On arrival to the MICU, the pt reports feeling "great," in no
acute distress. Her O2 sats are in the low 90s, but will desat
to low-mid 80s with any activity and sleep.
.
Review of systems:
(+) Per HPI
(-) Denies headache, sinus tenderness, or congestion. Reports
alternating diarrhea and constipation x2mos; denies abdominal
pain. Denies dysuria, hematuria, pyuria. Reports left shoulder
pain x3 yrs. Denies rashes or skin changes.
Past Medical History:
-Grade 1 diastolic CHF: per most recent echo [**1-/2179**], LVEF =55%
and mild concentric left ventricular hypertorphy. Impaired LV
relaxation (grade I diastolic dysfunction). Most recent BNP 479
(09/[**2180**]).
-COPD: Pt is on 2L of home O2, though non-adherent; able to
complete AODL and housework w/o difficulty. Most recent
spirometry on [**10/2180**] w/moderate mixed restrictive (likely [**2-23**]
obesity) and obstructive defect w/FVC 1.39 (58%), FEV1 1.39
(58%), FEV1/FVC 72%.
-Hypertension: SBP 110-130s.
-HL: most recent on [**8-/2180**] was cholest 115, TG 67, HDL 62, LDL
40
-Atrial fibrillation: on coumadin, INR 4.9
-DM2: HbA1c in [**6-/2180**] was 6.2%, insulin dependent
-Gout
-OSA: does not use prescribed CPAP
-GERD
Social History:
15 pack year smoking history, still smokes [**6-28**] cigs daily. Pt
with 1 EtOH/day. Denies illcits. She previously worked as a
switchboard operator, but retired 1 yr ago. She is married, and
lives in [**Location 5110**] with her husband. Two daughters.
Family History:
Mom died of MI at age 80. Dad died from "brain cancer" in 50s.
Sister died from ESRD at age 52 and brother died of liver cancer
in 60s. No known FH of early MI or clotting disorders.
Physical Exam:
Admission-
General: Speaking in full sentences, no accessory muscle use, no
acute distress. Alert, oriented, no acute distress.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI w/o
nystagmus or double vision, PERRL
Neck: No JVD.
CV: Irregularly irregular, no murmurs, rubs, gallops
Lungs: Pt with diffuse end expiratory wheezes in all lung fields
and increased E/I ratio. Air movement throughout. No rales or
ronchi.
Abdomen: Obese abdomen, soft, non-tender, non-distended, bowel
sounds x4 quadrants. Organomegaly difficult to appreciate given
habitus. No tap tenderness. No suprapubic or CVA tenderness.
GU: Foley in place.
Ext: 1+ pitting edema to mid-shins BL. Ext warm, well perfused,
2+ pulses DP pulses BL, no clubbing, cyanosis.
Neuro: CNII-XII intact, 5/5 strength BL upper extremities and
moving lower extremities, grossly normal sensation, gait
deferred
.
Discharge-
VS - T 98.7 BP 150/88 P 84 R 20 S 99% on 2.5L
GENERAL - well-appearing woman in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple
LUNGS - Good air entry, no wheezes/rales/rhonci, resp unlabored,
no accessory muscle use
HEART - PMI non-displaced, +rate irregularly irregular, no MRG,
nl S1-S2
ABDOMEN - NABS, +obesity, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no cyanosis/clubbing, 2+ peripheral pulses
(DPs), 1+ LE edema b/l (unchanged).
SKIN - no rashes or lesions noted
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-25**] throughout, sensation grossly intact throughout
Pertinent Results:
Admission-
[**2180-11-23**] 11:28AM BLOOD WBC-6.9 RBC-4.28 Hgb-13.8 Hct-44.5
MCV-104* MCH-32.2* MCHC-31.0 RDW-17.5* Plt Ct-219
[**2180-11-23**] 11:28AM BLOOD Neuts-66.5 Lymphs-27.2 Monos-5.1 Eos-0.8
Baso-0.5
[**2180-11-23**] 09:15PM BLOOD PT-46.4* INR(PT)-4.9*
[**2180-11-23**] 11:28AM BLOOD Glucose-143* UreaN-24* Creat-1.1 Na-141
K-2.8* Cl-98 HCO3-32 AnGap-14
[**2180-11-23**] 07:40PM BLOOD Calcium-6.0* Phos-3.1 Mg-0.9*
.
Discharge-
[**2180-11-29**] 06:20AM BLOOD WBC-10.7 RBC-4.26 Hgb-13.4 Hct-44.2
MCV-104* MCH-31.4 MCHC-30.2* RDW-16.8* Plt Ct-296
[**2180-11-29**] 06:20AM BLOOD PT-18.1* PTT-26.2 INR(PT)-1.6*
[**2180-11-29**] 06:20AM BLOOD Glucose-115* UreaN-22* Creat-0.6 Na-140
K-4.2 Cl-96 HCO3-38* AnGap-10
[**2180-11-29**] 06:20AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.5*
.
Microbiology-
[**2180-11-23**] Blood Culture, FINAL No growth
.
Imaging-
CXR ([**2180-11-23**]): Persistent moderate enlargement of the cardiac
silhouette with possible minimal pulmonary vascular congestion
but without overt pulmonary edema.
CXR ([**2180-11-24**]): Stable moderate cardiomegaly with slight
increase in mild interstitial edema. Increasing right basilar
opacity could reflect developing pneumonia.
Brief Hospital Course:
1. Acute exacerbation of COPD: The patient has used oxygen
supplementation (2L) at home for "many years". There were
reports that she had not used her home oxygen for 24 hours prior
to admission or that it was not fully functional. She was found
to have diffuse wheezing throughout and oxygen on 4L NS in
mid-90s w/desats to low to mid-80s with activity and sleep. Her
symptoms were most consistent with COPD exacerbation in the
setting of limited to no home oxygen for a day compounded by URI
symptoms (rhinorrhea) with on going cough and increased sputum
production. Her poor respiratory status was also likely
complicated by concurrent CHF exacerbation, particularly in
setting of missed furosemide dose
She was admitted to the ICU due to her low oxygen saturations.
She was given iprtropium/albuterol nebulizer treatments, a five
day course of azithromycin, and a 10 day course of prednisone
(40 mg). She was transferred to the general medical floor when
she was satting in the low to mid 90s on her home 2L of oxygen.
Her exam improved and upon discharge, she had no wheezing with
good air entry.
2. Atrial flutter/fibrillation: During her MICU course, she
developed aflutter, and her metoprolol dose was increased. She
was monitored on telemetry and was found to be alternating
between normal sinus and atrial fibrillation. Prior to
discharge, she was noted to be persistently tachycardic with
heart rates ranging from 110-120s and her metoprolol dosing was
increased further. Her blood pressures remained stable during
these dose adjustments.
She was found to have an elevated INR upon admission. The
etiology was not entirely clear. Her anticoagulation was
initially held and restarted when her INR was within the
therapeutic range. She was asked to follow up her INR 48 hours
following her discharge.
3. OSA: The patient reports being unable to tolerate her home
NIPPV. She initially refused NIPPV ventilation but after
meeting with an inhouse pulmonologist, she was slowly able to
tolerate 3-5 hours of the mask at night. She was noted to
desaturate at night to low 80s without mask, but oftentimes
asymptomatically. She was counseled to speak to her outpatient
physicians about this as well as a new sleep study or mask
fitting.
4. Hypokalemia / Hypomagnasemia: Patient hypokalemia resolved
with repletion. She was given total of 50 mEq KCl in ED.
Previously on PO K+ with limited adherence. Her magnesium was
also noted to be low and she was repleted as necessary.
5. Diabetes, type II: The patients home insulin regimen was
increased due to her steroid course. She was instructed to
continue the higher doses of lantus while she continues to take
her prednisone and to return to her home dose the evening she
completes her last steroid dose.
6. Hypertension: Her home meds were continued and metoprolol was
uptitrated as above. Her lasix was initially held upon
admission but restarted the following day.
7. HL: Continued her home pravastatin dose.
8. Degenerative joint disease/Gout: The patient did not complain
of symptoms of gout and did not receive colchicine during this
admission.
9. GERD: While she was in the hospital, she was transitioned to
the formulary pantoprazole. She was restarted on her home
lansoprazole upon discharge.
============================================================
TRANSITIONS OF CARE
============================================================
-COPD: The patient was most recently admitted with a similar
presentation in [**Month (only) **] of this year. She continues to smoke
while acknowledging the adverse effect this has on her health
-OSA: The patient was noted to have significant (<88%) desats
while sleeping. She reports being unable to tolerate her NIPPV
mask on a regular basis. She was able to tolerate the mask
while in the hospital, for at least part of the night. She was
counseled on the importance of this and was advised to see her
pulmonologist and possible undergo a new sleep study or mask
fitting if deemed necessary
-Medication adjustments: Her home metoprolol dose was increased
due to an episode of atrial flutter as well as persistent
tachycardia (Sinus and atrial fibrillation). Her BP remained
stable.
Medications on Admission:
Colchicine 0.6 mg PO prn gout flare
Furosemide 40 mg PO BID
Metoprolol Tartrate 25 mg PO BID
Pravastatin 80 mg PO QHS
Lansoprazole 30 mg PO BID
Calcium Carbonate (CALCIUM 500) 500 mg calcium (1,250 mg) PO
Ipratropium-Albuterol Nebulizer 0.5 mg-3 mg/3 mL TID and prn
Lisinopril 2.5 mg PO DAILY
Insulin Lantus 10 units QHS
Cholecalciferol, Vitamin D3, 50,000 unit PO QWeek
Warfarin 2.5 mg PO 3 days/wk, 3.75 mg PO 4 days/wk
Verapamil 240 mg PO Daily
Discharge Medications:
1. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day as
needed for Gout flair.
2. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
4. lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO twice a day.
5. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO once a day.
6. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution
for Nebulization Sig: One (1) nebulizer treatment Inhalation TID
and prn as needed for shortness of breath or wheezing.
7. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. insulin glargine 100 unit/mL Cartridge Sig: Ten (10) units
Subcutaneous once a day: Please take 40 units of lantus while on
prednisone. The evening of your last prednisone dose, please
return to taking 10 units daily.
9. cholecalciferol (vitamin D3) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week.
10. warfarin 5 mg Tablet Sig: 0.5-0.75 Tablet PO once a day:
Please alternate between 2.5 mg and 3.75 mg. Begin with 3.75 mg
the evening of discharge.
11. verapamil 240 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q24H (every 24 hours).
12. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 3 days: Please take your last dose on [**12-2**]. .
Disp:*10 Tablet(s)* Refills:*0*
13. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: 1.5 Tablet Extended Release 24 hrs PO once a day.
Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*2*
14. Outpatient [**Name (NI) **] Work
PT/PTT/INR checked at your [**Hospital3 **] on Friday
[**2180-12-1**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Primary:
-Chronic obstructive pulmonary disease
.
Secondary:
-Diastolic congestive heart failure
-Obstructive sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 805**],
It was a pleasure taking part in your care. We hope your health
continues to improve. You were admitted bcause your doctor
noted that your oxygen saturation was low, despite being on
oxygen. You were monitored closely in the ICU, who felt this
was likely due to an exacerbation of your COPD. You were
treated with steroids and antibiotics and your lung exam and
oxygen saturation improved. It was also noted that your oxygen
saturation decreases significantly at night when you sleep
without wearing the mask. We recommend you wear this mask as
much as possible at night and suggest gradually increasing how
many hours you wear it until you are able to tolerate it.
.
We recommend that you stop smoking as this is only going to
worsen your ability to breath and represents a significant
fire/explosion [**Doctor Last Name 13205**] given you oxygen supplementation.
.
Please make the following changes to your medications:
-START: Prednisone 40 mg daily for the next three days.
-START: Insulin glargine 40 units daily ***PLEASE RETURN TO YOUR
USUAL INSULIN DOSE THE DAY YOU FINISH PREDNISONE!!!!*****
-INCREASE: Metoprolol to 50 mg three times a day
.
If you feel your breathing has not improved when you finish your
last dose of prednisone, please contact your doctor about the
possibility of continuing this medication for a few more days.
You will be prescribed a few extra pills in case this is the
case, however your last dose is scheduled to be on [**2180-12-3**].
While you are on prednisone, your blood sugars will be elevated.
We recommend that you take high doses of your long acting
insulin while you are on this medication. Once you complete
your course, you should go back to your home doses of insulin
that evening.
Please have your INR checked on Friday [**2180-12-1**] at your
[**Hospital3 **].
Please follow up with your doctor's appointments as outlined
below. We would also recommend you speak to your doctor about
being re-evaluated by a sleep specialist.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] L.
Location: [**Location (un) 2274**] [**Location (un) **] Internal Medicine
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 11962**]
Appt: [**12-4**] at 11:40am
***PLease discuss a referral to see a Sleep Specialist during
this visit for your Sleep Apnea issues.
Name: [**Last Name (LF) 2294**],[**Name8 (MD) 2295**] MD
Location: [**Location (un) 2274**] [**Location (un) **]-Pulmonary
Address: [**Location (un) **] PULMONARY DEPT 5TH FL, [**Location (un) **],MA
Phone: [**Telephone/Fax (1) 2296**]
***The office is working on an appt for you in the next week and
will call you at home with the appt. If you dont hear from them
in 2 business days, please call directly to book.
|
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3,850
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23947
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Discharge summary
|
report
|
Admission Date: [**2198-5-5**] Discharge Date: [**2198-5-9**]
Date of Birth: [**2135-8-25**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization with placement of 3 cypher stents
History of Present Illness:
62 yo male, h/o HTN, hypercholesterolemia, c/o epigastric
discomfort/chest tightness with radiation to left arm since 6 am
morning of admission. He states that this pain began in the
morning (did not wake him from sleeping). It persisted all day,
was [**3-15**] at its worst, and he had 1 episode of associated
diaphoresis. He denied
nausea/vomiting/sob/pleuritis/palpitations, abdominal pain. He
also denies any PND/orthopnea, no urinary/bowel symptoms (states
has blood in stool at times [**3-7**] hemorrhoids). He went to [**Hospital1 2519**], where he had 2/10 chest pain that went to [**2-12**] after
SL NTG. His EKG showed 2-3 mm STE with Q's in II, III, AvF and
[**Street Address(2) 4793**] depressions in I, L, V4, V5. He was transferred here
for catheterization. Cath showed mid and distal RCA lesion that
was stented (3 cypher stents placed prox, mid vessel, distal)
with residual left sided disease.
Past Medical History:
PMH:
1. CAD; cath on [**5-5**] showing 70% prox RCA, with mid vessel total
occlusion, no collaterals; 70% proximal LAD, 50-60% hazy LCX;
distal OM branch 70%. CO=3.92, CI=1.77, PCWP=24, RA mean=17.
2. HTN
3. Hypercholesterolemia
4. Glucose intolerance
Social History:
Retired, formerly worked for [**Location (un) 86**] Herald
Married
Smoked cigars 10 yrs ago
Can drink up to [**2-4**] six packs/wk
Family History:
Brother with CABG age 58, son died CAD age 42, brother died 58
CAD, Mother died 55 CAD
DM
HTN
Physical Exam:
VS: afeb 118/81 111 9 95% RA
Gen: obese male, lying in bed, NAD
HEENT: OP clear
Neck: ?JVD 4 cm, no bruits
CV: distant HS, RRR, nl s1/s2, no m/r/g
Lungs: CTA bilatrally, no w/r/r
Abd: obese, nt/nd, NABS, no masses
Right groin: with some ooze, no bruits, no hematoma or
tenderness
Extr: no c/c/e, DP 2+ bilaterally
Neuro: moving all 4 extremities
Pertinent Results:
Labs on Admission:
136 / 102 / 14
------------< 141
3.6 / 21 / 0.9
MCV= 79 WBC=14.6 HgB=13.4 Plt=181 Hct=37.3
PT: 14.2 PTT: 118.2 INR: 1.3
Initial EKG: NSR with normal axis, ?top normal PR
[**Street Address(2) 4793**] depressions in I, AVL, V4/v5
2-[**Street Address(2) 2051**] elevations in II, III, AVF; q's in III, AVF
After cath:
improvement in ST depressions and elevations
First Catheterization:
1. Selective coronary angiography revealed a right dominant
system
with three vessel coronary artery disease. The LMCA had no
angiographically apparent flow limiting lesions. The LAD had a
70%
proximal stenosis as well as a 50% lesion in the diagonal
branch. The
LCX had a 70% proximal stenosis of the OM with a 50 to 60% hazy
lesion
in the distal vessel.
2. Resting hemodynamics demonstrated elevated right sided (mean
RA 19
mmHg), pulmonary (mean PA 35 mmHg), and left sided pressures
(mean PCWP
24) with a moderately depressed cardiac index (1.8 l/min/m2).
3. Left ventriculography was deferred.
4. Successful PTCA and stenting of the mid to proximal RCA with
overlapping Cypher DES (3.0x23mm distal, 3.0x23mm mid and
3.5x18mm
prox). Final angiography revealed no residual stenosis, no
dissection
and TIMI-3 flow (see PTCA comments).
TTE after first catheterization:
1. The left atrium is moderately dilated.
2. Left ventricular wall thicknesses and cavity size are normal.
Inferior hypokinesis is present.. Overall left ventricular
systolic function is mildly depressed.
3. Right ventricular chamber size is normal. There is mild
global right ventricular free wall hypokinesis.
4. The ascending aorta is mildly dilated.
5. The aortic valve leaflets (3) are mildly thickened.
Second Cardiac Catheterization:
1. Selective coronary arteriography revealed angiographic
evidence of
two vessel coronary artery disease. The LMCA had no flow
limitations.
The LAD had a 70% lesion in the proximal segment just after the
first
diagonal branch. The LCX had a 70% lesion in the distal segment
at the
level of a moderate caliber obtuse marginal branch. The RCA had
no flow
limitations.
2. FFR interrogation of the LCX revealed a FFR of 0.98 at
baseline and
0.80 during maximal hyperemia with Adenosine.
3. Successful direct stenting of the proximal LAD with a
2.5x13mm Cypher
DES and of the LCX with a 3.5x18mm Cypher DES complicated by
jailing of
the OM branch. Final angiography revealed 30% residual stenosis
in the
OM branch, no dissection and TIMI-3 flow (see PTCA comments).
Brief Hospital Course:
1. CAD: RF's include HTN, hypercholesterolemia. He had ST
elevations in his inferior leads on admission with ST
depressions in V1/V2, suggesting a posterior inferior MI. On
initial cardiac catheterization, he was found to have 70%
proximal RCA and 100% mid RCA lesion (also found to have 70%
proximal LAD lesion with 70% distal circumflex lesion). 3
cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 10157**] were placed in the RCA. Post-catheterization
TTE revealed an EF=45% with mild RV free wall hypokinesis. He
returned to the cath lab for intervention on his left system. At
this time, cypher stents were placed in each of these vessels.
He was chest pain free after these interventions and discharged
to follow up with Dr. [**Last Name (STitle) 10543**] at [**Hospital3 4107**]. He was
discharged on ASA, plavix, Toprol, Lisinopril, and Lipitor.
2. CHF: TTE after his initial catheterization showed EF=45%.
He had no problems with volume overload. He was started on
Lisinopril prior to discharge which can be titrated up as needed
by his cardiologist as an outpatient.
3. HTN: Metoprolol and Lisinopril were started in-house and can
be titrated as needed as an outpatient.
4. Hypercholesterolemia: His dose of Lipitor was increased to
80 mg and Zetia was discontinued. He will need regular LFT
monitoring while on this medication. He was advised of the
possible side effect of myalgias/myositis with this medication.
5. ?DM: states has history of glucose intolerance. Blood
glucose was within normal limits while in-house, and HbA1C was
sent and pending at time of discharge.
6. PVD: He gave a history consistent with symptoms of
claudication (not unreasonable given his coronary disease). He
will follow up with Dr. [**Last Name (STitle) 911**] for possible intervention and
management of his peripheral vascular disease.
7. Disposition: He was discharged on ASA, Plavix, Lipitor,
Toprol, and Lisinopril. He will follow up with Dr. [**Last Name (STitle) 10543**]
(cardiologist) upon discharge. He will need cardiac
rehabilitation and further lifestyle/risk factor modification.
Medications on Admission:
Lipitor
HCTZ
Zetia
Quinarctic (?)
NKDA
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*5*
3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
7. Nitroglycerin SubLingual Sig: One (1) Tablet SL Q5mins PRN.
Disp: *100 Tablet (s) * Refills:*2*
8. Cardiac Rehabilitation
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Inferoposterior Myocardial Infarction
Secondary Diagnoses:
1. Hypertension
2. Hypercholesterolemia
Discharge Condition:
Good
Discharge Instructions:
1. Please take all your medications as prescribed and described
in this discharge paperwork. We made the following changes to
your medication regimen.
- We added Toprol XL 25 mg daily, a medication to help with
your heart and blood pressure
- We added Lisinopril 10 mg daily, a medication to help with
your heart and blood pressure
- We increased your dose of Lipitor to 80 mg daily and
stopped your Zetia. Let your doctor know if you are
experiencing all-over body aches (this can be a side effect of
Lipitor). In addition, you should have your liver function
tested monthly while on this medication.
- We added Plavix 75 mg daily, a medication to thin your
blood and protect your new stents. We also added Aspirin 325 mg
daily. You must take these medications every day. Even missing
1 dose could result in thrombosis of your stent and death.
2. Follow up with Dr. [**Last Name (STitle) 10543**] at [**Hospital3 **] as described
below. Dr. [**Last Name (STitle) 911**] will also be in communication with you to
address your peripheral vascular disease.
3. Please call your PCP if you are experiencing chest pain,
shortness of breath, fever, chills, or any other concerns.
4. You should undergo cardiac rehabilitation following
discharge. Do not lift heavy objects or do intense physical
activity for 1 month following discharge. You should also take
measures to lose weight, eat a healthy, low fat/cholesterol
diet.
Followup Instructions:
1. Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10543**] at [**Hospital3 4107**]
([**Telephone/Fax (1) 61012**]) within 1-2 weeks of discharge. Please bring
this discharge paperwork with you at time of your appointment.
2. Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 61013**]) 1-2 weeks following discharge
3. Dr. [**Last Name (STitle) 911**] in cardiology here will contact you with respect
to possible treatment for your peripheral vascular disease.
4. You should undergo cardiac rehabilitation
|
[
"443.9",
"410.31",
"414.01",
"401.9",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"36.05",
"36.07",
"37.23",
"99.20",
"36.01",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
7958, 7964
|
4752, 6876
|
305, 364
|
8132, 8138
|
2239, 2244
|
9636, 10296
|
1757, 1852
|
6967, 7935
|
7985, 7985
|
6902, 6944
|
8162, 9613
|
1867, 2220
|
8067, 8111
|
255, 267
|
392, 1312
|
8004, 8046
|
2259, 4729
|
1334, 1593
|
1609, 1741
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,207
| 198,966
|
10323
|
Discharge summary
|
report
|
Admission Date: [**2172-7-7**] Discharge Date:
Date of Birth: [**2109-12-21**] Sex: M
Service:
CHIEF COMPLAINT: The patient was transferred from outside
hospital after ventricular tachycardia with AICD shock times
two this morning in the setting of a potassium of 3.0.
The patient is a 62-year-old gentleman transferred from an
outside hospital for an AICD workup after multiple shocks.
PAST MEDICAL HISTORY: Significant for ventricular
tachycardia with AICD placement in [**2167**]. Revised most
recently here at [**Hospital1 69**] in
[**2172-1-9**]. History of coronary artery disease with
cardiomyopathy, ejection fraction of 25% Has a mechanical
mitral valve placement.
The patient was in his usual state of health until 10 days
ago when he noted increased lower extremity edema and short
of breath. The patient progressively worsened and came to
the emergency department of an outside hospital [**2172-7-4**] for a
congestive heart failure exacerbation. The patient
progressively diuresed with Lasix and Zaroxolyn with good
symptomatic response. However, the patient has fluctuating
electrolytes and on [**2172-7-7**] in the early morning went into
V-tach and was shocked three times then recurred and shocked
three more times and was found to have a potassium of 3.0 at
that time.
He is currently on a regimen of Amiodarone and Mexiletine to
suppress ventricular tachycardia and to make the ventricular
tachycardia more responsive to the shocks. After shocks the
patient's labs were corrected and he was transferred here for
AICD interrogation and evaluation.
PAST MEDICAL HISTORY:
1. Coronary artery disease. Status post inferior wall
myocardial infarction in [**2147**]. Two vessel coronary artery
bypass graft in [**2169**].
2. Mechanical mitral valve.
3. Ejection fraction of 25%
4. Ventricular tachycardia with AICD placement in [**2167**].
Revised in [**2169**]. Added a pacemaker in [**2172-1-9**].
5. Epilepsy.
6. Cerebrovascular accident in [**2169**].
7. Diverticulitis.
8. Benign prostatic hypertrophy status post
Transurethral resection of prostate in [**2167**].
9. Gastritis.
10. H. pylori positive.
11. History of gallstones.
12. Ulcerative colitis with diagnosis in [**2128**].
13. Small unstable abdominal aortic aneurysm.
14. Appendectomy in [**2120**].
MEDICINES:
1. Norvasc 10 mg q day.
2. Atenolol 25 mg q day.
3. Ranitidine 150 mg twice a day.
4. Amiodarone 200 mg q day.
5. Coumadin 7.5 mg q day.
6. Lasix 80 mg twice a day.
7. Potassium chloride 20 mg q.i.d.
8. Mysoline 250 mg twice a day.
9. Folate 1 mg q day.
10. Lipitor 10 mg q day.
11. Aldactone 100 mg q day.
12. Isosorbide 10 mg three times a day
13. Mexiletine 150 mg three times a day.
14. Aspirin 81 mg q day.
15. Multivitamins q day.
SOCIAL HISTORY: The patient is married, has 140 pack year
history of tobacco. Occasional alcohol use.
FAMILY HISTORY: Positive for coronary artery disease.
PHYSICAL EXAMINATION: The patient was temperature 97.7,
pulse 70, blood pressure 112/60, respirations 18, sating 97%
on room air. The patient was an obese older gentleman in no
acute distress. HEAD, EYES, EARS, NOSE AND THROAT: Mucous
membranes moist. Pupils are equal and reactive to light and
accommodation. Neck: Unable to see the IJ. No bruits.
Heart: Regular rate and rhythm. Mechanical S1, no murmurs.
Lungs: Distant breath sounds otherwise clear. Abdomen soft,
nontender, positive bowel sounds, nondistended. Extremities:
1+ edema to the mid-calf. NEUROLOGICAL: The patient had
cranial nerves II through XII intact. Alert and oriented
times three. 5/5 strength. Sensation grossly intact.
LABS: White count 7.2, hematocrit 42.4, platelet 106, SMA 7
139, 4.1. 96/27, BUN 51, creatinine 2.3, glucose 120,
calcium 8.7, alk phos 5.3, mag 2.5. The patient had a
prothrombin time of 19.4, INR 2.5, PTT 22.8.
The patient's last echo in [**2172-1-9**] which showed focal
systolic left ventricular dysfunction, mechanical mitral
valve normal. EF 25%
HOSPITAL COURSE:
1. V. Tach. The patient was admitted to the [**Hospital Unit Name 196**] service.
The patient was taken to the EP Laboratory where the patient
had a NIPS, non-invasive procedure done. The patient had an
oblation was then done of the V-tach, this was unsuccessful.
The patient returned to the EP- laboratory on [**2172-7-16**] for a
experiment cold tip catheterization which was successful in
ablating his ventriculoperitoneal focus.
After [**7-16**] the patient had no more runs of ventricular
tachycardia. The patient's Mexiletine was stopped after
[**2172-7-16**] successful cold tip catheterization.
2. Congestive heart failure. The patient admitted with
increased lower extremity swelling, short of breath, the
patient was continued to be diuresed with Lasix, Zaroxolyn.
Zaroxolyn was discontinued after the patient was deemed to be
uvolemic. The patient was returned back to his normal dose
of Lasix 80 mg p.o. b.i.d. with resolvement in congestive
heart failure symptoms.
3. Renal. The patient admitted with a creatinine of 2.3,
unknown baseline creatinine, most likely this was an acute
renal failure on top of chronic renal failure. The patient's
Lasix was held initially. The patient's creatinine
stabilized and was discharged with a creatinine of 2.1.
4. Heme. The patient admitted with an INR of 2.5, however,
the patient's Coumadin was held secondary to EP studies. The
patient was transitioned to Heparin. The patient had EP
study done the second and again on the 9th with successful
catheterization on the 9th. The patient was kept on Heparin
and transitioned over to Coumadin. The patient was
discharged on both Heparin drip and Coumadin dose at 7.5 mg q
day. The goal is to have the patient therapeutic on Coumadin
with an INR ranging between 2.5 and 3.5 prior to discharge
from the rehabilitation.
The patient had a hematocrit of 42.4 on admission, the
patient's hematocrit was stable however after the patient's
[**7-16**] procedure the patient had an episode of epistaxis. After
epistaxis the patient's hematocrit dropped to 27 the patient
was transfused as needed. After the procedure the patient's
hematocrit stabilized and after discharge the hematocrit was
30.7.
5. ID: The patient on [**2172-7-19**] developed symptoms of
dysuria. The patient had a positive urine culture for E.
coli. The patient was started on Ciprofloxacin 500 mg twice
a day. The patient had two doses prior to discharge. The
patient will follow-up with a seven day course of
Ciprofloxacin 500 mg twice a da
6. BLOOD PRESSURE: The patient admitted with multiple
medications for high blood pressure. The patient's Atenolol
25 mg was increased and switched over to Lopressor 75 mb
twice a day. The patient's Losartan was discontinued and the
patient was started on Hydralazine and was discharged with 20
mg b.i.d. with blood pressures on discharge in the 130 to
140/60 to 70 range.
7. PSYCHIATRIC: The patient had anxiety issues related to
the number of shocks or to the possibility of the patient
being shocked. Psychiatry was consulted. They felt it was
necessary to start the patient on low dose of Klonopin. The
patient was started on .5 mg of Klonopin b.i.d. The patient
discharged on this dose. The patient without anxiety upon
discharge. The patient told to follow-up with his therapist.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSIS: As on diagnosis on admission.
MEDICATIONS:
1. Amiodarone 400 mg p.o.q day.
2. Lasix 80 mg p.o. b.i.d.
3. Aldactone 100 mg q day.
4. Folate 1 mg q day.
5. TUMS one to two p.o. q 4 to 6
6. Klonopin .5 mg p.o. b.i.d.
7. Isordil 30 mg three times a day.
8. Aspirin 81 mg q day.
9. Multivitamin one tab q day.
10. Lopressor 75 mg twice a day.
11. Hydralazine 20 mg q.i.d.
12. Potassium chloride 20 mEq q day.
13. Lipitor 10 mg q day.
14. Colace 100 mg twice a day.
15. Mysoline 250 mg twice a day.
16. Coumadin 7.5 mg q day.
17. Heparin drip with a PTT target of 60 to 100.
18. Protonics 40 mg q day.
19. Norvasc 10 mg q day.
20. Ciprofloxacin 500 mg p.o. b.i.d. for seven days.
DISPOSITION: The patient will be discharged to an acute care
cardiac rehabilitation facility.
CONDITION UPON DISCHARGE: Stable.
[**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**MD Number(1) 25755**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2172-7-20**] 13:43
T: [**2172-7-20**] 13:55 JOB#: [**Job Number 34297**]
|
[
"440.1",
"414.01",
"427.1",
"599.0",
"V45.81",
"041.4",
"428.0",
"412",
"V43.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"88.42",
"37.26",
"88.48",
"37.34"
] |
icd9pcs
|
[
[
[]
]
] |
2912, 2951
|
7433, 8225
|
4041, 7377
|
2974, 4024
|
132, 409
|
8242, 8498
|
1621, 2790
|
2807, 2895
|
7402, 7411
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,206
| 108,135
|
42292
|
Discharge summary
|
report
|
Admission Date: [**2105-9-10**] Discharge Date: [**2105-9-18**]
Date of Birth: [**2084-3-6**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
"My neck and chest hurts"
Major Surgical or Invasive Procedure:
C6-7 anterior corpectomy/discetomy, allograft fusion [**9-12**]
lumbar drain [**9-12**]
History of Present Illness:
This is a 21 year old male [**Location (un) **] from outside hospital
for a cervical fracture after a motor vehicle colision. He was
a
unrestraint driver who was driving approximate 45 mph and was
involved in a MVC rollover. He was ejected from the vehicle.
When EMS arrived, patient was a GCS 15 and was ambulatory. He
was taken to [**Hospital 8641**] Hospital in [**Location (un) 3844**] and a C-spine Ct
showed a C6-7 fracture.
On arrival, pt c/o [**7-26**] neck and chest pain. He was moving all
extremities. He was wanting to urinate. He complains of
numbness from his left forearm down to his hand most
predominately left index/thumb predominately. No other ares of
numbness or paresthesia
Past Medical History:
none
Social History:
married with 2 Children, +smoke, no ETOH, no ilicit
drug use
Family History:
NC
Physical Exam:
O: T: 97 BP: 120/80 HR: 90 R 17 O2Sats 98%
Gen: WD/WN, complaining of pain and discomfort, in a hard collar
and flat board
HEENT: traumatic with head lacs/abrasions; Eyes clear, nasal
passages patent, hearing intact, Pupils: PERRL 4-2mm EOMs -
full
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor is [**5-21**] bilaterally except with slight left HI weakness
5-/5
Sensation to light touch intact bilaterally
Reflexes: B T Br Pa Ac
Right 2+----------
Left 2+----------
No clonus, negative [**Doctor Last Name **]
Toes downgoing bilaterally
Rectal exam normal sphincter control
PHYSICAL EXAM UPON DISCHARGE:
left tricep 4+/5 otherwise NF
incision C/D/I,steri's
1 suture from lumbar drain removal
Pertinent Results:
CHEST X-RAY AP portable view [**2105-9-10**]
1. No acute intrathoracic injury.
CT HEAD W/O CONTRAST; OUTSIDE FILMS READ ONLY [**2105-9-10**]
1. No acute intracranial process.
CT C-SPINE W/O CONTRAST; OUTSIDE FILMS READ ONLY [**2105-9-10**]
1. Left-sided unilateral facetal dislocation at C6-C7 with
extensive C6 and C7 vertebral body and left-sided C7 lamina and
pedicular fractures with probable extension into the transverse
foramen. Free fracture fragment is seen in the anterior and left
aspects of the spinal canal.
CT CHEST W/CONTRAST; OUTSIDE FILMS READ ONLY; CT ABD & PELVIS
WITH CONTRAST; OUTSIDE FILMS READ ONLY [**2105-9-10**]
1. Cervical spine fracture at C6-C7 level, will be discussed in
detail as on the accompanying CT cervical spine; however,
irregularity to the left
vertebral artery slightly above this level with possible intimal
flap could reflect vertebral artery dissection. CTA of the neck
is recommended for further evaluation.
2. No additional sites of traumatic injury to the torso.
3. 3-cm left paraaortic enhancing nodal conglomerate and other
non-pathologically enlarged, but prominent retroperitoneal and
right pelvic nodes are concerning for neoplastic process with
differential diagnosis including lymphoma vs testicular
malignancy. If not performed in the recent past, further
evaluation with scrotal ultrasound can be obtained on a
non-emergent basis with subsequent tissue sampling of
retroperitoneal lymph node conglomerate.
CTA NECK W&W/OC & RECONS [**2105-9-10**]
1. The vertebral arteries are patent without evidence of
stenosis, aneurysm
formation, dissection, or other vascular abnormality.
2. The carotid arteries are patent without evidence of stenosis.
3. The fracture/subluxation of C6-C7 is again seen.
SHOULDER (AP, NEUTRAL & AXILLA; ELBOW (AP, LAT & OBLIQUE) LEFT;
WRIST(3 + VIEWS) LEFT [**2105-9-10**]
1. Suboptimal evaluation of the left shoulder as no axillary or
Y view was
obtained to fully evaluate for dislocation, and if dislocation
continues to be of concern, suggest obtaining either Y or
axillary view.
2. Mild widening of the left acromioclavicular joint. Recommend
clinical
correlation for possible AC joint injury or comparison with
radiographs of the contralateral side.
3. No evidence of acute fracture of the left shoulder, elbow, or
wrist.
MR CERVICAL SPINE W/O CONTRAST [**2105-9-11**]
1. Three column fracture of C6/C7, with disruption of the middle
column at C6, the anterior column at C7 (including the ALL) as
well as bilateral facet dislocation and disruption of the
posterior ligamentous complex.
2. No evidence of spinal cord trauma
CT C-SPINE W/O CONTRAST [**2105-9-11**]
1. Status post C6 and C7 corpectomies, adjacent diskectomies,
and C5-T1
anterior fusion, without evidence of hardware-related
complications.
Alignment is now anatomic.
2. Bilateral C7 posterior element fractures are again seen. The
left C6-7
facets are no longer perched, but now demonstrate anatomic
alignment. The
right C6-7 facets remain well aligned.
CHEST PORTABLE AP VIEW [**2105-9-11**]
The patient is after spinal surgery. The newly placed
endotracheal
tube projects with its tip over the mid trachea. There is no
evidence of
complications, notably no pneumothorax. No other relevant
changes.
CHEST PORTABLE AP VIEW [**2105-9-12**]
There are low lung volumes. Cardiac size is top normal. Left
lower lobe
atelectasis has minimally worsened. Right lower lobe atelectasis
is
unchanged. There are no new lung abnormalities. There is no
evident
pneumothorax or large pleural effusion. Spinal hardware is
noted. ET tube
tip is in standard position.
BILAT LOWER EXT VEINS [**2105-9-14**]
No deep venous thrombosis in right or left lower extremity.
Brief Hospital Course:
21 y/o M who presents s/p MVC rollover. Patient was an
unrestrained driver who was ejected from a car after a
collision. He presented to OSH where he was found to have
cervical spine fractures and was then transferred to [**Hospital1 18**] for
further neurosurgical evaluation. At scene, he was a GCS of 15
and ambulatory. On examination, patient reported neck and chest
pain and numbness in his L forearm. He was admitted to the
neurosurgical service for treatment of a C6-7 burst fracture and
perched L facet. He was taken to the OR on [**9-11**] for an anterior
corpectomy and discectomy. A lumbar drain was also placed for
further decompression. He was transferred to the ICU s/p OR for
close monitoring. He remained intubated. On [**9-13**], patient was
extubated. His WBC was elevated and febrile, he was pancultured
and started on antibiotics for presumed VAP. His sputum cultures
showed positive and was started on vanc/zoysn. On exam, he has
some L tricep weakness 4/5, otherwise appears full. On [**9-14**],
patient had bilateral LENIs read as negative, continued lumbar
drain, and followed cultures with primary reads showing
commensal respiratory flora and Haemophilus sp. On [**9-15**], he was
transferred to the floor and his lumbar drain continues to drain
at 15-20cc/hr. On [**9-16**], lumbar drain was removed and he will be
able to mobilize on [**9-17**]. He had no issues overnight on [**9-16**] into
[**9-17**] and PT and OT worked with him and he was mobilized. His pain
was under control on a stable regimen as well.
On [**9-18**] he was seen by PT/OT and cleared for discharge home. His
pain is well controlled and he is tolerating a PO diet. He
agrees with the plan for discharge home.
Medications on Admission:
none
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for Pain.
Disp:*90 Tablet(s)* Refills:*0*
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
5. Physical & Occupational Therapy Sig: One (1) as
determined: Dx: cervical spine fracture.
Disp:*1 * Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
C6-7 burst fracture with L perched facet
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Do not smoke.
?????? Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
?????? If you have steri-strips in place, you must keep them dry for
72 hours. Do not pull them off. They will fall off on their own
or be taken off in the office. You may trim the edges if they
begin to curl.
?????? 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.
?????? Wear your cervical collar at all times.
?????? You may shower briefly without the collar or back brace;
unless you have been instructed otherwise.
?????? 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.
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
?????? 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?????? F.
?????? Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
Follow Up Instructions/Appointments
??????Please return to the office in [**7-26**] days (from date of surgery)
for removal of your staples/sutures and/or a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **] to be seen in 6 weeks.
??????You will need a CT-scan prior to your appointment.
?????? Please call for a follow up with Cognitive Neurology,
[**Telephone/Fax (1) 1690**] within one week of discharge.
Completed by:[**2105-9-18**]
|
[
"997.31",
"E816.0",
"E849.7",
"E879.8",
"805.08",
"E849.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.09",
"77.79",
"81.63",
"84.51",
"03.53",
"81.02",
"80.51"
] |
icd9pcs
|
[
[
[]
]
] |
8296, 8302
|
5973, 7684
|
334, 424
|
8387, 8387
|
2233, 5950
|
10366, 11111
|
1282, 1287
|
7740, 8273
|
8323, 8366
|
7710, 7717
|
8538, 10343
|
1302, 1678
|
268, 296
|
2125, 2214
|
452, 1158
|
8402, 8514
|
1180, 1187
|
1203, 1266
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,766
| 120,303
|
44093
|
Discharge summary
|
report
|
Admission Date: [**2163-1-6**] Discharge Date: [**2163-1-22**]
Date of Birth: [**2087-8-29**] Sex: M
Service: EMERGENCY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
Left leg pain
Major Surgical or Invasive Procedure:
Central Venous Catheter
Temporary Dialysis Catheter
Endotracheal Intubation
Foley Catheter
Arterial Line
History of Present Illness:
75 yo Russian man h/o Bladder Cancer (s/p ureterostomy; recent
admit for TURBT), osteoarthritis, CAD, DM-2 p/w acute onset of L
posterior leg/buttock pain x 2 days.
.
Pt has not been able to walk since onset of pain. Denies
similar episodes in past. No recent trauma. No numbness of
extremity. No dysuria/hematuria. No chest pain/sob. No
HA/dizziness. No back pain. No fevers, cough/cold, recent
infection.
Past Medical History:
*Bladder cancer diagnosed in [**2147**] s/p TURB x4, BCG with R->L
transureter-ureterostomy in [**4-5**] c/b hemorrhagic cystitis; TURBT
done [**12-8**]
*CAD s/p CABG in [**2162**]
*CHF, EF 32%
*DMII
*CRI, baseline Cr 1.6-1.7
*HTN
*severe burns with multiple skin grafts
*atrial fibrillation, not on coumadin given significant
hematuria
*Psoriasis
* Varicose veins
Social History:
Mr. [**Known lastname **] was a former metal worker in the [**2125**]'s. He suffered
severe third degree burns and survived. He is married and has 2
sons. [**Name (NI) **] was a former 1 [**2-2**]
pack per day smoker for over 40 years and stopped approximately
7 years ago. He drinks EtOH rarely.
Family History:
significant for colon CA.
Physical Exam:
Vitals: T-96.5, P-66, BP-122/64, RR-16, O2-100% (RA)
Gen - Obese man in mild distress secondary to pain
Eyes - EOMi, PERRLA
ENT - dry MM
CV - irreg/irreg, nl s1/s2, no murmurs. 3+ b/l LE edema
Resp - comfortable, CTAB
GI - protruberant, soft, NT/ND, nl bs
Musculoskeletal - RLE 5/5 strength; LLE 4/5 strength. Pain on
palpation over lateral aspect of L hip and buttock. No spinal
tenderness.
Neuro - +SLR on L; negative SLR on R. AAOx3. Fluent speech.
Skin - multiple skin grafts. warm
Psych - appropriate/pleasant
Lymph - no cervical LAD
GU - L urostomy tube in place
Pertinent Results:
Admit Labs:
--------------
[**2163-1-6**] 04:40PM WBC-6.4 RBC-3.70* HGB-9.0* HCT-28.2* MCV-76*#
MCH-24.3* MCHC-31.8 RDW-17.8*
[**2163-1-6**] 04:40PM NEUTS-82.9* LYMPHS-8.9* MONOS-7.0 EOS-1.0
BASOS-0.2
[**2163-1-6**] 04:40PM PLT COUNT-271
[**2163-1-6**] 04:40PM GLUCOSE-120* UREA N-90* CREAT-2.2* SODIUM-137
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-26 ANION GAP-14
.
L-SPINE (AP & LAT) [**2163-1-6**] 3:09 PM
FINDINGS: There are five non-rib-bearing lumbar-type vertebrae.
Severe multilevel degenerative disc disease is evident, most
notably at L3-L4 and L5-S1. Extensive facet arthropathy is noted
at the lumbosacral junction. Grossly alignment is preserved. No
suspicious osteolytic or blastic lesions are identified. The
sacrum and sacroiliac joints are unremarkable. Incidental note
is made of an indwelling left-sided nephrostomy.
IMPRESSION: Extensive multilevel degenerative disease with no
suspicious osseous lesions evident.
.
UNILAT LOWER EXT VEINS LEFT [**2163-1-6**] 2:38 PM
FINDINGS: Grayscale, color Doppler, Doppler waveform evaluation
were performed of the left lower extremity. The common femoral,
superficial femoral, and popliteal veins were interrogated and
demonstrated normal compressibility, color Doppler signal, and
Doppler waveforms.
IMPRESSION: No evidence of deep venous thrombosis in the veins
interrogated above.
.
FEMUR (AP & LAT) LEFT and TIB/FIB [**2163-1-6**] 3:09 PM
FINDINGS: Mineralization is within normal limits. The hip, knee,
and ankle joints are grossly appropriately aligned. Mild
degenerative changes are noted at the knee. The ankle mortise is
congruent. The talar dome is intact. There is diffuse soft
tissue swelling throughout the lower extremity particularly at
the ankle and anterior to the proximal tibia. Extensive vascular
calcification is incidentally noted.
IMPRESSION: No underlying fracture. Mild degenerative change in
the knee. Soft tissue swelling as above.
.
CHEST (SINGLE VIEW) [**2163-1-6**] 3:09 PM
FINDINGS: Lung volumes are further diminished. There is no
consolidation. There is mild central vascular congestion,
although no overt edema is seen. Again noted are prominent
pulmonary arteries. There is tortuous aorta. The cardiac
silhouette size remains enlarged but stable. There is pleural
thickening along the lateral aspects of both hemithoraces. No
pleural effusion or pneumothorax is evident. Median sternotomy
wires are stably aligned.
IMPRESSION: No acute pulmonary process.
.
ECG ([**1-6**]) - A-fib@56, LAD, RBBB, Q's II/III/aVF. (no
significant change vs. previous)
.
.
MRI L-spine:
IMPRESSION:
1. No evidence of bony metastasis or acute compression fracture.
2. Mild-to-moderate spinal stenosis at L3-4 level.
3. Moderate-to-severe left foraminal and mild to moderate right
foraminal narrowing at L5-S1 level with disc and facet
degenerative changes.
..
..
MRI hips:
FINDINGS: The ilia are not completely imaged in coronal STIR or
axial sequences. There is abnormal bone marrow signal within the
left iliac [**Doctor First Name 362**], extending to the articular surface at the left
sacroiliac joint and to the medial acetabular wall and roof. The
marrow signal within the sacrum is within normal limits, so is
in the right ilium except for a small focus of T1 low signal and
T2 high signal in the medial acetabulum, which likely represents
a subchondral cyst. The heterogeneous marrow signal within the
proximal femoral shafts likely represents hematopoietic marrow.
The bone marrow signal within the visualized vertebrae is
unremarkable except for mild endplate changes. There is
increased T2 signal within the adductor and obturator internus
muscles, left greater than right, and within left gluteus medius
and minimus muscles.
The urinary bladder is contracted, and shows nodular thickening,
which is concordant with the patient's history of bladder
carcinoma. There is also dilatation of the visualized distal
ureters bilaterally. There are multiple shotty and mildly
enlarged perirectal and retroperitoneal lymph nodes, the largest
measuring 11 mm in the right iliac chain.
IMPRESSION:
1. Abnormal left ilium, which likely represents a non-displaced
fracture; however, metastatic disease cannot be excluded.
Atypical radiation changes are much less likely. Edema within
the adductor and gluteus muscles as described above. Ilia are
not completely imaged. We will be happy to complete the MRI of
the pelvis at no additional charge; however, followup CT would
be better to assess for fracture.
2. Findings in the bladder are concordant with the patient's
history of bladder carcinoma. There is distal bilateral
hydroureters.
3. Multiple shotty and mildly enlarged lymph nodes, the largest
measuring 11 mm in the right iliac region.
SPECIMEN SUBMITTED: LEFT ILIAC BONE LESION.
Procedure date Tissue received Report Date Diagnosed
by
[**2163-1-14**] [**2163-1-14**] [**2163-1-18**] DR. [**Last Name (STitle) **]. BROWN/tcc
Previous biopsies: [**-8/4539**] Bladder Tumor.
[**-8/2588**] BLADDER CANCER.
[**Numeric Identifier 94656**] BLADDER TUMOR (1).
[**Numeric Identifier 94657**] LT/RT DISTAL URETER
(and more)
DIAGNOSIS:
Left iliac bone lesion:
Metastatic urothelial carcinoma.
CT HEAD W/O CONTRAST [**2163-1-15**] 5:33 AM
CT HEAD W/O CONTRAST
Reason: Assess for CVA/bleed
[**Hospital 93**] MEDICAL CONDITION:
75 year old man with h/o Afib and metastastic bladder CA, p/w
lethargy and acute change MS
REASON FOR THIS EXAMINATION:
Assess for CVA/bleed
CONTRAINDICATIONS for IV CONTRAST: None.
HEAD CT WITHOUT CONTRAST
INDICATION: A 75-year-old man with history of atrial
fibrillation, metastatic bladder carcinoma, presenting with
lethargy and acute mental status change. Assess for hemorrhage,
CVA.
COMPARISON: Not available.
FINDINGS: There is no acute intracranial hemorrhage, edema,
shift of normally midline structures or hydrocephalus. There is
no evidence of major vascular territorial infarction.
Surrounding soft tissues and osseous structures are
unremarkable. Minimal mucosal thickening is noted in the right
maxillary sinus. The rest of the paranasal sinuses and mastoid
air cells are well aerated.
The ventricles, sulci and extra-axial spaces are prominent,
consistent with age-related involutional change. There are
periventricular white matter hypodensities, mild, consistent
with chronic microvascular ischemic changes.
IMPRESSION: No acute intracranial hemorrhage.
No CT evidence of major vascular territorial infarction, but MRI
remains most sensitive for evaluation of acute ischemia.
RENAL U.S. PORT [**2163-1-21**] 9:15 AM
RENAL U.S. PORT
Reason: re-evaluate for hydronephrosis
[**Hospital 93**] MEDICAL CONDITION:
75 year old man with acute on chronic renal failure and
nephrostomy tube in place
REASON FOR THIS EXAMINATION:
re-evaluate for hydronephrosis
INDICATION: Acute and chronic renal failure, nephrostomy tube in
place.
RENAL ULTRASOUND: Comparison with [**2163-1-20**]
nephrostogram and renal ultrasound, [**2163-1-16**]. This
study is limited by patient inability to position and bowel gas.
The left kidney measures 11.7 cm, with a nephrostomy tube
faintly visible. There is no hydronephrosis. The right kidney is
not well identified due to habitus and inability to position.
The bladder is collapsed around the Foley.
IMPRESSION: No hydronephrosis.
[**2163-1-17**] ECHO:The left atrium is mildly dilated. Left
ventricular wall thicknesses and cavity size are normal. There
is mild to moderate regional left ventricular systolic
dysfunction with severe hypokinesis of the inferior and
inferolateral wall. The remaining segments contract well (LVEF =
35 %). Right ventricular chamber size is normal with mild 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. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2163-1-14**],
mild mitral regurgitation is not seen on the current study.
URINE CULTURE (Final [**2163-1-18**]):
YEAST. >100,000 ORGANISMS/ML..
Brief Hospital Course:
75 yo man h/o bladder CA (s/p multiple TURBTs & s/p urostomy
tube), CAD s/p CABG, OA presents with severe pain of left
buttock, radiation into hamstring found to have metastatic
bladder cancer in the bone, lung, and liver. Patient had a
complicated medical admission resulting in transfer to the
medical ICU after mental status change post IR guided bone
biopsy. After progressive deterioration including multi-system
organ failure requiring triple pressor therapy, mechanical
ventilation, and CVVHD, goals of care were changed to comfort
measures only and the patient quickly died minutes after removal
of care from respiratory failure.
Outlined by problem is his hospital course:
#hypotension: Multiorgan system failure. Initial concern for
septic shock v. possible cardiogenic. Other possible etiologies
hemorrhagic, obstructive unlikely. Cardiac ezymes cycled and
unrevealing. Patient not responsive to trial of dobutamine. ECHO
shows LVEF>35%
Concern for urosepsis vs question new aspiration pna (may have
aspirated while intubated for IR procedure). Empiric treatment
for aspiration pneumonia and candiduria initiated. Culture data
was unrevealing. Repeat RUQ US was negative for cholelithiasis.
Patient was continued on neosynephrine, levophed, and
vasopressin and patient received course of stress dose steroids.
.
# Respiratory Failure: Patient requiring intubation in setting
of altered mental status and hypotension for adequate airway
management and management of acidosis. Altered mental status
improved on [**1-19**]. Patient not hyperventilating to compensate
for metabolic acidosis appropriately.
Patient verified that he wanted to be intubated on [**1-21**] via
interpretor, given multi-system organ failure and multiple
pressor requirement, will keep intubated and sedated.
.
# Anion Gap Acidosis: [**3-5**] uremia, lactic acidosis, attempted
correct w/ CVVHD, vent settings.
.
#Altered mental status: Initially in setting of hypotension,
likely toxic metabolic due to sepsis. CT of the head is without
acute hemorrhage or stroke (although MR is more sensitive).
Differential included narcotics vs. sepsis vs. hypercarbia v
hyperkalemia. ABG 7.24/66/66. However, did not wake up with
narcan. Pco2 down s/p CPAP then intubation. MS improved on
[**1-19**], pt responding appropriately, following commands.
.
# Candiduria: persistent yeast in urine, with no other culture
data to support infectious etiology of hypotension. Treated
with caspofungin as per ID. Nerphostomy tube chnaged at IR on
[**1-20**]
.
# Elevated LFTs/RUQ pain: Shock liver vs. metastatic disease in
liver.
.
#Acute on CKD: likely prerenal due to hypotension; concern for
ATN s/p multiple insults. No muddy brown casts seen in sediment
on initial examination. Renal US on [**1-7**] did not show any
evidence of hydro. Nephrostomy tube replaced on [**1-20**] by IR,
intitially put out well, now UOP has dropped off. Initiated on
CVVHD on am of [**1-22**] after ROJ temporary dialysis line placed.
CVVHD discontinued when goals of care changed.
.
# Bladder Cancer s/p multiple TURBT w/ urostomy tube: #1,
pathologic fracture, metastasis as above. Urostomy changed by
interventional radiology in the setting of candiduria.
.
# Left buttock pain, ilium fracture, history of bladder cancer:
MRI L-spine and hip done on admission [**1-7**] demonstrated ?
fracture of left ilium, concern for pathologic fracture. Patient
denied trauma before admit. CT scan performed [**1-7**] for better
definition of lesion, concern for pathologic fracture.
[**Date range (1) 68760**] patient non weight bearing, pain management, see by
orthopoedics but ortho/onc, rad/onc unavailable. On [**1-10**], CT
scan reviewed, ortho/onc and rad/onc consulted. Pt underwent CT
guided biopsy of the bone lesion on [**1-14**] which showed
metastatic bladder cancer.
In staging, bone scan had no further lesions, CT torso showed
lesions in liver and nodules in lung. Oncology prognosis was
less than 6 months.
.
#Urinary Tract infection: Pt passes urine only through left
nephrostomy tube. Right ureter is divert to left ureter.
Started on cipro on [**1-8**]. Urine culture returned klebsiella and
enterococcus (though only low grade). Pt was treated to cover
Klebsiella only with Ciprofloxacin.
.
#CAD s/p CABG [**2154**]. Antihypertensives held in setting of
hypotension. Aspirin was not given as patient had a history of
hematuria.
.
#CHF, systolic [**Last Name (LF) 94658**], [**First Name3 (LF) **] 30% ([**4-5**]): systolic dysfunction
on repeat ECHO, LVEF 35%.
.
#HTN - Held meds in setting of hypotension.
.
# Atrial fibrillation: Patient not anti-coagulated because of
severe hematuria in the past. Beta blocker with good rate
control. While in the ICU, patient anticoagulated with a heparin
gtt.
.
# FEN: Tube feeds provided while NPO.
.
# Prophylaxis: heparin gtt, bowel regimen.
.
# Access: Aline, LIJ, RIJ dialysis cath
.
# Code: changed to full on [**1-16**] when patient intubated and
lined, DNR as of [**1-21**] and changed to comfort measures only on
[**2163-1-22**].
Medications on Admission:
Percocet 1-2 tabs q4h PRN pain
Lasix 120mg daily
Losartan 50mg daily
Toprol XL 50mg daily
Neurontin 300mg [**Hospital1 **]
ASA 81
NPH 15U qAM
Humalog sliding scale
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Metastatic bladder Cancer
Multisytem Organ Failure
Respiratory Failure
Acute Renal Failure
Shock Liver
Candiduria
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
|
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49,255
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55113
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Discharge summary
|
report
|
Admission Date: [**2138-6-28**] Discharge Date: [**2138-7-21**]
Date of Birth: [**2055-9-7**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Severe Thunderclap Headache found on imaging to be
intraparenchymal hemorrhage
Major Surgical or Invasive Procedure:
Tracheostomy placement
PEG Tube placement
History of Present Illness:
Ms. [**Known lastname 83553**] is an 82 year old right handed woman with a past
medical history significant for Multiple Sclerosis, Diabetes,
Hypertension, previous stroke, and
legal blindness who presents to [**Hospital1 18**] after having been found to
have sudden onset of worst headache of her life, which on
subsequent imaging was found to be a large right parietal
intraparenchymal hemorrhage with subarachnoid hemorrhage at OSH.
She had been in her usual state of health until the day prior to
admission. On [**2138-6-27**], the patient began to complain about a
severe headache which is frontal and radiates towards the top of
her head. Initially she attempted to sleep for amelioration,
but at 0400hrs on [**2138-6-28**], the headache recurred, waking her
from sleep. Per her husband she [**Name2 (NI) 63582**]'t herself, and had
urinary incontinence. She took an oxycodone which ameliorated
the pain later that morning, but it returned later in the
afternoon. Upon arrival of her daughter later that evening, she
was found with altered mental status still complaining of severe
headache. Given this, EMS was activated and the patient was
transported to [**Hospital3 **] for evaluation. Upon arrival, vitals
were significant for BP of 210/79, HR: 97, RR: 18, T: 98.4 95%
on RA. There, a NCHCT was performed revealing a right parietal
intraparenchymal hemorrhage with a small subarachnoid
hemorrhage. She was then transferred to [**Hospital1 18**] for urgent
evaluation.
Neurosurgery saw her in the ED, recommending platelets and
Nicardipine for hypertension, but recommended no immediate
surgical intervention and further management per the neurology
service.
Past Medical History:
- Multiple Sclerosis -- diagnosed at age 45 managed by PCP. [**Name10 (NameIs) **]
apparently been on betaseron in the past (per unsure daughter).
Has baseline right sided weakness and a b/l LE neuropathy, but
is otherwise ambulatory with a walker and has no urinary
incontinence at baseline.
- Hypertension
- Type 2 Diabetes Mellitus on oral hypoglycemics
- Previous stroke unknown location, with no residual deficits
- Legally blind - s/p bilateral laser surgery
- Obstructive Sleep Apnea
Social History:
Lives at home with husband. Previously worked in a shoe
department repairing shoes. History of tobacco use, but quit
over 40 years ago. No Alcohol or Illicit Substances.
Family History:
Mother died [**2-6**] brain tumor many years ago. Otherwise,
non-contributory.
Physical Exam:
Physical Examination on Admission:
Initial VS: 98.6 68 182/54 14 97%
General: Awake, alert, NAD
HEENT: Sclerae anicteric, no conjunctival injection, oropharynx
clear
Cardiac: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops
Chest: CTA bilaterally, no wheezes, rhonchi, rales
Abdominal: NABS, soft, NTND abdomen
Extremities: No lower extremity edema bilaterally
Neurologic examination:
Mental status: Awake, but with waxing and [**Doctor Last Name 688**] alertness.
Cooperative with exam, though needs directions repeated to her
multiple times. Oriented to person, "[**Hospital3 **]", and "[**Month (only) **]
[**2138**]". Inattentive, unable to say [**Doctor Last Name 1841**] backwards, but starts to
say them forwards after a different question was asked.
+dysarthric, but fluent speech. Unable to assess naming [**2-6**]
poor
visual acuity. No right-left confusion. +perseveration on exam.
Cranial Nerves: +surgical pupil on left that's non-reactive
(~2mm) and irregular. +normal pupil on right, but reactive
(~1mm). Unable to assess visual fields. Visual acuity to only
to shapes and colors (though she complimented this examiner's
beauty which may verify her poor visual acuity). Extraocular
movements intact bilaterally without nystagmus. Sensation intact
V1-V3. Facial movement symmetric. Palate elevation symmetric.
Sternocleidomastoid and trapezius full strength bilaterally.
Tongue midline, movements intact.
Motor: Normal bulk and tone bilaterally. No observed myoclonus,
asterixis, or tremor. No pronator drift. Apparent full strength
throughout, but unable to fully cooperate for strength testing,
particularly in the LE.
Sensation: Intact to light touch throughout, but unable to test
any other modalities.
Reflexes: 2+ and symmetric in b/l UE and UTO in b/l LE. Toes
mute bilaterally.
Coordination: finger-nose-finger normal.
Gait: deferred
***************
Physical Exam on Discharge:
Physical Examination on Admission:
Initial VS: Temp = 99F, HR = 92, BP = 122/59, 96% on 10 pressure
support, 10 PEEP, 50% FiO2
General: Awake, alert but unable to respond to command
HEENT: Sclerae anicteric, no conjunctival injection, oropharynx
clear, tracheostomy in place with some dried blood in the
proximal aspect of tube
Cardiac: Irregular Rate & Rhythm, no murmurs, rubs, or gallops
Chest: CTA bilaterally, no wheezes, rhonchi, rales
Abdominal: Soft, non-tender, non-distended, with positive bowel
sounds. PEG tube in place c/d/i
Extremities: No lower extremity edema bilaterally
Neurologic examination:
Mental Status: Awake, with spontaneously opening eyes, no
response to commands.
Cranial Nerves:
CN I: Deferred
CN II: Right reactive to light 3-2mm briskly, Left post-surgical
pupil non-reactive, fixed at 3mm. No blink to confrontation.
Unable to assess visual fields / acuity
CN III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
CN V: Sensation intact to pain V1-V3.
CN VII: Facial movement symmetric. Palate elevation symmetric.
CN VIII: Alerts to voice in either ear.
CN [**Doctor First Name 81**]: Sternocleidomastoid and trapezius full strength
bilaterally.
CN XII: Tongue midline, movements intact.
Motor: Normal bulk and tone bilaterally. No observed myoclonus,
asterixis, or tremor. Unable to cooperate for strength testing,
moves right upper and lower extremities greater than left but
withdraws to pain in all extremities.
Sensation: Intact to painful stimuli throughout, but unable to
test
any other modalities.
Reflexes: 2+ and symmetric in b/l UE and UTO in b/l LE. Plantar
reflexes are equivocal bilaterally.
Coordination and Gait were not able to be assessed.
Pertinent Results:
[**2138-6-28**] 09:00PM GLUCOSE-125* UREA N-29* CREAT-1.2* SODIUM-137
POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-29 ANION GAP-14
[**2138-6-28**] 09:00PM estGFR-Using this
[**2138-6-28**] 09:00PM WBC-12.5* RBC-4.69 HGB-13.4 HCT-41.0 MCV-87
MCH-28.6 MCHC-32.7 RDW-16.1*
[**2138-6-28**] 09:00PM NEUTS-84.4* LYMPHS-11.8* MONOS-3.3 EOS-0.2
BASOS-0.4
[**2138-6-28**] 09:00PM PLT COUNT-159
[**2138-6-28**] 09:00PM PT-11.9 PTT-28.1 INR(PT)-1.1
EKG [**6-28**]:
Sinus rhythm with borderline first degree A-V conduction delay.
Poor R wave progression.
MRI/A [**6-29**]:
IMPRESSION: 1. Limited examination due to patient motion.
Unchanged right parieto-occipital intraparenchymal hematoma with
associated vasogenic edema. Long-term followup is recommended to
identify underlying lesions within the hematoma.
2. Areas of small vessel disease are noted in the subcortical
white matter.
3. MRA of the head is limited, however, the major vascular
branches are
patent. Segmental narrowing is noted in the vessels of the
circle of [**Location (un) 431**], suggesting atherosclerotic disease.
4. No diffusion abnormalities are detected to suggest acute or
subacute
territorial infarction.
CXR [**6-29**]:
FINDINGS: The NG tube is coiled in the stomach. There is
obscuration of the left hemidiaphragm laterally likely due to a
combination of effusion and volume loss. An underlying
infiltrate cannot be excluded. There are no old films available
for comparison. There is mild pulmonary vascular
redistribution and mild cardiomegaly.
CT head [**6-30**]:
IMPRESSION:
1. New trace intraventricular hemorrhage layering in the
bilateral occipital horns of the lateral ventricles.
2. No significant change in the amount of intraparenchymal and
subarachnoid hemorrhage.
3. Stable surrounding edema and mild mass effect.
CXR [**6-30**]:
IMPRESSION: Moderate-to-severe pulmonary edema and trace left
effusion.
CXR [**7-1**]:
IMPRESSION: Unchanged pulmonary edema.
CXR [**7-2**]:
IMPRESSION: Increased moderate asymmetric right greater than
left pulmonary edema and moderate bilateral pleural effusions.
MRI head [**7-2**]:
IMPRESSION:
1. Unchanged appearance of the right parieto-occipital
parenchymal hemorrhage
and its associated mass effect with compression of the occipital
[**Doctor Last Name 534**] of the
right lateral venticle. No evidence of transtentorial or
tonsillar
herniation.
2. Stable small subarachnoid and intraventricular blood, with
no evidence of
developing hydrocephalus.
3. Internal blood-fluid layer, and scattered punctate chronic
"microbleeds"
with susceptibility artifact are strongly suggestive of
underlying cerebral
amyloid angiopathy.
4. New bilateral frontal and right posterior parietal foci of
slow diffusion;
given the ditribution, these are concerning for acute embolic
infarction.
5. Stable periventricular FLAIR-signal abnormalities are
consistent with
known multiple sclerosis, with possible component of small
vessel ischemic
disease.
**************
TTE [**7-1**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Left ventricular global
systolic function is normal. Doppler parameters are most
consistent with Grade II (moderate) left ventricular diastolic
dysfunction. Right ventricular chamber size and free wall motion
are normal. The right ventricular free wall is hypertrophied.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. 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 at least borderline pulmonary artery
systolic hypertension. There is a small pericardial effusion.
There is an anterior space which most likely represents a
prominent fat pad.
*****************
Labs selected from days immediately prior to discharge
[**2138-7-21**] 03:48AM BLOOD WBC-8.4 RBC-2.52* Hgb-7.2* Hct-22.4*
MCV-89 MCH-28.8 MCHC-32.3 RDW-17.6* Plt Ct-243
[**2138-7-21**] 03:48AM BLOOD Glucose-156* UreaN-64* Creat-1.3* Na-142
K-4.5 Cl-106 HCO3-25 AnGap-16
[**2138-7-21**] 03:48AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.4
[**2138-7-18**] 9:16 pm URINE Source: Catheter.
**FINAL REPORT [**2138-7-19**]**
URINE CULTURE (Final [**2138-7-19**]):
YEAST. >100,000 ORGANISMS/ML..
Brief Hospital Course:
Neuro:
82yo RH woman presented with severe headache and was found to
have a right occipital intraparenchymal hemorrhage with
subarachnoid component. She was hypertensive to 210 systolic
upon arrival and was started on a nicardipine IV for BP control.
She was admitted to the Neurology ICU for close monitoring with
telemetry and further management.
She was maintained on Q2hour neurochecks and close BP monitoring
with a goal SBP < 160. Nicardipine gtt was titrated off and she
was started on labetalol PRN. MRI/A was performed initially on
[**6-29**] and showed no obvious underlying lesion or vascular
abnormality to explain her hemorrhage. However this study was
limited by motion artifact and no GRE sequence was able to be
completed. A repeat head CT was performed on [**6-30**] which was
essentially unchanged, except for trace intraventricular
hemorrhage layering in the bilateral occipital horns of the
lateral ventricles.
Her exam initially remained stable and essentially nonfocal,
other than some dysarthria and her baseline visual impairment.
She developed intermittent agitation and disorientation and
received a few doses of haldol and ativan IV. Routine EEG showed
slow encephalopathic 5.5 Hz background, no epileptic discharges
or seizures.
On [**7-2**] she was noted to be moving her left side somewhat less
at times. A repeat MRI showed stable R occipital hemorrhage but
new acute infarcts in bilateral frontal and right posterior
parietal regions. There were also scattered punctate lesions of
susceptibility artifact suggestive of amyloid angiopathy.
Over the course of the next two weeks, the patient became more
active and interactive with staff and family. She remains
globally aphasic, and poorly responds to any commands. The
patient also experiences occasional epochs of agitation which
are relieved with pain control or Seroquel for agitation.
Cardiopulmonary:
She had a brief respiratory decompensation in the afternoon on
[**6-30**] for which Lasix 20mg IV x 1 was administered with some
initial improvement. However, renal function subsequently
worsened with decreased UOP and an increase in Cr to 1.7. She
received albumin x 2 followed by additional Lasix.
On [**7-1**], the patient was noted to have difficulty breathing,
non-invasive positive pressure ventilation was attempted and
ABGs were obtained which showed poor O2 saturation and worsening
hypercapnea. CXR obtained was concerning for pulmonary edema.
Pt became bradycardic and sustained a brief cardiopulmonary
arrest for which resuscitation was accomplished with one round
of epi and chest compressions. The patient was intubated and
placed on ventilation for respiratory failure. EKG showed no
ischemic changes, troponin initially rose to 0.34 but then
downtrended.
Between [**7-5**] and [**7-10**], the patient had episodes of hypertension
which were associated with agitation requiring increased
anti-hypertensive management. The patient at times was sedated
on propofol for agitation which occurred with any attempts to
wean from sedation. Blood pressures which ranged in the
systolic range of 140-160 would escalate to the 180s with
sedation weaning attempts. Her neurologic exam during this
period was remarkable for increasing motion and strength in her
extremities with left remaining greater than right, however
thorough evaluation was not possible [**2-6**] sedation. Initially
Nicardipine gtt was used, but was able to be discontinued in
favor of increased dosages of the patient's home
anti-hypertensive regiment.
Between [**7-12**] and [**7-15**], the patient experienced several episodes
of hypotension requiring a course of fluid boluses and pressors
to maintain adequate perfusion, first with phenylephrine, and
then later with norepinephrine for better pulse management. Of
note following, [**7-16**] the patient did not require further pressor
use with the exception of a period of hypotension to the 80/60s
with some bradycardia to the 50s on [**7-18**]. Since this time, her
cardiovascular function has been allowed to autoregulate with
only her anti-hypertensive medications continued. The patient
upon discharge does still have hypertensive swings into the
160-170 systolic blood pressure range which are relieved with
medication or adequate sedation/pain relief.
Renal:
Over the next few days, renal failure persisted with Cr levels
in the 1.7-2.0 range. Urine/Blood Osmolality and Lytes were
obtained which were consistent with a pre-renal etiology for the
worsening function. Additional free water flushes were added to
the patients regimen (initially hypotonic lactated ringers were
added as well, but were subsequently discontinued with worsening
hypernatremia). With this intervention Creatinine improved over
the next week to 1.2.
GI:
On [**7-8**], the decision to perform a tracheostomy and PEG tube was
made which was accomplished on [**7-10**].
Prophylaxis:
Over her ICU course, the patient was maintained on pneumoboots
for DVT prophylaxis. SC heparin was held in the setting of her
bleed but subsequently restarted on [**7-1**]. She was maintained on
a bowel regimen for GI prophylaxis.
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 77) - () No
5. Intensive statin therapy administered? (for LDL > 100) () Yes
- (x) No (if LDL >100, Reason Not Given: )
6. Smoking cessation counseling given? () Yes - (x) No (Reason
(x) non-smoker - (x) unable to participate)
7. Stroke education given? (x) Yes - () No
8. Assessment for rehabilitation? (x) Yes - () No
9. Discharged on statin therapy? () Yes - (x) No (if LDL >100,
Reason Not Given: )
10. Discharged on antithrombotic therapy? () Yes (Type: ()
Antiplatelet - () Anticoagulation) - (x) No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A -- Aspirin (as
concern for bleeding given admission suggested against warfarin
management)
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Sertraline 12.5 mg PO DAILY
2. Gabapentin 600 mg PO DAILY AM dose
3. Gabapentin 900 mg PO HS
4. CloniDINE 0.1 mg PO BID
5. Metoprolol Tartrate 25 mg PO BID
6. Docusate Sodium 100 mg PO DAILY qAM
7. Lorazepam 0.5 mg PO HS
8. Aspirin 81 mg PO DAILY
9. GlyBURIDE 2.5 mg PO DAILY
10. Levothyroxine Sodium 125 mcg PO DAILY
11. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral daily
12. Acetaminophen 650 mg PO Q6H
home is PRN, keep standing here.
Discharge Medications:
1. Sertraline 12.5 mg PO DAILY
2. Gabapentin 600 mg PO/NG DAILY
3. Gabapentin 900 mg PO/NG HS
4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **]
5. OxycoDONE Liquid 5 mg PO/NG Q6H:PRN pain
6. Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
7. Docusate Sodium 100 mg PO/NG [**Hospital1 **]
8. Acetaminophen 650 mg PO Q6H:PRN Fever
9. Levothyroxine Sodium 125 mcg PO/NG DAILY
10. Famotidine 20 mg PO/NG DAILY
11. Aspirin 81 mg PO/NG DAILY
12. Captopril 50 mg PO/NG TID Hold for SBP < 110
13. CloniDINE 0.1 mg PO/NG [**Hospital1 **]
14. Fluconazole 200 mg PO/NG Q24H (PLEASE CONTINUE THIS
MEDICATION FOR 12 DAYS FROM DISCHARGE)
15. Quetiapine Fumarate 25 mg PO/NG [**Hospital1 **]
16. Calcium 500 + D 400 Units (calcium carbonate-vitamin D3)
17. GlyBURIDE 2.5 mg PO DAILY
18. NUTRITION - Tubefeeding: "Replete with fiber" Full strength;
Starting rate: 20 ml/hr; Advance rate by 10 ml q4h Goal rate: 50
ml/hr
Residual Check: q4h Hold feeding for residual >= : 200 ml
Flush w/ 100 ml water q6h
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital
Discharge Diagnosis:
1. Right Intraparenchymal Hemorrhage with small subarachnoid
hemorrhage with radiologic findings strongly suggestive of
underlying cerebral amyloid angiopathy
2. Small bilateral frontal and right posterior parietal foci of
ischemia
3. Cardiac Arrest status post resuscitation
4. Ventilator Dependant Respiratory Failure status post
tracheostomy and PEG placement
5. Urinary Tract Infection status post treatment (on two week
course of fluconazole)
Discharge Condition:
Ventilator-dependant respiratory failure, but stable.
Discharge Instructions:
* Please note the patient has paroxysms of hypertension
associated with agitation. This patient has responded very well
to either morphine sulfate or oxycodone. Please attempt these
interventions if the patient becomes acutely agitated, with
elevated blood pressures.
* The patient has passed spontaneous breathing trials while
inpatient and was able to use trach collar oxygen for a number
of hours at times. Please attempt to wean ventilator support as
possible.
* The patient has regained movement of her arms bilaterally and
legs bilaterally but remains globally aphasic with poor response
to command. It is unclear whether this is a permanent deficit,
or will improve with time.
Followup Instructions:
* Please continue follow-up appointments with your primary care
physician, [**Name10 (NameIs) 2085**], and other existing physicians.
* An appointment is being scheduled for you to follow up with
[**First Name8 (NamePattern2) 2530**] [**Name8 (MD) **], MD with our Neurology Stroke Service.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2138-7-21**]
|
[
"401.9",
"285.8",
"V12.54",
"327.23",
"514",
"584.9",
"427.31",
"276.0",
"784.3",
"427.5",
"277.39",
"458.9",
"427.89",
"437.9",
"340",
"250.00",
"599.0",
"263.9",
"431",
"430",
"426.12",
"369.4",
"518.81",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"96.04",
"33.24",
"99.60",
"96.6",
"38.97",
"96.72",
"43.11",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
18847, 18918
|
11099, 17172
|
351, 394
|
19409, 19464
|
6576, 11076
|
20200, 20633
|
2823, 2904
|
17808, 18824
|
18939, 19388
|
17198, 17785
|
19488, 20177
|
2919, 2940
|
4839, 4860
|
233, 313
|
422, 2102
|
5549, 6557
|
4874, 5429
|
5468, 5533
|
5453, 5453
|
2124, 2617
|
2633, 2807
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,664
| 166,826
|
21407
|
Discharge summary
|
report
|
Admission Date: [**2191-7-4**] Discharge Date: [**2191-7-22**]
Date of Birth: [**2126-6-23**] Sex: F
Service: [**Doctor First Name 147**]
Allergies:
Mellaril / Lithium / Thorazine
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Gallstone pancreatitis
Major Surgical or Invasive Procedure:
Open [**First Name9 (NamePattern2) 56537**] [**7-12**].
History of Present Illness:
Pt was transferred from Laswcne [**Hospital1 **] for ERCP for gallstone
pancreatitis. ERCP was attempted at the ouside but the patient
desaturated with midazolam. She was admitted to this hospital
for a work up. Pt has some abdominal pain but denied cough,
chest pain, or shortness of breath. she was admited for MRCP
and medical management of her pancreatitis.
Past Medical History:
S/p Open cholecystectomy
gallstone pancreatitis
Mechanical aortic valve
Abdominal aortic aneurysm
Schizoaffective Disorder
Non insulin dependend diabetes mellitus
congestive heart failure
s/p R masectomy
pt has MRSA by nasal swab
s/p CVA with L hemiparesis
Social History:
non contributory
Family History:
non contributory
Physical Exam:
Physical exam on admission was as follows:
General: eldelry woman
Head and Neck: Pupils equal round and reactive to light and
accomodation, extraocular movements intact, no icterus,
oropharynx clear
Neck: No lymhadenopathy
Heart: Regular rate and rhythm, mechanical valve clicks audible
Lungs: Clear to auscultation
Abdomen: Multiple surgical scars, soft non tender non distended
extremeties: No clubbing cyanosis or edema. Palpable pulses
bilaterally
Neuro: alert and oriented times 3, Cranial nerves grossly
intact.
Pertinent Results:
[**2191-7-4**]-MRI ABDOMEN: Sequences are degraded by patient motion.
There are several small stones within the gallbladder. The bile
ducts are not dilated. No ductal stones are seen. The pancreatic
duct is normal. The pancreas is normal in thickness and signal
intensity. There are renal cysts bilaterally and strands of
fluid signal intensity within the retroperitoneum around both
kidneys. There is also a small amount of fluid around the
spleen. The liver is unremarkable. No enlarged lymph nodes are
seen. There is a 4.5 cm infrarenal aortic aneurysm.
Brief Hospital Course:
In brief, The patient recovered with medical management and was
followed for her other medical problems. She was evaluated and
cleared medically for an elective cholecystectomy with
intraoperative cholangiogram for gallstone pancreatitits.
patient was admitted to the intensive care unit after surgery on
[**7-12**]. After being on the floor, the paitent was sent to the
Intensive care unit for hypotension and hypoxia on [**7-14**].
patient had a nosocomia aspiration pneumonia and was intubated
and treated with antibiotics. She was extubated on [**7-20**] and
transferred to the floor. She has done well, with her incision
healing nicely, is tolerating a nectar consistency meal by
mouth, and is getting out of bed with assistance. The patient
is ready to go back to her residency pre admission with her
issues of gallstone pancreatitis resolved
Medications on Admission:
Unclear but by report:
Depakote 1000 mg [**Hospital1 **] or TID
Aerobid 3 puffs [**Hospital1 **]
Risperdal 3 mg qhs
Soumedrol 20 mg IV BID
Protonix 40 mg [**Hospital1 **]
Rocephin 1 gram IV qd
Trazotone 100 mg qhs
Coumadin
Discharge Medications:
1. Risperidone 1 mg Tablet, Rapid Dissolve Sig: Three (3)
Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)).
Disp:*90 Tablet, Rapid Dissolve(s)* Refills:*2*
2. Risperidone 1 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet,
Rapid Dissolve PO QAM (once a day (in the morning)).
Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*2*
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 inhaler* Refills:*2*
5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*1 inhaler* Refills:*2*
6. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*2*
7. Valproate Sodium 250 mg/5 mL Syrup Sig: 1000 mg, please
dispense as liquid PO Q HS ().
Disp:*600 ml* Refills:*2*
8. Valproate Sodium 250 mg/5 mL Syrup Sig: 1000mg PO Q 2PM ().
Disp:*600 ml* Refills:*2*
9. Valproate Sodium 250 mg/5 mL Syrup Sig: 750 mg PO Q AM ().
Disp:*500 ml* Refills:*2*
10. Acetaminophen-Codeine 120-12 mg/5 mL Elixir Sig: 12.5 MLs PO
Q4H (every 4 hours) as needed for pain.
Disp:*500 ML(s)* Refills:*1*
11. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO at
bedtime.
Disp:*30 Tablet(s)* Refills:*2*
12. Trazodone HCl 50 mg Tablet Sig: One (1) Tablet PO three
times a day.
Disp:*90 Tablet(s)* Refills:*2*
13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
14. Benztropine Mesylate 0.5 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
15. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl
Topical PRN (as needed).
Disp:*1 TUBE* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care
Discharge Diagnosis:
S/p Open cholecystectomy
gallstone pancreatitis
Mechanical aortic valve
Abdominal aortic aneurysm
Schizoaffective Disorder
Non insulin dependend diabetes mellitus
congestive heart failure
s/p R masectomy
pt has MRSA by nasal swab
s/p CVA
Discharge Condition:
stable
Discharge Instructions:
Please [**Name8 (MD) 138**] MD [**First Name (Titles) **] [**Last Name (Titles) 152**] fevers, severe abdominal pain,
intractable nausea or vomiting, yellowing of the skin.
The patient has a small hematoma in her wound. Please just put
dry dressings on top of it, and some leakage is to be expected.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 468**] in [**1-21**] weeks, you can call for
an appointment
|
[
"287.5",
"496",
"577.0",
"507.0",
"276.5",
"428.0",
"997.3",
"518.5",
"574.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"96.6",
"38.93",
"87.53",
"96.72",
"33.23",
"96.04",
"51.22",
"99.04",
"51.10"
] |
icd9pcs
|
[
[
[]
]
] |
5216, 5270
|
2268, 3122
|
331, 388
|
5551, 5559
|
1686, 2245
|
5909, 6020
|
1113, 1131
|
3395, 5193
|
5291, 5530
|
3148, 3372
|
5583, 5886
|
1146, 1667
|
269, 293
|
416, 783
|
805, 1063
|
1079, 1097
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,428
| 164,632
|
16934
|
Discharge summary
|
report
|
Admission Date: [**2119-7-22**] Discharge Date: [**2119-7-27**]
Date of Birth: [**2095-5-6**] Sex: F
Service: MEDICINE
Allergies:
Sulfamethizole / Zosyn / Penicillins / Sulfa (Sulfonamides) /
Iodine / Vancomycin
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Fever, headache, nausea, vomiting, blurry vision
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
This is a 24 year old woman with history of SLE and ESRD on
dialysis MWF who presents with fever and mild headache after
dialysis yesterday.
.
She underwent scheduled dialysis procedure yesterday and several
hours later developed subjective fever and mild headache. She
presented to the ED 12 hrs post dialysis where she was note to
be hypotensive and tachycardic. She has had similar symptoms
post dialysis in the past and was hospitalized at [**Hospital1 **] twice over
last month. She could not qualify her headache, i.e. denied it
being dull or sharp or squizing, but disclosed that it felt like
lightheadedness. There is no neck stiffness, weakness or
confusion. She also complains of nausea and vomiting x3 (no
blood). No recent travel or sick contacts. She denies any other
localizing symtoms for her fever, i.e. denies any abdominal
pain, diarrhea, shortness of breath, chest pain, rashes, she has
had no urine output in the past and she denies worsenig of her
arthritis. Denies night sweats or chills. No heat or cold
intolerance.
.
Initially was dialyzed through an AV fistula but this was
complicated by pseudoaneurysm and thereafter his fistula was
replaced with a tunneled LIJ (placed [**2119-6-30**]). On [**2119-7-10**] she
was admitted to [**Hospital1 **] with post dialysis fevers and this was
attributed to thrombosis in AVF. Transplant surgery attempted a
thrombectomy, but was unsuccessful. On that admission it was
felt that there was no evidence of infection in or around the
thrombus and felt that her fevers were likely related to her
significant clot burden. No other source of infection was
identified.
.
SLE diagnosed in '[**15**] after noted to have anasarca, pericardial
effusion, leukopenia, arthritis and positive [**Doctor First Name **], Ro, and
P-ANCA. Was on prednisone until [**4-8**] and plaquenyl until [**10-7**].
.
She was diagnosed with ESRL in '[**15**] and biopsy was nonspecific
althought despite this there remains strong suspicion that her
ESRD is secodary to SLE. She has been evaluated for, and is on a
list for transplantation. She is hepatitis B surface antigen,
surface antibody, and core antibody negative. At last check,
hepatitis C antibody negative and HIV negative.
.
In the ED, initial vs were: 100.6 131 80/41 16 100%. CXR
negative. ECG sinus tach. Patient was given 2 Lt IVF as well as
gentamycin and daptomycin. She has extensive abx allergies. This
was the same abx regimen that she was treated for similar
admission recently. Was also given acetaminophen in ED. Prior
to transfer her vitals were 100.1, 106, 94/40, 16, 100RA.
Baseline BP 100/60.
.
In the MICU, patient received total og 5L IVF and SBP 100s. She
was started on Daptomycin/Gent for emperic coverage given
extensive ABX allergies. She has had multiple line infxns in the
past. She was also started on 20mg po prednisone. CXR negative.
Blood cultures no growth to date. UE ultrasound showed stable
clot. TTE ordered, but not yet done. Tunnelled line was kept in
and patient was dialyzed today (Monday). Rheumatology was
consulted for concern of lupus flare, see recs below and
recommended continuing current prednisone dose with start of
taper.
Past Medical History:
1. Lupus (diagnosed [**2115**]) c/b Lupus nephritis and ESRD on HD.
Outpt nephrologist is Dr. [**First Name (STitle) 805**]. Goes to [**Location (un) **] on MWF.
No longer on any BP meds given borderline low BPs.
2. Hypertension in the past.
3. Diagnosis of Sjogren's.
4. She has a swollen gland that was removed by ENT last year
5. BOOP
6. Inflammatory arthropathy
7. Hx of myositis
8. History of pericarditis and pericardial effusion
9. Numerous line infections
10.Genital herpes
11. Depression
12. History of thrombosed AV fistula- L tunneled catheter placed
on [**2119-6-30**]
Social History:
Lives in [**Location 686**], moving to [**Location (un) 583**] in 1 week. College
student at Baypath College. Lives with mother, grandmother. [**Name2 (NI) **]
smoking history. Denies alcohol consumption. No illicit drug
use. Sexually active with boyfriend in stable relationship.
Family History:
Sister has SLE. Mother: DM. Father: no diagnosed medical issues.
Maternal grandmother: asthma and HTN.
Physical Exam:
V/S: T: 98.4, BP: 110/80, P: 91, RR: 18, O2sat: 97% RA
General: Alert, oriented, no acute distress. sitting in bed
eating.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Tachycardic, regular rhythm, no murmurs, rubs, gallops.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly.
Neuro: CN 2-12 intact, Kernigs and Brudzinski negative.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. R hand digits are mildly swollen.
Skin: HD line intact without erythrema or exudate, AVF
thrombectomy site clean.
Pertinent Results:
ADMISSION LABS:
.
[**2119-7-22**] 06:10AM BLOOD WBC-9.0# RBC-3.99* Hgb-10.1* Hct-33.5*
MCV-84 MCH-25.4* MCHC-30.2* RDW-15.4 Plt Ct-272
[**2119-7-22**] 06:10AM BLOOD Neuts-92* Bands-2 Lymphs-2* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2119-7-22**] 06:10AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-OCCASIONAL
Bite-OCCASIONAL
[**2119-7-22**] 06:10AM BLOOD Plt Ct-272
[**2119-7-22**] 04:53PM BLOOD PT-14.7* PTT-34.5 INR(PT)-1.3*
[**2119-7-22**] 06:10AM BLOOD Glucose-93 UreaN-14 Creat-8.2*# Na-138
K-4.1 Cl-99 HCO3-28 AnGap-15
[**2119-7-22**] 04:53PM BLOOD Calcium-8.3* Phos-3.9# Mg-1.5*
[**2119-7-22**] 06:13AM BLOOD Lactate-1.5
[**2119-7-22**] 04:53PM BLOOD ALT-4 AST-10 LD(LDH)-183 AlkPhos-52
.
PERTINENT LABS/STUDIES:
.
[**2119-7-27**] 07:35AM BLOOD WBC-5.5 RBC-4.05* Hgb-10.3* Hct-34.5*
MCV-85 MCH-25.3* MCHC-29.7* RDW-15.8* Plt Ct-194
[**2119-7-25**] 07:00AM BLOOD WBC-8.3 RBC-3.36* Hgb-8.5* Hct-28.8*
MCV-86 MCH-25.4* MCHC-29.6* RDW-15.0 Plt Ct-193
[**2119-7-27**] 07:35AM BLOOD Glucose-90 UreaN-21* Creat-6.6*# Na-138
K-3.8 Cl-101 HCO3-26 AnGap-15
[**2119-7-26**] 07:00AM BLOOD Glucose-82 UreaN-28* Creat-8.9*# Na-139
K-3.9 Cl-100 HCO3-28 AnGap-15
[**2119-7-27**] 07:35AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.0
[**2119-7-23**] 04:32AM BLOOD TSH-0.90
[**2119-7-24**] 05:50AM BLOOD dsDNA-NEGATIVE
[**2119-7-22**] 12:41PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2119-7-22**] 06:10AM BLOOD C3-79* C4-30
[**2119-7-24**] 05:50AM BLOOD Genta-1.9*
[**2119-7-23**] 04:32AM BLOOD Genta-2.2*
.
.
CXR ([**7-22**]): No evidence of pneumonia or other acute
cardiopulmonary process.
.
CT Head/Sinus ([**2119-7-22**]): No acute intracranial process.
.
LUE U/S ([**2119-7-23**]): 1) No DVT. 2) Partially thrombosed left-sided
A-V fistula.
.
Echo ([**2119-7-24**]): Mild symmetric LVH. Normal regional and global
biventricular systolic function. No pathologic valvular
abnormality seen.
Compared with the prior study (images reviewed) of [**2118-8-16**],
the degree of LVH is less. The other findings are similar.
.
CT L-SPINE W/O CONTRAST ([**2119-7-25**]):
No evidence of osteomyelitis. Findings suggestive of renal
osteodystrophy.
There is mild diffuse disc bulge at L3-4, L4-5l and L5-S1
without significant central canal stenosis or neural foraminal
narrowing.
Brief Hospital Course:
24 year old woman with Lupus and ESRD on HD (MWF) presents with
fever after dialysis.
.
# Fever, tachycardia, relative leukocytosis and hypotension,
consistent with systemic inflammatory response syndrome: Unknown
etiology, with broad differential. [**Month (only) 116**] have been multifactorial
in nature. Low grade fever may have been secondary to transient
bacteremia due to seeding from tunneled catheter site,
considering current resolution of symptoms, negative blood cx to
date and lack of fever x3 days. Hypotension and tachycardia
could have been secondary to fluid shifts during dialysis.
Patient received a CT head and CT sinuses (given initial c/o HA)
that were both negative. CXR on [**7-22**] was negative for PNA or
acute pulmonary process. Bilateral UE u/s on [**7-23**] showed
partially thrombosed L sided A-V fistula with no evidence of
DVT. AV fistula site remained non erythematous, non-tender and
without any signs of infection throughout the hospitalization.
Given that the patient was recently admitted with a fever on
[**2119-7-5**], there was concern that she may have been having
intermittent fevers for the past 2 weeks. Lupus flare as the
etiology of her low grade fever was explored and Rheumatology
was consulted. They were not confident that the myriad of
symptoms could be appropriately attributed to SLE alone. DsDNA
and CH50 were sent with complement returning mildly decreased(C3
79) and dsDNA being negative. Clinical suspicion for meningitis
was low given that the presenting HA was better qualified as
lightheadedness by the patient, absence of AMS, neuro findings
or meningismus. Patient was started on Gentamycin 80mg and
Daptomycin 400mg empirically on [**7-24**] in the MICU given her
vancomycin and Zosyn allergies and these were discontinued on
[**7-26**] given negative infectious workup to date. She did not
develop any fevers for 48 hours following abx cessation.
Prednisone 20mg was also begun on [**7-23**] in the MICU, prior to the
Rheum consult, and discontinued on [**7-24**] due to low suspicion for
lupus flare as etiology. Patient was monitored after
discontinuation of abx and remained afebrile for more than 24
hours prior to discharge. On day 4 of hospitalization ([**7-25**]),
patient developed complaints of lower back pain. She reported
that similar episodes have happened in the past after her HD
sessions, but described this incident as more severe. Lumbar CT
without contrast (patient has contrast allergy) was performed
and was negative for osteomyelitis but did show mild disc bulge
at L3-4, L4-5l and L5-S1, which could explain her lower back
pain.
.
# ESRD on HD (MWF): Etiology of patient's kidney failure still
unknown, suspected secondary to lupus. Patient's creatinine on
admission was 8.2 and remained around her baseline throughout
the hospitalization. She continued to be dialyzed while in house
([**7-24**], [**7-25**] and [**7-26**]) and will follow up with her nephrologist,
Dr. [**First Name (STitle) 805**], within 2 weeks after discharge.
.
# SLE: Patient has a likely diagnosis of SLE and has been off
immunosuppressants for three months. Per rheumatology, SLE flare
less likely to be responsible for fever in this patient.
Rheumatology consulted her in-house and will plan to follow up
with her as an outpatient within 2 weeks for possibly initiation
of plaquenil therapy.
Medications on Admission:
1. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever: do not take more than 3500mg
per day.
Discharge Medications:
1. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO once a day.
2. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO once a
day.
3. Outpatient Physical Therapy
Please begin physical therapy for your low back pain as an
outpatient. You may [**Telephone/Fax (1) 2484**].
4. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Discharge Disposition:
Home
Discharge Diagnosis:
Fever of unknown etiology
SLE, complicated by lupus nephritis
End stage renal disease on hemodialysis - history of thrombosed
AV fistula. Left tunneled catheter placed on [**2119-6-30**]
Sjogren's Syndrome
History of multiple line infections
History of hypertension
BOOP
Inflammatory arthropathy
Depression
Discharge Condition:
Afebrile, vital signs stable.
Discharge Instructions:
You were admitted because you had a fever, your blood pressure
was very low, and your heart rate was very fast in the emergency
department. You were given fluids and started on IV antibiotics
to treat any possible infection. You were also started on
prednisone in the event that your symptoms were due to a lupus
flare, which was stopped after three days. You were seen by the
Rheumatology service. Several blood cultures were drawn, the
results of which are still pending, however, they are negative
to date. Several imaging studies were performed to look for
sources of infection and these were also negative. You underwent
dialysis on Monday, Tuesday and Wednesday of this week.
.
We have made no changes or additions to your medications.
.
Please take all other medication as previously directed prior to
your hospitalization.
.
Should you develop lightheadedness, feeling faint, fever,
chills, stiff neck, nausea, vomiting, or diarrhea, please call
your primary care physician or visit the emergency room.
Followup Instructions:
Please continue your dialysis schedule.
.
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who is covering for Dr.
[**First Name (STitle) 9466**] [**Name (STitle) **].
Date: [**8-8**]
Time: 1:45 PM
Phone: [**Telephone/Fax (1) 250**]
.
Please follow up with Dr. [**First Name4 (NamePattern1) 2048**] [**Last Name (NamePattern1) **], a Rheumatologist
her at [**Hospital1 18**] for you lupus. Phone: [**Pager number 5537**]Provider: [**First Name11 (Name Pattern1) **]
[**Last Name (NamePattern1) 4900**], MD
Date: [**2119-8-1**]
Time: 2PM
Number: [**Telephone/Fax (1) 2226**]
.
Please follow up with your previously scheduled appointment with
your transplant surgeon, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
Date: [**2119-8-22**]
Time: 1:30 PM
|
[
"780.60",
"583.81",
"403.91",
"710.0",
"V12.51",
"710.2",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11754, 11760
|
7685, 11047
|
390, 404
|
12111, 12143
|
5357, 5357
|
13202, 14021
|
4525, 4629
|
11394, 11731
|
11781, 12090
|
11073, 11371
|
12167, 13179
|
4644, 5338
|
302, 352
|
432, 3607
|
5373, 7662
|
3629, 4211
|
4227, 4509
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,132
| 127,886
|
34547
|
Discharge summary
|
report
|
Admission Date: [**2177-1-25**] Discharge Date: [**2177-2-11**]
Date of Birth: [**2124-7-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
MS changes
Major Surgical or Invasive Procedure:
LP
History of Present Illness:
52 year-old male with a history of Hepatitis C, prior strokes
with left hemiparesis, HTN, HL who presents with altered mental
status.
.
Per the family he had been complaining of constipation and gas
in his abdomen. He was complaining of abdominal pain as well. He
was having poor po intake and altered mental status off from his
baseline.
.
In the ED, initial vital signs were 97.7 77 155/74 12 100%. The
patient was reportly very confused and agitated. He was oriented
x0. He was incoherent even with a spanish interpreter present.
The family stated that he was acutely worsened from his
baseline. The patient was given 10mg IV haldol and 2mg ativan
after being very combative and was unable to be settled down.
Due to the need for further radiologic workup he was intubated
for sedation. He vent setting were CMV Vt:500, PEEP: 5,
FiO2:40%, RR:14. (7.36/46/387/27) He underwent CT-head that was
negative for acute process. He had a CT-torso that was
significant for right lower lobe pneumonia, extensive stool and
left iliac aneurysm. No evidence of ascites. He was treated
initially with vanco/zosyn. His labs were significant for a
normal WBC of 7.6, ALT:71, AST:46, lactate 1.2, negative UA and
negative serum and urine tox screen. His ammonia level was 57.
Given the initial concern for menengitis he was treated with CTX
2g and an LP was performed. WBC 2, RBC: 0, Prot: 34 and Glc: 62.
Past Medical History:
Hepatitis C (genotype 1) Dx [**2172**]
Stroke [**2173**] with residual left hemiparesis
Hypertension
Hyperlipidemia
Social History:
He denies IV drug abuse or blood transfusions. He mentions
moderate alcohol use; his last drink was three years ago. He
used to drink one bottle of rum a day five days a week for 20
years. He is not married. He does not have any children. He
lives with his sister. [**Name (NI) **] is currently on disability. He used
to work in housekeeping.
Family History:
Father suffers from hypertension and diabetes mellitus. His
mother died of a heart attack at the age of 72. He has five
siblings, a 36-year-old sister with vaginal cancer, a
37-year-old
sister who has hypertension, a 37- year-old sister with
hypothyroidism.
Physical Exam:
GEN: Intubated and sedated, no acute distress
HEENT: pupils reactive to light, sclera anicteric, no epistaxis,
MMM
NECK: No JVD,
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: intubated and sedated. Moving all ext. withdraws to pain
Pertinent Results:
[**2177-1-25**] 03:35AM BLOOD WBC-7.6 RBC-4.17* Hgb-11.8*# Hct-35.6*
MCV-86 MCH-28.4 MCHC-33.2 RDW-15.6* Plt Ct-285
[**2177-2-10**] 05:35AM BLOOD WBC-10.6 RBC-4.31* Hgb-12.2* Hct-37.3*
MCV-87 MCH-28.4 MCHC-32.9 RDW-15.1 Plt Ct-424
[**2177-1-25**] 03:35AM BLOOD PT-12.1 PTT-32.7 INR(PT)-1.0
[**2177-2-7**] 05:10AM BLOOD PT-12.5 PTT-33.8 INR(PT)-1.1
[**2177-1-25**] 03:35AM BLOOD Glucose-97 UreaN-25* Creat-1.0 Na-138
K-4.2 Cl-100 HCO3-29 AnGap-13
[**2177-2-11**] 05:40AM BLOOD Glucose-113* UreaN-18 Creat-0.7 Na-133
K-4.5 Cl-95* HCO3-30 AnGap-13
[**2177-1-25**] 03:35AM BLOOD ALT-71* AST-46* AlkPhos-106 TotBili-0.5
[**2177-2-11**] 05:40AM BLOOD ALT-105* AST-76* LD(LDH)-205 AlkPhos-92
TotBili-0.4
[**2177-1-25**] 03:35AM BLOOD cTropnT-<0.01
[**2177-1-25**] 03:42PM BLOOD CK-MB-5 cTropnT-<0.01
[**2177-1-29**] 04:54AM BLOOD CK-MB-8 cTropnT-<0.01
[**2177-1-26**] 03:59AM BLOOD Albumin-4.0 Calcium-9.1 Phos-4.1 Mg-1.6
[**2177-2-11**] 05:40AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.0
.
[**2177-1-28**] RPR NEG
[**2177-1-28**] URINE CULTURE NEG
[**2177-1-28**] BLOOD Culture NEG
[**2177-1-28**] BLOOD Culture NEG
[**2177-1-25**] CSF VIRAL CULTURE NONE
[**2177-1-25**] SPUTUM CULTURE {STAPH AUREUS COAG +}
[**2177-1-25**] MRSA SCREEN {POSITIVE FOR MRSA}
[**2177-1-25**] URINE Legionella Urinary Antigen - NEG
[**2177-1-25**] CSF STAIN-FINAL; FLUID CULTURE - NEG
[**2177-1-25**] URINE CULTURE FINAL {ENTEROCOCCUS SP., ENTEROCOCCUS
SP.}
[**2177-1-25**] BLOOD CULTURE NEG
[**2177-1-25**] BLOOD CULTURE NEG
.
RUQ US: IMPRESSION: 1. Technically limited examination. No
intrahepatic or extrahepatic biliary duct dilatation is seen.
.
ECG: Sinus rhythm at 70 bpm, normal axis, normal PR, QRS, and QT
intervals, q in III, TWI in III, avF. no prior for comparison
.
CT Torso: 1. Right lower lobe pneumonia. 2. Extensive amount of
fecal loading throughout the colon. 3. Left iliac artery
aneurysm measuring up to 2.4 x 2.4 cm, not significantly
changed.
.
CT-head: IMPRESSION: No acute intracranial process. Note that CT
has limited sensitivity for the detection of acute infarction
and MR could be obtained as clinically indicated.
Brief Hospital Course:
52 year-old male with a h/o HCV, left hemiparesis [**1-21**] stroke,
HTN, HL who presents with altered mental status [**1-21**] pna and UTI.
.
#. Altered Mental Status: Multiple etiology contribute to AMS.
Patient was noted for agitated delirium in the setting of
infection (PNA and UTI), with baseline psychosis and cognitive
deficits secondary to stroke. No acute CNS process or infection
as per imaging or LP. History of hepatitis C infection and lab
work significant for mild transaminitis; though, no signs of
decompensated liver failure or hepatic encephalopathy. Serum
toxicity was negative. Required significant Haldol to control
agitation initially. Psychiatry was consulted and recommended
to use only zyprexa with intermittent ativan at a PRN bases to
control agitation. Patient's mental status improved after these
intervention. He did not require haldol, easily redirectable,
responded well to 1:1 sitter with zyprexa PRN and ativan at
times of agitated delirium. He remained stable at the time of
discharge with mental status at baseline confused and mummbles
spanish words. However, he dose follow command and is able to
communicate his wishes.
.
# Pneumonia/UTI: Initial workup was notable for RLL pneumonia
(MRSA) and UTI (enterococcus) both were sensitive of vancomycin.
This could have contributed to his AMS. He completed 14 day
course of vancomycin. Last dose was on [**2177-2-9**], he remained
afebrile afterwards.
.
# Abdominal Pain: Patient complained of epigastric/RUQ pain.
Given elevated LFT's and history of HEP C, RUQ US was performed
which showed normal findings. LFTs showed transaminitis, lipase
normal. This presisted to the time of discharge. Other
contributors of the transaminitis could be due to medications
like simvastatin.
.
# HEP C: Pt with mild transaminitis, no evidence of
encephalopathy per report. Ammonia level of 57. Last PCR showed
13.7 million copies. No treatment and followed by hepatology.
.
# HTN: on long acting nifedipine and Metoprolol Tartrate,
titrated to normal tensive.
.
# HL: cont simvastatin
.
# Constipation: Contributing factor to delirium - on docusate,
biscodyl, senna, and lactulose to titrate up to 2 BM a day.
.
# FEN: Regular; Cardiac/Heart healthy
.
# PPx: PPI/heparin sq/ bowel regimen
.
# Code: FULL
.
# Comm: Sister: [**Name (NI) **] [**Telephone/Fax (1) 79345**]
Medications on Admission:
Atenolol 12.5mg [**Hospital1 **]
Simvastatin 20mg Daily
Cogentin 0.5mg TID
Celexa 20mg daily
Dipyridamide/ ASA [**Hospital1 **]
Cymbalta 60mg daily
Haldol 5mg qhs
HCTZ 12.5mg daily
Nifedipine 20mg [**Hospital1 **]
Zyprexa 10mg qhs
Protonix 40mg daaily
Hep SQ
Colace 100mg
Zyprexa prn
Discharge Medications:
1. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO BID (2 times a day) as needed for agitation.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
8. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr
Sig: One (1) Cap PO BID (2 times a day).
9. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
10. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for
agitation.
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital 16662**] Nursing and rehab
Discharge Diagnosis:
delirium
pneumonia mrsa
uti enterococcus
HTN
HEP C
HL
constipation
Discharge Condition:
Mental Status: Confused - always
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
It was a pleasure taking care of you at [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **]
Medical Center.
You came to the hospital with altered mental status. We
determined that you had a infection in the lung and the urine,
for which you were treated. You were also treated for delirium
which was likely due to your infection and the previous stroke.
You tolerated the treatments well. You were discharged in
stable condition.
You need to follow up with your doctors [**Name5 (PTitle) 7928**].
We made the following medication changes:
STOPPED
Atenolol 12.5mg [**Hospital1 **]
Cogentin 0.5mg TID
Celexa 20mg daily
Haldol 5mg qhs
Hydrochlorothiazide 12.5mg daily
Nifedipine 20mg [**Hospital1 **]
Zyprexa 10mg qhs
STARTED:
1. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1)
Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)) as
needed for agitation.
2. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for agitation.
3. Nifedipine 60 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
6. Simvastatin 20 mg Daily
Followup Instructions:
Please call Dr. [**Last Name (STitle) 14919**],[**First Name3 (LF) **] E. [**Telephone/Fax (1) 14918**] for follow up as an
outpatient.
|
[
"V12.04",
"070.70",
"272.4",
"298.9",
"482.42",
"041.04",
"560.39",
"438.0",
"293.0",
"438.20",
"438.89",
"E939.2",
"V11.3",
"564.09",
"294.8",
"442.2",
"599.0",
"333.72",
"311",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"03.31",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8990, 9055
|
5059, 5214
|
326, 330
|
9166, 9166
|
2912, 5036
|
10720, 10859
|
2270, 2530
|
7753, 8967
|
9076, 9145
|
7444, 7730
|
9336, 9913
|
2545, 2893
|
9933, 10697
|
276, 288
|
358, 1753
|
9181, 9312
|
1775, 1893
|
1909, 2254
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,611
| 177,181
|
20781
|
Discharge summary
|
report
|
Admission Date: [**2136-5-26**] Discharge Date: [**2136-5-31**]
Date of Birth: [**2057-6-27**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
woman with the sudden onset of a headache who then fell to
the ground. She was taken to [**Hospital3 **] where she
was awake, alert and oriented times three. At 1:00 p.m. her
mental status declined, and she was intubated. A head
computer tomography showed a subarachnoid hemorrhage. She
was given Mannitol, vecuronium, Versed, and labetalol and
transferred to [**Hospital1 69**] for
further management.
PAST MEDICAL HISTORY: Diabetes, arthritis, myocardial
infarction, and congestive heart failure. .
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: The patient had
corneal, gag, and localized to pain in the right side greater
than the left, and withdrew her lower extremities. Her toes
were downgoing bilaterally. She was afebrile, her pulse was
69, her blood pressure was 165/117, her respiratory rate was
25, and her saturations were 100 percent. Her eyes were
closed. The neck was supple. She had no carotid bruits.
Cardiovascular examination revealed a regular rate and
rhythm. The chest was clear to auscultation bilaterally.
The abdomen was soft, nontender, and nondistended.
Extremities revealed no clubbing, cyanosis, or edema.
PERTINENT RADIOLOGY-IMAGING: Her chest x-ray showed no
infiltrate.
Electrocardiogram revealed a normal sinus rhythm with ST
elevations.
A noncontrast head computer tomography showed a subarachnoid
hemorrhage (right greater than left) with blood in the basal
cisterns.
A computer tomography showed a left middle cerebral artery
aneurysm next to the clip site.
SUMMARY OF HOSPITAL COURSE: Neurologically, her eyes were
closed. Her pupils were 6 mm down to 4 mm and reactive. She
had positive doll's eyes. Her face was symmetric. She had
corneal and gag. She localized in the left upper extremity
at 3/5 and on the right [**2-23**]. Sensation was intact to light
touch. Her reflexes were [**3-22**] throughout. The toes were
upgoing.
On [**2136-5-27**] the patient opened her eyes to voice. The
pupils were 3 mm down to 2 mm and reactive. She was
localizing to pain in all four extremities. She was
following commands. Squeezing right greater than left. On
[**5-27**], she underwent an angiogram which showed a left
internal carotid artery aneurysm with an occlusion of the
right internal carotid artery. The patient had an occluded
right internal carotid artery, occluded left subclavian with
subclavian seal syndrome, and poor collateral circulation.
On [**5-28**], the patient underwent an angiographic stent and
coiling. However, it was not possible to deploy the stent
due to the patient's tortuous vessels and aneurysm morphology.
Vascular Surgery was consulted on [**2136-5-30**] as the patient
had lost both pulses in her lower extremities. She was taken
emergently to the Operating Room for a thrombectomy and
postoperatively had dopplerable dorsalis pedis and posterior
tibial pulses bilaterally. The patient had good pulses in
her lower extremities on postoperative day one, however, the
patient did drop her pressure and then lost the pulses in her
lower extremities.
The family approached the physicians in the Intensive Care
Unit regarding making the patient comfortable given the
patient's poor prognosis. The patient was extubated, and the
patient passed away on [**2136-5-31**].
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 6583**]
MEDQUIST36
D: [**2136-7-9**] 13:47:41
T: [**2136-7-9**] 17:12:14
Job#: [**Job Number 55433**]
|
[
"433.10",
"412",
"430",
"444.22",
"428.0",
"435.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.29",
"38.18",
"88.41",
"96.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
1777, 3757
|
174, 611
|
634, 1748
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,845
| 128,035
|
49920
|
Discharge summary
|
report
|
Admission Date: [**2127-1-18**] Discharge Date: [**2127-1-30**]
Date of Birth: [**2052-7-17**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1042**]
Chief Complaint:
Acute Epigastric Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
74 yo W with RA, SLE, LBP, hx c.diff, DM2 who presents with
acute onset epigastric abdominal pain radiating to back. Started
on Friday, comes in spasms. Better sitting up, worse lying down.
Not affected by eating, worse with consumption of hot beverages.
Denies nausea, vomiting, and diarrhea. States that she feels as
though she has gas that she cannot belch up. Patient states that
she has never has this pain before. Bedside u/s in ED, neg for
gallbladder distension, aortic aneurysm. Patient also states
that she has a headache. States that she has had it for an
extended period of time and that it now feels a little better
with Tylenol. She also complains of low back pain. Stating that
she has new pain that radiates down the back of her legs
bilaterally. She also note right eye pain. She states that she
has surgery in her right eye and that it is painful to day.
.
Pt was seen in the ED for evaluation of her epigastric pain.
Vitals at triage, T: 97.8 BP: 196/102 P: 88 O2: 99%. Pt
hypertensive to 226/120 without symptoms of headache, dizziness
or nausea. Given 5mg lopressor IV and 10 mg hydralazine IV. At
10:50 am. pt experienced increasing tachypnea, nausea, HR up to
100s then down to 50-60s. O2 sats ok on 2L NC, but also
complained of HA. EKG without ischemic changes. Repeat CXR
showed no increased infiltrate. Stopped baricat and sent to CT.
CT findings - chronic thickening. Bedside US shows no stone,
formal US shows no stone. Patient given 2mg morphine iv. Patient
then given an additional 20mg Hydralazine IV and 1" nitropaste
that precipitated a headache. Per report, patient has history of
non-compliance with medications. Was supposed to be one 360mg
diltiazem daily so dose was administered in the ED. Patient also
given Tylenol for her headache with good effect. CT headache
also performed with no acute intracranial process noted. Pt seen
by general surgery for evaluation of her abdominal pain. Not
felt to have a surgical abdomen, appendiceal edema stable from
[**6-10**], no stranding or abscess, requesting abd U/S by rads to r/o
cholelithiasis which was performed and negative. Stool was
guaiac negative. Transferred to [**Hospital Unit Name 153**] for further management of
hypertensive urgency.
.
ROS: + for hearing loss, occasional shortness of breath,
productive cough with white phlegm, constipation, and joint
pain.
Past Medical History:
1. DM2 since [**2118**], w/ occasional episodes of hypoglycemia
2. Rheumatoid arthritis diagnosed at age 50; [**Doctor First Name **] 1:1280 -
followed by Dr. [**Last Name (STitle) 6426**]; on steroids
3. Osteoarthritis greater than 20 years
4. Possible SLE, discoid lupus since [**2121**] with a positive right
sided lymph node biopsy recently
5. Left renal mass detected in [**2121-8-4**] - pt doesn't want
further w/u
6. Anemia - Normocytic in past
7. Asthma
8. Hypertension - TTE [**6-10**] - EF >60%. Mild AR
9. Back pain (related to arthritis)
10. c. diff colitis with recurrence 8 and [**10-9**]
11. Pseudomonas UTI [**10-9**]
12. Hypothyroidism
13. ?Cecal Mass on CT - [**Last Name (un) **] [**6-10**] negative. CEA 5.7. [**Doctor Last Name **]
recommended f/u CT in 4 weeks.
Social History:
Pt lives in [**Location 16174**] with daughter. [**Name (NI) 6934**] with a walker. Denies
tobacco, EtOH, illicits. States that she is able to feed herself
but had a caregiver 2 days a week who helps bathe her. She also
has home nursing for blood pressure checks. She is incontinent
of urine.
Family History:
F: DM, CAD, HTN; No Cancer in family.
Physical Exam:
Vitals: T: 99.8 BP: 173/109 P: 73 RR: 18 O2: 100%
GEN: NAD, Sitting up in bed
HEENT: NC, AT, right eye red.
CV: RRR, harsh III/VI systolic murmur
RESP: soft crackles, right base
ABD: soft, palpable gas, epigastric tenderness, hypoactive BS
EXT, mild peripheral edema, DP's 2+
Pertinent Results:
CXR -
Moderate cardiomegaly with tortuous aorta is stable. S-shaped
scoliosis and associated degenerative changes also unchanged.
Surgical clips
noted within the thyroid bed. Linear radiodensity within the
left
retrocardiac region is most consistent with atelectasis. Right
lower chest
pleural based densities may represent pleural based mass.
Recommend repeat
study with AP and lateral radiographs.
.
RUQ US -
.
CT Head -
1. No acute intracranial hemorrhage or mass effect. There is
increase in
periventricular hypodensity with notable extension into the
right centrum
semiovale, most consistent with chronic small vessel ischemia.
2. Mucosal thickening within the sphenoid sinus which is
improved since
previous study.
.
EKG - unchanged from baseline
.
PA/lateral CXR ([**1-27**]). The right PICC line distal tip projects
at the expected location of the mid
SVC. The surgical clips of the lower neck are most likely
related to the prior surgery at this area. The moderately
enlarged heart is unchanged. Small right pleural effusion is
unchanged. No focal infiltrate is noted to suggest pneumonia.
No pulmonary vascular congestion is noted. The S-shaped
scoliosis of the thoracic spine is unchanged.
Brief Hospital Course:
This is a 74yo F with a h/o HTN, Lupus, DM and RA who presents
with acute epigastric abdominal pain found to be hypertensive to
the 220s with questionable compliance home antihypertensive
regimen.
.
1. Hypertensive urgency/emergency: ruled out for MI, no evidence
CVA or aortic dissection by imaging. Likely [**3-8**] non-compliance
with home anti-hypertensive regimen and chronic kidney disease.
No RAS by MRI. Patient ran out of diltiazem and unclear if
using clonodine patch. Admitted to ICU and then to floor on
[**1-20**] with improved control. Diltiazem xr split into twice
daily dose. Clonidine patch continued. Losartan re-added on
[**1-22**] after resolution of ARF-see below (had been on
candesartan--not on formulary). Additionally, imdur added.
Nitropaste for sbp>170. By [**1-24**] bp ranging 130-160's on
clonidine patch, losartan 50, diltiazem 180XR [**Hospital1 **], imdur 60.
Medications were further adjusted, and on discharge her blood
pressure was 137/74 with a heart rate of 65, on a regimen of two
clonidine TTS-3 patches, losartan, nifedipine, metoprolol
succinate, and furosemide. Goal STANDING blood pressure is
<130/80 and >110/55.
.
2. Acute Renal failure/chronic kidney disease stage III:
Baseline creatinine 1.3 to 1.6. On admit 1.6, but then on [**1-20**]
up to 2.2 Possibly secondary to BP changes, mild ATN vs.
pre-renal. Improved after holding [**Last Name (un) **], lasix, nsaids and
hydration.
[**Last Name (un) **] and lasix re-initiated [**1-22**]. NSAID re-started [**1-24**]. On
discharge, serum creatinine was stable 1.6-1.9.
.
3. Epigastric Pain - new, acute onset. Resolved by [**1-19**]. RUQ
ultrasound negative for cholelithiasis. No evidence of
pancreatitis on scan. Seen by general surgery not felt to have a
surgical abdomen. Recommended follow-up colonoscopy-see below.
Continued PPI. MRI chest/abdomen without evidence aortic
dissection
.
4. Hospital Acquired Pneumonia: Cough, fevers, opacity on cxr on
[**1-22**]. Given levoquin on [**1-22**], levoquin/vanc on [**1-23**] and then
changed to cefipime/levoquin [**1-24**]. Cefipime discontinued after
one dose--developed rash around IV site after infusion.
Levoquin continued for rest of course, defervesced, and to be
continued for 7 days on discharge.
.
5. Catheter Associated UTI: started levoquin on [**1-22**]. Grew
Morganella pan-sensitive by [**1-24**]. To get 7 day course for
catheter associated UTI on discharge.
.
6. Cecal/appendiceal thickening, inflammation: Seen by surgery,
recommended outpatient colonoscopy for follow up. Should be
done within one month of discharge.
.
7. Rheumatoid Arthritis: maintained on oxycontin, prednisone.
NSAID held with ARF and re-started [**1-24**].
.
8. Asthma: maintained on advair, albuterol
.
9. Hypothyroidism: levothyroxine maintained
.
10. Pericardial Effusion: outpatient monitoring, small, no
tamponade.
Medications on Admission:
Insulin 4 units daily
Aspirin 81 mg PO DAILY
Levothyroxine Sodium 50 mcg PO DAILY
Atacand 32 mg Oral daily
Prilosec 20 mg PO Q24H
Bisacodyl 10 mg PO/PR DAILY:PRN
Mecoxicam 15 mg PO DAILY
Clonidine TTS 1 Patch 1 PTCH TD QSAT
PredniSONE 5 mg PO DAILY
Diltiazem Extended-Release 360 mg PO DAILY
Senna 1 TAB PO BID:PRN
Docusate Sodium 100 mg PO BID
Furosemide 40 mg PO
Oxycontin 20mg daily prn
Discharge Medications:
1. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H
(every 48 hours) for 7 days.
Disp:*4 Tablet(s)* Refills:*0*
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Clonidine 0.3 mg/24 hr Patch Weekly Sig: Two (2) Patch Weekly
Transdermal QMON (every Monday).
Disp:*8 Patch Weekly(s)* Refills:*1*
6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(s)* Refills:*1*
7. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
Disp:*120 Capsule(s)* Refills:*1*
9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*1*
10. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO twice a day.
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*1*
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
12. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
13. Meloxicam 15 mg Tablet Sig: One (1) Tablet PO once a day.
14. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
15. Miralax 100 % Powder Sig: Seventeen (17) grams PO once a
day.
Disp:*QS * Refills:*1*
16. Losartan 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*1*
17. Lispro Insulin Sliding Scale
Check fingerstick glucose before each meal and at bedtime, and
following lispro sliding scale. Glucose <70: give juice and
contact M.D., 71-150: observe, 151-200: 2 units lispro SQ,
201-250: 4 units, 251-300: 6 units, 301-350: 8 units, 351-400:
10 units, >400: 12 units and contact M.D.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
1. Malignant Hypertension
2. Acute Renal Failure
3. Hospital Acquired Pneumonia
4. Catheter Associated Urinary Tract Infection
5. Cecal/Appendiceal Thickening
Secondary:
1. Chronic Kidney Disease Stage III
2. Hypothyroidism
3. Type II diabetes mellitus, controlled
Discharge Condition:
Stable, tolerating PO, to be discharged to rehab.
Discharge Instructions:
Follow up as below.
Contact your doctor if you develop chest pain, shortness of
breath, fevers, chills, abdominal pain or any other concerning
symptoms.
All medications as prescribed. We have made multiple changes.
STOP taking Diltiazem and Atacand (candesartan). Your Catapres
(clonidine) patch was increased to TTS-3 (do not take the old
TTS-1 patch anymore).
Followup Instructions:
Make a follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] [**Telephone/Fax (1) 65443**] in
1 weeks time.
Follow up with your rheumatologist DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2127-4-16**] 9:45
|
[
"585.3",
"584.9",
"V15.81",
"599.0",
"244.9",
"710.0",
"569.9",
"250.00",
"714.0",
"403.00",
"423.9",
"493.90",
"486",
"996.65",
"789.06"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10948, 11018
|
5428, 8305
|
317, 324
|
11327, 11378
|
4197, 5405
|
11791, 12137
|
3846, 3885
|
8746, 10925
|
11039, 11306
|
8331, 8723
|
11402, 11768
|
3900, 4178
|
256, 279
|
352, 2711
|
2733, 3518
|
3534, 3830
|
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