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19,698
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29227
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Discharge summary
|
report
|
Admission Date: [**2185-11-13**] Discharge Date: [**2185-11-29**]
Date of Birth: [**2129-8-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Fevers to 104
Major Surgical or Invasive Procedure:
Continued intubation
History of Present Illness:
56M s/p recent traumatic C1-4 fracture with subsequent
quadraplegia from C4 down with affection of the phrenic nerve on
chronic ventilation who presents from [**Hospital3 **] with
desaturation to 80%, and a fever to 104.
.
In the ED, he was found to have a multifocal PNA and was started
on Vancomycin and Zosyn for VAP. A BNP was sent and was found to
be elevated. CTA was negative for PE. CT abdomen and CT neck was
negative for abscess or other infectious source. the patient was
hemodynamically stable througout his ED stay.
Past Medical History:
DM2, CAD, AMI [**7-17**], s/p CABG
.
Past surgical history:
1. Application of halo.
2. Closed reduction C1 fracture.
3. Posterior cervical decompression with laminectomy of C3
and C4.
4. Posterior cervical arthrodesis C2 to C5.
5. Posterior cervical instrumentation segmental C2 to C5.
6. Right iliac crest bone graft with application of morselized
autograft to posterior cervical spine.
7. Right femoral [**Location (un) 260**] filter (titanium).
8. Tracheostomy.
9. [**Last Name (un) **] gastrostomy.
Social History:
[**12-13**] ppd smoker.
Estranged from wife.
Kids involved in care.
Family History:
Noncontributory.
Physical Exam:
VS T:101.4 BP:108/52 HR75 RR22 O2Sat:100 on PS10/10, FiO2 40, TV
600
Gen: NAD, AAOx3
HEENT: PERRLA, mmm
NECK: no LAD, no JVD, Halo in place
COR: S1S2, regular rhythm, no m/r/g
PULM: CTA b/l anteriorly
ABD: + bowel sounds, soft, nd, nt
Skin: warm extremities, no rash, no open wounds
EXT: 2+ DP, trace edema/c/c
Neuro: quadriplegic, PERRLA
Pertinent Results:
Imaging:
CHEST (PORTABLE AP) [**2185-11-25**] 6:29 AM
The ET tube tip remains in unchanged standard position. The
right PICC line tip terminates in mid SVC. The heart size is
enlarged but unchanged. The sternal wires are intact. There is
some improvement in the previously demonstrated pulmonary edema.
The bilateral pleural effusions are grossly unchanged as well as
bibasilar atelectasis.
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2185-11-22**] 1:04 PM
IMPRESSION: No evidence of acute cholecystitis.
.
CT PELVIS W/O CONTRAST [**2185-11-24**] 5:47 PM
IMPRESSION:
1. Limited study without intravenous contrast [**Doctor Last Name 360**].
2. No evidence of significant bowel obstruction.
3. Small free fluid along the right paracolic gutter inferior to
the cecum.
4. No free air.
5. Bilateral pleural effusion with bibasilar consolidations,
most likely due to atelectasis.
6. High density in IVC, right iliac and common femoral vein
worrisome for thrombosis.
.
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2185-11-24**] 5:46 PM
IMPRESSION: Air-fluid level in the sphenoid sinus on the right
and complete opacification of the left sphenoid sinus with
aerosolized secretions, most likely representing acute
sinusitis.
.
ABDOMEN (SUPINE & ERECT) PORT [**2185-11-24**] 9:51 AM
IMPRESSION:
Distended loops of the entire large bowel. Diagnostic
considerations include a distal obstruction, ileus, and less
likely toxic megacolon (given that haustral folds appear normal.
.
CT NECK W/CONTRAST (EG:PAROTIDS) [**2185-11-13**] 5:56 PM
IMPRESSION:
1. Post-operative scan demonstrate a posterior fusion of C2
through C5 with no evidence of abscess.
2. Lung apices demonstrate consolidation in the right middle
lobe which will be further commented on dedicated chest CT.
NOTE ADDED AT ATTENDING REVIEW: The small fluid collection in
the surgical site posterior to the spine appears somewhat larger
than on the cervical spine CT of [**2185-10-31**]. The collection is
poorly evaluated on both studies due to overlying artifact from
the fusion hardware. It may be better analyzed with MR imaging.
However, the apparent enlargement raises a concern of a CSF leak
or an abscess. There is no evidence of an enhancing rim on this
examination. However, this area is so obscured by artifact that
enhancement would be difficult to detect if present
.
CT ABDOMEN W/CONTRAST [**2185-11-13**] 5:18 PM
IMPRESSION:
1. No evidence of pulmonary embolus.
2. Right upper, mid and bibasilar consolidation concerning for
aspiration versus multifocal pneumonia. Clinical correlation is
recommended.
3. Fatty infiltration of the liver.
4. Diffuse stranding in the soft tissues consistent with
anasarca
.
CHEST (PORTABLE AP) [**2185-11-13**] 4:18 PM
IMPRESSION: Left lower lobe opacity which may represent
atelectasis or pneumonia, but unchanged.
.
Labs:
.
Microbiology:
[**2185-11-13**]
Urine Cx: NGTD
Blood Cx: NGTD
Swab/Sputum Culture: pansensitive Klebsiella oxytoca,
pansensitive E.coli
.
[**2185-11-14**]
Urine Legionella Antigen; negative
MRSA Screen: negative
VRE Screen: negative
.
[**2185-11-23**]
C. diff negative x 3
.
[**2185-11-24**]
Sputum gram stain: GNR
.
Labs on admission:
[**2185-11-13**] 02:25PM PT-13.3* PTT-36.0* INR(PT)-1.2*
[**2185-11-13**] 02:25PM PLT COUNT-206
[**2185-11-13**] 02:25PM WBC-9.4 RBC-2.78* HGB-9.1* HCT-26.7* MCV-96
MCH-32.7* MCHC-34.0 RDW-15.3
[**2185-11-13**] 02:25PM CALCIUM-7.5* PHOSPHATE-3.7 MAGNESIUM-2.6
[**2185-11-13**] 02:25PM proBNP-1346*
[**2185-11-13**] 02:25PM ALT(SGPT)-31 AST(SGOT)-24 ALK PHOS-54
AMYLASE-41 TOT BILI-0.4
[**2185-11-13**] 02:25PM GLUCOSE-200* UREA N-27* CREAT-0.7 SODIUM-132*
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-23 ANION GAP-12
[**2185-11-13**] 04:34PM LACTATE-1.7
Brief Hospital Course:
56 yo with quadriplegia from recent MVA, ventilator dependent,
now p/w multifocal pneumonia.
.
# Sinusitis: Although the patient was treated for a full course
of antibiotics for VAP, he still had refractory fevers. After
scanning of the sinuses and abdomen, it was determined that the
patient had acute sinusitis that was likely causing temperature
spikes. He had his medication changed to Levofloxacin and was
treated concominantly with Afrin and Nasal saline. After these
measures were taken the patient remained afebrile.
.
# Multifocal PNA: The patient was started on broad coverage with
Vancomycin and Zosyn for suspected ventilator associated
pneumonia. The patient fever curve trended downward through the
course of his hospital stay and he received frequent suctioning
to reduce recurrent aspiration. After sputum cultures grew out
pansensitive Klebsiella oxytoca and pansensitive E. coli,
antibiotic therapy was switched to Ceftriaxone for a full
course. CXRs revealed moderate improvement in his lung fields,
although had constant small pleural effusions.
.
C.diff - The patient was having fevers refractory to Ceftriaxone
and the patient was also having some abdominal distension. He
was started empirically on Flagyl and is to finish a 14 day
course of this medication. The patient had stool studies
obtained and has had 3 negative for C. diff. The abdominal
distension was thought to be due to constipation, and this
resolved after institution of an aggressive bowel regimen.
.
Fluid collection at surgical site - As the patient was having
fevers despite antibiotic therapy, he had a CT that revealed an
accumulation of fluid at the surgical site. This was initially
thought to be a CSF leak or an abscess as his fevers were
intermittent, but it was thought that this collections was a
likely due to post-operative changes. He had his neck re-imaged
and there was no interval change suggestive of a constant CSF
leak or abscess formation/growth.
.
# Respiratory failure: This patient is ventilator dependent
since the MVA, and given his phrenic nerve paralysis he is
exempt from typical weaning protocol, and the patient was
maintained on a PEEP of 5 while in house. A wean was
nonsuccessful and this can be attempted while at rehab. However,
the patient was given PSV sprints and he was also able to
tolerate cuff deflation in order to phonate.
.
# Quadriplegia: The patient was maintained on his current care
regimen consisting of PT and skin prophylaxis. These are issues
that will need to be continued while at rehab.
.
# DM: The patient had difficult to control sugars while in
house. The patient initially had been on NPH [**Hospital1 **] with morning
dosing of 80 and pm dosing of 60. Once his tube feeds were
restarted he required constant modification of his insulin
sliding scale. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was obtained and his current
sliding scale is in accordance with their recommendations. He
will likely require constant modification of this sliding scale
dependent on his TF and oral intake.
.
# FEN: The patient was restarted on tube feeds, of which he
tolerated without complication. His electrolytes were repleted
daily as needed.
.
# Prophylaxis: Pneumoboots
.
Medications on Admission:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (NamePattern4) **]: One (1)
Injection TID (3 times a day).
2. Albuterol 90 mcg/Actuation Aerosol [**Last Name (NamePattern4) **]: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (NamePattern4) **]: Two (2)
Puff Inhalation Q6H;PRN () as needed for wheeze/decreased air
movement.
4. Docusate Sodium 150 mg/15 mL Liquid [**Last Name (NamePattern4) **]: One (1) PO BID (2
times a day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (NamePattern4) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Senna 8.6 mg Tablet [**Last Name (NamePattern4) **]: One (1) Tablet PO BID (2 times a
day) as needed.
7. Acetaminophen 325 mg Tablet [**Last Name (NamePattern4) **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
8. Ranitidine HCl 15 mg/mL Syrup [**Last Name (NamePattern4) **]: One [**Age over 90 1230**]y (150) mg
PO BID (2 times a day).
9. Glipizide 5 mg Tablet [**Age over 90 **]: Two (2) Tablet PO BID (2 times a
day).
10. Aspirin 81 mg Tablet, Chewable [**Age over 90 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Oxycodone 5 mg/5 mL Solution [**Age over 90 **]: 5-10 mg PO Q4H (every 4
hours) as needed.
12. Acetylcysteine 10 % (100 mg/mL) Solution [**Age over 90 **]: 1-10 MLs
Miscell. Q4-6H (every 4 to 6 hours) as needed for thick
secretions/mucus plugging.
13. Magnesium Hydroxide 400 mg/5 mL Suspension [**Age over 90 **]: Thirty (30)
ML PO Q4H (every 4 hours) as needed for constipation.
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Age over 90 **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Paroxetine HCl 20 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY
(Daily).
3. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Age over 90 **]: Six (6)
Puff Inhalation Q6H (every 6 hours) as needed.
4. Albuterol 90 mcg/Actuation Aerosol [**Age over 90 **]: 4-6 Puffs Inhalation
Q6H (every 6 hours) 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. Oxycodone-Acetaminophen 5-325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
7. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
8. Trazodone 50 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO HS (at bedtime) as
needed.
9. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed.
10. Docusate Sodium 150 mg/15 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day).
11. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
DAILY (Daily) as needed.
12. Ranitidine HCl 15 mg/mL Syrup [**Last Name (STitle) **]: One (1) 150 mg PO twice a
day.
13. Insulin NPH Human Recomb 100 unit/mL Suspension [**Last Name (STitle) **]: One (1)
80 Subcutaneous qam.
14. Insulin NPH Human Recomb 100 unit/mL Suspension [**Last Name (STitle) **]: One (1)
55 Subcutaneous at dinner.
15. Levofloxacin 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily) for 9 days.
Disp:*9 Tablet(s)* Refills:*0*
16. Metronidazole 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3
times a day) for 9 days.
Disp:*27 Tablet(s)* Refills:*0*
17. Oxycodone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
18. Cyanocobalamin 500 mcg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
19. Ferrous Sulfate 325 (65) mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
DAILY (Daily).
20. Nystatin 100,000 unit/g Ointment [**Last Name (STitle) **]: One (1) Appl Topical
QID (4 times a day) as needed.
21. Sodium Chloride 0.65 % Aerosol, Spray [**Last Name (STitle) **]: [**12-13**] Sprays Nasal
QID (4 times a day).
22. Ammonium Lactate 12 % Lotion [**Month/Day (2) **]: One (1) Appl Topical
ASDIR (AS DIRECTED).
23. Lorazepam 0.5-2 mg IV Q6H:PRN
hold for oversedation
24. Lactulose 10 g/15 mL Syrup [**Month/Day (2) **]: Thirty (30) ML PO TID (3
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnosis: Ventilator Associated Pneumonia/sinusitis
.
Secondary Diagnoses:
Quadriplegia s/p MVA s/p C1-4 fracture and
fixation/decompression
DM2
CAD, AMI [**7-17**], s/p CABG
Discharge Condition:
Afebrile, stable vital signs
Discharge Instructions:
You were treated for E.coli/Klebsiella pneumonia and sinusitis.
You had your surgical staples removed without complication.
.
1. Please return to [**Hospital1 18**] if you have any concerning symptoms.
Followup Instructions:
As needed
Completed by:[**2185-12-14**]
|
[
"V44.0",
"787.91",
"276.1",
"461.9",
"564.00",
"E929.0",
"250.00",
"412",
"344.00",
"V45.81",
"482.0",
"907.2",
"482.82",
"V46.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.6",
"38.93",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
13177, 13247
|
5695, 8955
|
330, 353
|
13475, 13506
|
1934, 5095
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13756, 13798
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1541, 1559
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10578, 13154
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13268, 13268
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8981, 10555
|
13530, 13733
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994, 1439
|
1574, 1915
|
13352, 13454
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277, 292
|
381, 912
|
13287, 13331
|
5109, 5672
|
934, 971
|
1455, 1525
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,822
| 109,540
|
44967
|
Discharge summary
|
report
|
Admission Date: [**2191-9-26**] Discharge Date: [**2191-9-30**]
Date of Birth: [**2118-4-10**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5129**]
Chief Complaint:
altered mental status and fever
Major Surgical or Invasive Procedure:
Lumbar puncture [**9-26**]
History of Present Illness:
Pt. was in USOH until 6.30pm on the night prior to admission,
when he felt generally fatigeud and ill. He noted to have had a
low grade fever and took a nap. At 8.30, his wife heard
grunting noises from bedroom, as she arrived, she noted that he
could not get OOB despite attempts. He was able to answer some
of her questions, but was "confused" some of his words were part
of normal volcabulary, but did not make sense situationally.
After ~ 20 mins, he was eventually able to get OOB and walk to
kitchen. He was able to drink a glass of water, however wife
noted that he continued to not be himself (he did not know how
to check his BG which he does regularly). She then noted again
that he appeared weak (stumbling in the room, from side to
side). She helped him to a chair, where he was unable to
support himself and slumped down. He was able to respond to
her, however, again was felt to be confused. There was no
aphasia, he did not have anomia, his words were no "gibberish"
but simply did not make sense in the context. He did not have
any premontory sx, no auras, no shaking, no incontinence, no
tongue biting. No prior episodes like this before. No HA, no
neck stiffness, phono/photophobia. No recent travel, no
exposures.
.
In the ED, initial vs were: 100.2 90 137/65 15 98% 4L NC.
Patient was noted to have a WBC given 16K, INR 2.3, Cr 1.8 and
Troponin of 0.02. He underwent CXR and CT head that were
negative for infection and ICH respectively. He was found to
have an oral temp of 103.9F and noted to have SBPs drop to high
80s. He received 4L NS, 1g of tylenol, Vancomycin 1g,
CeftriaXONE 1g, Aspirin 325mg, and Neutra-Phos Powder Packet 1.
.
On the floor, VS were 97.7F 89/56 84 96% 3LNC. Pt. was alert
and oriented x3, however w/ mild recall deficit.
Past Medical History:
- Afib
- HL
- DM
- CKD, stage unknown.
Social History:
LIves in [**Location **] w/ wife. [**Name (NI) **] [**Name2 (NI) **] in computer training,
website design and sales.
- Tobacco: pipe, quit 25yrs ago.
- Alcohol: 2d/wk
- Illicits: denies.
Family History:
No CAD,MI.
Gfa/Gmo - CVA
Breast cancer/BRCA mutation in multiple female family members.
Physical Exam:
VS: 97.7F 89/56 84 96% 3LNC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, + JVD.
Lungs: crackles at bases.
CV: [**Last Name (un) 3526**]/[**Last Name (un) 3526**], normal S1 + S2, no murmurs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, trace edema b/l to 1/2 up shins, 2+
pulses, no clubbing, cyanosis or edema
NEURO:
MS: alert, oriented x 3. Attn: DOWb in 7 seconds. Naming intact
to low and high frequency objects, repetition intact, [**Location (un) 1131**]
and writing intact. No evidence of apraxia or neglect.
Registration intact, recall at 5 mins [**1-2**].
CNs: VFF to confront, EOMi, PERRL, face symmetric, intact to LT,
tongue and palate midline/symmetric, shoulder shrug intact.
Motor: normal tone, nl. bulk. UEs [**5-4**] in UMN distribution and
[**5-4**] at IP/H/TA in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]/l. No pronator drift. DTRs 1+ at
[**Hospital1 **]/tri, 1+ at patella b/l. Toe down on R, equivocal on L. FNF
and HKS intact. Gait deferred.
Pertinent Results:
Admission labs
[**2191-9-25**] 10:20PM BLOOD PT-24.6* PTT-28.9 INR(PT)-2.3*
[**2191-9-25**] 10:20PM BLOOD WBC-16.4* RBC-4.48* Hgb-13.8* Hct-39.9*
MCV-89 MCH-30.9 MCHC-34.6 RDW-13.8 Plt Ct-190
[**2191-9-25**] 10:20PM BLOOD Glucose-160* UreaN-28* Creat-1.8* Na-134
K-5.0 Cl-99 HCO3-27 AnGap-13
[**2191-9-25**] 10:20PM BLOOD Calcium-10.0 Phos-0.7* Mg-1.8
[**2191-9-25**] 10:20PM BLOOD ALT-20 AST-27 AlkPhos-58 TotBili-1.1
[**2191-9-26**] 05:03AM BLOOD CK(CPK)-196
[**2191-9-26**] 03:55PM BLOOD LD(LDH)-259*
[**2191-9-25**] 10:20PM BLOOD cTropnT-0.02*
[**2191-9-26**] 05:03AM BLOOD CK-MB-3 cTropnT-<0.01
[**2191-9-26**] 05:03AM BLOOD Calcium-8.4 Phos-2.0* Mg-1.5*
[**2191-9-25**] 10:33PM BLOOD Lactate-1.9
[**2191-9-26**] 10:16AM BLOOD Lactate-2.3*
Blood Cx ([**9-25**]) Pending
UCX [**9-25**] pending
CSF gram stain - no PMNs or organisms seen
CSF Cell count:
[**2191-9-26**] 10:48AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-3* Polys-0
Lymphs-67 Monos-30 Macroph-3
[**2191-9-26**] 10:48AM CEREBROSPINAL FLUID (CSF) TotProt-39 Glucose-91
Brief Hospital Course:
# Metabolic encephalopathy: Etiology unclear. Initial concern
was for embolic event vs. Seizure activity vs Menengitis. He
had a LP on [**9-26**] that was clear fluid and cell count/prelim gram
stain which was negative for menengitis. He also underwent an
EEG on [**9-26**] and results are pending as of [**9-27**]. Embolic event
secondary to A. fib was less likely given therapeutic INR (2.3).
Throughout the day on [**9-26**] pt's mental status improved and he
was lucid, A/O x3 and interactive by time of transfer to the
floor.
.
# Sepsis syndrome. Source of leukocytosis and fever unclear.
[**Name2 (NI) **] with septic physiology in the ED, but responded to IVF.
He did not require pressors. UA neg, CXR w/o focal infiltrate,
and LP did not show menengitis. He was initially started on
emperic treatment for menengitis (CTX 1g [**Hospital1 **] and Vanc) and
azithro for possible CAP on [**9-26**]. After LP came back negative,
CTX was changed to 1g daily for pna coverage, azithro was
continued, and vanc was d/c'd on [**9-27**]. LFTs were unremarkable,
and Bcx is pending from [**9-25**]. WBC trended down throughout [**Hospital Unit Name 153**]
stay as did his fevers.
# Hypotension. Likely due to septic physiology. Received 4 L
of IVF in the ED and pressures were stable throughout [**Hospital Unit Name 153**]
course. EKG w/o ischemic signs/changes, and troponin trended
down from 0.02 to 0.01. Also had elevated lactate of 1.9 on
[**9-25**] which actually increased to 2.3 on [**9-26**] but clinically
remained stable and no clinical concern for hypoperfusion.
.
# Volume overload by CXR and lung exam on [**9-27**], likely [**2-1**] to
IVF. (+6L over last 24 hr in [**Hospital Unit Name 153**]). We diuresed him to a goal
of -1-2L on [**8-27**]. Resp status remained stable on NC.
.
# Hypoxemic resp. distress. Likely due to volume overload as
above and possible PNA (treated for CAP, given clinical criteria
w/o CXR changes). Continued CAP tx (ctx and azithro) and
diuresis with a goal of negative 1-2 L/day with good response.
He did have some desats into the low 90s on 5L NC on the morning
of [**9-28**], but by transfer to floor, satting mid 90s on 4-5L NC.
.
# Renal failure. Cr elevated at 1.9 but was stable and this is
his baseline per PCP. [**Name10 (NameIs) **] held lisinopril.
.
# Atrial flutter/fibrillation. Rate controlled. We restared his
digoxin on [**9-27**] and continued his coumadin after his LP, which
was increased to his home dose of 6mg daily on [**9-28**] after INR
became subtherpeutic. Remained in AF.
.
# DM. FS stable throughout admission on Lantus 14U AM and HISS
which pt. self regulates with carb counting
Medications on Admission:
Digoxin 0.25mg daily
Apidra Insulin ss
Glyburide 5mg daily
Lantus 14-16U in AM
Lisinopril 5mg daily
Simvastatin 20mg daily
Vit D 1000U daily
Coumadin 5mg daily.
Discharge Medications:
1. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig:
One (1) gm Intravenous Q24H (every 24 hours) for 4 doses.
Disp:*4 gm* Refills:*0*
2. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous daily and prn as needed for line flush.
Disp:*10 ML(s)* Refills:*0*
3. Insulin Glargine 100 unit/mL Solution Sig: Sixteen (16) units
Subcutaneous once a day.
Disp:*480 units* Refills:*2*
4. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO once a day
for 14 days.
Disp:*42 Tablet(s)* Refills:*0*
5. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*20 Tablet(s)* Refills:*0*
6. Insulin Lispro 100 unit/mL Solution Sig: 10-20 units
Subcutaneous four times a day as needed for hyperglycemia: using
the sliding scale and carb counting you have used previously at
home.
Disp:*500 ml* Refills:*0*
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Sepsis - resolved
Community-acquired pneumonia
Type II diabetes mellitus with complications, controlled
Chronic kidney disease Stage II
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were diagnosed with sepsis from community-acquired
pneumonia. The infection is improved but you should finish the
full 10 day course of IV antibiotics. Your diabetes is now well
controlled on your home insulin regimen. You received a great
deal of IV fluids as part of the treatment for sepsis and you
still have a great deal of fluid swelling in your body for which
you were started on a diuretic. You will probably only need to
take the diuretic until the swelling resolves, after which you
can stop it. The diuretic (furosemide) can cause your blood
potassium level to drop ( dangerous condition), so you need to
have your blood levels checked periodically and followe by your
primary care doctor.
Followup Instructions:
Name: [**Last Name (LF) 639**],[**First Name3 (LF) **] V.
Address: [**Location (un) 96153**], E23-281, [**Hospital1 **],[**Numeric Identifier 26661**]
Phone: [**Telephone/Fax (1) 96154**]
Appt: [**10-5**] at 11:30am
|
[
"293.0",
"584.9",
"995.92",
"427.31",
"403.90",
"038.9",
"V58.61",
"585.2",
"486",
"427.32",
"250.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
8835, 8893
|
4781, 7458
|
304, 332
|
9093, 9093
|
3719, 4758
|
9973, 10192
|
2432, 2521
|
7669, 8812
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8914, 9072
|
7484, 7646
|
9244, 9950
|
2536, 3700
|
233, 266
|
360, 2145
|
9108, 9220
|
2167, 2207
|
2223, 2416
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
518
| 141,787
|
44016
|
Discharge summary
|
report
|
Admission Date: [**2109-6-11**] Discharge Date: [**2109-6-16**]
Date of Birth: [**2062-9-18**] Sex: M
Service: MEDICINE
Allergies:
Clindamycin
Attending:[**First Name3 (LF) 2234**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
46 y/o Ethiopian male hx T1DM, HIV, ESRD (secondary to
nephrolithiasis, htn and T1DM) presented to the ED complaining
of shortness of breath and chest pain. He claims that the chest
pain is the same all the time, nonpleuritic, nonpositional,
nonradiating, but that his shortness of breath worsens when he
lays flat. He notes that the last time he felt this kind of
pain, he was found to have a large pleural effusion. The bedside
ultrasound was brought over and did not show any evidence of an
effusion, and because he is HD dependent, he was sent for a CTA,
which showed an acute PE as well as evidence of chronic PE's.
His pressures were in the 200's systolic, and he was started on
a nitroglycerin gtt, with little benefit. Otherwise, he was
afebrile and with mild respiratory distress to the low 20's.
He was seen by renal in the ED (he is followed by Dr. [**Last Name (STitle) 1366**] as
an outpatient) who felt that his hypertension was likely
secondary to him missing his AM meds, as he had just had HD the
day prior to admission.
He also had a head CT, prior to initiating heparin gtt to rule
out head bleed, and it could not rule out SAH given the dye load
from the CTA. The ED therefore did not start anticoagulation and
sent the patient to the [**Hospital Unit Name 153**] for further management of his
hypertension, renal failure and PE's.
Past Medical History:
- Type 1 diabetes
- HIV (boosted atazanavir, lamivudine, stavudine), dx'd [**2096**]
VL <50, CD4 393 [**2-13**])
- ESRD previously on HD, attempted on PD
on transplant list (clinical study for HIV/solid organ
transplant)
- Malignant Hypertension
- hx Serratia bacteremia (presumed AV graft) tx 6 wks meropenem
- Hx schistosomiasis
- Restless leg syndrome
- Peripheral neuropathy on gabapentin
- S/p cholecystectomy
- s/p R nephrectomy in [**2092**] secondary renal nephrolithiasis
Social History:
Moved from [**Country 4812**] in [**2091**]. Lives with wife in [**Location (un) 538**].
Works in support services for a law firm. Denies any alcohol or
IV drug use. Quit smoking last year; previous 30 pack-year
history.
Family History:
Non-contributory.
Physical Exam:
Vitals: 98.0 80 [**Telephone/Fax (2) 94519**]% 4LNC
General: NAD, comfortable
HEENT: JVD to 9cm, PERRL, eomi, op clear
Heart: RRR no m/r/g
Lungs: CTAB no w/r/r
Abd: soft NT/ND +BS
Ext: no e/c/c, wwp, 2+ dp pulses
Neuro: nonfocal
Skin: warm and dry
Pertinent Results:
Admit Labs:
[**2109-6-11**] 10:30AM WBC-4.5 RBC-3.20* HGB-12.0* HCT-34.4*
MCV-107* MCH-37.6* MCHC-35.0 RDW-15.8*
[**2109-6-11**] 10:30AM NEUTS-60.8 LYMPHS-26.1 MONOS-8.1 EOS-4.0
BASOS-1.0
[**2109-6-11**] 10:30AM PLT COUNT-203
[**2109-6-11**] 10:30AM GLUCOSE-95 UREA N-47* CREAT-9.2*# SODIUM-137
POTASSIUM-6.2* CHLORIDE-94* TOTAL CO2-29 ANION GAP-20
[**2109-6-11**] 10:30AM ALT(SGPT)-24 AST(SGOT)-31 CK(CPK)-130 ALK
PHOS-153* TOT BILI-2.3*
.
Cardiac Enzymes:
[**2109-6-11**] 10:30AM cTropnT-0.29*
[**2109-6-11**] 10:30AM CK-MB-5
[**2109-6-11**] 10:30AM CK(CPK)-130
[**2109-6-11**] 08:47PM CK-MB-5 cTropnT-0.23*
[**2109-6-11**] 08:47PM CK(CPK)-97
.
.
Imaging:
[**6-11**]: CXR - IMPRESSION: No acute cardiopulmonary process.
.
[**6-11**]: CTA IMPRESSION: 1. Segmental and subsegmental right lower
lobe acute pulmonary embolism. 2. Stable findings of chronic
right lower lobe PE. 3. Diffuse and more focal ground-glass
opacities, which could represent an infectious process such as
viral or atypical pneumonia. Pneumocystis pneumonia could also
have this appearance in the proper clinical setting. Asymmetric
pulmonary edema is a less likely consideration.
.
[**6-11**]: Head CT: IMPRESSION: 1. No definite acute intracranial
hemorrhage; however, intravascular contrast remains on board
from the recent CTA PE study, and thus subarachnoid and subtle
extra-axial hemorrhage cannot be excluded on this CT. 2.
Prominent ventriculomegaly, not significantly changed from
[**2108-7-9**]. 3. Low-lying cerebellar tonsils consistent with Chiari
I malformation.
.
[**6-12**]: Head CT:
FINDINGS: There is no evidence of hemorrhage, mass effect,
shift of midline structures, or infarction. The ventricles
remain prominently enlarged, unchanged from recent examination.
There is stable appearance to low lying cerebellar tonsils as
noted on prior exams. Soft tissues and osseous structures are
unremarkable. Perinasal sinuses and mastoid air cells are well
aerated.
IMPRESSION:
1. No evidence of hemorrhage.
2. Unchanged Chiari I malformation and prominent
ventriculomegaly
.
[**6-13**] Echo: Conclusions:
The left atrium is mildly dilated. The estimated right atrial
pressure is
11-15mmHg. There is mild symmetric left ventricular hypertrophy.
The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF 60%). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets aremildly thickened. There is no mitral
valve prolapse. There is severe mitral annular
calcification. At least mild (1+) mitral regurgitation is
present. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2108-7-10**], the [**Last Name (un) 22837**] annular calcification is now
severe, and the mitral regurgitation is increased.
.
Discharge Labs:
Brief Hospital Course:
46 year old Ethiopian man with a history of Type I diabetes
mellitus, CKD stage V on hemodialysis, malignant hypertension,
HIV on HAART who presented with concomitant severe nausea,
vomiting, chest pain and subsequent shortness of breath. The
following issues were addressed on this admission:
.
1. Respiratory distress: Initiating event thought to be nausea
and vomiting secondary to gastroparesis. Patient unable to take
anti-hypertensives and combined with sympathetic tone from
nausea, vomiting, patient then likely devloped hypertension with
systolics to >200's (>250 in emergency room). Chest pain
secondary to vomiting or possibly ischemia with severe
hypertension. Shortness of breath appears to have developed
secondary to pulmonary edema from severe hypertension. Low
oxygen requirements even in this setting. Patient underwent CTA
of chest and found to have acute segmental and subsegmental PE's
as well as chronic PE's, ultimately not thought to have been
responsible for presentation. Patient was placed on
nitroglycerin drip in ER and in the [**Hospital Unit Name 153**] for short time. Once
nausea controlled, home blood pressure regimen re-initiated with
good control. Patient dialyzed morning after admission for
pulmonary edema. With control of nausea, blood pressure and
dialysis, resp distress resolved. No further episodes
throughout admission. Patient transferred to the floor on HD#2,
[**6-12**]. See PE below. Cardiac enzymes cycled and remained flat,
no concerning ECG changes.
.
2)Pulmonary Emboli: Patient found to have acute segmental and
subsegmental PE in RLL and chronic PE. Initially unable to rule
out head bleed (CT head images affected by contrast dye from
CTA) and therefore heparin therapy withheld. Patient transferred
to the floor and had repeat head CT [**6-12**] without evidence of head
bleed. Heparin gtt and coumadin 7.5 mg initiated [**6-12**]. Coumadin
7.5 mg on [**6-13**], INR then 2.3 on 7/6AM. 5mg [**6-14**] pm and then INR
4.1 on [**6-15**]. Coumadin held [**6-15**] and INR 3.8 on [**6-16**]. Given INR>2
x 48 hours on heparin, heparin discontinued on [**6-16**] and patient
instructed to take no coumadin on [**6-16**] evening and have INR
checked [**6-17**] at scheduled dialysis. Dr. [**Last Name (STitle) 1366**] will follow INR
at dialysis. Given script for 2mg coumadin tablets. Appears
that dosing in past for graft was around [**1-14**] daily.
.
3)Malignant hypertension: As above in #1, patient hypertensive
to systolic 250's on presentation. Likely secondary to
gastroparesis and missing meds with nausea, vomiting. Initially
on nitro drip in Er and quickly weaned once nausea controlled
and home anti-hypertensives re-initiated. Home
anti-hypertensives of lisinopril 20, diltiazem XR 90mg,
valsartan 160 [**Hospital1 **] and atenolol 100mg daily maintained throughout
rest of admission. Bp's generally 140-160.
.
4. Nausea/vomiting/epigastric pain: Daily symptoms in setting of
DM1 suggested gastroparesis. Reglan initiated. GI consulted
and recommended Reglan. Continued throughout admission with
good effect. Will need to be vigilant for side effects given
complex medical issues/regimen. To follow up with Dr.
[**First Name4 (NamePattern1) 450**] [**Last Name (NamePattern1) 79**].
.
5.CKD stage V, on hemodialysis: Complicated history, had been on
PD, on transplant list. Dr. [**Last Name (STitle) 1366**] and renal team followed
throughout admission. Dialysis performed on [**6-11**]. Patient
will get dialysis on [**6-17**]. INR check at that time as above.
Unclear if patient taking lanthanum as outpatient. TAking
sensipar. Here lanthanum 2000mg TID with meals and sensipar 60mg
daily continued. To follow up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **]
for transplant evaluation.
.
6. HIV: HAART regimen continued. Meds given after dialysis on
dialysis days. Patient to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**].
.
7 Anemia: FElt to be result of longstanding ESRD. Continued
Epogen w/ HD
.
8. Peripheral Neuropathy: Longstanding secondary to DM1.
Continued gabapentin
.
9. Type I Diabetes Mellitus: outpatient regimen continued with
good glucose control, generally 90's to 140's. NPH 10 qam, 7qPM
and regular ISS.
.
10. Patch of Alopecia: Outpatient dermatology consult as
arranged by PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4026**].
.
11. Finding of Chiari I malformation, increased size of
ventricles. Not cliniically significant on this admission, no
acute issues. Recommend neurosurgery follow up if patient has
not seen at discretion of Dr. [**Last Name (STitle) 4026**].
Patient instructed on all medications including changes and side
effects. No coumadin tonight, [**6-16**] and check tomorrow at
dialysis. Follow up instructions provided including with Dr.
[**Last Name (STitle) **], Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) 79**], Dr. [**Last Name (STitle) 724**], dermatology
and potentially neurosurgery. See discharge information for
details.
Medications on Admission:
Gabapentin 100 mg tid
Lanthanum 2000mg TID with meals
Cinacalcet 60mg daily
lisinopril 20mg daily
Atenolol 100 mg PO daily
Valsartan 160mg [**Hospital1 **]
Diltiazem 90XR daily
Compazine PRN
Insulin (NPH 10 U [**Hospital1 **] and Regular 5 U QAM)
Tenofovir 300 mg PO QSAT
Ritonavir 100 mg p.o. daily
Atazanavir 300 mg p.o. daily
Stavudine (Zerit) 20 mg PO daily
Lamivudine (Epivir) 25 mg PO daily
(Of note HAART given after dialysis).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Hypertensive emergency
2. Pulmonary Emboli
3. Respiratory Distress
4. Gastroparesis
Secondary:
1.Type I DM with complications
2. CKD stage 5 on hemodialysis
3. HIV
Discharge Condition:
Stable, tolerating PO, ambulating, therapeutic on coumadin.
Discharge Instructions:
Take all medications as prescribed. The new medications are:
1)coumadin, take none tonight, have your INR checked tomorrow at
dialysis, and then they will tell you how much to take starting
[**6-17**].
2)lanthanum: you should take 2000mg with each meal to help
regulate your calcium and phosphorus. 3)Reglan(metoclopramide):
take this with each meal for your gastroparesis as discussed.
Continue to take your blood pressure medications, insulin and
HIV medications as before, these have not been changed. All your
other medications as before.
.
Make sure to follow up with each of the doctors below, as we
discussed in detail.
.
If you have return of nausea, vomiting, shortness of breath,
chest pain or develop fevers or any other new concerning
symptoms contact your doctor or go to the emergency room.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 1366**] in dialysis, tomorrow, [**6-17**] as
scheduled. You must have your INR checked and they will
instruct you how much coumadin to take for the rest of the week.
.
Follow up with Dr. [**Last Name (STitle) 4026**]. Call him tomorrow at [**Telephone/Fax (1) 1247**] to
set up an [**Telephone/Fax (1) 648**] for this week. I will tell him about your
hospitalization.
.
Follow up with Dr. [**Last Name (STitle) 724**] for your HIV medications. His number is
[**Telephone/Fax (1) 3395**]. You should call this week to set up an
[**Telephone/Fax (1) 648**] with him.
.
Follow up with Dr. [**Last Name (STitle) **] on Tuesday for your transplant
evaluation: Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2109-6-18**] 10:50
.
Follow up with the dermatologist for your hair loss:
Provider: [**Name10 (NameIs) 2975**] [**Name8 (MD) 2976**], MD Phone:[**Telephone/Fax (1) 2309**]
Date/Time:[**2109-7-25**] 10:45
.
You can follow up with Dr. [**First Name4 (NamePattern1) 450**] [**Last Name (NamePattern1) 79**] in [**Hospital **] clinic for your
gastoparesis. She saw you as an inpatient here. Her number is
[**Telephone/Fax (1) 94520**]. Call tomorrow to set up an [**Telephone/Fax (1) 648**]. You can
ask Dr. [**Last Name (STitle) 4026**] if you have questions.
.
You may need evaluation by neurosurgery for a possible
congenital defect which is not an emergency. (Chiari I
malformation). Let Dr. [**Last Name (STitle) 4026**] know about this.
|
[
"348.4",
"424.0",
"042",
"585.6",
"416.8",
"536.3",
"403.01",
"415.19",
"357.2",
"333.94",
"250.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11634, 11640
|
6036, 11149
|
283, 289
|
11860, 11922
|
2733, 3186
|
12777, 14358
|
2431, 2450
|
11661, 11839
|
11175, 11611
|
11946, 12754
|
6013, 6013
|
2465, 2714
|
3204, 3926
|
233, 245
|
317, 1671
|
4331, 5995
|
1693, 2176
|
2192, 2415
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,633
| 114,030
|
17603
|
Discharge summary
|
report
|
Admission Date: [**2118-5-23**] Discharge Date: [**2118-6-1**]
Date of Birth: Sex: M
Service:
REASON FOR ADMISSION: Dehydration.
DISCHARGE DIAGNOSIS: Unresectable cholangiocarcinoma.
DETAILS OF HOSPITAL COURSE: Patient is a 67-year-old male
who presented with a history of obstructive jaundice. He
underwent placement of transhepatic catheters in both the
right and left biliary system and brushings and biopsies
confirm the presence of cholangiocarcinoma.
The patient was discharged home after placement of the tubes
and subsequently returns with inability to eat and unable to
keep up with the transhepatic catheter output.
PHYSICAL EXAMINATION: On exam, the patient's blood pressure
is 102/52, pulse 73, respirations 20, and temperature is
96.7. He was alert, oriented, jaundiced, and obvious scleral
icterus. His chest was clear bilaterally. Cardiac
examination: Regular, rate, and rhythm without murmurs.
Abdomen was soft, nontender, nondistended. His transhepatic
catheters were in place. There was no leakage from around
the catheter sites, slight pericatheter cellulitis, no
abdominal discomfort, no hepatosplenomegaly.
Admission white count was 11.2 thousand. His electrolytes
were significant for a sodium of 130. His bilirubin was 13.3
with an alkaline phosphatase of 230.
The patient was admitted to the Surgical service. Started on
IV fluids and started on IV antibiotics.
On hospital day one, he developed marked shortness of breath
and hypotension, and blood pressure dropped into the 70s. He
underwent urgent laboratory studies and stabilization. His
hematocrit remained stable at 30, and he was transferred to
the Intensive Care Unit with a presumptive diagnosis of
biliary sepsis.
The chest x-ray demonstrated a large right sided pleural
effusion and the chest tube was placed with return of greater
than 2 liters of clear fluid. We were concerned that the
right pleural effusion was biliary effusion secondary to
malposition of the catheter, but the chemical analysis of the
fluid did not confirm this.
He continued aggressive volume resuscitation. He received
multiple colloid transfusions. On hospital day three, he
developed marked azotemia with an increase in his creatinine
to 37.2 and oliguria. We were concerned that due to his
markedly elevated bilirubin and cholangiocarcinoma, he may
in-fact be developing hepatorenal syndrome. We continued his
resuscitation and then gradually over the course of the next
several days, his oliguria and azotemia improved.
Due to patient's poor medical condition and probable
unresectable disease due to his marked jaundice, we did not
believe that he was an operative candidate in light of the
ongoing blood pressure problems and we believe that he would
not make it to surgery. We had a lengthy discussion with his
family and the patient regarding this, and at that time we
elected to offer palliative care. Patient and his family
agreed to this.
Palliative care was consulted, and he was discharged home on
the [**6-1**] with home hospice.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**]
Dictated By:[**Last Name (NamePattern1) 30156**]
MEDQUIST36
D: [**2118-11-15**] 18:25
T: [**2118-11-17**] 13:42
JOB#: [**Job Number 49052**]
|
[
"250.00",
"157.8",
"511.9",
"458.9",
"996.59",
"584.5",
"790.7",
"572.4",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.15",
"00.14",
"34.04",
"87.54",
"97.05"
] |
icd9pcs
|
[
[
[]
]
] |
180, 225
|
243, 661
|
684, 3341
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,452
| 169,571
|
22389
|
Discharge summary
|
report
|
Admission Date: [**2156-9-14**] Discharge Date: [**2156-9-22**]
Date of Birth: [**2095-6-2**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 61-year-old white male
who has a known history of coronary artery disease. He had
prior myocardial infarctions at the age of 39 and 44 with an
angioplasty of the proximal left circumflex in [**2139**]. He
reports doing until one month prior to admission when he
began feeling more fatigued with less activity, and he was
experiencing dyspnea on exertion - especially with stairs.
He had a cardiac catheterization on [**8-5**] which
revealed three vessel disease and 100 percent right coronary
artery lesion, 80 percent mid left anterior descending
lesion, and 80 percent first obtuse marginal lesion, mild
pulmonary hypertension. He also had an echocardiogram on
[**8-5**] which revealed mild dilatation of the left
atrium, an ejection fraction of 45 percent, and inferior wall
hypokinesis. He was recommended to have surgery at that time
but refused.
He presented back to the hospital shortness of breath, and
chest pain, and numbness in his left arm which was relieved
with nitroglycerin.
PAST MEDICAL HISTORY: Significant for a history of coronary
artery disease (status post myocardial infarctions at the age
of 39 and 44), status post PTCA in [**2139**], history of diabetes,
hypertension, hyperlipidemia, chronic obstructive pulmonary
disease, status post left leg deep venous thrombosis, history
of gastroesophageal reflux disease, diabetic neuropathy,
varicose veins, and peripheral vascular disease.
PAST SURGICAL HISTORY: He is status post repair of a right
knee aneurysm, status post a right bypass, status post
bilateral hip surgery, status post carpal tunnel release,
status post cholecystectomy, and status post excision of
benign skin growth.
ALLERGIES: He is allergic to SULFA DRUGS (he gets gas) and
he is allergic to KEFLEX (he gets difficulty breathing).
MEDICATIONS ON ADMISSION: Aspirin 325 mg by mouth daily,
diltiazem 180 mg by mouth daily, metformin 1000 mg by mouth
twice daily, Colace 100 mg by mouth twice daily, glipizide 10
mg by mouth twice daily, lisinopril 40 mg by mouth daily,
Crestor 10 mg by mouth daily, atenolol 25 mg by mouth daily,
Avandia 4 mg by mouth daily, and hydrochlorothiazide 25 mg by
mouth daily.
SOCIAL HISTORY: He lives with his wife and works the night
shift. He smoked two packs a day for 60 years and quit two
days prior to admission. He does not drink alcohol.
FAMILY HISTORY: Significant for coronary artery disease.
REVIEW OF SYSTEMS: As above. In addition, he also has
dysuria and urinary retention.
PHYSICAL EXAMINATION ON ADMISSION: He is an elderly white
male in no apparent distress. Vital signs were stable. He
was afebrile. Head, eyes, ears, nose, and throat examination
revealed normocephalic and atraumatic. The extraocular
movements were intact. The oropharynx was benign. The neck
was supple. Full range of motion. No lymphadenopathy or
thyromegaly. Carotids were 2 plus and equal bilaterally. No
bruits. The lungs had fine rales at the bilateral bases.
Cardiovascular examination revealed a regular rate and
rhythm. A 2/6 systolic ejection murmur. The abdomen was
soft and nontender. There were positive bowel sounds. The
extremities were without clubbing, cyanosis, or edema. His
right leg was significantly larger than the left. The pulses
were 2 plus and equal bilaterally with the exception of the
left dorsalis pedis which was a dopplerable pulse and
posterior tibial pulse which was 1 plus. His neurologic
examination was nonfocal.
SUMMARY OF HOSPITAL COURSE: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] was
consulted. On [**9-16**], the patient underwent a coronary
artery bypass grafting times two with a left internal mammary
artery to the left anterior descending and reversed saphenous
vein graft to the obtuse marginal. His cross-clamp time was
39 minutes. Total bypass time was 52 minutes.
He was transferred to the Cardiac Surgery Recovery Unit on
nitroglycerin and propofol. On his postoperative night he
had a right upper lobe collapse and was bronched, and his
lung fully reexpanded. He required aggressive treatment with
Combivent inhaler. He was extubated that night.
The following day he continued to progress. He had his chest
tubes out on postoperative day one. He required a lot of
respiratory therapy and diuresis. He was transferred to the
floor on postoperative day four. He had his epicardial
pacing wires discontinued prior to that. He continued to
require aggressive pulmonary therapy and physical therapy.
DISCHARGE DISPOSITION: On postoperative day six, he was
discharged to home in stable condition.
LABORATORY VALUES ON DISCHARGE: Hematocrit was 30.1, white
count was 7400, and platelets were 128,000. Sodium was 136,
potassium was 5, chloride was 100, bicarbonate was 26, blood
urea nitrogen was 32, creatinine was 1.2, and blood glucose
was 60.
MEDICATIONS ON DISCHARGE:
1. Percocet one to two tablets by mouth q.4-6h. as needed
(for pain).
2. Plavix 75 mg by mouth daily.
3. Aspirin 325 mg by mouth once per day.
4. Colace 100 mg by mouth twice daily.
5. Combivent 2 puffs q.6h.
6. Glipizide 5 mg by mouth twice daily.
7. Crestor 10 mg by mouth daily.
8. Avandia 4 mg by mouth daily.
9. Nicotine 14-mg patch transdermally daily.
10. Flovent 2 puffs twice daily.
11. Metformin 1000 mg by mouth twice daily.
12. Lopressor 100 mg by mouth twice daily.
13. Lasix 40 mg by mouth twice daily (for 10 days).
14. Potassium 20 mEq by mouth daily (for 10 days).
DISCHARGE FOLLOWUP: He will be followed by Dr. [**First Name11 (Name Pattern1) 518**] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 6700**] in one to two weeks, and by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] in
six weeks, and by Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7047**] in two to three weeks.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Non-insulin-dependent diabetes.
3. Hypertension.
4. Cholesterol.
5. Chronic obstructive pulmonary disease.
6. Peripheral vascular disease.
7. Gastroesophageal reflux disease.
8. Status post deep venous thrombosis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) 18588**]
MEDQUIST36
D: [**2156-9-22**] 18:55:18
T: [**2156-9-22**] 20:24:07
Job#: [**Job Number 58230**]
|
[
"V15.82",
"V12.51",
"250.60",
"530.81",
"401.9",
"V45.82",
"411.1",
"997.3",
"443.9",
"357.2",
"496",
"285.9",
"272.4",
"518.0",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"96.56",
"39.61",
"33.23",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
4691, 4783
|
2527, 2569
|
6079, 6598
|
5042, 5654
|
1988, 2336
|
1616, 1961
|
3655, 4667
|
4798, 5016
|
2589, 2678
|
5675, 6058
|
164, 1172
|
2693, 3626
|
1195, 1592
|
2353, 2510
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,659
| 144,818
|
13335
|
Discharge summary
|
report
|
Admission Date: [**2145-2-14**] Discharge Date: [**2145-3-30**]
Date of Birth: [**2087-12-9**] Sex: F
Service: MEDICINE
Allergies:
Zanaflex
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Xfer for syncope, decompensated liver disease
Major Surgical or Invasive Procedure:
paracentesis
History of Present Illness:
57F with HCV cirrhosis and ESLD with ascites/encephalopathy as
well as varices who presents from an OSH for work up for
episodes of syncope and management of her ESLD. Patient is a
relatively poor historian and part of history is obtained from
records. The patient states that over the last few weeks she has
been "passing out" about 4-5 times. These episodes occur
randomly, not with exertion, but suddenly without warning.
During these episodes she denies any lightheadedness/dizziness,
CP or palps, and denies any incontinence or post-ictal symptoms.
She does state that she has also had increased SOB and abdominal
girth as well. She recently came back from a trip to [**Male First Name (un) 1056**]
where she syncopal episodes there. She denies any fevers but
endorses chills over this time. She therefore presented to
[**Hospital 40572**] Hosp on [**2-6**] and was admitted. Of note, she had had
past admissions for similar symptoms thought to be due to
orthostatic hypotension. She has had negative holters and
unremarkable Echos. She has also been admitted for SOB/CHF as
well in the past.
.
At the OSH, her syncopal symptoms were thought to be orthostatic
in nature per cardiology consult, as past BPs have been low (70s
sytolic) in the setting of these episodes. Her BPs were 100-110
syst in house. Her Lisinopril and Aldactone were held as was her
[**Last Name (un) **], but she was continued on her Lasix and Propranolol. She
underwent holter monitoring which was unremarkable for
arrythmia, and her EKGs were unchanged. Carotid U/S was
unremarkable, as was head CT.
.
With regards to her ESLD and ascites, she was noted to have
increasing leg edema and ascites. Her lab data was notable for
baseline anemia, thrombocytopenia, and mild hyponatremia. Her Cr
was elevated at 2.3 on admission, and improved to 1.4 on
transfer. Her albumin remained low, and her bili was slightly
elevated at 9->[**7-3**], BNP 7049. Abdominal U/S demonstrated ascites
but no acute biliary pathology. Over the course of her admission
her UOP decreased necessitating renal consult. They felt her
symptoms were due to intravasculr volume depletion, though could
not rule out HRS given her liver disease.
.
Prior to transer, PICC was placed for access [**2145-2-12**].
.
On arrival to the floor, patient feels well. She denies any
dizziness/lightheadedness, CP, SOB, abd pain, nausea. She states
she feels slightly confused but is near her baseline.
Past Medical History:
ESLD secondary to HCV cirrhosis, with ascites, encephalopathy,
grade 3 varices with portal gastropathy
Hepatitis C
Depression
Anxiety
GERD
IDDM
Seizure disorder
HTN
OSA
s/p CCY
Social History:
From [**Male First Name (un) **] and visited recently. ? past h/o IVDU. Denies
tobacco, EtOH, or current recreational drug use
.
Family History:
non-contributory
Physical Exam:
VS: T 100.1, BP 108/68, HR 84, RR 20, 100%RA
Gen: awake, alert, lucid but slow to answer questions, NAD
HEENT: EOMI, PERRL, icteric sclera, MMM
Neck: supple, no bruits, no LAD
Lung: CTAB no wheeze or crackles good air flow
Heart: RRR, soft [**3-3**] pan systolic murmur at LLSB
Abd: Distended throughout and typanic superiorly with + fluid
wave, + shifting dullness. non-tender, could not appreciate
liver edge, surgical scars noted
Back: No midline tenderness
Ext: Pitting edema to 1/4cm indentation to beyond knee, warm
Skin: mildly icteric, no occhymoses
Neuro: Awake, alert and oriented to place and time, appropriate
but slow to answer questions. + mild asterixis. CNII-XII intact,
5/5 strength in all extremities. NO resting tremor or nystagmus
noted.
Pertinent Results:
[**2145-2-13**]:
WBC 5.5, Hct 32.9, Plt 102, INR 1
Na 131, K 4.7, Cl 105, C02 21, Cr 1.4, BUN 31, NH3 38
.
[**2145-2-9**]
Alb 2, T bili 6.1, D bili 4.6
AST 34, ALT 19
AFP 6.4
.
Urine cx ENTEROCOCCUS AND ECOLI:
ESCHERICHIA COLI
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ =>32 R <=2 S
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
PIPERACILLIN---------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
VANCOMYCIN------------ <=1 S
.
.
IMAGING:
CXR:
A left PICC line is seen with the tip in the SVC. There is an
oval opaque density adjacent to the right hemidiaphragm which
has an appearance of a partial collapse. A followup is
recommended as this could be evolving into a pneumonia. Shallow
inspiration limits the study. The left CP angle is sharply
delineated and the pulmonary vascular markings are within normal
limits for technique.
.
[**Last Name (un) **] U/S:
RIGHT UPPER QUADRANT ULTRASOUND: The liver is shrunken and
nodular consistent with cirrhosis. No focal intrahepatic masses
are identified, and there is no intrahepatic ductal dilatation.
The common duct is enlarged measuring 9 mm (previously 6 mm).
The portal vein is patent with hepatopetal flow. The patient is
status post cholecystectomy. Splenomegaly is again noted
measuring up to 17 cm. There is a moderate-to-large amount of
ascites, which appears to have increased compared to the prior
exam. A suitable spot was marked in the right lower quadrant for
paracentesis.
IMPRESSION: Unchanged cirrhotic liver and splenomegaly.
Moderate-to-large amount of ascites. A spot was marked in the
right lower quadrant for paracentesis to be performed by the
clinical team.
.
P-MIBI:
IMPRESSION: No anginal symptoms or ischemic ST segment changes.
Nuclear
report sent separately.
.
ECHO:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%) Overall left ventricular systolic function is
normal (LVEF>55%). The estimated cardiac index is normal
(>=2.5L/min/m2). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. No masses or
vegetations are seen on the aortic valve. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve.
Moderate (2+) mitral regurgitation is seen. Moderate to severe
[3+] tricuspid regurgitation is seen. There is borderline
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: No cardiac source of syncope identified. Normal
regional and global biventricular function. Moderate mitral
regurgitation, moderate to severe tricuspid regurgitation.
Borderlie pulmonary artery systolic hypertension.
.
IMAGING: OSH Reports
.
.
EKG: NSR with nl axis, nl intervals TWI in III, unchanged EKG
compared with priors from admission.
.
Holter [**2-6**]: Sinue without vent ectopic beats, no pauses.
.
L spine/ribs/hips films [**2-7**]: mild spondylosis, no fracture
.
Abd U/S [**2-6**]: Ascites in all four quadrants, no intrahepatic
ductal dilatation, no gallbladder visualized.
.
CXR [**2-6**]: Linear opacity at R base unchanged from prior
.
CT Head: No acute processes
.
Carotid U/S [**2-6**]: NO significant stenosis
Brief Hospital Course:
57-year-old woman with HCV cirrhosis and ESLD with ascites,
varices, gastropathy was transferred from OSH for further
management of ESLD and hepatic encephalopathy.
.
# ESLD: Because of refractory ascites, the patient underwent
multiple paracenteses then TIPS on [**2145-3-22**] with post-TIPS course
complicated by hematocrit drop requiring blood transfusions.
After TIPS, the patient had more paracenteses with albumin
administration. She was given lactulose and rifaximin during
this stay. Her mental status improved to baseline by discharge.
Her grade three esophageal varices were banded on [**2145-3-10**]. She
initially had significant post-banding epigastric discomfort,
which then quickly resolved.
.
# Portal vein thrombus: non-occlusive PV thrombus seen on CT
abd/pelvis done for liver transplant work-up. Most likely acute
thrombus as now seen on liver u/s and was not seen on U/S on
admission. Anticoagulation was started initially, however
stopped due to BRBPR.
.
# Left shoulder pain: acromial spur on Xray. Her pain was
controlled with hydromorphone and lidocaine patch.
.
# ARF: Likely secondary to hepatorenal syndrome. Her creatinine
gradually trended down by discharge. Nephrology was consulted
and saw no indication for a combined liver/kidney transplant.
.
# Pancytopenia: Most likely secondary to ESLD. Per past records,
HCt appeared below baseline. All cell lines low but stable.
.
# DM2: stable FS. She was continue on an insulin SC regimen.
# GERD: Continueed on PPI.
.
# Depression/Anxiety: stable. Continued on mirtazapine.
.
# Code: Full Code (on liver transplant list)
.
# Contact: son [**Name (NI) **] [**Telephone/Fax (1) 40573**]; [**Telephone/Fax (1) 40574**]
Medications on Admission:
MEDS ON TRANSFER:
Carbamazepine 200mg qAM, 400mg qPM
Colace 100mg [**Hospital1 **]
Lasix 40mg daily
Heparin SQ
HISS
Lactulose 30mEq q6
Mirtazapine 15mg HS
Protonix 40mg daily
Propranolol 40mg [**Hospital1 **]
Tylenol prn
Albuterol prn
Lorazepam 0.5mg [**Hospital1 **] PRN
Maalox prn
Morphine 2-4mg q2 prn
Zofran 2mg q6 prn
Oxazepam 10mg qHS
Oxycodone 5-10mg q6prn
Trazodone 50mg qHS
.
Has been on Aldactone 50mg, Lisinopril 10mg, [**Last Name (un) **] 250mg TID,
Imitrex, and Lantus in the past that has been held recently
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever/pain: NO MORE THAN 2g/day .
2. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
3. Carbamazepine 200 mg Tablet Sig: Two (2) Tablet PO QPM (once
a day (in the evening)).
Disp:*30 Tablet(s)* Refills:*2*
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day): titrate for [**3-30**] bowel movements a day.
Disp:*1 bottle* Refills:*2*
5. 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*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
Disp:*1000 ML(s)* Refills:*0*
10. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*15 Tablet(s)* Refills:*2*
13. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
14. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for GI discomfort.
Disp:*120 Tablet, Chewable(s)* Refills:*0*
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
Disp:*120 Tablet, Chewable(s)* Refills:*0*
16. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) INH Inhalation Q2H (every 2 hours) as needed for
shortness of breath.
Disp:*1 inhaler* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA OF SOUTHEASTERN MASS
Discharge Diagnosis:
End stage liver disease
.
SECONDARY DIAGNOSES:
Hepatitis C
Acute renal failure
Hypotension
h/o gastrointestinal bleed
Esophageal varices
Discharge Condition:
stable
Discharge Instructions:
You were admitted after a hospitalization to evaluate fainting
where no direct causes were identified. You heart was monitored
while you were in the hospital and no concerning events were
noted.
You have significant liver disease from hepatitis C and were
admitted for evaluation for a liver transplant. You also had
worsening renal function that was believed to be secondary to
your liver disease. You continued to have worsening ascites even
after fluid removal by multiple paracenteses and underwent a
procedure called TIPS. Your mental status improved, and your
kidney function was improving by discharge.
Your medications have been changed. Please discard all previous
medications and adhere to the currently prescribed medications
and doses.
.
You will need to continue lactulose and rifaximin to prevent any
confusion you may develop that is secondary to your liver
disease. You must take lactulose four times a day.
.
If you develop any concerning symptoms such as bleeding,
worsening pain, persistent fevers, worsening abdominal size,
shortness of breath or chest pain, please call your physician or
proceed to the emergency department.
Followup Instructions:
Please call your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], at
[**Telephone/Fax (1) 40575**] to make an appointment within 2 weeks.
You have an appointment with your liver doctor, Dr. [**First Name (STitle) **] H.
[**Doctor Last Name **] (Phone:[**Telephone/Fax (1) 2422**]) Date/Time:[**2145-4-6**] 11:30
|
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29,844
| 169,604
|
32356
|
Discharge summary
|
report
|
Admission Date: [**2192-1-2**] Discharge Date: [**2192-1-12**]
Date of Birth: [**2135-7-5**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
hypotension, hypoxia (transfer from urology)
Major Surgical or Invasive Procedure:
Nephrectomy
Central Venous Catheter placement
Arterial Line placed
Femoral Dialysis Catheter placed
History of Present Illness:
56 yo F w pmh of lithium toxicity induced CRI (baseline crt 5),
HTN, Asthma, GERD, bipolar d/o, transferred to the [**Hospital Unit Name 153**] [**1-4**]
for hypotension, hypoxia. She is s/p a laproscopic right
nephrectomy on [**2192-1-2**] due to a right renal mass noted on MRI.
Following surgery her creatinine began to rise (7.0). Nephrology
was consulted, and hemodialysis initiation was planned. On
[**1-4**], she became acutely hypotensive, vitals at the time were:
T 99.4, BP 72/48, HR 95, 02sat 90 on 2L with low UOP 5-10cc/hr.
She had some response to a fluid bolus with sBP to the 90's. She
then became hypoxic with escalating 02 req (95% on 5L). Her
initial ABG was 7.21/48/73. She was given lasix 80mg IV, po
mucomyst, placed on a non-rebreather and had a PE protocol CT.
She was then transferred to the [**Hospital Unit Name 153**].
.
In the [**Hospital Unit Name 153**], she was managed temporarily on BiPap, but never
required intubation, and was started empirically on vancomycin
and zosyn for likely aspiration pneumonia. Her O2 requirements
were weaned, and she remained afebrile with stable blood
pressures. She required 4U PRBC for post-op hct drop, which
urology has been following. A temporary femoral HD catheter was
placed, and HD has been done over the last two days. Surgical
pathology from nephrectomy consistent with oncocytoma with
atypical features (extensive invasion into fat).
Past Medical History:
Past Medical History:
CKD stage VI [**2-25**] LI toxicity w secondary hyperPTH
right renal mass x 2
gout
HTN
asthma
GERD
Bipolar D/O
.
PSH: ureteroscopy, removal of tumor on back of knee, CCY, cone
bx
Social History:
no smoking, no etoh, no IVDU
Family History:
non-contributory
Physical Exam:
VS: Temp: 97.1 BP:76 /43 HR:102 RR:18 O2sat 95 on NRB
GEN: appears tired, mildly confused. breathing comfortably on
NRB
HEENT: large neck, could not assess JVD
RESP: rhonchi in anterior lung fields, distant breath sound
posteriorly, bibasilar crackles.
CV: tachycardic, reg rhythm, no murmurs
ABD: 3 post-surgical scars, stapled, dry, intact. obese,
tenderness surrounding surgical sites, soft, hypoactive bs
EXT: warm, non-edematous, 2+ distal pulses
NEURO: slightly confused,awake and oriented x 3
Pertinent Results:
CTA [**1-4**] - IMPRESSION:
1. Limited study but no main or lobar pulmonary embolus.
2. Partial right lower lobe atelectasis and left basilar
atelectasis.
3. 10-mm nodule in the anterior segment of the right upper lobe.
Given the history of malignancy this is concerning for
metastasis and further evaluation with PET-CT can be performed.
4. Nodular right apical opacity with surrounding ground-glass
halo. In the absence of infectious symptoms, considerations
would include bronchoalveolar cell carcinoma and hemorrhagic
metastasis. If there is a history of immunocompromised or
infectious symptoms fungal infection such as aspergillosis
should be considered.
.
EKG - [**1-4**] -
Sinus rhythm with atrial premature beats. Baseline artifact.
Presence of
ST-T wave abnormalities cannot be ruled out. Since the previous
tracing
of [**2191-12-28**] probably no major change.
Head MRI:
Mild-to-moderate brain atrophy. No enhancing brain lesions or
acute infarcts seen. Although no obvious bony or soft
parenchymal metastatic disease is identified, direct correlation
with PET scan would help for better assessment if clinically
indicated.
Labs on Admission:
[**2192-1-2**] 04:42PM GLUCOSE-165* UREA N-54* CREAT-5.1*
SODIUM-148* POTASSIUM-3.9 CHLORIDE-118* TOTAL CO2-19* ANION
GAP-15
[**2192-1-2**] 04:42PM WBC-13.0* RBC-2.83* HGB-8.0* HCT-24.5* MCV-87
MCH-28.2 MCHC-32.5 RDW-15.1
[**2192-1-2**] 04:42PM PLT COUNT-178
Labs on Discharge:
[**2192-1-11**] 07:35AM BLOOD Glucose-83 UreaN-24* Creat-4.0*# Na-146*
K-3.7 Cl-106 HCO3-31 AnGap-13
Brief Hospital Course:
A/P: 56 yo F w pmh of CKD [**2-25**] to lithium toxicity, htn, asthma,
bipolar d/o s/p R nephrectomy found to have an oncocytoma.
1. ESRD: The initial impairment was thought to be attriubted to
lithium toxicity. The patient was initially admitted to the
urology service for the nephrectomy and mass removal but was
subsequently transferred to the [**Hospital Unit Name 153**] after her creatinine/ renal
failure worsened in the post-operative setting. She was placed
on hemodialysis with a temporary groin line until IR placed a
tunneled right IJ catheter for continued HD. She was followed
by the renal consult team during the admission and tolerated HD
well. She will continue with HD on a Tu,Thurs,Sat schedule in
the future.
2. Renal mass: Pathology returned as oncocytoma with atypical
features. OSH PET scan reportedly showed some brain enhancement.
Also, CTA demonstrated R apical nodular apical opacity
concerning for metastatic disease. An MRI was obtained of the
head to eval for previously mentioned PET lesions however no
focal lesions were seen on our study here. In regards to the
patient's oncocytoma, these lesions are generally considered
benign however she will need close follow up in the future with
urology. Additionally, the nodules seen on CT scan will need to
be reevaluated in [**2-26**] months. This was conveyed to both her and
to her family.
3. PNA: The patient developed a likely left retrocardiac pna
while in the ICU that was initially treated with vanc and zosyn
and subsequently switched to levaquin, renally dosed. She was
afebrile at the time of discharge and will continue on levaquin
for 10 days.
4. Htn: the patient's BP was in the 100s-110s during the
hospitalization and did not require BP pharmacological
management. She will need to follow up with her PCP about
restarting [**Name Initial (PRE) **] regimen.
5. Bipolar d/o-patient had no evidence of mania during the
hospitalization and was continued on her prior regimen.
She was discharged with home PT.
Discharge Medications:
1. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 10 days.
Disp:*5 Tablet(s)* Refills:*0*
2. commode
please provide one three in one commode
3. Divalproex 500 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO HS (at bedtime).
4. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Aripiprazole 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*2*
6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
9. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for anxiety.
10. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS
(3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
13. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Na Ferric Gluc Cplx in Sucrose 12.5 mg/mL Solution Sig: One
(1) Intravenous HD PROTOCOL (HD Protochol).
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
oncocytoma
s/p nephrectomy
ARF on HD
pneumonia
bipolar disorder
Discharge Condition:
stable, no oxygen requirement, afebrile
Discharge Instructions:
You were admitted with ARF and found to have an oncocytoma which
was removed with your right kidney. You are now on hemodialysis
and will continue to need dialysis sessions three times a week
(Tu,Th,Sat). You are also being treated for a pneumonia.
Continue to take all of the antibiotics prescribed to you.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 365**] in 1 week after discharge from the
hospital. Call his office at ([**Telephone/Fax (1) 6441**] to schedule your
appointment.
You were found to have nodules on your chest CT scan and will
require a follow up CT in [**2-26**] months. This can be arranged by
your PCP.
You will have hemodialysis at FMC-[**Hospital3 **], located on [**Street Address(2) 75588**], [**Location (un) 3610**], MA ([**Telephone/Fax (1) 33711**]). You are scheduled to
begin this Saturday at 6am. Moving forward your normal days
will be Tues./Thurs./Saturday at 6am. The Nephrologist at that
facility is Dr. [**Last Name (STitle) 15170**].
|
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icd9cm
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[
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icd9pcs
|
[
[
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7829, 7890
|
4312, 6327
|
358, 459
|
7998, 8040
|
2741, 3887
|
8398, 9068
|
2187, 2205
|
6350, 7806
|
7911, 7977
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8064, 8375
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2220, 2722
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274, 320
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|
487, 1900
|
3901, 4167
|
1944, 2125
|
2141, 2171
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,223
| 193,958
|
39300
|
Discharge summary
|
report
|
Admission Date: [**2121-8-1**] Discharge Date: [**2121-8-6**]
Date of Birth: [**2039-8-13**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
retroperitoneal bleed
Major Surgical or Invasive Procedure:
Cardiac catheterization with no intervention
History of Present Illness:
Patient presented to PCP with vague chest pain and was found to
have reversible small anterior defect on stress test so she was
referred to cath where 40% stenosis of LAD was found. Two hours
after the procedure, her blood pressure dropped to 50s with HR
in 30s. She was given epi, dopamine, 1 L fluid and 2 units of
blood, and was taken back to the cath lab for a selective
angiography which failed to show the source of the bleed. Her
vitals stabilized however and dopamine was weaned off. She is
transferred to the CCU for monitoring.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis,
recent fevers, and exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of current
chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle
edema, palpitations, syncope or presyncope. Patient notes recent
chest pressure/heaviness and shortness of breath with walking
which had originally prompted her to see her PCP.
Past Medical History:
1. CARDIAC RISK FACTORS: + Dyslipidemia, Denies DM and HTN
2. CARDIAC HISTORY: none
3. OTHER PAST MEDICAL HISTORY:
anxiety/difficulty sleeping
dizziness
constipation/stomach pain
Social History:
SOCIAL HISTORY
-Tobacco history: none
-ETOH: occassionally
-Illicit drugs: none
Lives with her husband and daughter, previously independent with
[**Name (NI) 5669**].
Family History:
mother had heart disease, passed at age [**Age over 90 **]
Physical Exam:
GENERAL: NAD. Alert and Oriented x3. Mood, affect appropriate.
HEENT: Sclera anicteric. EOMI. no oral lesions.
NECK: Supple, no JVD
CARDIAC: RRR, no murmurs, rubs, gallops
LUNGS: CTAB
ABDOMEN: soft, mild tenderness improved s/p stooling. Distention
of right lower quadrant with overlying bruising and tenderness
to palpation. no bruits.
EXTREMITIES: no pedal edema. 2+ DP/PT pulses. no femoral bruit,
groin area mild tenderness and major bruising extending to the
groin area bilat and up above right hip area. At time of
discharge, the area was becoming softer, less painful and pt was
able to ambulate comfortably.
Pertinent Results:
On admission:
[**2121-8-1**] 06:19PM BLOOD WBC-6.8 RBC-4.17* Hgb-12.2 Hct-36.8
MCV-88 MCH-29.3 MCHC-33.2 RDW-14.1 Plt Ct-202
[**2121-8-1**] 06:19PM BLOOD Neuts-36.3* Bands-0 Lymphs-57.5*
Monos-4.6 Eos-0.7 Baso-0.9
[**2121-8-1**] 11:44PM BLOOD Glucose-164* UreaN-12 Creat-0.6 Na-142
K-3.9 Cl-109* HCO3-24 AnGap-13
.
On discharge:
[**2121-8-6**] 07:37AM BLOOD WBC-5.3 RBC-3.47* Hgb-10.5* Hct-30.4*
MCV-88 MCH-30.3 MCHC-34.6 RDW-14.8 Plt Ct-167
[**2121-8-6**] 07:37AM BLOOD Glucose-100 UreaN-14 Creat-0.7 Na-140
K-3.8 Cl-103 HCO3-29 AnGap-12
[**2121-8-6**] 07:37AM BLOOD Calcium-9.2 Phos-3.9 Mg-2.2
.
Right groin ultrasound [**2121-8-4**]:
RIGHT GROIN ULTRASOUND: The right common femoral artery and
common femoral vein demonstrate normal color flow and waveforms.
There is no evidence of pseudoaneurysm. There is a right groin
hematoma also seen one day ago.
IMPRESSION: Hematoma without aneurysm.
.
CTA abdomen [**2121-8-3**]:
IMPRESSION:
1. Right anterior abdominal wall hematoma, which contains
contrast likely
related to administration during a prior examination.
2. Hematoma in the left groin and left iliac fossa.
3. No evidence of active extavasation or retroperitoneal
hematoma.
.
Cardiac catheterization [**2121-8-1**]:
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Systolic hypertension.
Brief Hospital Course:
82 yo female s/p cath complicated by retroperitoneal bleed
.
#1 Retroperitoneal Bleed s/p cardiac catheterization:
Selective angiography in cath lab unable to identify source of
bleed. CT abdomen and ultrasound revealed a large right
retroperitoneal bleed and intrapelvic collection of blood on the
left side, likely from the right inferior epigastric artery.
Vascular surgery was involved and an embolectomy was considered
but not done. There was no evidence of psuedoaneurysm on
ultrasound and pt was managed conservatively with blood
transfusions x 2 and close monitoring. Her right groin
tenderness and appearance improved slowly during her hospital
stay and she was able to ambulate comfortably prior to
discharge. Hct at discharge was stable at 30.
.
# CORONARIES: No history of CAD. 40% stenosis of LAD in cath.
Cont Simvastatin at home dose, holding aspirin for now given
bleeding.
.
# Gait Disorder: noted to have slightly unsteady gait while
ambulating. Pt and family state this is not a new finding. Pt
has a walker that she uses sometimes at home. Neuro exam benign,
no evidence of acute neurological event. Strengths are equal and
[**3-17**] bilat. PT saw pt and recommended using cane and f/u with PT
at home.
Medications on Admission:
Amitriptyline 50 mg qhs
Clonazepam 1 mg qhs
Carafate 1 gram Po four times per day
Meclizine 12.5 mg TID
Omeprazole 40 mg daily
Simvastatin 20 mg daily
Aspirin 81 mg daily
Calcium Carbonate-Vitamin D3 500 mg (1,250 mg)-500 unit
[**Unit Number **] Tablet daily
Multivitamin 1 tablet daily
Discharge Medications:
1. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
2. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
3. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
4. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Carafate 1 gram Tablet Sig: One (1) Tablet PO four times a
day.
7. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1)
Tablet PO once a day.
8. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
10. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once
a day as needed for constipation.
11. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed
for constipation.
12. Outpatient Lab Work
Please check hct on [**8-8**] and [**8-11**] and call results to Dr. [**Last Name (STitle) **]
at [**Telephone/Fax (1) 86920**]
13. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: [**12-14**]
Sprays Nasal DAILY (Daily) as needed for nasal congestion.
Disp:*1 bottle* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary Artery Disease
Right groin Hematoma
Gait Disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent using walker
Discharge Instructions:
You had a cardiac catheterization and developed a large
collection of blood (hematoma) in your right groin area. You
needed to get blood infusions to stabilize your blood count, it
has been stable for the last 24 hours now. We did a few studies
to see if there was any damage to the vessels and we did not
find any. We expect that the bruising and pain will go away
gradually and you do not need any further testing or treatment
at this time. We would like you to have your blood checked
regularly for the next few days to make sure the bleeding does
not start again. The VNA can check this and call the results to
Dr. [**Last Name (STitle) **]. You have been dizzy when you stand quickly here,
please try to change positions slowly and be very careful when
you first start to walk. You will get physical therapy at home
and should use your cane.
.
Medication changes:
1. Stop taking aspirin, Dr. [**Last Name (STitle) **] will tell you when you can
restart the aspirin
2. Start taking tylenol for right groin pain as needed.
3. You can take Miralax or senna that you buy over the counter
to treat any constipation.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 3947**].
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 6086**]
Phone: [**Telephone/Fax (1) 86920**]
Appointment: Friday [**2121-8-8**] 2:30pm
Completed by:[**2121-8-14**]
|
[
"998.12",
"272.4",
"E879.0",
"458.29",
"780.4",
"781.2",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"88.47",
"37.22",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
6768, 6817
|
3990, 5215
|
334, 381
|
6920, 6920
|
2654, 2654
|
8223, 8551
|
1942, 2002
|
5553, 6745
|
6838, 6899
|
5241, 5530
|
3900, 3967
|
7083, 7932
|
2017, 2635
|
1639, 1644
|
2985, 3883
|
7952, 8200
|
273, 296
|
409, 1538
|
2669, 2970
|
6935, 7059
|
1675, 1741
|
1560, 1619
|
1757, 1926
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,476
| 141,689
|
38544
|
Discharge summary
|
report
|
Admission Date: [**2161-10-19**] Discharge Date: [**2161-10-31**]
Date of Birth: [**2093-7-29**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Neurontin / Cyclosporine / Methotrexate And
Derivatives / Levofloxacin
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
abominal pain
Major Surgical or Invasive Procedure:
[**2161-10-20**]
CT Guided percutaneous cholecystotomy tube placement
[**2161-10-22**]
Open partial cholecystectomy with over-sew of the cystic duct
and drainage of the gallbladder
[**2161-10-29**]
ERCP with sphincterotomy and stent placement
History of Present Illness:
68-y.o. man with chronic abdominal pain, frequent SBOs requiring
multiple rounds of enterolysis presented to [**Hospital3 **]with
abdominal pain and had US showing acute cholecystitis. He
reports having gradual onset constant abdominal pain starting
3-4
days ago in a band-like distribution in the upper abdomen
without
radiation. He reports concomitant nausea/vomiting/diarrhea.
Last formed BM was 5 days ago, and he reports still passing
flatus. Denies fever/chills.
Past Medical History:
PMH: multiple epsiodes of SBO, GERD, Barrets esophagous, CAD,
CHF, MIx2, stroke, Hypertension, hyperlipidemia, OSA on BiPAP,
asthma, COPD, gastroparesis, h/o GI bleed, stroke in [**2154**],
polymyalgia rheumatica, polyarthralgia, chronic neck pain
PSH: splenectomy, bowel resection x2, lysis of adhesions x10
Social History:
Single. Never married. No children. Denies tobacco use,
drinks
occasionally.
Family History:
Father died at 85 with throat cancer and CAD. Mother died at 73
of MI
Physical Exam:
Temp: 100.1 HR: 73 BP: 122/60 RR: 26 O2 Sat: 95% on
RA
GENERAL: Awake, alert, NAD.
HEENT: NCAT, EOMI, PERRLA, anicteric. NGT in place, draining
bilious fluid.
RESPIRATORY: CTAB, no respiratory distress.
CARDIOVASCULAR: RRR.
GI: Soft, diffuse abdominal tenderness with moderate focal
tenderness in RUQ and epigastrium, positive [**Doctor Last Name 515**] sign, no
guarding/rebound.
EXTREMITIES: WWP, no CCE.
Pertinent Results:
[**2161-10-19**] 07:44PM WBC-28.6*# RBC-3.64* HGB-11.5* HCT-34.3*
MCV-94 MCH-31.6 MCHC-33.5 RDW-15.2
[**2161-10-19**] 07:44PM PLT COUNT-565*
[**2161-10-19**] 07:44PM PT-14.8* PTT-29.2 INR(PT)-1.3*
[**2161-10-19**] 07:44PM CALCIUM-8.8 PHOSPHATE-2.4*# MAGNESIUM-2.0
[**2161-10-19**] 07:44PM LIPASE-12
[**2161-10-19**] 07:44PM ALT(SGPT)-56* AST(SGOT)-25 LD(LDH)-152 ALK
PHOS-194* TOT BILI-0.6
[**2161-10-19**] 07:44PM GLUCOSE-72 UREA N-12 CREAT-1.3* SODIUM-136
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-24 ANION GAP-14
[**2161-10-19**] Liver US :
1. Findings concerning for acute cholecystitis.
2. Diffusely echogenic liver without focal lesion, most
compatible with
diffuse fatty infiltration. Other forms of advanced liver
disease including fibrosis or cirrhosis cannot be excluded.
[**2161-10-19**] CT Abd/pelvis :
1. Bibasilar atelectasis vs. consolidation, correlate
clinically.
2. Findings consistent with previously known diagnosis of acute
cholecystitis, this appears uncomplicated.
3. Splenosis.
4. Other chronic changes including atherosclerotic disease,
degenerative disc disease.
[**2161-10-20**] CT guided percutaneous cholecystostomy tube placement:
Technically successful transhepatic percutaneous cholecystostomy
tube placement. 40 cc of purulent bilious drainage were seen and
a specimen was sent to microbiology for further analysis
[**2161-10-20**] 9:10 am BILE
GRAM STAIN (Final [**2161-10-20**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final [**2161-10-24**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
due to the presence of mixed bacterial flora detected
after further
incubation due to the presence of mixed bacterial flora
detected
after further incubation.
GRAM NEGATIVE ROD(S). HEAVY GROWTH.
GRAM NEGATIVE ROD #2. MODERATE GROWTH.
GRAM NEGATIVE ROD #3. MODERATE GROWTH.
ANAEROBIC CULTURE (Final [**2161-10-24**]): NO ANAEROBES ISOLATED.
[**2161-10-26**] CT Torso :
1. No evidence of pulmonary embolus, bibasilar consolidation
versus collapse, correlation is necessary to discern between the
two.
2. Extensive coronary artery and aortic calcification.
3. Diffusely dilated esophagus, stomach, and large and small
bowel, most
consistent with a postoperative ileus. There is an abrupt
transition in bowel caliber involving the distal sigmoid colon,
which was present on the prior study, no mass lesion is seen;
however, given its unchanged appearance on two
CT scans, a stricture should be considered.
4. Postoperative changes and surgical drain in this patient is
apparently
status post cholecystectomy.
5. Remaining findings such as splenosis, degenerative changes,
radiopaque
foreign densities are all unchanged.
[**2161-10-27**] 4:03 am SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2161-10-27**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI IN
CLUSTERS.
RESPIRATORY CULTURE (Preliminary):
SPARSE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. MODERATE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
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.
YEAST. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
Brief Hospital Course:
Mr. [**Known lastname 29179**] was evaluated by the Acute Care service in the
Emergency Room and based on his physical exam, lab data and
Abdominal CT scan he was admitted to the hospital for treatment
of acute cholecystitis. Due to his multiple co morbidities he
underwent percutaneous drainage of the gallbladder on [**2161-10-20**].
He tolerated the procedure well and returned to the Surgical
floor with a drain in place and on broad spectrum IV
antibiotics. He did well and was tolerating a regular diet with
plans to be discharged with his drain in place.
Unfortunately he developed hypotension and oxygen desaturation
on [**2161-10-22**] prompting transfer to the Surgical ICU for
resuscitation as he appeared in septic shock. His
cholecystotomy tube was no longer draining. He was taken to the
Operating Room after his hemodynamics were stable and he
underwent an open subtotal cholecystectomy. He tolerated that
procedure well and returned to the ICU in stable condition. He
maintained stable hemodynamics and his pain was well controlled.
He was transferred to the Surgical floor the following day and
gradually started a liquid diet. His abdominal incision was
healing well but his abdomen was a bit distended therefore his
oral intake was limited. The JP drain was draining clear fluid.
Over the next few days he developed intermittent respiratory
issues with bronchospasm and increased secretions. He underwent
vigorous pulmonary toilet including Chest PT, nebulizers and
incentive spirometry but had only transient improvement. His
chest xray showed bilateral lower lobe infiltrates vs.
atelectasis and on [**2161-10-26**] he had an episode of desaturation
and altered mental status.
As he transferred back to the Surgical ICU, he continued
vigorous pulmonary toilet and did not require intubation. His
WBC peaked at 31.2K and his sputum culture eventually grew out
MRSA. A CTA of the chest was done which ruled out pulmonary
embolism. His JP drain was now producing bilious material.
Over the next 24 hours his pulmonary status improved and the GI
service was contact[**Name (NI) **] for a possible ERCP for bile leak given
the color of the JP drainage.
During his ICU stay his WBC gradually decreased, he was
maintained on Meropenum and his blood cultures were no growth.
He was transferred back to the Surgical floor on [**2161-10-28**]
looking much better. On [**2161-10-29**] he underwent an ERCP with
sphincterotomy and stenting of the cystic duct secondary to a
leak at the cystic duct stump. He tolerated the procedure well,
maintained NPO until the following day and the was evaluated by
the Speech and swallow service to r/o aspiration as a cause of
his respiratory distress. He was able to swallow all
consistencies without any evidence of aspiration. Currently he
is tolerating a regular diet and he has no respiratory concerns.
He was started on a two week course of Vancomycin on [**10-30**]
after the results from his [**10-28**] sputum culture were obtained.
At the time of discharge on [**10-31**], the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet, and
pain was well controlled. He has had trouble voiding so he was
started on Flomax and a foley is in place; this will be
reassessed at follow up at his Acute Care Surgery Clinic
appointment on [**2161-11-5**]. His abdominal sutures will be removed
at this time.
Medications on Admission:
Advair 250-50mcg 2 puffs [**Hospital1 **]
Albuterol INH PRN
Amitriptyline 50mg QPM
Amlodipine 5mg QPM
Aspirin 81mg daily
Carvedilol 12.5mg [**Hospital1 **]
Calcitriol 0.25mcg QMWF
Ciclopirox 8% daily
Cyclobenzaprine 10mg [**Hospital1 **]
Furosemide 120mg [**Hospital1 **]
Hydrocodone-acetaminophen 7-750mg Q4-6H PRN pain
Hyoscyamine 0.125mg daily
Isosorbide (Imdur) 60mg daily
Metoclopramide 10mg daily
Nitroglycerin 0.4mg PRN
Omeprazole 40mg [**Hospital1 **]
Ondansetron 4mg PRN
Miralax 17g [**Hospital1 **]
Potassium Chloride 40mg [**Hospital1 **]
Simvastatin 40mg daily
Spironolactone 25mg daily
Sucralfate 1g TID
Discharge Medications:
1. amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. sucralfate 1 gram Tablet Sig: One (1) Tablet PO TID (3 times
a day).
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
9. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
10. Miralax 17 gram Powder in Packet Sig: One (1) packet
PO twice a day.
11. ciclopirox 8 % Solution Sig: One (1) application Topical
once a day.
12. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO twice a
day.
13. Lasix 80 mg Tablet Sig: 1 [**11-15**] Tablet PO twice a day.
14. potassium chloride 20 mEq Packet Sig: Two (2) packets PO
twice a day.
15. hyoscyamine sulfate 0.125 mg Tablet Sig: One (1) Tablet PO
once a day.
16. Reglan 10 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
17. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
18. Advair Diskus 250-50 mcg/dose Disk with Device Sig: Two (2)
puffs Inhalation twice a day.
19. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO every
M-W-F.
20. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 13 days.
Disp:*qs * Refills:*0*
21. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO at bedtime.
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
22. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation Q6H (every 6 hours) as needed for shortness
of breath or wheezing.
23. hydrocodone-acetaminophen 7.5-750 mg Tablet Sig: 1-2 Tablets
PO every 4-6 hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
24. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual once a day as needed for chest pain.
25. Zofran 4 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Acute cholesyctitis with septic shock
Bile leak
MRSA Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
* You were admitted to the hospital with abdominal pain and your
tests showed stones in your gallbladder.
* You underwent percutaneous drainage of the gallbladder which
relieved your symptoms initially but then you developed high
fevers and nd your gallbladder was incompletely drained. You
were taken to the ICU for resuscitation then to the Operating
Room for removal of your gallbladder.
* You developed a bile leak after the surgery and required an
ERCP with stent placement.
* You will need to return for a repeat ERCP with stent removal
next month.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 [**3-23**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at rehab. on [**2161-11-5**]
Followup Instructions:
Please follow up with the Acute Care Clinic on Thursday [**11-5**]. Please call [**Telephone/Fax (1) 600**] on Monday [**2161-11-2**] to confirm
your appointment time.
|
[
"428.0",
"574.00",
"482.42",
"568.0",
"070.54",
"725",
"997.4",
"038.9",
"E878.6",
"V45.82",
"327.23",
"576.8",
"428.22",
"V02.54",
"493.20",
"250.00",
"995.92",
"530.81",
"785.52",
"412",
"V10.46"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.79",
"51.21",
"51.85",
"51.01",
"51.87",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
12788, 12835
|
6467, 9875
|
360, 607
|
12942, 12942
|
2083, 5500
|
15547, 15718
|
1557, 1629
|
10543, 12765
|
12856, 12921
|
9901, 10520
|
13125, 15138
|
15154, 15524
|
1644, 2064
|
5541, 6444
|
307, 322
|
635, 1109
|
12957, 13101
|
1131, 1443
|
1459, 1541
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,696
| 132,605
|
31630
|
Discharge summary
|
report
|
Admission Date: [**2133-9-13**] Discharge Date: [**2133-10-23**]
Service: CARDIOTHORACIC
Allergies:
Ace Inhibitors / Hydrochlorothiazide / Chlorthalidone
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
sternal click and bloody drainage
Major Surgical or Invasive Procedure:
sternal debridement [**9-14**]
sternal plating with bilateral pectoralis advancement flaps [**9-16**]
History of Present Illness:
83 yo M s/p MVR (tissue) [**2133-8-24**], post op course c/b afib, CHF,
heart block which resolved. Discharged to rehab [**9-7**], readmitted
to MWMC [**9-8**] for CHF, Af. Surgery consult was obtained for
sternal click, large amount of old blood was expressed from the
wound. Transferred to [**Hospital1 18**] for further eval and management.
Past Medical History:
Mitral Regurgitation, Hypertension, Hypothyroidism,
Gastroesophageal Reflux Disease, Degenerative Joint Disease, h/o
Prostate Cancer s/p lupron and XRT, h/o hyponatremia
Social History:
Married, lives with wife. Former [**Name2 (NI) 1818**], quit 15 yrs ago after
3ppd x 49yrs. [**2-10**] alcoholic drinks per day.
Family History:
Non-contributory
Physical Exam:
NAD AAOx3
Lungs with bilateral rales
Heart 2/6 SEM
Abdomen Benign
Extrem warm, 2+ BLE edema 2+ dp/pt pulses
Neuro grossly intact
Sternum + click, Parodoxical movement of tissue in center of
wound with respiration. Serous drainage from lower pole. NO
purulent drainage, no erythema.
Pertinent Results:
[**2133-10-23**] 03:40AM BLOOD WBC-11.3* RBC-2.91* Hgb-9.2* Hct-26.6*
MCV-91 MCH-31.6 MCHC-34.6 RDW-18.0* Plt Ct-436
[**2133-9-13**] 07:35PM BLOOD WBC-9.2 RBC-3.95* Hgb-11.4*# Hct-33.2*
MCV-84 MCH-28.9 MCHC-34.4 RDW-17.5* Plt Ct-668*
[**2133-10-21**] 03:11AM BLOOD PT-14.2* INR(PT)-1.3*
[**2133-10-21**] 03:11AM BLOOD Fibrino-267
[**2133-10-23**] 03:40AM BLOOD Glucose-110* UreaN-22* Creat-0.6 Na-136
K-4.3 Cl-104 HCO3-25 AnGap-11
[**2133-10-7**] 03:14AM BLOOD ALT-13 AST-17 AlkPhos-57 Amylase-12
[**2133-10-22**] 03:08AM BLOOD Calcium-7.6* Phos-2.7 Mg-1.8
[**2133-10-23**] 03:58AM BLOOD Type-ART pO2-72* pCO2-36 pH-7.48*
calTCO2-28 Base XS-3
[**2133-10-22**] 09:40PM BLOOD Type-ART pO2-72* pCO2-40 pH-7.46*
calTCO2-29 Base XS-4
[**2133-10-22**] 04:46PM BLOOD Type-ART pO2-69* pCO2-34* pH-7.49*
calTCO2-27 Base XS-2
[**2133-10-22**] 01:06PM BLOOD Type-ART pO2-83* pCO2-38 pH-7.46*
calTCO2-28 Base XS-2
[**2133-10-22**] 09:40PM BLOOD Glucose-90 K-3.8
[**2133-10-21**] 04:06AM BLOOD Glucose-141* Lactate-1.8 Na-130* K-3.3*
Cl-102
Cardiology Report ECHO Study Date of [**2133-10-5**]
PATIENT/TEST INFORMATION:
Indication: Mitral valve bioprosthesis (#31).
Hypotension.Evaluate valvular function. ?Tamponade
Height: (in) 68
Weight (lb): 180
BSA (m2): 1.96 m2
BP (mm Hg): 90/50
HR (bpm): 88
Status: Inpatient
Date/Time: [**2133-10-5**] at 06:53
Test: Portable TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007W000-0:00
Test Location: West SICU/CTIC/VICU
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Mitral Valve - Mean Gradient: 4 mm Hg
INTERPRETATION:
Findings:
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]
LAA. Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dynamic interatrial septum.
Small secundum
ASD.
LEFT VENTRICLE: Low normal LVEF.
AORTA: Focal calcifications in ascending aorta. Simple atheroma
in descending
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No
masses or
vegetations on aortic valve. Trace AR.
MITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). MVR
well seated,
with normal leaflet/disc motion and transvalvular gradients. No
mass or
vegetation on mitral valve. No MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. No mass or
vegetation on tricuspid valve.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic
(normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. The patient
was monitored
by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the procedure. The patient
was monitored
by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the procedure. The patient
was sedated for
the TEE. Medications and dosages are listed above (see Test
Information
section). No TEE related complications.
Conclusions:
No spontaneous echo contrast or thrombus is seen in the body of
the left
atrium or left atrial appendage. A small secundum atrial septal
defect is
present. Overall left ventricular systolic function is low
normal (LVEF
50-55%). There are simple atheroma in the descending thoracic
aorta. The
aortic valve leaflets (3) are mildly thickened. No masses or
vegetations are
seen on the aortic valve. Trace aortic regurgitation is seen. A
bioprosthetic
mitral valve prosthesis is present. The mitral prosthesis
appears well seated,
with normal leaflet/disc motion and transvalvular gradients. No
mass or
vegetation is seen on the mitral valve. No mitral regurgitation
is seen. There
is no pericardial effusion.
IMPRESSION: Normal functioning mitral valve prothesis.
Low-normal left
ventricular function. Small secundum atrial septal defect.
Simple
atherosclerotic plaque in thoracic aorta. No pericardial
effusion.
Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD on [**2133-10-5**] 07:30.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2133-10-20**] 8:51 AM
CHEST (PORTABLE AP)
Reason: r/o inf, eff
[**Hospital 93**] MEDICAL CONDITION:
83 year old man with sternal plating now s/p trach /PEG
REASON FOR THIS EXAMINATION:
r/o inf, eff
HISTORY: 83-year-old male with sternal plating, now status post
tracheostomy and PEG tube placement. Rule out infiltrate and
effusion.
COMPARISON: Radiograph [**2133-10-16**].
SINGLE PORTABLE VIEW OF THE CHEST: There is again demonstrated
bilateral diffuse interstitial process, with no significant
change from the previous radiograph. There is a small left
pleural effusion. The tracheostomy tube remains approximately 6
cm above the carina, with no significant change in position. No
pneumothorax is identified. The cardiomediastinal contours are
unremarkable.
IMPRESSION:
1. Diffuse bilateral interstitial process, with no change since
[**2133-10-16**].
2. Small left pleural effusion.
[**2133-10-5**] 2:05 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2133-10-8**]**
GRAM STAIN (Final [**2133-10-5**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2133-10-7**]):
OROPHARYNGEAL FLORA ABSENT.
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
236-0683C
[**2133-10-4**]. MODERATE GROWTH.
[**2133-10-5**] 2:07 am BLOOD CULTURE Source: Line-aline.
**FINAL REPORT [**2133-10-11**]**
AEROBIC BOTTLE (Final [**2133-10-11**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2133-10-9**]):
REPORTED BY PHONE TO CC7C [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 74344**] [**2133-10-7**].
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
SENSITIVITIES PERFORMED ON REQUEST..
[**2133-10-5**] 2:06 am URINE Source: Catheter.
**FINAL REPORT [**2133-10-6**]**
URINE CULTURE (Final [**2133-10-6**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
Mr. [**Known lastname 4469**] was admitted to cardiac surgery. He was taken to the
operaitng room on [**2133-9-14**] where her underwent sternal
debreidement for sternal wound infection. He was transferred to
the ICU in stable condition on neosynephrine with an open chest,
as and such was paralyzed. He was started on vancomycin and
zosyn. He was seen by plastic surgery, and underwent sternal
plating on [**2133-9-16**]. He received a chest tube for a tension
pneumothorax. He was difficult to wean from the ventilator due
to agitation and was given haldol. He was extubated on [**2133-9-18**].
He was started on tube feeds due to lethargy. He was seen by
wound care for a coccyx and intergluteal pressure ulcer. A
right chest tube was placed for pleural effusion on [**9-22**]. He
remained awake but with decreased mental status, which slowly
improved. This chest tube was removed on [**9-25**]. He was
reintubated and he failed to wean off of the ventilator and was
taken to the operating room for a tracheostomy and a PEG on [**10-16**].
He has a hx of bladder cancer requiring XRT and while in the
ICU he developed hematuria which required 5 units of PRBCs over
the course over a week. He was taken to OR for cyctoscopy on
[**10-21**] and he has no longer has hematuria. On [**10-23**], he remains
stable and in good condition to be discharged to a rehab
facility.
By systems:
Neuro: On exam he is alert, awake, following commands. Meds:
Lorazepam and Haldol prn dose for insomnia/agitation.
CV: On exam he remains in atrial-fib, however his blood pressure
remains stable. Meds: Amiodarone, Metoprolol, Captopril,
[**Last Name (LF) 74345**], [**First Name3 (LF) **].
Pulm: He has positive sputum cx showing E. Coli resistant to
Cipro which was treated with Cefipime for 2wks. He has a
history of COPD. On exam lungs are clear bilaterally. He
requires CPAP + PS and has failed multiple trials of trach mask
due to hypoxia. CPAP + PS FiO2:50% PEEP/PS: [**6-13**] his usual
setting. Meds: Albuterol and Ipotropium Bromide nebs and
inhalers.
GI: He has a PEG in place and is on Impact with Fiber 60cc/hr.
His goal rate is 80cc/hr. He was C.Diffx3 NEAGTIVE.
GU: He had UTI with E.Coli resistant to Cipro and was also
treated with Cefipime for 2wks. He required 5units of PRBCs
over about a week for gross hematuria. He underwent cystoscopy
on [**10-21**] where gross blood clots were irrigated and bleeding
surface of the bladder wall was coagulated. Since the procedure
he has not required continuos bladder irrigation. If he has
gross hematuria in the future, he needs to be started on CBI
until urine is clear. Meds: Oxybutynin, Lasix.
Heme: S/P Multiple blood products transfused, but his hematocrit
remains stable. Patient was on coumadin 1mg HS at home, however,
it has been on hold for hematuria. Goal is INR of 1.5
ID: As of today he reamins on no antibiotics. He was on
Vancomycin for Coag negative Staph A in his blood. UTI/Sputum +
for E Coli resistant to Cipro treated with Cefipime. He has not
had a fever in the past week and WBC today is 11.3.
ENDO: He is on Humolog Insulin SS intermittently and his blood
sugars have remained stable. He is also taking Levothyroxine
for hypothyroidism
T/L/D: Trach/PEG, 22French 3 way [**Last Name (un) **] Catheter (should remain
inplace until 1wk from now and can be discontinued next week if
pt has no hematuria. Call Dr [**Last Name (STitle) 770**] from Urology with questions
([**Telephone/Fax (1) 7707**]. Balloon in Catheter has 30cc of fluid, remove
all 30 cc before d/c of catheter), L PICC
Code Status: Full code
Medications on Admission:
Coumadin 1 mg QHS
Ultram 50 mg Q4 PRN
Restoril 15mg HS PRN
Vicodin PRN
Synthroid 50 mcg
[**Telephone/Fax (1) **] 81 mg QD
Protonix 40mg QD
Fluticasone 2 Puffs [**Hospital1 **]
Doxazosin 1mg QHS
Lasix 40 mg IV BID
Haldol PRN
FeSO4 325 [**Hospital1 **]
Amiodarone 400 [**Hospital1 **]
Toprolol XL 25mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Levothyroxine 50 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
3. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
4. Atorvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
5. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
6. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Hospital1 **]: Two (2)
Inhalation Q4H (every 4 hours) as needed.
7. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours) as needed.
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Sodium Chloride 0.65 % Aerosol, Spray [**Last Name (STitle) **]: [**2-10**] Sprays Nasal
QID (4 times a day) as needed.
10. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: One (1) PO BID (2
times a day).
11. Ascorbic Acid 90 mg/mL Drops [**Month/Day (2) **]: One (1) PO DAILY (Daily):
500mg total daily.
12. Zinc Sulfate 220 (50) mg Capsule [**Month/Day (2) **]: One (1) Capsule PO
DAILY (Daily).
13. Albuterol 90 mcg/Actuation Aerosol [**Month/Day (2) **]: 6-8 Puffs Inhalation
Q2-4H (every 2 to 4 hours).
14. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Day (2) **]: Six (6)
Puff Inhalation Q4H (every 4 hours).
15. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol [**Month/Day (2) **]:
[**5-15**] Inhalation [**Hospital1 **] ().
16. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Hospital1 **]: [**2-10**]
Drops Ophthalmic PRN (as needed).
17. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Month/Day (2) **]: 2.5 MLs
PO Q6H (every 6 hours) as needed.
18. Oxybutynin Chloride 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID
(2 times a day).
19. Captopril 25 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO TID (3 times a
day).
20. Clonazepam 0.5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times
a day).
21. Haloperidol 1 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO HS (at
bedtime).
22. Insulin Lispro 100 unit/mL Solution [**Month/Day (2) **]: One (1)
Subcutaneous ASDIR (AS DIRECTED).
23. Metoprolol Tartrate 25 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO TID
(3 times a day).
24. Amiodarone 200 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily).
25. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Month/Day (2) **]: One
(1) ML Intravenous DAILY (Daily) as needed.
26. Haloperidol Lactate 5 mg/mL Solution [**Month/Day (2) **]: One (1) mg
Injection TID (3 times a day) as needed.
27. Metoclopramide 5 mg/mL Solution [**Month/Day (2) **]: One (1) Injection Q6H
(every 6 hours) as needed for nausea/vomiting.
28. Sodium Chloride 0.9 % 0.9 % Syringe [**Month/Day (2) **]: Three (3) ML
Injection DAILY (Daily) as needed.
29. Furosemide 10 mg/mL Solution [**Month/Day (2) **]: Four (4) Injection [**Hospital1 **] (2
times a day): 40mg IV.
30. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Hospital1 **]: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
sternal dehiscence
83M s/p MVR (31mm [**Company **] mosaic)[**8-24**]
post op afib
PMH: HTN, known MR, DJD, prostate ca with olupron / Xrt,
hypothyroidism, GERD, history of hyponatremia
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incisions or weight
gain more than 2 pounds in one day or five in one week.
[**Last Name (NamePattern4) 2138**]p Instructions:
Please follow up with Dr. [**Last Name (Prefixes) **] 1 month after discharge
from rehab facility.
Dr [**Last Name (STitle) 770**], Urology. Follow up next week if patient is able for
Foley removal. [**Telephone/Fax (1) **]
Completed by:[**2133-10-23**]
|
[
"512.1",
"244.9",
"V42.2",
"427.5",
"998.32",
"293.0",
"867.0",
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"427.31",
"599.7",
"530.81",
"041.4",
"428.0",
"401.9",
"518.81",
"715.90",
"599.0",
"V10.46",
"707.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.82",
"86.22",
"96.6",
"78.41",
"31.1",
"96.72",
"34.03",
"99.04",
"38.91",
"38.93",
"43.11",
"77.61",
"34.04",
"96.04",
"57.49",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
15797, 15863
|
8598, 12206
|
302, 406
|
16093, 16101
|
1471, 2556
|
1135, 1153
|
12562, 15774
|
5870, 5926
|
15884, 16072
|
12232, 12539
|
16125, 16245
|
16296, 16553
|
2582, 5606
|
1168, 1452
|
229, 264
|
5955, 8575
|
434, 779
|
5638, 5833
|
801, 972
|
988, 1119
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,959
| 111,148
|
40672
|
Discharge summary
|
report
|
Admission Date: [**2101-6-10**] Discharge Date: [**2101-6-19**]
Date of Birth: [**2039-6-17**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
Multiple injuries sustained after MVC
Major Surgical or Invasive Procedure:
1. Removal of traction pin.
2. Open reduction and internal fixation of left posterior
wall acetabular fracture with bone grafting of marginal
impaction.
History of Present Illness:
This patient is a 61 year old male who complains of MVC.Patient
was unrestrained driver mod to high speed MVC into [**Doctor Last Name 6641**]. LOC at
scene, anamnestic. Presents with obvious L hip deformity and
stigmata of head injury.
Past Medical History:
1) DMII
2) HTN
3) CHF (EF unknown)
4) CAD, stents placed 2 years ago, one in [**2088**]
5) CLL c/b cryoglubulins (initially had a creatinine of 2.5
started on on chemotherapy (rituximab, vincristin, cytoxan
because none nephrotoxic and creatinine got better, last regimen
given [**2101-5-25**], due for next one [**2101-6-15**], followed by Dr. [**Last Name (STitle) 11182**]
at [**Hospital1 2025**])
6) CKD: from HTN, DM, but also [**12-22**] cryo
Social History:
employed in maintenance, denies tob/EtOH/drugs
Family History:
HTN in brother
Physical Exam:
VS: 99.1 (100.8) 160/90 (144-196/72-108) 102 (90s-110s) 20 93%RA
[**3-29**] pain PO/IV//O: 1850/1155//1800 (600/600 last shift)
Gen: sleeping comfortably in bed, arousable to voice, then
appeared restless
HEENT: EOMI, PERRL, MMM, OP clear
Neck: no JVD, no LAD
CV: regular rate and rhythm, no murmurs
Resp: CTAB, no wheezes or crackles
GI: soft NTND no HSM, +BS
Ext: no c/c/e, +pneumoboots
Neuro: CNII- CNXII intact, no tremor, pronator drift strength
UE/LE flexion/extension (minus him movement), reflexes, and
sensation intact throughout and symmetric
Psych: A&OX3, appropriate
Pertinent Results:
CT head [**2101-6-10**]
IMPRESSION:
1. Subdural hematoma has redistributed to the posterior falx,
with equivocal minimal increase, likely due to repositioning.
2. Right parietal subarachnoid hemorrhage, unchanged.
3. Possible left parafalcine frontal focus of subarachnoid
hemorrhage. No hydrocephalus or mass effect
[**2101-6-10**] CT Pelvis
1. Left hip posterior dislocation and fracture of the posterior
acetabulum,
with free osseous fragment.
2. T1 fracture of the vertebral body at the anterior inferior
corner.
3. Cholelithiasis.
4. Post-surgical changes in the left axilla with lobulated
hypodense
structure, likely seroma or lymphocele.
5. Nodular opacities in the lungs and low lung volumes with
tree-in-[**Male First Name (un) 239**]
pattern in keeping with bronchiolitis. Suboptimally evaluated
nodular
opacities due to inappropriate breath-hold.
Brief Hospital Course:
The patient was admitted to the trauma surgery service on
[**2101-6-10**] after sustaining multiple injuries from a MVC. The only
procedure he underwent was an left ORIF of his acetabular
fracture. The patient tolerated the procedure well.
Neuro: Post-operatively, the patient received Dilaudid IV/PCA
with good effect and adequate pain control. When tolerating oral
intake, the patient was transitioned to oral pain medications.
He was found to have a SDH and SAH. Over time he was moving UE's
with good strengths, following all commands and wiggling toes
b/l. The neurosurgery team was satisfied with his progress and
recommended no futher imaging upon discharge.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored. He had several episodes of
hypertention with the systolic pressure climbing into the 200's.
The medicine team was consulted and after adjusting his
medication, his blood pressure stabilized.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. His diet was advanced when appropriate,
which was tolerated well. He was also started on a bowel regimen
to encourage bowel movement. Foley was removed on POD#6. Intake
and output were closely monitored.
ID: Post-operatively,the patients WBC and platelet counts
increased transiently. After not finding a source of infection,
it was speculated that these increased counts were either due to
an inflammatory response to the surgery or due to his underlying
leukemia. The patient's temperature was closely watched for
signs of infection.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge on HD 9 and POD #5, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating with asistance, voiding without
assistance, and pain was well controlled.
Medications on Admission:
1) Amlodipine 10mg PO daily
2) Lisinopril 40mg PO daily
3) Furosemide 20mg PO daily
4) Metformin 500mg PO BID
6) Aspirin 81mg PO daily
7) Clopidogrel 75mg PO daily
8) Actively on chemotherapy per above
9) Xanax 1mg PO Q6-8H PRN Anxiety
10) Metoprolol XL 25mg PO daily
11) Fluoxetine 60mg PO daily
12) Simvastatin 40mg PO daily
13) Ativan 1mg PO Q4H PRN anxiety
14) Trazadone 150mg PO HS PRN insomnia
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day) as needed for anxiety.
8. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily).
9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
10. fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
11. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
14. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
16. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. HydrALAzine 5-10 mg IV Q6H:PRN SBP >160
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
SAH, SDH, acetabular fracture, T1 fracture, nasal bone fracture,
spinal cord compression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the trauma surgery service for multiple
injuries sustained in a motor vehicle accident.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* You may take a shower after 24 hours from your surgery have
passed, but do not bathe or go swimming until instructed by your
surgeon.
* No strenuous activity until instructed by your surgeon.
*You have a C-Collar on. Please wear C-collar at all times, you
will need to wear for 4-6 weeks.
*you can do touch down weight bearing on your left leg. Please
adhere to posterior hip precautions until your follow up- avoid
hip flexion and adduction.
Followup Instructions:
Call Dr. [**First Name (STitle) **] from Cognitive Neurology at [**Telephone/Fax (1) 1690**] for
a folow up appointment in 1 week.
Call Dr. [**Last Name (STitle) 1005**] at ([**Telephone/Fax (1) 2007**] for orthopedics follow up
in [**11-21**] weeks. Please call his office when you are discharged.
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] upon discharge to
arrange a follow up appointment in [**12-23**] weeks. Office is located
at [**Hospital1 18**], [**Hospital 2577**] Medical Office Building, [**Location (un) **].
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2101-6-19**]
|
[
"852.06",
"280.0",
"E819.0",
"852.26",
"403.90",
"204.10",
"808.0",
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"802.0",
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icd9cm
|
[
[
[]
]
] |
[
"79.39",
"79.09",
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] |
icd9pcs
|
[
[
[]
]
] |
6832, 6929
|
2837, 4882
|
340, 503
|
7062, 7062
|
1954, 2814
|
8577, 9255
|
1322, 1338
|
5333, 6809
|
6950, 7041
|
4908, 5310
|
7213, 8554
|
1353, 1935
|
263, 302
|
531, 769
|
7077, 7189
|
791, 1242
|
1258, 1306
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,707
| 164,334
|
7335
|
Discharge summary
|
report
|
Admission Date: [**2128-1-20**] Discharge Date: [**2128-1-27**]
Service: MEDICINE
Allergies:
Lisinopril / Aspirin / Plavix
Attending:[**First Name3 (LF) 19836**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 85 F with history of HTN, Afib, moderate aortic stenosis,
GI bleed, presents with four days of increasing shortness of
breath. She feels she may have overdone herself on a recent trip
to [**State 531**]. She sat next to a sick person at the Rockettes.
This Sunday, she had chills, cough and a running nose. She
improved somewhat with hydration. She denies cp, fever, h/a,
changes in vision, leg swelling. She called her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 9006**]
who recommended holding of on the Lasix, which she had been on
in the past.
She continued to worsen over the next day and was having
signficant breathing difficulty. Her family called EMS. She was
found by EMS to be in respiratory distress with at sat in the
70s and RR 30-40. She was started on BiPAP on scene. EMS started
on CPAP, NTG x [**3-11**], Lasix 40mg IV.
In the ED, intial vitals 99.6 111 133/73 39 97%/ BiPAP. A&Ox3.
Lungs with crackles to mid lung fields. No JVD or LE edema.
Blood cultures were sent. She was on a nitro gtt for about 10
minutes, which was stopped for pressures in the 100s. Her RR
improved, and her more comfortable. Prior to transfer, VS: 82
109/54 24 100 on [**11-13**] and 100% CPAP. Levo/CTX were started prior
to transfer. She had 1 PIV, getting a second.
.
Currently, her breathing is better.
.
ROS: (+) for chills, cough productive of white sputum,
congestion, shortness of breath
(-) fever, headache, vision changes, rhinorrhea, sore throat, ,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Aortic stenosis: [**Location (un) 109**] 1.0-1.2 and gradient 55 mmHg on [**6-14**]
Hypertension
Hyperlipidemia
Gout
Hidrocystoma
Colonic plasma cell neoplasim: P/W BRBPR in [**2121**], recurred in
[**2125**], colonoscopy showed a mass, biopsy showed + plasma cell
infiltrate. SPEP showed MGUS, UPEP neg. BM in [**10-13**] showed
changes c/w Paget's disease. Repeat biopsy via colonoscopy
negative.
Duodenal angioectasia: with GI bleed seen on capsule endoscopy
Hematuria: nl renal u/s [**11-13**] and cystoscopy in [**12-14**]
Social History:
She used to enjoy cocktail or champagne once in a while. Since
she had GI bleeding last year, she has not had alcohol intake.
She also denies smoking.
Family History:
Mother died of [**Name (NI) 2481**] disease. Father died of unknown form
of cancer. She had a brother who had a melanoma. Another brother
died of a myocardial infarction.
Physical Exam:
Vitals - BP:125/65 HR:83 RR:28 02 sat: 95 on 5 L NC
GENERAL: Well appearing, NAD, A&Ox3
HEENT: O/P clear
CARDIAC: RRR, mid to late peaking systolic murmur at base
radiating to carotids.
LUNG: crackles to mid lung bilaterally
ABDOMEN: S NT ND NABS
EXT: WWP
Pertinent Results:
ADMISSION:
[**2128-1-20**] 09:15PM BLOOD WBC-17.6*# RBC-3.95* Hgb-11.2* Hct-34.1*
MCV-86 MCH-28.5 MCHC-33.0 RDW-16.0* Plt Ct-212
[**2128-1-20**] 09:15PM BLOOD Neuts-86.4* Lymphs-10.3* Monos-2.9
Eos-0.3 Baso-0.2
[**2128-1-20**] 09:15PM BLOOD PT-12.7 PTT-23.9 INR(PT)-1.1
[**2128-1-25**] 06:00AM BLOOD Gran Ct-6250
[**2128-1-20**] 09:15PM BLOOD Glucose-204* UreaN-20 Creat-1.1 Na-139
K-3.3 Cl-100 HCO3-27 AnGap-15
[**2128-1-20**] 09:15PM BLOOD CK(CPK)-74
[**2128-1-20**] 09:15PM BLOOD cTropnT-<0.01
[**2128-1-21**] 03:23AM BLOOD CK(CPK)-63
[**2128-1-21**] 03:23AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2128-1-21**] 11:38AM BLOOD CK(CPK)-64
[**2128-1-21**] 11:38AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2128-1-20**] 09:15PM BLOOD CK-MB-NotDone proBNP-2875*
[**2128-1-21**] 03:23AM BLOOD Calcium-8.5 Phos-3.5 Mg-1.6
[**2128-1-21**] 10:01AM BLOOD %HbA1c-6.3*
[**2128-1-20**] 09:40PM BLOOD Lactate-1.7
DISCHARGE
[**2128-1-27**] 06:30AM BLOOD WBC-8.0 RBC-3.63* Hgb-9.7* Hct-30.2*
MCV-83 MCH-26.7* MCHC-32.1 RDW-14.8 Plt Ct-322
[**2128-1-21**] 03:23AM BLOOD PT-13.3 PTT-22.4 INR(PT)-1.1
[**2128-1-27**] 06:30AM BLOOD Glucose-110* UreaN-41* Creat-1.2* Na-142
K-4.2 Cl-101 HCO3-31 AnGap-14
[**2128-1-27**] 06:30AM BLOOD Calcium-9.9 Phos-4.1 Mg-1.9
MICRO
[**2128-1-22**] URINE URINE CULTURE-FINAL: NEGATIVE
[**2128-1-21**] Influenza A/B by DFA DIRECT INFLUENZA A ANTIGEN
TEST-FINAL; DIRECT INFLUENZA B ANTIGEN TEST-FINAL: NEGATIVE
[**2128-1-21**] MRSA SCREEN MRSA SCREEN-FINAL: NEGATIVE
[**2128-1-20**] BLOOD CULTURE Blood Culture, Routine-FINAL
NEGATIVE
[**2128-1-20**] BLOOD CULTURE Blood Culture, Routine-FINAL
NEGATIVE
REPORTS:
CXR AP [**2129-1-19**]:
IMPRESSION: Mild-to-moderate pulmonary edema with small right
pleural
effusion.
Transthoracic Cardiac Echo [**2129-1-20**]:
The left atrium is mildly dilated. The right atrial pressure is
indeterminate. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with hypokinesis of the distal
half of the inferolateral wall. The remaining segments contract
normally (LVEF = 55-60 %). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are moderately
thickened. There is moderate to severe aortic valve stenosis
(valve area 1.0-1.2cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is mild
functional mitral stenosis (mean gradient 4 mmHg) due to mitral
annular calcification. Moderate (2+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
estimated pulmonary artery systolic pressure is high normal.
There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2127-7-2**], a
mild left ventricular wall motion abnormality is now apparent
and the severity of mitral regurgitation is slightly worse. The
severity of aortic stenosis and mitral regurgitation are
similar. Is the patient a candidate for intervention?
Renal U/S [**2129-1-24**]:
1. No evidence of hydronephrosis.
2. Bilateral renal cysts.
CXR PA/LAT [**2129-1-25**]:
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Mild pulmonary edema is still present. Moderate
cardiomegaly.
Neither of the frontal nor the lateral radiographs show evidence
of pleural
effusion. No focal parenchymal opacity suggesting pneumonia. No
pneumothorax.
Brief Hospital Course:
85 yo woman with a h/o paroxysmal atrial fibrillation not on
coumadin, HTN, HLP, moderate AS (valve area 1.0-1.2, gradient
55), moderate MR, ischemic colitis with LGIB who presents with
acute dyspnea and respiratory failure in setting of URI.
.
# Hypoxemic respiratory failure: This was thought to be
secondary to acute on chronic heart failure secondary to
worsening valve disease and likely triggered by an respiratory
infection (question URI vs PNA?). She was initially admitted to
the ICU where she improved after positive pressure ventilation
and some diuresis. She arrived on the floor looking well and
feeling asymptomatic. After some further diuresis she continued
to improve. She finished a 5 day course of levofloxacin However,
she continued to desat upon ambulation and it was felt that she
was not at her baseline. Therefore she underwent several days of
diuresis until she was able to ambulate without desaturating and
was able to go home with physical therapy. She was also to
follow up with her outpatient cardiologist Dr. [**Last Name (STitle) **] for
continued management of her congestive heart failure.
.
# Guiac positive stool with melena: We considered GI bleed in
the setting of a pt with h/o GI bleed and receiving sub C
heparin. However, given melena asymptomatic PUD was also
possible. We continued Pantoprazole 40mg PO BID and an active
type and screen was maintained. Fortunately, this self resolved
and HCTs remained stable. She was not interested in any
aggressive measures to intervene. She was to follow up with her
PCP regarding this probable GI bleed.
.
# Probable coronary artery disease: This was evidenced by a new
focal wall motion defect op echo. Lipids were checked and were
at goal except HDL of 39.
-Continued statin at 40mg PO Daily
-Held off on Aspirin given recent GI bleed and hematuria.
.
# Paroxysmal AFib: Had been stable for years off
anticoagulation. NSR on admit and well-rate controlled.
- Continued beta-blocker
.
# Hematuria: Pt endorsed traumatic foley placement hx. Hematuria
remained for several days requiring CBI. After several days the
hemauturia resolved with irrigation. Pt was to f/u for an
outpatient [**Last Name (STitle) **] evaluation for cystoscopy
.
# Hyperglycemia: Resolved with the acute illnesss.
.
# Hypertension: continued BB and ACE.
.
# CODE: DNR/DNI, confirmed with pt, and left a message with HCP.
.
# CONTACT: HCP, [**Name (NI) 2048**] [**Name (NI) **] [**Telephone/Fax (1) 27075**]
Medications on Admission:
ALLOPURINOL - 300 mg by mouth once a day
ATENOLOL - 25 by mouth once a day
PANTOPRAZOLE 40 mg by mouth twice a day
SIMVASTATIN - 20 mg by mouth once a day
VALSARTAN [DIOVAN] - 160 mg Tablet by mouth once a day
CALCIUM-VITAMIN D3-VITAMIN K [VIACTIV]
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] twice a day
FERROUS SULFATE once per day
PSYLLIUM [METAMUCIL] by mouth once a day
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained
Release Sig: One (1) Capsule, Sustained Release PO once a day: 2
Tablet(s) by mouth once per day as needed for take with [**Location (un) 2452**]
juice or vitamin c .
5. Ergocalciferol (Vitamin D2) 400 unit Capsule Sig: One (1)
Capsule PO once a day.
6. Psyllium Packet Sig: One (1) PO once a day.
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day. Tablet,
Delayed Release (E.C.)(s)
Discharge Disposition:
Home
Discharge Diagnosis:
1) Acute on chronic congestive heart failure secondary to
worsening valvular disease
2) Mitral regurgitation
3) Aortic stenosis
4) Community acquired pneumonia
5) Respiratory failure
6) Hematuria
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
It was a pleasure to take care of you here at [**Hospital1 18**]. You were
admitted to the hospital because of respiratory failure. You
were given positive pressure airway treatment and transferred to
the medical intensive care unit for further management. The
cause of your respiratory failure was thought to be congestive
heart failure (excess fluid in the lungs) secondary to a
respiratory infection and worsening heart valve disease (the
cause of your murmurs). You were given Lasix (water pills) to
remove the excess fluid in your lungs and your breathing and
oxygenation improved.
We have made the following changes to your medications:
Take Furosemide (Lasix) 40mg by mouth daily until instructed by
your primary care physician to stop
STOP Valsartan (Diovan) 80mg daily
Followup Instructions:
Please call [**Telephone/Fax (1) 250**] to schedule an appt with Dr. [**First Name8 (NamePattern2) **] [**Last Name (STitle) **],
M.D. Please try to schedule an appt with Dr. [**Last Name (STitle) 9006**] on [**2-3**] (the
same day you see Dr. [**Last Name (STitle) **].
You have an appointment with Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD
Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2128-2-3**] 9:40
You have an appointment with Provider: [**Name10 (NameIs) **] UNIT
Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2128-2-4**] 10:30
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 19838**]
Completed by:[**2128-4-11**]
|
[
"274.9",
"V58.61",
"584.9",
"424.1",
"401.9",
"E944.4",
"424.0",
"562.10",
"428.33",
"564.00",
"272.0",
"518.81",
"285.1",
"427.31",
"428.0",
"250.00",
"599.70",
"285.29"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10335, 10341
|
6633, 9097
|
247, 254
|
10581, 10581
|
3078, 6610
|
11561, 12287
|
2615, 2787
|
9518, 10312
|
10362, 10560
|
9123, 9495
|
10758, 11373
|
2802, 3059
|
11402, 11538
|
200, 209
|
282, 1879
|
10595, 10734
|
1901, 2430
|
2446, 2598
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,922
| 134,192
|
13259
|
Discharge summary
|
report
|
Admission Date: [**2109-6-7**] Discharge Date: [**2109-6-8**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year-old
female who was found down in her bathroom with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] coma
score of three. She was taken to the Emergency Department
for a possible stroke. There was a small bruise on her head
probably related to falling off of the toilet. She moved all
of her extremities. There was a 2 cm right forehead
hematoma. She developed progressive loss of responsiveness
requiring emergency intubation, this could not be performed,
however, and due to progressive desaturation an emergency
cricothyroidotomy was performed. Due to some bleeding from
the site she was then taken to the Operating Room for
revision, which was completed. A peritoneal lavage was
performed, which ruled out intraabdominal bleed. The patient
had a complete nonresponsiveness from a presumed large
cerebrovascular accident.
By the following day she was more and more hemodynamically
unstable with need for pressors. She had progressive
increase in her ventilator requirements. A family conference
was held where we discussed the fact that the patient's
prognosis was extremely poor given the minimal neurologic
function. The family decided to provide comfort measures
only and the patient expired shortly after.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18153**], M.D. [**MD Number(1) 18154**]
Dictated By:[**Last Name (NamePattern4) 40380**]
MEDQUIST36
D: [**2109-9-17**] 20:18
T: [**2109-9-24**] 07:49
JOB#: [**Job Number 40381**]
|
[
"E888.9",
"803.06",
"731.0",
"733.00",
"401.9",
"V10.3",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"31.1",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
109, 1676
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,016
| 192,002
|
23174
|
Discharge summary
|
report
|
Admission Date: [**2174-6-3**] Discharge Date: [**2174-6-7**]
Date of Birth: [**2099-9-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Tachypnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
74 year old male with h/o DM, frequent aspiration, CVA (left
weakness, at baseline unable to converse), presents to ED for
tachypnea.
Pt found at facility to be be congested, with difficulty
breathing. chief complaint of lung congestion, difficulty
breathing. Questionable seizure activity prior to being found.
Confirmed DNR/DNI with family but confirmed otherwise aggressive
care.
.
In the ED, initial vs were: 98.4 105 159/72 30s-40s 100 on 3-4L,
with eventual spike to 101 rectally. Although CXR neg, exam
revealed diffuse crackles, pt was treated for possible
aspiration pneumonia with vanc and zosyn (levo planned but not
yet administered). Labs sig for WBC 15.5, hyperglycemia and UA
with SG 1.[**Telephone/Fax (1) 59607**] glucose, lactate 3.5. Head CT ucnhanged
except newly dislocated lens in right eye. Stage 2 sacral decub
appeared uninfected. EKG without ischemic changes.
.
VS on transfer: 101.2, 124/56, 100, 32, 98 4L
Past Medical History:
strokes from ruptured intracerebral aneurysms in [**2160**] and [**2162**]
or [**2163**] with residual left sided deficits (has not been able to
walk since the stroke in '[**63**]) and aphasia, PEG for dysphagia
h/o seizure do
dementia
HTN
h/o HepC hepatitis, apparently not active
h/o neurosyphilis, treated in [**2163**]
hypothyroidism
Social History:
Nursing home resident ([**Hospital3 2558**]) since [**2163**]. Sent here
with no personal belongings.
Family History:
Noncontributory
Physical Exam:
Vitals: T: afeb BP: 120/69 P: 102 R: 26 18 O2:
General: NAD
HEENT: Sclera anicteric, PERRLA, MMM
Neck: supple, no LAD
Lungs: Diffuse ronchi, no resp distress
CV: Tachy, no murmurs
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, G tube in
palce
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Opens eyes slightly to command, withdraws to pain on
right, no movement on left
Pertinent Results:
[**2174-6-3**] 12:00PM WBC-15.5* RBC-4.19* HGB-12.4* HCT-38.3*
MCV-91 MCH-29.6 MCHC-32.4 RDW-15.0
[**2174-6-3**] 12:00PM NEUTS-76* BANDS-1 LYMPHS-12* MONOS-10 EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2174-6-3**] 12:00PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2174-6-3**] 12:00PM PLT SMR-NORMAL PLT COUNT-146*
[**2174-6-3**] 12:00PM PTT-32.8
[**2174-6-3**] 12:00PM cTropnT-<0.01
[**2174-6-3**] 12:00PM GLUCOSE-327* UREA N-23* CREAT-0.9 SODIUM-139
POTASSIUM-4.8 CHLORIDE-107 TOTAL CO2-21* ANION GAP-16
[**2174-6-3**] 12:40PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.029
[**2174-6-3**] 12:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-1000 KETONE-TR BILIRUBIN-NEG UROBILNGN-4* PH-6.0
LEUK-NEG
[**2174-6-3**] 12:40PM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2174-6-3**] 12:40PM URINE HYALINE-[**6-30**]*
EEG: FINDINGS:
ROUTINE SAMPLING: The background activity was slow reaching a
maximum
of about 6 Hz biposteriorly in the most awake parts of this
recording.
In addition, there was focal slowing in the delta and theta
range seen
in the right central area. There were sharp waves seen
independently in
the right frontal, right central parietal, as well as left
fronto-temporal areas.
SPIKE DETECTION PROGRAMS: Showed some of the above-mentioned
right and
left sharp waves.
SEIZURE DETECTION PROGRAMS: Captured periods of muscle artifact
as well
as blinking artifact but not ongoing seizure activity.
PUSHBUTTON ACTIVATIONS: There were no entries in these files.
SLEEP: The patient progressed from wakefulness to sleep. The
above-mentioned sharp waves were seen more frequently in sleep.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: This telemetry captured no ongoing seizure activity.
Interictally, it captured epileptic discharges independently in
the
right frontal, right central parietal, and left fronto-temporal
areas.
The background activity was slow suggestive of diffuse
encephalopathy
with additional focal slowing seen in the right central area
suggestive
of subcortical dysfunction in that region.
CT Head: IMPRESSION:
1. No acute intracranial process.
2. Chronic left pontine lacunar infarct, new compared to [**Month (only) **]
[**2172**].
3. Posterior dislocation of the right ocular lens, new since [**Month (only) **]
[**2172**].
CTA Chest:
IMPRESSION:
1. No central, segmental or large subsegmental pulmonary
embolism.
2. Bibasilar consolidations, could reflect atelectasis or
pneumonia.
3. Left thyroid lobe nodule.
4. Coronary artery disease.
5. Indeterminant right hepatic lobe lesion most likely cyst or
hemangioma
Micro:
[**2174-6-5**] URINE URINE CULTURE negative
[**2174-6-5**] URINE Legionella Urinary Antigen negative
[**2174-6-5**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST negative
[**2174-6-4**] MRSA SCREEN MRSA SCREEN-positive
[**2174-6-3**] BLOOD CULTURE Blood Culture, pending
[**2174-6-3**] BLOOD CULTURE Blood Culture, pending
Brief Hospital Course:
Mr. [**Known lastname 4587**] is a 74 yo M with h/o strokes resultant in minimal
responsiveness, aphagia, frequent aspiration, who presented from
[**Hospital3 **] with tachypnea and question of seizure-like
activity.
# ?Aspiration Pneumonia:
Patient presented with tachypnea, fever, tachycardia, elevated
WBC and was admitted to the MICU. He was started empirically on
Vancomycin and Zosyn for aspiration pneumonia. Chest CT-A ruled
out PE, as he was not on any DVT prophylaxis at the nursing
facility. Chest CT also showed bibasilar atelectasis vs
consolidation. Patient was transitioned to azithromycin and
transferred to floor when hemodynamically stable. On the floor,
he was restarted on Vancomycin and Zosyn for concern of
aspiration pneumonia, re-evaluating bibasilar consolidations on
Chest CT, likely secondary to chronic aspiration from tube
feeds. Pt was discharged bac kto the facility to continue IV
antibiotics for a total of 7 days. Pt was without fevers or
leukocytosis at the time of discharge.
# History of Seizures:
Patient was reported to have had seizure-like activity prior to
presentation. Corrected Dilantin level was within therapeutic
range. Pt was continued on seizure ppx, and had no clinically
evident seizure activity. A 48 hr EEG was performed which showed
no seizure activity, only epileptic interictal discharges,
consistent with past stroke.
# Diabetes Mellitus:
Patient was continued on home insulin regimen.
# Hypertension:
Patient was continued on BB, Hydralazine and Lisinopril.
# Anemia: Is normocytic, likely secondary to chronic disease.
Hct was stable, a fecal occult blood was ordered.
.
# Patient was DNR/DNI during this hospitalization. Pt has a
left PICC for IV access. Pt was maintained on SC Heparin for DVT
ppx. Pt was on tube feeds for nutrition.
Medications on Admission:
Lisinopril 60mg via G tube daily
KCL elixir 20Meq twice daily
Novolin 4 SS
Lantus 26U daily
Dilantin 25mg at 10am, 50mg 50mg at bedtime
Enulose 30ml via G tube BIC
Docusate liquid 150mg [**Hospital1 **]
Metoprolol 10mg [**Hospital1 **]
Hydralazine 40mg [**Name (NI) **]
MOM 30mg NGT TIW
Albuterol nasal neb q6h prn SOB
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
3. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
4. Phenytoin 50 mg Tablet, Chewable Sig: 0.5 Tablet, Chewable PO
DAILY (Daily) as needed for 10am.
5. Phenytoin 50 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QHS (once a day (at bedtime)).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB.
7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
9. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 5 days.
10. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: One (1) Intravenous Q8H (every 8 hours) for 5 days.
11. Potassium Chloride 20 mEq Packet Sig: One (1) PO twice a
day.
12. Novolin R 100 unit/mL Solution Sig: Four (4) units Injection
four times a day: sliding scale.
13. Lantus 100 unit/mL Solution Sig: Twenty Six (26) units
Subcutaneous once a day.
14. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) mg
PO three times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Aspiration Pneumonia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Mr. [**Known lastname 4587**] was admitted to the hospital because he was having
difficulty breathing. He was initially in the ICU, where he was
started on IV antibiotics for aspiration pneumonia. Pt was then
transferred to the medicine floor. An EEG was performed which
showed no seizure activity. Pt was then discharged back to the
facility.
He needs immediate medical attention if he experiences
difficulty breathing, has fevers or any other concerning
symptoms.
Please make th following changes to his medications:
START Piperacillin-Tazobactam 4.5 g IV every 8 hours for 5 more
days
START Vancomycin 1000 mg IV every 12 hours for 5 more days
You will need to have your thyroid nodule followed up.
Followup Instructions:
You will be followed by doctors at the facility. They will
provide you with a follow-up appointment with your primary care
doctor in the future.
Completed by:[**2174-6-7**]
|
[
"573.8",
"785.0",
"E878.1",
"996.53",
"438.82",
"E942.6",
"285.29",
"241.0",
"401.9",
"707.03",
"244.9",
"V44.1",
"438.20",
"250.00",
"438.11",
"345.90",
"414.01",
"070.54",
"287.5",
"507.0",
"707.22",
"294.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8803, 8873
|
5337, 7146
|
322, 329
|
8938, 8938
|
2311, 4454
|
9807, 9983
|
1791, 1808
|
7515, 8780
|
8894, 8917
|
7172, 7492
|
9074, 9784
|
1823, 2292
|
273, 284
|
357, 1293
|
4463, 5314
|
8953, 9050
|
1315, 1655
|
1671, 1775
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,558
| 133,692
|
34993
|
Discharge summary
|
report
|
Admission Date: [**2165-11-14**] Discharge Date: [**2165-11-22**]
Date of Birth: [**2143-4-3**] Sex: M
Service: NEUROLOGY
Allergies:
Dilantin / Tegretol
Attending:[**First Name3 (LF) 7567**]
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Transferred from OSH on [**11-14**], intubated for status epilepticus.
The history was obtained from the mother and the girlfriend. 23
yo with reported GTC seizures since the age of 5 years, mostly
in sleep. His last visit from CHB in [**2158**] documented a normal
MRI and an awake only EEG. The only documented electrographic
abnl was on an EEG in [**2156-12-1**] which showed slowing of the
background. There were significant complicance issues even at
that time. The impression was that it was some what unusual to
have such frequent, almost daily, seizures as per report without
abnormal detected on EEGs. It was thought that these could
represent parasomnias vs nocturnal seizures. His mother seems to
have been told he has frontal lobe seizures.
Mr [**Known lastname 3549**] has been lost to f/u, not having seen a PCP in at least
1 yr, and with non-compliance such that he has not taking his
AEDs over at least the past 4 months. He was previously on VPA
500 [**Hospital1 **] and Lamictal 25 or 50 [**Hospital1 **] as per his mother. [**Name (NI) **] has had
daily seizures lasting 45 mins each over the past [**1-2**] wks. No
head injury, fever, or recent illnesses. He sometimes reports a
prodrome of dizziness. He usually has post-ictal fatigue x 10
mins. His usual seizure semiology seems to begin with rightward
head deviation, no gaze deviation, eyes open and revulsed, then
generalized tonic posturing with clonic movements. No urinary
incontinence, no tongue biting. This am he was found prone in
bed, had 2 sz lasting 45 mins and a third lasting 30 mins within
a 3 hr time period. He was brought to OSH ED where he had
another seizure witnessed by RN but no further description
documented. Gluc was 127. He was tx with LZP 2 mg x 4, required
intubation, and started on Propofol gtt. At 10h30 am he was
loaded with VPA 1g iv. His labs were remarkable for an AST of
383 and an ALT of
830. He does have a hx of regular EtOH. NCHCT reportedly nml.
He had recently presented to [**Hospital3 10377**] Hospital on
[**11-10**] with migraine and neck pain. Because of his frequent
seizures and VPA level < 10, Dr. [**Last Name (STitle) 10653**] from Neurology was
contact[**Name (NI) **] and he suggested not restarting any AEDs at that time,
but rather referring him to the [**Hospital 875**] clinic here for
evaluation given his lack of medical insurance. He has an apt
with Dr. [**First Name (STitle) 3322**] [**Name (STitle) **] [**11-26**].
ROS otherwise negative as per family.
Past Medical History:
-epilepsy
-migraines
-ADHD
-depression
Social History:
Unemployed due to seizures, 1 ppd tobacco, regular EtOH and
cannabis, was in group home in [**Location (un) 8973**] in recent years, lives
with mother, has a child with his girlfriend [**First Name8 (NamePattern2) **] [**Name (NI) **]
[**Telephone/Fax (1) 80028**]) but they do not currently live together.
Family History:
No seizures
Physical Exam:
EXAM
VITALS: T 100 R HR 83 BP 104/66 RR sO2
GEN: intubated
HEENT: mmm
NECK: no LAD; no carotid bruits
LUNGS: Clear to auscultation bilaterally
HEART: Regular rate and rhythm, normal S1 and S2, no murmurs,
gallops and rubs.
ABDOMEN: normal bowel sounds, soft, nontender, nondistended
EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema
NEURO: examined off Propofol x 5 mins
PERRL 3 to 2 bilat, optic discs normal to fundoscopy, EOMI to
oculocephalic reflex, absent corneal reflex, grimaces to nasal
tickle
withdraws all libes symmetrically to noxious and attempts to
localize
DTRs 2+ in UEs, 3+ in LEs with 1 beat of clonus bilat, plantar
response flexor bilat
Pertinent Results:
EEG telemetry from [**11-14**] to [**11-22**] did capture bifrontal
seizures.
[**11-22**] MRI of the brain with and without contrast: preliminary
read is a normal brain.
[**2165-11-14**] US abdomen mild splenomegaly
[**2165-11-19**] US renal tract was normal
HCV VIRAL LOAD (Final [**2165-11-19**]): 1,420,000 IU/mL
HIV-1 negative
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct INR
[**2165-11-22**] 06:20AM 4.5 4.28* 12.8* 36.5* 85 29.9 35.0 12.9
247 1.2
1.2*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2165-11-22**] 06:20AM 102 11 1.1 143 4.0 106 27 14
CSF studies [**2165-11-15**]
ANALYSIS WBC RBC Polys Lymphs Monos
[**2165-11-15**] 12:26PM 11 2* 22 56 42
CLEAR AND COLORLESS
CHEMISTRY TotProt Glucose
[**2165-11-15**] 12:26PM 26 55
CMV, HSV, Lyme, Varicella were all negative in the CSF
Brief Hospital Course:
[**2165-11-14**]
In the [**Hospital1 18**] ED, his temp was 100.0. BP was 104/66. Off
sedation, did not open eyes to verbal or pain. In the ED a
portable EEG showed an excessively regular widespread alpha
frequency background and due to the occasional bursts of
generalized slowing but no overtly epileptiform abnormalities.
There were definitely no repetitive discharges or electrographic
seizures. LP studies unremarkable but cultures and PCR still
pending. He is being treated empirically for HSV with
acyclovir. He was extubated yesterday morning and transferred to
the floor last night.
[**2165-11-14**] to [**2165-11-16**] Admitted to the Neuro ICU Service
(attending Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **])
Due to his temp of 100 and severe headache since [**11-10**], he had an
LP carried out to exclude meningitis. He was admitted to the ICU
where he was treated with keppra for his seizures, as he had
been found to have a transaminitis, depakote was subsequently
discontinued. He was extubated on [**2165-11-16**].
[**2165-11-17**] transfer to [**Hospital Ward Name 121**] 11
He had frequent frontal seizures, the dose of Keppra was
increased to 1500 mg [**Hospital1 **]. He had EEG telemetry from [**Date range (1) 80029**].
Due to the number of seizures recorded, a second anti-epileptic
medication was added (Lyrica). His CSF PCR for HSV did not come
back until [**2165-11-18**], and he had been commenced on broad spectrum
antibiotics and acyclovir. However, he did have acute renal
failure secondary to acyclovir, with Cr up to 5.2. He had a
normal renal ultrasound, FeNa>41, and he was reviewed by
Nephrology. His ARF resolved after stopping the acyclovir. In
addition, the cause of his deranged liver enzymes is most
probably due to his hepatitis C status which was discovered
during his admission. He was reviewed by hepatology, and he will
be followed up by the team in the outpatient setting. He had an
MRI of his brain prior to discharge, and had a seizure for a
couple of minutes which resolved without Ativan.
Medications on Admission:
None
Discharge Medications:
1. Pregabalin 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*1*
2. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
3. Fioricet 50-325-40 mg Tablet Sig: One (1) Tablet PO every [**6-9**]
hours as needed for headache for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Status epilepticus, generalized
Intractable partial epilepsy, 345.41
Acute renal failure, drug-induced
Hepatitis C with abnormal liver function tests
Antiepileptic drug toxicity
Alcohol abuse
Discharge Condition:
Still having seizures, but decreased in number and severity.
Discharge Instructions:
If you have increasing seizure frequency, or episodes where you
feel as if you are fainting, or you have a severe headache,
please be sure to go to your nearest emergency room.
You have been started on two new seizure medications: Keppra and
a low dose of Lyrica. Both medications may cause fatigue. Keppra
may cause mood changes. Lyrica may cause a fine tremor, but it
is usually seen at high doses. Both are used in treating both
seizures and migraines.
Followup Instructions:
1. NEUROLOGY: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7025**], MD Phone:[**Telephone/Fax (1) 5285**]
Date/Time:[**2165-12-2**] 4:30
2. GI (LIVER): With Dr [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] on [**1-12**] at 13:30 h, [**Last Name (un) 80030**]
Building, [**Street Address(2) 80031**], [**Location (un) **], [**Hospital Unit Name **]
Completed by:[**2165-11-22**]
|
[
"584.9",
"345.3",
"070.70",
"E931.7",
"314.01",
"V15.81",
"311",
"305.00",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
7395, 7401
|
4898, 6959
|
291, 303
|
7636, 7699
|
3948, 4875
|
8204, 8640
|
3232, 3245
|
7014, 7372
|
7422, 7615
|
6985, 6991
|
7723, 8181
|
3260, 3929
|
243, 253
|
331, 2828
|
2850, 2891
|
2907, 3216
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,761
| 156,200
|
39189
|
Discharge summary
|
report
|
Admission Date: [**2174-12-5**] Discharge Date: [**2174-12-14**]
Date of Birth: [**2100-1-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2174-12-9**]
Coronary artery bypass grafting x5 with the left internal
mammary artery to the left anterior descending artery, and
reverse saphenous vein graft to the right coronary artery, the
diagonal artery and sequential reverse saphenous vein grafts to
the first and second obtuse marginal arteries.
History of Present Illness:
74yoM with h/o metastic RCC to lung and sinuses who was getting
surveillance CT of his cancer earlier today and was sent to
[**Hospital 3782**] clinic for post-CT hydration when he experienced sharp,
focal Left sided chest pain along Ledt sternal
border with diaphoresis, SOB. He was tachy to 110's, sbp 160's,
RA 84-89% with 100% FM placed, unclear subsequent sats. He was
given 2 SL NTG with CP relief, O2 sats 89-90% and sent to ED. No
fevers or chills. Referred for cardiac catheterization.
Cardiac Catheterization: Date:[**2174-12-6**] Place:[**Hospital1 18**]
LMCA:Distal in stent restenosis 70%
LAD: mid 80% at large diagonal bifurcation
LCX: diffuse proximal in stent restenosis extending to LM-80-90%
RCA: distal 50%
Past Medical History:
[**7-/2174**] NSTEMI with BMS to OM1 and LCx complicated by LMCA
dissection and BMS to LMCA
Hypertension
Gout
Hypothyroidism
Stage IV clear cell renal cell carcinoma
[**2174-2-11**]: PET CT confirmed multiple pulmonary nodules
[**2174-3-4**]: Biopsy of the right and left maxillary
sinuses: the right maxillary sinus mass biopsy confirmed the
presence of metastatic clear cell renal cell carcinoma; the
left-sided sinus biopsy was benign.
[**2174-6-27**] Started therapy with Sunitinib + AMG 386 on protocol
09-014 (CT Torso [**7-12**] showed decrease size of some of the
pulmonary lesions, the other being stable)- sunitinib d/c [**7-18**]
Past Surgical History
[**2163**]: Left-sided nephrectomy
Social History:
retired; former garage supervisor; married; quit smoking 30
years ago (20 ppy history); no EtOH currently; denies IVDU
Wife has liver cancer. 19yo son just found out he is having
twins.
Family History:
sister with stomach cancer
Physical Exam:
Pulse:78 Resp:16 O2 sat:95/4L
B/P Right:140/93 Left: 157/90
Height:5'7" Weight:183 lbs
General:NAD, alert, cooperative
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] no Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: +2 Left:+2
DP Right:+2 Left:+2
PT [**Name (NI) 167**]: +2 Left:+2
Radial Right: +2 Left:+2
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2174-12-9**] ECHO
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Mild regional LV
systolic dysfunction. Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Simple
atheroma in ascending aorta. Simple atheroma in aortic arch.
Complex (>4mm) atheroma in the descending thoracic aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: No TR.
[**2174-12-14**] 06:19AM BLOOD WBC-7.9 RBC-3.20* Hgb-9.6* Hct-28.7*
MCV-90 MCH-29.9 MCHC-33.4 RDW-16.7* Plt Ct-227#
[**2174-12-10**] 03:20AM BLOOD PT-13.4 PTT-28.8 INR(PT)-1.1
[**2174-12-14**] 04:54AM BLOOD Glucose-97 UreaN-23* Creat-1.6* Na-137
K-4.2 Cl-98 HCO3-32 AnGap-11
[**Known lastname **],[**Known firstname **] [**Medical Record Number 86775**] M 74 [**2100-1-17**]
Radiology Report CHEST (PA & LAT) Study Date of [**2174-12-12**] 9:26 AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2174-12-12**] 9:26 AM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 86776**]
Reason: eval for effusion
Final Report
HISTORY: CABG.
FINDINGS: In comparison with study of [**12-11**], the patient has
taken a much
better inspiration. There are improving atelectatic changes at
the left base
with no evidence of pulmonary vascular congestion or pleural
effusion. There
is some increased opacification in the right hilar and perihilar
region of
unknown significance. There should be closely checked on
subsequent
radiographs to determine whether it could represent a region of
aspiration.
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
Approved: MON [**2174-12-12**] 10:39 AM
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2174-12-9**] where the patient underwent coronary
artery bypass grafting x5 with the left
internal mammary artery to the left anterior descending artery,
and reverse saphenous vein graft to the right coronary artery,
the diagonal artery and sequential reverse saphenous vein grafts
to the first and second obtuse marginal
arteries. Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. The morning of
POD 1 the patient was extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact and
hemodynamically stable on no inotropic or vasopressor support.
Beta blocker was initiated and the patient was gently diuresed
toward the preoperative weight. He did go into a rapid atrial
fibrillation on POD 2 and was started on Amiodarone bolus and
drip with conversion to sinus rhythm, which he maintained at the
time of discharge. The patient was transferred to the telemetry
floor for further recovery. Chest tubes and pacing wires were
discontinued without complication. He did have a creatinine
that was rising with a peak of 1.7 (baseline 1.3). Lisinopril
and Lasix were decreased and creatinine was stable at the time
of discharge at 1.6. Per Dr. [**Last Name (STitle) **], no need for Plavix as
coronaries with stents were bypassed. The patient was evaluated
by the physical therapy service for assistance with strength and
mobility. By the time of discharge on POD #5 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged home with VNA
services in good condition with appropriate follow up
instructions.
Medications on Admission:
Plavix 75 mg daily
Vicodin 5-500 daily prn
Crestor 40 mg daily
ASA 325 daily
Allopurinol 300 daily
Hydralazine 25 mg PO tid
Paroxetine 20 mg daily
Levoxyl 25 mcg daily, except 50 mcg Wednesday
Folate 400 mcg daily
Ranitidine 150 mg [**Hospital1 **]
Toprol XL 50 mg daily
Lisinopril 40 mg daily
Amlodipine 10 mg daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
Disp:*10 Tablet(s)* Refills:*0*
5. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO every twenty-four(24)
hours for 10 days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain,, fever.
8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
9. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Take 25 mcg daily except Wed. On Wed only take 50 mcg
(2 tablets) .
Disp:*40 Tablet(s)* Refills:*0*
12. folic acid 400 mcg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
13. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
14. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
15. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO three
times a day.
Disp:*135 Tablet(s)* Refills:*0*
16. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 2 months: Take 400 mg [**Hospital1 **] x 2 weeks then 400 mg daily
x 2 weeks then 200 mg daily x 1 month then discontinue.
Disp:*80 Tablet(s)* Refills:*0*
17. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronary Artery Disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
1+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**2174-1-4**] at 1:45 PM
Cardiologist: Dr. [**Last Name (STitle) 171**] [**2174-2-8**] at 2:20 PM
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 4899**] in [**4-4**] weeks [**Telephone/Fax (1) 86777**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2174-12-14**]
|
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59,201
| 177,744
|
42874
|
Discharge summary
|
report
|
Admission Date: [**2151-4-4**] Discharge Date: [**2151-4-10**]
Date of Birth: [**2086-12-23**] Sex: M
Service: MEDICINE
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
VF arrest
Major Surgical or Invasive Procedure:
Arterial Line
Central Venous Line
Mechanical Intubation
Dialysis
History of Present Illness:
Patient's name per driver license is [**Known firstname **] [**Known lastname **] of [**Doctor First Name 92582**],
[**State 108**]. Phone number is [**Telephone/Fax (1) 92583**]. Next of [**Doctor First Name **] is [**Name (NI) 7279**]
[**Name (NI) **] (wife). Phone number is [**Telephone/Fax (1) 92583**].
64M history of Prinzmetal's angina transferred from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
to [**Hospital1 18**] s/p cardiac arrest. He has a history of recurrent chest
pain due to "coronary artery spasm" per wife with extensive
evaluation. He is very athletic.
While driving, the patient complained of acute onset of chest
pain. He took aspirin as usual. Approximately 20 minutes after
onset of chest pain, the patient had an acute alteration of
mental status. She pulled off the road and started CPR but could
not get a pulse.
EMS arrived and the patient was undergoing CPR. Total downtime
was approximately 7 minutes prior to arrival EMS. On arrival of
EMS the patient was in ventricular fibrillation. The patient was
intubated with 7.5 ETT placed at 22 and ACLS was initiated with
epinephrine and shocks for ventricullar fibrillation.
Pt was brought to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] during which he received 3 shocks
for fine ventricullar fibrillation. He was given lidocaine 100
mg x 2 and epinephrine 1 mg x 4. He transiently converted to
asystole and then back to V. fib. He also received 150 mg
amiodarone. He was also given magnesium and IV calcium. And
thereafter appeared to be hypotensive and bradycardic, and was
given atropine. Because of persistent hypotension and
bradycardia, a dopamine drip was initiated. Patient was packed
with ice and transported via med flight.
Per Med Flight documentation, patient received dopamin @ 15
mcg/kg/min, fentanyl 100 mcg in 50 mcg doses, amiodarone 1
mg/min. Vent settings were SIMV/PS 400x18 PEEP 7 PS 10 cm FiO2
100 %.
The patient was noted to have pulmonary edema on chest x-ray on
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. ECG prior to transport showed an idioventricular
rhythm with wide complex rhythm.
In the [**Hospital1 18**] ER, initial VS were HR 92 102/85 RR 19 pOx 97 on
100%, 500x18, volume-control. His initial rhythm on arrival was
narrow complex.
An arterial line was placed in left groin. Central line was
placed in the left groin as well. Per ER reports, lines were
placed in sterile fashion although documentation was not sent
with ER paperwork. This has been requested.
CXR was performed showing diffuse bilateral opacities with air
bronchograms suggesting severe pulmonary edema, potentially
capillary permeability edema. Cardiac size was within normal
limits.
Labs were performed
CBC WBC 18 Hct 53 MCV 104 Plt 175 with differential N 81 B 7 L
12 INR 1.4 PT 14.7 PTT 51.7
CK 997 CK-MB 104 cTropnT 1.52
pH 7.09 pCO2 46 pO2 83 HCO3 15 Lactate 8.2 (from 10.4). After
ABG showed significant acidosis, RR was increased.
Cardiology was consulted and recommended admission to CCU for
post-arrest care. He was loaded plavix 600 mg PO x 1, aspirin
325 mg PO x 1, and started on heparin infusion.
The post-arrest consult service was consulted. Artic Sun cooling
protocol was initiated with goal temperature of 33 x 24 hours
(cooling start time: 15:10 on [**2151-4-4**]) and sedated to RASS -5.
He was given midazolam 2 mg/hr, fentanyl 50 mcg/hr, vecuronium
10 mg IV x 1 in addition to amiodarone 1 mg, dopamine 20 mg/kg.
Patient also became hypotensive (SBP 80-90s). His dopamine was
increased from 15 to 20, and he was started on levophed.
Admission Vitals: T 34.5 HR 86 BP 96/84 pOx 97 on 100%, 500x22,
volume-control.
.
Patient is not able to provide ROS given sedated.
.
In CCU, ECHO showed relatively preserved LVEF, no global wall
motion abnormalities, ? pericardial effusion, worse at apex.
Limited study.
Family meeting held with wife at bedside with CCU. She was
updated on clinical situation including cardiac arrest,
neuroprotection strategy, and potential for poor prognosis. She
will visit tonight.
Past Medical History:
? Prinzmetal's angina. Patient was last hospitalized in [**Month (only) 1096**]
for chest pain and diaphoresis. Per wife, negative cardiac
work-up.
Social History:
unable to obtain as sedated
Family History:
unable to obtain as sedated
Physical Exam:
Vitals: 97.7F, HR 70, BP 126/65, 99% CMV 26/500/40%/5
General: Intubated, sedated, does not respond to voice or follow
simple commands, artic sun pads in place
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: Soft crackles at bases, no wheezes, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
On Admission:
[**2151-4-4**] 02:45PM PT-14.7* PTT-51.7* INR(PT)-1.4*
[**2151-4-4**] 02:45PM PLT SMR-NORMAL PLT COUNT-175
[**2151-4-4**] 02:45PM NEUTS-81* BANDS-7* LYMPHS-12* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2151-4-4**] 02:45PM WBC-18.0* RBC-5.07 HGB-17.3 HCT-53.0*
MCV-104* MCH-34.1* MCHC-32.7 RDW-13.5
[**2151-4-4**] 02:45PM CALCIUM-8.7 MAGNESIUM-2.6
[**2151-4-4**] 02:45PM CK-MB-104* MB INDX-10.4*
[**2151-4-4**] 02:45PM cTropnT-1.52*
[**2151-4-4**] 02:45PM CK(CPK)-997*
[**2151-4-4**] 02:45PM estGFR-Using this
[**2151-4-4**] 02:45PM GLUCOSE-224* UREA N-14 CREAT-1.4* SODIUM-140
POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-15* ANION GAP-24*
[**2151-4-4**] 02:55PM LACTATE-10.4*
[**2151-4-4**] 02:55PM TYPE-[**Last Name (un) **] RATES-/18 TIDAL VOL-500 PEEP-5
O2-100 INTUBATED-INTUBATED VENT-CONTROLLED
[**2151-4-4**] 03:07PM VoidSpec-[**First Name9 (NamePattern2) 21799**] [**Male First Name (un) **]
[**2151-4-4**] 03:25PM LACTATE-8.2*
[**2151-4-4**] 03:25PM TYPE-ART TEMP-35.1 RATES-18/ TIDAL VOL-500
PEEP-5 O2-100 PO2-73* PCO2-64* PH-7.03* TOTAL CO2-18* BASE
XS--15 AADO2-579 REQ O2-95 INTUBATED-INTUBATED VENT-CONTROLLED
[**2151-4-4**] 03:56PM TYPE-ART TEMP-34.7 RATES-26/ TIDAL VOL-600
PEEP-12 O2-100 PO2-83* PCO2-46* PH-7.09* TOTAL CO2-15* BASE
XS--15 AADO2-587 REQ O2-96 -ASSIST/CON INTUBATED-INTUBATED
[**2151-4-4**] 05:51PM PT-16.4* PTT-150* INR(PT)-1.5*
[**2151-4-4**] 05:51PM PLT COUNT-140*
[**2151-4-4**] 05:51PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-2+
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL BURR-2+
[**2151-4-4**] 05:51PM NEUTS-90* BANDS-5 LYMPHS-3* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2151-4-4**] 05:51PM WBC-18.2* RBC-5.36 HGB-17.4 HCT-54.8*
MCV-102* MCH-32.4* MCHC-31.7 RDW-13.9
[**2151-4-4**] 05:51PM ALBUMIN-3.8 CALCIUM-8.6 PHOSPHATE-6.6*
MAGNESIUM-2.3
[**2151-4-4**] 05:51PM CK-MB-275* MB INDX-13.7* cTropnT-7.32*
[**2151-4-4**] 05:51PM ALT(SGPT)-213* AST(SGOT)-412* CK(CPK)-[**2145**]*
ALK PHOS-126 TOT BILI-1.0
[**2151-4-4**] 05:51PM GLUCOSE-241* UREA N-16 CREAT-1.4* SODIUM-141
POTASSIUM-3.5 CHLORIDE-108 TOTAL CO2-11* ANION GAP-26*
[**2151-4-4**] 06:00PM freeCa-1.17
[**2151-4-4**] 06:00PM GLUCOSE-223* LACTATE-8.4*
[**2151-4-4**] 06:00PM TYPE-ART PO2-104 PCO2-41 PH-7.10* TOTAL
CO2-13* BASE XS--16
[**2151-4-4**] 09:47PM LACTATE-10.5*
[**2151-4-4**] 09:47PM TYPE-ART TEMP-33.2 PO2-175* PCO2-30* PH-7.25*
TOTAL CO2-14* BASE XS--12 INTUBATED-INTUBATED
Relevant Labs:
[**2151-4-5**] 04:17AM BLOOD PT-15.0* PTT-32.5 INR(PT)-1.4*
[**2151-4-6**] 09:21PM BLOOD PT-17.4* PTT-34.9 INR(PT)-1.6*
[**2151-4-9**] 03:07AM BLOOD PT-29.4* PTT-68.2* INR(PT)-2.8*
[**2151-4-6**] 09:21PM BLOOD Fibrino-348
[**2151-4-6**] 04:10AM BLOOD Glucose-127* UreaN-31* Creat-2.1* Na-135
K-5.7* Cl-110* HCO3-13* AnGap-18
[**2151-4-6**] 10:09AM BLOOD Glucose-136* UreaN-38* Creat-2.6* Na-134
K-6.5* Cl-107 HCO3-15* AnGap-19
[**2151-4-4**] 05:51PM BLOOD ALT-213* AST-412* CK(CPK)-[**2145**]*
AlkPhos-126 TotBili-1.0
[**2151-4-5**] 12:03AM BLOOD ALT-146* AST-380* CK(CPK)-2527*
[**2151-4-5**] 04:17AM BLOOD ALT-166* AST-400* CK(CPK)-2887*
[**2151-4-6**] 04:10AM BLOOD ALT-125* AST-270* CK(CPK)-1889*
AlkPhos-34* TotBili-0.5
[**2151-4-4**] 02:45PM BLOOD cTropnT-1.52*
[**2151-4-4**] 05:51PM BLOOD CK-MB-275* MB Indx-13.7* cTropnT-7.32*
[**2151-4-5**] 12:03AM BLOOD CK-MB-411* MB Indx-16.3* cTropnT-7.22*
[**2151-4-5**] 04:17AM BLOOD CK-MB-GREATER TH cTropnT-7.42*
[**2151-4-6**] 04:10AM BLOOD CK-MB-375* MB Indx-19.9* cTropnT-5.42*
[**2151-4-6**] 09:21PM BLOOD Hapto-<5*
[**2151-4-6**] 09:21PM BLOOD D-Dimer-3660*
[**2151-4-7**] 05:26AM BLOOD Hapto-15*
[**2151-4-8**] 10:10AM BLOOD Hapto-119
[**2151-4-5**] 12:46PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Barbitr-NEG Tricycl-NEG
[**2151-4-4**] 03:25PM BLOOD Type-ART Temp-35.1 Rates-18/ Tidal V-500
PEEP-5 FiO2-100 pO2-73* pCO2-64* pH-7.03* calTCO2-18* Base
XS--15 AADO2-579 REQ O2-95 Intubat-INTUBATED Vent-CONTROLLED
[**2151-4-5**] 09:28AM BLOOD Type-ART Temp-33 pO2-99 pCO2-24* pH-7.28*
calTCO2-12* Base XS--13
[**2151-4-4**] 02:55PM BLOOD Lactate-10.4*
[**2151-4-4**] 03:25PM BLOOD Lactate-8.2*
[**2151-4-4**] 06:00PM BLOOD Glucose-223* Lactate-8.4*
[**2151-4-5**] 10:55PM BLOOD Lactate-5.4*
[**2151-4-9**] 10:05AM BLOOD Glucose-139* Lactate-1.9
Studies:
[**4-4**] EEG:
IMPRESSION: This telemetry captured no pushbutton activations.
The
recording showed a burst suppression pattern throughout. It did
not
change appreciably over the course of the record. There were no
electrographic seizures.
[**4-5**] EEG:
This telemetry captured one pushbutton activation. It
showed some muscle activity on EEG without signs of
electrographic
seizure. There was some chin movement seen clinically on video.
Overall, the patient remained in a burst suppression pattern
throughout
but, later in the record, there was some muscle artifact. There
were no
clear epileptiform features or electrographic seizures.
[**4-7**] EEG: This telemetry captured no pushbutton activations. The
background was of such low voltage that no activity or clearly
cortical
origin could be discerned. [Of note, this monitoring recording
was not
performed with technological investigations to determine the
presence or
absence of cortical activity.] The recording suggests an
extremely
severe encephalopathy. This assumes the absence of sedating
medication.
[**4-8**] EEG
Markedly abnormal portable EEG due to the profound suppression
of the background rhythm such that no electrolytes or video
cortical origin was observed. There were some deflections
attributed to
movement artifact. It should be noted that this study was
performed as
a routine portable EEG without using technical specifications
for
obtaining an "electrocerebral silence" record. The very low
voltage
background without apparent reactivity indicates a very poor
prognosis
assuming that the lower voltages or not too sedating
medications,
hypotension, or hypothermia at the time.
[**4-4**] Echo:
Normal biventricular cavity sizes with preserved global
biventricular systolic function. Mildly dilated descending
thoracic aorta. No definite pathologic valvular flow identified.
Brief Hospital Course:
64M history of ? Prinzmetal's angina s/p witnessed VF arrest
with ROSC after defibrillation and ACLS who despite cooling
protocol and supportive therapy developed poor indicators of
perfusion (presenting lactate 10.4) and multi-organ failure with
hypotension requiring pressor support, acute respiratory
failure, acute renal failure, evolving shock liver, and impaired
neurological status after completion of rewarming and withdrawal
of sedation. Care was ultimately withdrawn per family, and the
patient passed away.
# s/p cardiac arrest
Patient s/p witnessed VF arrest in field. Prior cardiac work-up
negative in setting of chest pain episodes in past attributed to
coronary spasm. Etiology of current arrest was uncertain - may
be ischemic etiology vs. rhythm disturbance in setting of
coronary vasopasm. No evidence of STEMI. The pt's echo did not
demonstrate any systolic dysfunction which would be expected if
there were a large MI. Given downtime in field, pt had shock
with resultant multi-organ damage. Pt was initiated on Arctic
sun cooling protocol. Pt was placed on heparin infusion
initially for concern of thrombotic etiology of arrest, pt given
plavix and aspirin. Pt required pressor support with dopamine
and norepinephrine. The norepinephrine was able to be weaned
off. The dopamine was withdrawn with the rest of his care at
the family's request when it was clear that there would be no
meaningful neurologically recovery.
# Neuroprotection s/p arrest: Pt was initiated on Arctic Sun
cooling protocol s/p arrest. After rewarming, neurology
conducted serial exams and EEGs. This revealed anoxic brain
injury post-cooling with incomplete brainstem reflexes and flat
EEG showing no identifable brain activity and no reactivity to
stimulation. This occurred despite being fully off sedation.
These results were discussed with the family who subsequently
decided to withdraw care.
# Acute (uncompensated) primary respiratory acidosis, with
metabolic acidosis, with increased anion gap:
Patient had acute hypoxemic and hypercarbic respiratory failure
as result of arrest, s/p intubation and mechanical ventilation.
Decreased perfusion also lead to anion gap metabolic acidosis.
Pt was aggressively fluid resuscitated and was given HCO3
boluses as needed to correct lactic acidosis. Pt was
hyperventilated to correct respiratory acidosis. CVVH was
initiated. Pt's ABGs and lactates improved with these measures.
# Pulmonary edema
Patient had pulmonary edema in setting of cardiac arrest, shock,
most likely a mixed picture of both cardiogenic and
non-cardiogenic pulmonary edema. Aggressive fluid resuscitation
worsened pulmonary edema. The patient was started on CVVH to
remove fluid, which improved edema and decreased vent
requirements
# Acute renal failure:
Cr on admission 1.4 (eGFR 51) with unknown baseline. Patient
became anuric with worsening kidney function and fast rise in
potassium. Etiology likely pre-renal with ATN given prolonged
hypotension. Pt's acute renal failure necessitated CVVH. This
was used to normalize electrolytes, assist with pt's acid base
status, and remove fluid when the patient developed severe
pulmonary edema.
# Thrombocytopenia/Fingertip ischemia:
Most likely this occurred in setting of severe illness resulting
in suppression of platelet production. Other etiologies include
low grade DIC in setting of mostly normal DIC labs, sepsis, and
HIT. PF4 antibody was negative and 4T score was low, so HIT
unlikely. Coombs negative. Argatroban was initiated but then
stopped. Fingertip ischemia most likely from hypotension and
pressors.
# Leukocytosis/Low grade fever
WBC normalized, but pt did have elevated temperature which
required increased cooling. No clear localizing source. Pt
started on vancomycin and zosyn.
# Transaminitis
Unknown baseline. Elevation likely in setting of shock liver
from poor perfusion
Medications on Admission:
Xanax prn
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
cardiac arrest
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2151-4-18**]
|
[
"276.7",
"514",
"570",
"276.4",
"287.5",
"785.50",
"427.41",
"584.5",
"518.81",
"780.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.72",
"38.95",
"38.91",
"38.97",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
15511, 15520
|
11529, 15423
|
346, 412
|
15578, 15587
|
5346, 5346
|
15639, 15673
|
4749, 4778
|
15483, 15488
|
15541, 15557
|
15449, 15460
|
15611, 15616
|
4793, 5327
|
297, 308
|
440, 4516
|
5360, 11506
|
4538, 4687
|
4704, 4733
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,677
| 168,806
|
44329
|
Discharge summary
|
report
|
Admission Date: [**2111-8-24**] Discharge Date: [**2111-8-31**]
Date of Birth: [**2041-1-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Substernal chest pressure and shortness of breath
Major Surgical or Invasive Procedure:
Cardiac catheterization
Percutaneous cholecystostomy
History of Present Illness:
Mr. [**Known lastname **] is a 70 yo patient of Dr. [**Last Name (STitle) **] with CAD and h/o
anteroseptal QWMI, s/p CABG [**2097**] (left-dominant system;
LIMA-LAD, SVG-PDA, SVG-OM2. known ocluded SVG to PDA and OM2
with backfilling) with NSTEMI [**1-/2111**] treated with stents to LCX
and L-PDA, CHF with EF 35-40%, HTN, and hyperlipidemia. He had
been feeling fatigued/lethargic as per his wife but with was in
his usual state of cardiac health (able to walk [**1-27**]-mile without
chest pain or shortness of breath; no orthopnea, no PND, no
peripheral edema) until sunday evening around 3AM when he awoke
with dyspnea and substernal chest pressure that felt like an
"[**Location (un) 2452**] stuck in his chest." He thinks the pain may have
radiated to the shoulder, he did have diaphoresis (which he
attributed to symptomatic hypoglycemia), shortness of breath,
and feeling "off balance." He ignored his chest discomfort for
several hours and decided the next morning to visit his PCP who
sent him via ambulance to [**Hospital6 **] at 1:30pm.
En-route to the hospital he was given 1 spray of sL
nitroglycerine which relieved his chest pain permenantly. At
NWH his EKG revealed lateral ST depressions and his CK was
positive at 660, Trop 8.8. He was started on heparin drip; had
already taken aspirin. His initial vital signs were P 74, BP
123/60, RR 28, T 100.2 axillary, 95% on RA. CXR showed mild CHF
and later he was placed on 100%NRB for hypoxia and given 40mg IV
lasix without response. He was transferred to [**Hospital1 18**] for cardiac
catheterization.
.
Also significant to his history is an axillary temperature of
100.2 at the OSH with several days of feeling fatigued,
lethargic, with poor appetite. He denies any abdominal pain,
nausea, or vomiting. His platelets were noted to be 100 down
from a baseline of 250 and Hct of 25 down from a baseline of 30.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He does report recent T to 100.2 axillary
but denies chills or rigors. He denies exertional buttock or
calf pain. He denies abdominal pain, nausea or vomiting although
he did notice abdominal pain when his PCP pressed on his RUQ and
again when this maneuver was done here.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
Cardiac History: CABG, in [**2097**] anatomy as follows: LIMA-LAD,
SVG-PDA, SVG-OM2. known ocluded SVG to PDA and OM2.
Percutaneous coronary intervention, in [**1-/2111**] anatomy as
follows: known patent LIMA-LAD, known occluded SVG-PDA and
SVG-OM. diffuse LCX disease treated overlapping cypher stents;
BMS to PDA
Past Medical History:
-CAD [**4-/2097**]: CABG x 3 (LIMA to LAD, SVG to PDA, SVG to Cx);
Catheterization in [**2110**] revealed occluded SVGx2 and LIMA patent)
-Hypertension
-Type II Diabetes x 20 years, with peripheral neuropathy
-Chronic renal insufficiency with baseline Cr 1.1
-Anemia
-PVD
-Benign ??????lump?????? removed from right foot
-Osteoporosis
-Questionable GERD
-hypothyroidism
Social History:
Patient is married with four children. He previously worked at
Polaroid, in electronics division. Currently retired. Denies
alcohol and tobacco use. Wife [**Name (NI) 501**], can be reached at
[**Telephone/Fax (1) 95048**].
Family History:
Mother with angina in her 50??????s, died of MI at age 57.
Father had a stroke in his 50s.
Sister with CAD and DM.
Physical Exam:
VS: T 98.6, BP 107/53, HR 60, RR 24, O2 100% on 100% NRB
Gen: WDWN middle aged male in mild respiratory distress.
Oriented x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pale,
skin and oral pallor
Neck: Supple with JVP to level of earlobe.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3. Difficult to auscultate over
NRB mask
Chest: No chest wall deformities, scoliosis or kyphosis.
Crackles [**Date range (1) 14411**] up chest bilaterally, no wheezes, no ronchi.
Abd: notable for + RUQ TTP and [**Doctor Last Name **] sign. + voluntary
guarding, no rebound. + BS
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; DP/PT
dopplerable
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; DP/PT
dopplerable
Rectal: Guiac negative, no mass
Pertinent Results:
[**2111-8-24**] 10:46PM WBC-10.9 RBC-2.63* HGB-8.8* HCT-24.5* MCV-93
MCH-33.4* MCHC-35.8* RDW-14.4
[**2111-8-24**] 10:46PM NEUTS-71.0* LYMPHS-17.0* MONOS-11.4* EOS-0.7
BASOS-0.1
[**2111-8-24**] 10:46PM PLT COUNT-101*
[**2111-8-24**] 10:46PM PT-15.3* PTT-90.9* INR(PT)-1.4*
[**2111-8-24**] 10:46PM FIBRINOGE-532*
[**2111-8-24**] 10:46PM RET AUT-2.3
[**2111-8-24**] 10:25PM GLUCOSE-83 UREA N-39* CREAT-1.6* SODIUM-132*
POTASSIUM-3.1* CHLORIDE-94* TOTAL CO2-27 ANION GAP-14
[**2111-8-24**] 10:25PM ALT(SGPT)-27 AST(SGOT)-53* LD(LDH)-475*
CK(CPK)-596* ALK PHOS-68 AMYLASE-56 TOT BILI-0.8
[**2111-8-24**] 10:25PM LIPASE-17
[**2111-8-24**] 10:25PM CK-MB-10 MB INDX-1.7 cTropnT-1.58*
[**2111-8-24**] 10:25PM CALCIUM-8.8 PHOSPHATE-3.5 MAGNESIUM-1.9
IRON-13*
[**2111-8-24**] 10:25PM calTIBC-278 HAPTOGLOB-191 FERRITIN-186
TRF-214
EKG initially demonstrated NSR with normal axis, borderline
prolonged QRS at 110, decreased axial voltages, old anteroseptal
infarct. cove-shaped ST segments in III and aVF with possible
1mm STE in lead III and V1, 1mm ST depression in lead I, ST
Depression in aVL, aVF, ST depressio nand T wave inversion in
V4-V6.
.
EKG on presentation to CCU: NSR with TW flattening in all axial
leads, 1-[**Street Address(2) 1766**] depression and TWI in V4-V6.
.
CXR [**2111-8-24**]: Mild cardiomegaly with increased moderate
congestive heart
failure and increased left lower lobe atelectasis. Superimposed
infection in left lower lobe cannot be excluded.
.
RUQ US [**2111-8-24**]: mild GB wall edema, with mild GB wall edema of
3mm, GB distension w/o stones or sludge. concern for acute
acalculous cholcystitis.
.
ECHO
The left atrium is moderately dilated. There is mild symmetric
left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is
moderately depressed (LVEF= 30 %) with global hypokinesis and
regional akinesis of the inferior and infero-lateral walls.
Right ventricular chamber size is normal. There is moderate
global right ventricular free wall hypokinesis. The aortic root
is mildly dilated at the sinus level. 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. Moderate to severe (3+) mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
Compared to the prior study (images reviewed) dated [**2111-1-27**],
the overall LVEF has decreased and the severity of mitral
regurgitation has increased.
.
CATH
COMMENTS: Successful PTCA of the LCx/OM and left PDA
vessels. Final
angiography revealed 0% residual stenosis, no angiographically
apparent
dissection and timi 3 flow (see ptca comments).
Summary: Successful PTCA of the LCX/OM/Left PDA.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
.
Brief Hospital Course:
70 yo M with severe CAD s/p CABG in [**2097**] and stents to LCX and
L-PDA in [**1-/2111**], presenting with NSTEMI s/p balloon angioplasty
of LCX for in stent stenosis. Also with RUQ pain and distended
gall bladder on U/S consistent with acalculous cholecystitis s/p
percutaneous cholecystostomy tube placement.
.
#NSTEMI
Patient presented w/ ekg changes concerning for laternal
infarct, CK peak of 614, Troponins-T peak 2.09, in setting of
severe CAD history. Cardiac cath revealed in-stent stenosis of
LCX treated with balloon angioplasty. No new stents were placed
given fever, RUQ pain and concern for sepsis. Transfused 3
units PRBC for low HCT, with stable HCT since. Chest pain
resolved s/p angioplasty. ASA, plavix, lisinopril, atorvastatin
were provided. Metoprolol 50 mg [**Hospital1 **] was added and lisinopril
was titrated to 30 mg daily. Patient will likely need follow up
for repeat angiography / stenting given inability to place
coronary stents during catherization on this admission.
.
#Systolic Dsyfunction
Post cath echo w/ 30% (c/w 35-40% in [**1-/2111**]) also with 3+MR.
Initially was hypoxemic and hypervolemic, however resolved this
CHF exacerbation, which was likey precipitated by ischaemia, w/
lasix and afterload reduction w/ hydralazine and isosorbide
dinitrate. Afterload reduction was converted to metoprolol 50
[**Hospital1 **], lisinopril 20 daily. Lasix was continued at 20mg PO daily
for home dose. Patient was also discharged with home physical
therapy.
.
# Abdominal pain
Initial RUQ pain and dilated gallbladder on ultrasound were
consistent with acute acalculous cholecystitis; given pt was
poor operative candidate [**Hospital1 **] recommended IR guided
percutaneous cholecystostomy tube placement. Initial wbc,
fever, and abdominal pain resolved w/ perc chole tube and Zosyn
x 7 days. The perc. chole tube is scheduled to be followed by
Dr. [**Last Name (STitle) 6633**] in general surgery and will probably be removed
approximately 6 wks from discharge. Visiting nursing assistance
was scheduled post discharge.
.
# Hypoxia
During initial 2 days of hospitalization patient was hypoxic and
requiring oxygenation with 50% face mask. He was at first
though to have CHF and a superimposed LLL pneumonia. After
diuresis, ambulation, and repositioning, patient was weaned from
O2. Patient has no known history of lung disease, however exam
was positive for wheezing which responded to albuterol and
atrovent nebulization. Pulmonary was not consulted during the
admission; he was scheduled for outpatient pulmonary follow up
following discharge.
.
# Diabetes
Patient's DM is complicated by nephropathy and neuropathy. He
had been prescribed 70/30 sliding scale [**Hospital1 **] at home. [**Last Name (un) **] was
consulted for tighter DM management while inpatient and
recommended 17 units of lantus QHS w/ humalog sliding scale.
Patient will follow w/ [**Last Name (un) **] following discharge.
.
# Anemia/thrombocytopenia
Unclear etiology. Has been anemic for "year" with unclear
etiology. No evidence of HIT as platelets were low prior to
starting heparin. For anemia, iron was found to be low at 13,
and iron supplementation was initiated. Smear showed 1+
schistocytes. On ddx for thrombocytopenia was drug adverse
effect of plavix. Patient did not experience bleeding episides
during hospitalization. Given concern for possible
myelophthistic process, patient has been scheduled for
outpatient heme-onc appointment.
.
# Renal
Baseline creatinine 1.1, with peak of 1.9 during admission
likely [**2-27**] poor cardiac output. Creatinine trended down toward
baseline upon discharge. Lisinopril was initially held but
restarted and increased to 30 mg daily.
.
Patient defervesced on [**8-27**] and remained hemodynamically stable
during admission. Patient was started on the following
medications: ferrous sulfate / iron supplementation, metoprolol
50 mg [**Hospital1 **], insulin lantus 17 units qhs and sliding scale
humalog. Lisinopril was increased to 30 mg daily. Home Toprol
XL, nifedical, and diovan, and aldactone were discontinued.
Follow up appointments were made with pulmonary, his PCP,
[**Name10 (NameIs) 2086**], [**Name11 (NameIs) 478**], [**Name12 (NameIs) **], and [**Last Name (un) **].
Medications on Admission:
1. Aspirin 325 mg po daily
2. Diovan-hct 160-12.5mg po daily
3. Lipitor 80mg po daily
4. Lisinopril 20mg po daily
5. Nifedical XL 60mg po once daily
6. Plavix 75mg po daily
7. Synthroid 50mcg po daily
8. Toprol XL 200mg daily
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).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily): Do not take at the same time as your thyroid
medicine because it can decrease the absorption of the thyroid
hormone.
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Prilosec Oral
8. Lantus 100 unit/mL Solution Sig: Seventeen (17) units
Subcutaneous at bedtime.
Disp:*qs qs* Refills:*2*
9. Humalog 100 unit/mL Solution Sig: as directed per sliding
scale units Subcutaneous four times a day: see sliding scale.
Disp:*qs qs* Refills:*2*
10. Lisinopril 20 mg Tablet Sig: 1.5 Tablets PO once a day.
Disp:*45 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Non-ST segment elevation myocardial infarction
Acalculous Cholecystitis
Congestive Heart Failure
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital because you had a heart
attack. In addition, you also went into heart failure causing
fluid to accumulate in your lungs making it hard for you to
breathe. You had a cardiac catheterization and balloon
angioplasty to open up the stent in your artery which was
blocked. In addition, you had enlargement of the gallbladder,
called acalculous cholecystitis, which was causing your belly
pain. A tube was inserted into your gallbladder to drain the
bile fluid and relieve the pressure. You were given an
antibiotic for 7 days to treat this. You will need to follow-up
with surgery in [**5-1**] weeks at which time the drain may be pulled.
Please take all medications as directed. Several changes were
made to your medications. We stopped the following medications:
Diovan-HCTZ, nifedical, toprol xl and aldactone. We changed
your insulin from 70/30 to lantus 17 units which you should take
at bedtime. We increased your lisinopril from 20 mg daily to 30
mg daily. We added metoprolol 50 mg twice daily.
Please follow-up with all outpatient appointments.
Please call your doctor or return to the ED if you experience
chest pain, dizziness, shortness of breath, abdominal pain or
any other concerning symptoms.
In addition, please weigh yourself each morning. If you notice a
3 pound weight gain for two consecutive days, please call your
cardiologist and increase your lasix dose from 20 to 40 mg
daily.
Followup Instructions:
Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6633**] (general surgeon) on [**9-23**] at 1:30 pm. Her office is located on [**Location (un) 470**] of [**Last Name (NamePattern1) 12939**] in [**Location (un) 86**]. Call her office at ([**Telephone/Fax (1) 6347**] if
you need to reschedule this appointment. She will assess the
cholecystostomy tube at that time.
You should follow-up with your cardiologist, Dr. [**Last Name (STitle) **]. His
office number is [**Telephone/Fax (1) 5003**]. You have an appointment with Dr.
[**Last Name (STitle) **] on [**10-1**] at 4:20.
You should follow up with your primary care doctor, Dr. [**Last Name (STitle) 3845**]
on [**9-8**] at 2:15 pm. You should have repeat thyroid
function tests in approximately one month.
Please follow-up with hematology-oncology to follow-up on low
blood count and low platelets. The number for the office is
[**Telephone/Fax (1) 39833**]. We tried to make you an appointment, but the
office would prefer to call you with a date and time. If you do
not hear from them within a week, please call the above number.
Please follow-up in the pulmonary clinic. We made an appointment
for you on Monday [**9-21**] at 2 pm with Drs. [**Last Name (STitle) 2168**] and
[**Name5 (PTitle) **]. The office is located on the [**Location (un) 436**] of the [**Hospital Ward Name 23**]
Building at [**Hospital1 18**]. The phone number is [**Telephone/Fax (1) 612**] if you need
to reschedule this appointment.
Please follow-up at the [**Hospital **] Clinic with Dr. [**First Name (STitle) **]. You have
an appointment on Monday [**9-7**] at 2 pm. Please ask your
PCP for [**Name Initial (PRE) **] referral before going to the appointment or a $200
dollar deposit will be requested at the time of the visit.
|
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icd9cm
|
[
[
[]
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[
"00.42",
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icd9pcs
|
[
[
[]
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13638, 13696
|
8061, 12337
|
365, 419
|
13837, 13844
|
5077, 7976
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7993, 8038
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3733, 3961
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,195
| 173,632
|
13736
|
Discharge summary
|
report
|
Admission Date: [**2102-3-29**] Discharge Date: [**2102-4-21**]
Date of Birth: [**2079-10-7**] Sex: M
Service: Trauma Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 22-year-old
male who was repairing his truck (lying underneath the
truck), when the truck fell on him crushing his chest. The
patient was awake initially and was able to use his cell
phone while underneath the truck, and the paramedics arrived.
Upon arrival, he was extricated from underneath the truck;
and while in transport, he had an episode of desaturation
with a decrease in blood pressure, for which he was
intubated.
He arrived at the Emergency Department intubated and sedated.
His initial examination revealed bilateral pneumothoraces for
which bilateral chest tubes were placed. His secondary
survey revealed mild abdominal tenderness, but no other gross
abnormalities. The patient had been alert and oriented times
three upon arrival by the paramedics, but this quickly
deteriorated along the ambulance route.
PAST MEDICAL HISTORY: Gastroesophageal reflux disease.
PAST SURGICAL HISTORY: None.
MEDICATIONS ON ADMISSION: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: A truck driver from [**State 4260**].
PHYSICAL EXAMINATION ON PRESENTATION: Initial physical
examination with a blood pressure of 104/71, heart rate
of 125, respirations intubated at 24, oxygen saturation of
96%. Sedated an intubated. Pupils were equal, round, and
reactive to light. Mucous membranes were moist.
Endotracheal tube in place and G-tube in place. Mild facial
edema. Neck revealed cervical collar in place, mild crepitus
over the right neck. Chest revealed bilateral chest tubes in
place, decreased aeration bilaterally with coarse breath
sounds. Cardiovascular was tachycardic, a regular rhythm.
First heart sound and second heart sound were normal. No
murmurs. Abdomen was soft, nontender, and nondistended. No
bowel sounds. Pelvis was stable. Extremities revealed right
upper extremity abrasions, 2+ pulses distally in the
bilateral upper and lower extremities. Capillary refill of
less than two seconds. No edema. No gross deformities.
Back revealed no stepoff. Rectal examination was
heme-negative. No gross blood. Rectal tone was intact.
EMERGENCY DEPARTMENT COURSE: The patient quickly had two
chest tubes placed along with a right femoral trauma line.
The patient was apparently neurologically intact at the scene
and had no focal neurologic deficits. The patient was moving
both of his legs and arms. Therefore, a head injury or
spinal cord injury was felt unlikely. The patient's
condition stabilized after intravenous fluids, and he was
felt stable for a CAT scan.
RADIOLOGY/IMAGING: A CAT scan of his head revealed mild
effacement of the gyri consistent with mild edema.
A CAT scan of his chest with intravenous contrast showed no
injury to the great vessels. There was bilateral
pneumothoraces, right greater than left. There were
bilateral severe pulmonary contusions and bilateral
pneumatoceles. There was no evidence of pericardial fluid or
cardiac damage. There was right rib fractures posteriorly.
A CT scan of the abdomen revealed a small 3-cm X 2-cm
posterior liver laceration with no free fluid in the abdomen.
This laceration was self-contained. There was no apparent
injury to the spleen, kidneys, or bladder.
A CT of the pelvis revealed a nondisplaced femoral fracture.
CAT scan also revealed a right clavicle fracture.
HOSPITAL COURSE: The patient was transferred to the
Surgical Intensive Care Unit for further management.
The patient was admitted to the Surgical Intensive Care Unit
for close monitoring. His respiratory status was difficult
initially upon his arrival due to his bilateral severe
pulmonary contusions. He was placed on assist-control
ventilation; however, his oxygen saturations and PAO2 were
inadequate, and he was switched to pressure-control
ventilation as he progressed to an acute respiratory distress
syndrome picture. This slightly improved his oxygenation,
and his PO2 increased to approximately 70s to 80s.
He was sedated with Ativan and morphine and paralyzed during
this process. He was placed on Kefzol and Protonix
prophylaxis and received frequency nebulizer treatments. He
was transfused with fresh frozen plasma to correct a mild
coagulopathy and was transfused with 2 units of packed red
blood cells for a slight hematocrit drop to 27 initially with
an adequate response to a hematocrit of 36 afterwards.
The patient had a Swan-Ganz catheter placed to monitor
hemodynamic status, and he had a high central venous
pressures and pulmonary arterial pressures; indicating that
the patient was not hypovolemic. Therefore, fluids were
minimized to minimize excess of fluids in his lungs.
The patient had an echocardiogram to evaluate for evidence of
blunt myocardial injury, gross wall motion abnormalities, or
valvular defects. The echocardiogram showed normal overall
wall motion and ejection fraction, and no pericardial
effusion.
The patient's pulmonary status was such that he was requiring
increasing levels of positive end-expiratory pressure and
100% FIO2 to maintain adequate oxygenation while his PCO2
were rising as well; and this was felt to be secondary to a
very severe air dehiscent pulmonary contusions. He was
briefly placed on high-frequency oscillatory ventilation with
significant improvement in his oxygenation and ventilation,
allowing a decrease in his FIO2. The patient was able to
return to pressure-control ventilation soon thereafter and
began a slow wean from the ventilator.
Plain films of the patient's bilateral upper extremities
revealed no fractures, and a repeat chest x-ray showed no
change in his prior x-rays of bilateral long whiteout, but no
gross pneumothorax with chest tube in good position.
Throughout this time the patient began spiking temperatures,
and cultures were drawn peripherally and from urine and
sputum as well as bronchoscopy. The sputum cultures began
growing out hemophilus influenza for which the patient was
started on levofloxacin with slight defervescence of his
fever. The patient also began to experience decreasing
platelets at this time. He was switched from subcutaneous
heparin to Hirudin for possible heparin-induced
thrombocytopenia, and heparin-induced thrombocytopenia
antibodies were sent.
The patient began a slow pulmonary ventilator wean; at this
point down from his initial high FIO2 and positive
end-expiratory pressures. He was continued on sedation and
paralysis with Ativan, morphine, and cisatracurium.
He began having tube feeds through a Dobbhoff feeding tube
and was continued on gastrointestinal prophylaxis with
Protonix, nebulizers, and Venodyne boots.
While having high PCO2 of approximately 76, there was
concern for elevated intracranial pressure, and Neurosurgery
was consulted. They placed a intracranial pressure monitor.
This initially showed an intracranial pressure of 27. Once
his PCO2 came down to the low 50s, the intracranial pressure
dropped to a normal level of 12, and the intracranial
pressure monitor was discontinued. The cerebral perfusion
pressure throughout was maintained greater than 60.
The patient revealed intermittent boluses of albumin for an
elevated heart rate and decreased urine output despite high
right-sided filling pressures with good response. The
patient also had a thoracic, lumbar, and cervical spinal
x-rays which revealed no fractures.
By hospital day seven, the patient began to stabilize and his
intracranial pressure monitor had been discontinued and
high-frequency oscillatory ventilation had been discontinued.
He was responding to antibiotic treatment for the hemophilus
influenza in his sputum. He began to receive Lasix diuresis
for his overall body fluid overload.
The patient's sedation was continued, but his paralysis was
discontinued. At this time, the patient began having a
sputum that grew gram-positive cocci which was eventually
identified as methicillin-susceptible Staphylococcus aureus,
for which he was started on oxacillin in addition to the
levofloxacin that he was on for his hemophilus influenza.
After this, the patient continued to spike low-grade fevers
but was thought to be adequately covered for antibiotics, as
no other culture data grew out any additional organisms.
The patient's respiratory status continued to slowly improve,
and his ventilatory support was weaned down to assist-control
with decreasing positive end-expiratory pressures and
decreasing FIO2.
There was an initial discussion of need for tracheostomy and
percutaneous endoscopic gastrostomy tube placement, but as
the patient continued to be improving, it was felt that he
would hopefully improve rapidly enough once he was past his
pulmonary contusions and that he would not need this and
would be able to be extubated and return to oral feeds
quickly.
By hospital day 10, the patient was significantly improved
and was placed on pressure-support ventilation which he
tolerated well initially. He did require high pressure
support initially, but was quickly weaned over the next two
to three days and was finally extubated on hospital day 20.
He initially required increased supplemental oxygen to
maintain adequate oxygenation, but this was quickly weaned
down. His sedation was also fully weaned off and was
eventually discontinued.
The patient remained stable on mild supplemental oxygenation
and was initially transferred to the floor on hospital
day 21. His diet was quickly advanced, and Physical Therapy
evaluated the patient and worked with him to increase his
ambulation and strength.
The patient began to be fully ambulatory with a completely
regular diet and was doing extremely well. His mental status
was somewhat impulsive at times while he was suffering the
residual effects of the long-term Ativan and morphine drips
that he had been on; however, this quickly resolved over the
two days while he was on the floor, and he was nearly at his
baseline mental status with his parents happy with his
behavior.
The patient was evaluated by Physical Therapy who felt that
he was doing so well that he did not need inpatient
rehabilitation and just minimal outpatient rehabilitation for
strengthening and gait training.
The patient was to be discharged to the care of his parents
to take him back to [**State 4260**] where he will follow up with his
primary care physician who will coordinate a pulmonary
physician to follow the patient's pulmonary status. His room
air saturation was 96% to 97%, and his respirations were
unlabored at 18 to 20. He was able to ambulate throughout
the hospital with no respiratory distress.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: To home with parents.
MEDICATIONS ON DISCHARGE:
1. Protonix 40 mg p.o. q.d.
2. Colace 100 mg p.o. b.i.d.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Last Name (NamePattern1) 32895**]
MEDQUIST36
D: [**2102-4-20**] 17:37
T: [**2102-4-20**] 19:53
JOB#: [**Job Number 41348**]
|
[
"860.4",
"E918",
"864.05",
"861.21",
"482.2",
"482.41",
"518.82",
"861.22",
"821.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"33.22",
"96.72",
"34.04",
"33.23",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
10839, 11176
|
1133, 1178
|
3506, 10722
|
1099, 1106
|
10737, 10813
|
172, 1017
|
1040, 1074
|
1195, 3487
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,625
| 174,427
|
12780
|
Discharge summary
|
report
|
Admission Date: [**2119-1-16**] Discharge Date: [**2119-1-20**]
Date of Birth: [**2051-9-2**] Sex: M
Service: MEDICINE
Allergies:
Zestril / Lopid / Shellfish / Radioactive Diagnostics, General
Classif
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Substernal chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 20858**] is a 67 yo male with CAD s/p CABG, multiple stents
and PCIs, HTN who presented to [**Hospital6 33**] with SSCP
radiating to both arms during the Superbowl. He was sitting and
watching TV when he developed sharp [**9-22**] SSCP in a bandlike
distribution that spanned both the right and left sides of his
chest. He had similar symptoms 2 weeks ago and was transferred
from [**Hospital1 34**] to [**Hospital1 18**] for cath, but that was not performed for
unclear reasons. His pain initially was non radiating, but then
progressed to involve both his arms. He notes being nauseous and
sweaty and vomited in the [**Hospital1 18**] ED. He notes that he has had
this similar pain for many years and is similar to episodes in
the past when he has had MIs; he reports that this episode may
have been more severe. At home, he took 3 SL NTGs without relief
and called EMS. The EMTs provided additional nitroglycerin with
minimal relief. At [**Hospital1 34**], he was given nitroglycerin, heparin and
plavix loaded and transferred to [**Hospital1 18**]. Apparently, his pain was
relieved only with dilaudid.
.
On admission to [**Hospital1 18**], he was continued on nitro gtt and heparin
gtt, and was chest pain free. He was 99% on a NRB on admission
to the [**Hospital1 18**] ED. He was given 40mg IV lasix x 1 for potential
pulmonary edema.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, or rigors, but
did admit to chills yesterday. He denied heartburn (initially
also took maalox without relief).
.
He also noted SOB that was not changed from his baseline SOB. He
notes that he is SOB with minimal exertion - his ADLs cause him
to be SOB. He can still climb a flight of stairs, but becomes
SOB with this. 1 month ago, he was able to walk [**12-16**] mile per
day, but is no longer able to do so. His LE swelling is
unchanged, and 2 pillow orthopnea is baseline for him. He denied
medication noncompliance or dietary indiscretion. Denied
palpitations.
Past Medical History:
Hypertension
Hyperlipidemia
COPD
.
CAD, s/p CABG X4, MI X2, PCI's above. [**2106-3-13**] with a LIMA to
the LAD, SVG to the D2, OM1, OM2 and RCA
[**12/2104**] IMI
[**2105**]: MI
[**2107**] MI
.
Diabetes.
OSA - on CPAP but does not know home settings
[**2115-4-22**]: ? Seizure per patient's wife. She reports coming home
and finding her husband on the floor awake but incoherent, dried
blood on his body. Neuro workup was negative. No further events
since that time.
.
CABG, in [**2105**]: LIMA to the LAD, SVG to the D2, OM1, OM2 and RCA.
See cath report for recent anatomy.
Social History:
Cigarette smoking, 4 packs a day since age 9, quit 12 years ago.
Family History:
Mother died in her 60's from an MI. One cousin died at age 48
from an MI.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T:98.4 , BP: 150/83 , HR: 81 , RR:20 , O2 98 % on 6L NC
Gen: Pleasant NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP up to ear.
CV: + S1, + S2. RRR No M/R/G
Chest: No crackles. No wheezing. Good air movement through all
lung fields.
Abd: Soft, obese. NTND.
Ext: No c/c. 2+ edema in pretibial regions.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses: 2+ DP and PT pulses
Pertinent Results:
ADMISSION LABS:
[**2119-1-16**] 12:25AM BLOOD WBC-15.3* RBC-4.13* Hgb-11.3*# Hct-34.7*
MCV-84 MCH-27.4 MCHC-32.6 RDW-15.9* Plt Ct-315
[**2119-1-16**] 12:25AM BLOOD Neuts-84.5* Lymphs-10.4* Monos-3.2
Eos-1.5 Baso-0.3
[**2119-1-16**] 12:25AM BLOOD Plt Ct-315
[**2119-1-16**] 12:10PM BLOOD PT-13.6* PTT-34.5 INR(PT)-1.2*
[**2119-1-16**] 12:25AM BLOOD Glucose-378* UreaN-19 Creat-0.9 Na-142
K-4.6 Cl-103 HCO3-27 AnGap-17
[**2119-1-16**] 12:25AM BLOOD ALT-20 AST-34 LD(LDH)-174 CK(CPK)-220*
AlkPhos-119* TotBili-0.4
[**2119-1-16**] 05:21PM BLOOD Calcium-9.4 Phos-4.2 Mg-2.0
[**2119-1-16**] 12:25AM BLOOD Albumin-4.2
[**2119-1-17**] 05:22AM BLOOD calTIBC-497* VitB12-137* Folate-12.6
Ferritn-92 TRF-382*
[**2119-1-17**] 05:22AM BLOOD %HbA1c-8.7*
[**2119-1-17**] 05:22AM BLOOD Triglyc-216* HDL-41 CHOL/HD-2.4
LDLcalc-15 LDLmeas-<50
CARDIAC ENZYMES:
[**2119-1-16**] 12:25AM BLOOD CK-MB-15* MB Indx-6.8* proBNP-568*
[**2119-1-16**] 12:25AM BLOOD cTropnT-0.10*
[**2119-1-16**] 12:10PM BLOOD CK-MB-18* MB Indx-6.6 cTropnT-0.70*
[**2119-1-17**] 05:22AM BLOOD CK-MB-6 cTropnT-0.33*
EKG's demonstrated:
(1) At [**Hospital6 33**]: sinus tach @ 100 with TWI in I,
aVL, V6 (all old).
(2) At [**Hospital1 18**]: EKG showed NSR @ 87 with STD in I, aVL and V6 with
1mm STD in V3-V6.
[**2119-1-16**] TTE:
The left atrium is dilated. There is mild regional left
ventricular systolic dysfunction with [**Month/Day/Year 39407**] of the basal
to mid inferior and inferolateral segments. [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve is not well 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. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion. IMPRESSION: Mild regional left ventricular systolic
dysfunction. Moderate to severe mitral regurgitation. Reduced
ejection fraction - intrinsic LV function is likely more
depressed given the severity of regurgitation.
Brief Hospital Course:
Mr. [**Known lastname 20858**] was admitted with chest pain and found to have an
NSTEMI. He has known CAD with graft disease, but had
post-radiation skin changes from prior interventions and,
therefore, was not a candiate for invasive intervention this
hospitalization. He was placed on heparin for 48 hours after
admission as well as a nitroglycerin drip for relief of the
chest pain. Echocardiogram showed a decreased ejection fraction
(40-50%) with 3+ MR [**First Name (Titles) **] [**Last Name (Titles) 39407**] of basal and inferolateral
segments. He was continued on plavix, aspirin, lipitor (dose
increased from 40 mg to 80 mg), ramipril (dose changed from 5 mg
TID to 20 mg QD), metoprolol (dose increased from 50 mg [**Hospital1 **] to
100 mg TID), amlodipine and imdur (once the NG was
discontinued). He was also started on HCTZ. Of note, he had a
transient leukocytosis on admission, thought to be a stress
response to the MI and not infectious in nature; it resolved by
the time of discharge.
His hospital course was complicated by shortness of breath on
exertion and relative hypoxia with ambulatory sats 88-89% on
room air even after aggressive diuresis with IV Lasix. His
oxygen saturation inproved with 2 L NC supplementation, and he
was discharged with home oxygen. He was sent home on lasix 40
mg QD to maintain an even fluid balance. He was also sent home
with pulmonary follow-up for care of his COPD (he is not
currently on any medicines for his lung disease and has not had
PFT's).
Medications on Admission:
Lantus 85 units pm + SSI
ramipril 5mg tid
Plavix 75 mg qd.
Imdur 120 mg am
Norvasc 10 mg am.
Tricor 145 mg am.
Lopressor 50 mg [**Hospital1 **].
Ecotrin 325 mg daily.
Zantac 150 mg am.
Lipitor 40 mg pm.
Discharge Medications:
1. Home Oxygen
Home oxygen @ 2LPM continuous via nasal cannula conserving
device for portability.
2. Insulin
Take Lantus (also called Glarine) 85U every evening. Also take
humalog insulin according to sliding scale.
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
Disp:*180 Tablet(s)* Refills:*2*
9. Metformin 850 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed): Take one pill every 5
minutes as needed for chest pain. Seek medical attention if you
require 3 pills or more.
Disp:*20 Tablet, Sublingual(s)* Refills:*2*
11. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
13. Ramipril 10 mg Capsule Sig: Two (2) Capsule PO once a day.
Disp:*60 Capsule(s)* Refills:*2*
14. Imdur 120 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*
15. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
16. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
every eight (8) hours.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Non-ST Elevation Mycardial Infarction
Discharge Condition:
Stable-- no chest pain or shortness of breath at rest.
Patient's oxygen saturations in the mid-90's on room air at
rest; decreases as low as 88 - 89% on room air with ambulation.
Discharge Instructions:
You were admitted with chest pain and found to have a heart
attack.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if your weight increases
more than 3 lbs.
Adhere to 2 gm sodium diet (low salt)
Fluid Restriction: 1.5L
Increase your home ramipril from 5mg three times daily to 20mg
once daily. Increase your home metoprolol (also called
lopressor) from 50mg twice daily to 100mg three times daily.
Increase your home lipitor (also called atorvastatin) from 40mg
daily to 80mg daily. New medications started during this
hospitalization and should be continued at home are hydralazine
20mg every 8 hours, hydrochlorothiazide 25mg daily and lasix 40
mg daily. You also may take nitroglycerin dissolving tablets as
needed for chest pain. If you require more than 3 pills for
chest pain you must call an ambulance or come to the hospital.
Followup Instructions:
(1) Cardiology appointment with Dr. [**Last Name (STitle) 39408**] ([**Telephone/Fax (1) **])
[**2119-1-24**] 3:15PM-- please have your blood drawn to check
salt levels and blood cell count at this appointment.
(2) Appointment with Lung Doctor
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2119-1-23**] 4:10
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 1112**]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2119-1-23**] 4:30
|
[
"272.4",
"424.0",
"428.0",
"428.33",
"401.9",
"780.57",
"414.01",
"496",
"250.00",
"410.71",
"V45.82",
"V17.3",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9882, 9933
|
6174, 7689
|
351, 358
|
10015, 10196
|
3879, 3879
|
11087, 11619
|
3257, 3333
|
7942, 9859
|
9954, 9994
|
7715, 7919
|
10220, 11064
|
3348, 3358
|
3380, 3860
|
4722, 6151
|
290, 313
|
386, 2558
|
3895, 4705
|
2580, 3158
|
3174, 3241
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
822
| 191,344
|
48292
|
Discharge summary
|
report
|
Admission Date: [**2176-9-28**] Discharge Date: [**2176-10-8**]
Date of Birth: [**2145-10-30**] Sex: M
Service: MEDICINE
Allergies:
Bactrim Ds / Levaquin / Vancomycin Hcl / Dilantin
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
lethargy, nonproductive cough, subjective fevers
Major Surgical or Invasive Procedure:
IR guided hip aspiration
History of Present Illness:
30y/o M with h/o T12 paraplegia [**2-28**] MVA, h/o MRSA decubitus
ulcers, osteomyelitis, PsA urosepsis, C diff colitis, and
chronic kidney dz presents with nonproductive cough,
constipation, and MS changes x1 day. + LLQ pain, +SOB, dark
urine. On Monday, wound looked purulent; cultures were obtained
but cannot be found. On [**Name (NI) 5929**], mother noticed nonproductive
cough with louder respirations. Had MS changes x2 days - more
somnolent, less attentive, not eating well. Baseline MS per
mom: "argumentative and stubborn." Also had L sided abdominal
pain, no changes in BM. Takes suppositories qod. +
bowel/bladder incontinence, has been on Foley for about 1 year.
No fevers, chills, or night sweats at home. No chest pain,
shortness of breath.
In [**10-29**], had debridement of infected ischial/greater trochanter
decubitus wound. Is followed closely by [**Hospital1 **] Wound Care.
In [**Name (NI) **], pt's VS were Tm 100.2, BP 114/68 (107/54), HR 94 (max
120), 97% RA. WBC 37.7 with 11 bands. Rec'd linezolid 600mg IV
x1, Zosyn 3.375g IV x1, tylenol 1 gram.
Past Medical History:
paraplegia secondary to MVA
chronic kidney disease - baseline Cr [**2-29**]
MRSA decubitus ulcers
Pseudomonal UTI
h/o seizure disorder
Clostridium difficile colitis
osteomyelitis in the right hip
Social History:
Lives with his mother, who is his primary caretaker. [**Name (NI) **] RNs
come visit 2x/week, and brother also helps. No tobacco. Has
h/o EtOH, none in last 4-5 years. No IVDU.
Family History:
diabetes mellitus - maternal great aunt
colon cancer - maternal uncle
hypertension
no heart disease
Physical Exam:
VS: 97.1 123/54 103 20 100% RA
Gen: Pt sleepy, unwilling to answer questions, NAD
HEENT: PERRL, EOMI, dried blood around mouth
Neck: no JVD, no LAD, supple, no stiffness
CV: RRR, nl S1/S2, no murmurs
Pulm: CTAB, no wheezes or crackles
Abd: soft, NT/ND, +BS, no masses
Ext: flexion contractures in feet; somewhat cool to touch,
though + palpable pulses; no edema
Neuro: sleepy, answers some questions; follows commands, grip
strength intact bilaterally; no movement in lower extremities
Skin: sacral ulcers - 5 in number, no surrounding erythema;
gauze protruding from one ulcer, which is deeply punched out
Pertinent Results:
Admission labs:
CBC: WBC-37.7*# RBC-4.46*# HGB-12.0*# HCT-40.3# MCV-90 MCH-27.0
MCHC-29.8* RDW-16.0*
diff: NEUTS-78* BANDS-11* LYMPHS-5* MONOS-6 EOS-0 BASOS-0
ATYPS-0 METAS-0 MYELOS-0
PLT SMR-VERY HIGH PLT COUNT-639*#
electrolytes:
GLUCOSE-115* UREA N-49* CREAT-3.3* SODIUM-138 POTASSIUM-4.2
CHLORIDE-104 TOTAL CO2-7* ANION GAP-31*
ALBUMIN-3.2* CALCIUM-9.1 PHOSPHATE-2.5*# MAGNESIUM-2.2
LFTs:
ALT(SGPT)-8 AST(SGOT)-14 ALK PHOS-148* AMYLASE-56 TOT BILI-0.2
LIPASE-23
LACTATE-2.0
UA:
COLOR-Straw APPEAR-Cloudy SP [**Last Name (un) 155**]-1.015
BLOOD-LGE NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-15
BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD
RBC-[**7-5**]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-0 GRANULAR-[**3-30**]*
ABG: 7.17/20/110
coags: PT-25.0* PTT-86.2* INR(PT)-4.1
head CT: no mass or intracranial hemorrhage
CXR: tip of R IJ in SVC, no PTX, lung fields clear
LS spine: no new areas of osteomyelitis
Brief Hospital Course:
1. Altered mental status: The patient was admitted to the MICU
with AMS and elevated WBC count likely related to UTI and
bacteremia. His multiple decubitus ulcers were also a potential
source, but his blood grew E coli and Plastics felt the wounds
were clean. The patient improved on Zosyn and linezolid while
in the MICU. Other possible etiologies of the patient's AMS
include overdose and neurologic etiology. Head CT was negative
on admission and tox screen was positive only for
benzodiazepines, which he is taking as an outpatient. The
patient's mental status improved dramatically with treatment for
his infection and remained at baseline.
2. UTI: The patient had an elevated WBC count and had a urine
sample which grew pan-sensitive E coli. His blood cultures were
also positive for E coli. Given a concern for infected
decubitus ulcers as well, he was treated with both Zosyn and
linezolid in the MICU with improvement in his clinical status.
Platics did not feel that his ulcers were infected. On transfer
to the floor, the patient's linezolid was discontinued and his
Zosyn was continued. Follow-up cultures were negative.
3. Recurrent fevers: pt began spiking temps up to 103 even
though UTI has resolved. CT pelvis was performed and showed
osteo, specifically increased osteo (comp to [**2174**]) in much of
pelvis (ischial tuberocity; inf pubic rami); also new soft
tissue ulcers and L hip effusion in close proximity w/ sq
infection. consulted ortho for washout and L hip tap. consulted
ID. no involvement of spine on the scan. daily survailence cxs
showed no growth. s/p IR guided tap of L hip : cxs negative, so
no urgency for immediate washout.
Came up with the following plan: d/c pt on abxs (flagyl and
cefpodoxime). Plan splastics surgery on [**10-28**] by Dr. [**First Name (STitle) **]. Pt
will also be seen in [**Hospital **] clinic.
4. Decubitus ulcers: The patient has a long history of MRSA
infection of his decubitous wound. Plastics saw him in the ED
and felt that his wound was not actively infected and
recommended a CT pelvis when pt more stable. The patient had a
Kinair bed for decreased sacral pressure and wound dressing
changes with iodoform gauze per Plastics. He is scheduled for a
flap procedure by Dr. [**First Name (STitle) **] on [**10-28**]. Dressing changes to be
continued as outpt.
.
4. ARF: The patient was admitted with a creatinine of 3.3, over
his baseline around [**2-29**], suggesting acute on chronic kidney
disease. Likely due to prerenal azotemia in the setting of
infection as patient appeared dry and his creatinine improved to
his baseline with IVF resuscitation. His sevelamer was
continued.
.
5. Elevated INR: The patient was admitted with INR of 4,
significantly higher than baseline. Repeat measurements were
around 1.3. Not DIC as other coags and fibrinogen are normal.
.
6. Dysphagia: Mother has reported problems with swallowing over
the last several days. MICU RN reports pt aspirating water. All
resolved by time of d/c. able to tolerate regular diet.
.
7. Anion gap metabolic acidosis: due to infection. resolved.
.
8. H/o seizure disorder: Continue keppra per outpt regimen
.
9. Pain: The patient has chronic pain due to osteomyelitis and
sacral decubitus ulcers. His pain medications were held given
his mental status but were restarted when his mental status
improved.
Medications on Admission:
Oxycodone-Acetaminophen [**1-28**] TAB PO Q4-6H:PRN
Beclomethasone Dipro. AQ (Nasal) 2 SPRY NU DAILY
Aspirin EC 325 mg PO DAILY
Sevelamer 800 mg PO TID
Pantoprazole 40 mg PO Q24H
Multivitamins 1 CAP PO DAILY
Zinc Sulfate 220 mg PO DAILY
Oxycodone (Sustained Release) 50 mg PO QPM
Oxycodone (Sustained Release) 20 mg PO Q NOON
Oxycodone (Sustained Release) 50 mg PO QAM
Alprazolam 1 mg PO TID
Levetiracetam 500 mg PO TID
Discharge Medications:
In-hospital medications:
Oxycodone-Acetaminophen [**1-28**] TAB PO Q4-6H:PRN
Beclomethasone Dipro. AQ (Nasal) 2 SPRY NU DAILY
Aspirin EC 325 mg PO DAILY
Sevelamer 800 mg PO TID
Pantoprazole 40 mg PO Q24H
Multivitamins 1 CAP PO DAILY
Zinc Sulfate 220 mg PO DAILY
Alprazolam 1 mg PO TID
Levetiracetam 500 mg PO TID
Piperacillin-Tazobactam Na 2.25 gm IV Q6H
Linezolid 600 mg IV Q12H
1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
2. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*60 Capsule(s)* Refills:*2*
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*60 caps* 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:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
6. 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*
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
QOD ().
8. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: 2.5 Tablet
Sustained Release 12HRs PO Q12H (every 12 hours): In AM and HS.
9. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO QNOON ().
10. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
Disp:*1 bottle* Refills:*2*
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
13. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*100 Tablet(s)* Refills:*0*
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*1*
1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
2. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*60 Capsule(s)* Refills:*2*
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*60 caps* 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:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
6. 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*
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
QOD ().
8. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: 2.5 Tablet
Sustained Release 12HRs PO Q12H (every 12 hours): In AM and HS.
9. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO QNOON ().
10. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
Disp:*1 bottle* Refills:*2*
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
13. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*100 Tablet(s)* Refills:*0*
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary diagnoses:
1. E coli urinary tract infection
2. Bacteremia
3. Decubitus ulcers
4. Pelvic osteo
Secondary diagnoses:
1. T12 paraplegia
2. Acute on chronic renal insufficiency
3. Seizure disorder
Discharge Condition:
Good
Discharge Instructions:
You are discharged to home and will continue all medications as
prescribed. Please contact your [**Name2 (NI) 101741**] or present to the ER
if you experience fevers, chills, night sweats, altered mental
status or other concerns.Please continue taking antibiotics by
mouth unless recommended otherwise by infectious disease
specialists.
Followup Instructions:
Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],
within 1-2 weeks after discharge.
You should also follow-up with Plastic surgeon Dr. [**First Name (STitle) **] within
the next few weeks prior to OR on [**10-28**].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4340**], MD Where: LM [**Hospital Unit Name 4341**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2176-11-12**] 9:00
Completed by:[**2176-10-8**]
|
[
"780.39",
"599.0",
"038.8",
"593.9",
"276.5",
"707.8",
"286.9",
"995.92",
"285.29",
"730.15",
"730.05",
"907.2",
"707.03",
"344.1",
"719.05",
"276.2",
"E929.0",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"38.93",
"00.14",
"81.91"
] |
icd9pcs
|
[
[
[]
]
] |
11123, 11194
|
3632, 3643
|
359, 385
|
11441, 11448
|
2687, 2687
|
11834, 12344
|
1935, 2036
|
7456, 11100
|
11215, 11319
|
7012, 7433
|
11472, 11811
|
2051, 2668
|
11340, 11420
|
271, 321
|
413, 1502
|
3479, 3609
|
2704, 3470
|
3659, 6986
|
1524, 1721
|
1737, 1919
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,551
| 174,159
|
24956
|
Discharge summary
|
report
|
Admission Date: [**2136-5-28**] Discharge Date: [**2136-6-2**]
Date of Birth: [**2088-5-3**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Penicillins / Ciprofloxacin / Clindamycin
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
CT guided J tube replacement.
History of Present Illness:
48 year old male with history of DM2 complicated by
gastroparesis, GJ tube s/p recent revision, who presents with
nausea, vomiting, found to have hypotension, fever, hematemesis
initially admitted to the MICU for septic shock and ? UGIB now
transferred to the floor today [**2136-5-30**]. On admission, pt was
noted to be febrile, with hyperglycemia and an increased AG
concerning for DKA. He was witnessed to have a "tonic clonic"
seizure and was given 1mg of Ativan. He was started on an
insulin gtt, given IVF, and responded appropriately with closure
of his AG and normalization of his sugars. However, the patient
became hypotensive despite aggressive IVF and required a RIJ
central line and dopamine, which was subsequently changed to
levophed. He also developed coffee ground emesis, and his Hct
dropped from 30 to 22. GI was consulted, and recommended
stopping suction, transfusing 2u PRBCs, giving antiemetics and
IV PPI [**Hospital1 **]. He was admitted to the MICU for UGIB and shock
presumed from sepsis.
.
RECENT HISTORY PER MICU NOTE:
The patient was recently discharged from [**Hospital1 18**] on [**2136-5-11**] after
p/w similar complaints of abdominal pain, vomiting, GJ tube site
drainage and hematemesis. During that admission, his hematemesis
was felt to be from grade D esophagitis and responded to PPI [**Hospital1 **]
and carafate. His GJ tube site was inflamed, but felt to be [**1-12**]
irritation from leakage of stomach contents rather than true
infection. The tube was swabbed and grew polymicrobial flora
felt to be colonization, and a peri-tube u/s showed no fluid
collections. He received a short course of ceftriaxone but this
was stopped after the cultures came back. His abdominal pain was
felt to be [**1-12**] his chronic gastroparesis pain, plus possible
irritation from the GJ tube, and was treated with metoclopramide
and erythro, plus his home pain regimen of oxycontin and
percocet. He had [**12-12**] BCx bottles grow MSSA, which was initially
treated with Vanc but then felt to be a contaminant and so abx
were stopped. Of note, his admit level of phenytoin was <0.6, so
he was given an additional gram IV with a repeat level 3.7. He
had no seizures while in house. On [**5-14**] he presented to
[**Hospital **] Hospital for continued drainage from his GJ tube. Per
his wife (no documentation available) he was started on IV
antibiotics and completed a course of the antibiotics after a
[**4-14**] day stay in the hospital.
.
The pt cont to have nausea and represented on [**5-25**] when he
vomited out his GJ tube and returned to the [**Hospital1 18**] ER. He was
seen by IR and the tube was replaced. He was unable to use the
tube after discharge and anything that was infused into jejunal
tube was aspirated out of the gastric port. He also had severe,
nausea vomiting, and felt dehydrated spending most of the last 3
days in bed due to weakness. He called his GI [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 7306**] [**Last Name (NamePattern1) 62708**] who directed him to the ER for evaluation, hydration
and glycemic control. Per his wife he had been taking all of his
medications at home but she is unclear if he was taking insulin
since he was not eating well.
.
While in the MICU, patient was seen by GI and by psychiatry. GI
felt that the GJ tube was malpositioned, and recommended surgery
consult to place a surgical J tube. Patient also attempted to
leave AMA, and psychiatry was consulted to evaluate patient, and
he was written for haldol. Patient was also seen by neurology
who felt that the seizures patient has been experiencing are
pseudoseizures, and favored no further Dilantin loading.
Patient is now transferred to the medicine service.
Past Medical History:
1) Type 2 Diabetes, complicated by gastroparesis and peripheral
neuropathy x 15 years
2) Left BKA in [**2109**]'s after car accident
3) Esophagitis on EGD [**8-14**]. Last scope here [**10-14**] as follows:
Impression: Linear erosions with exudate in the lower third of
the esophagus compatible with erosive esophagitis. Fluids in
stomach. Mass in the cardia. Mass in the gastroesophageal
junction. Otherwise normal egd to second part of the duodenum.
Recommend repeat EGD.
4) Seizures-[**2-11**] yrs
5) PVD
6) HTN
7) Status post appendectomy for appendicitis in [**2101**].
8) History of DVT "many years ago," with permanent IVC filter
placed.
9) Path: red cell alloantibodies, anti-D and anti-C; should
receive D and C antigen negative red cells for transfusion if
required
Social History:
Lives with his wife and two children. Has smoked 1 PPD >20
years. He has a history of heavy alcohol use which he can't
quantify, but quit about 5 years ago. He used to use illicit
drugs, including heroin, cocaine, LSD. Disabled now since [**09**]'s
after car accident. Works at pig farm for recreation.
Family History:
Sister with [**Name (NI) 4522**] Disease. Father with [**Name2 (NI) 2320**].
Physical Exam:
Tc 99.3 130/60, 77, 13, 96% on RA
Gen: Malnourished male lying in bed.
HEENT: Poor dentition. No elevation in JVP. MMM.
Hrt: RRR. no MRG.
Lungs: CTAB. no RRW.
Abd: Hypoactive bowel sounds, small amount serous drainage from
around the GJ tube. No erythema. Mild tenderness to palpation
over abdomen diffusely.
Extr: L BKA. No edema, non palp dp pulse on rt
Skin: Numerous excoriations over arms, legs, back. None appear
infected. Patient is actively scratching all of his lesions.
Pertinent Results:
LABS:
[**2136-5-28**] 05:27PM GLUCOSE-80 UREA N-22* CREAT-0.6 SODIUM-138
POTASSIUM-3.2* CHLORIDE-100 TOTAL CO2-31 ANION GAP-10
[**2136-5-28**] 05:27PM ALT(SGPT)-9 AST(SGOT)-8 LD(LDH)-100
CK(CPK)-12* AMYLASE-42 TOT BILI-0.2
[**2136-5-28**] 05:27PM LIPASE-24
[**2136-5-28**] 05:27PM CK-MB-NotDone cTropnT-<0.01
[**2136-5-28**] 05:27PM ALBUMIN-3.0*
[**2136-5-28**] 05:27PM FERRITIN-8.4*
[**2136-5-28**] 05:27PM PHENYTOIN-<0.6* VALPROATE-<3.0*
[**2136-5-28**] 05:27PM HGB-7.7* HCT-22.8*
[**2136-5-28**] 02:39PM TYPE-ART PO2-118* PCO2-55* PH-7.44 TOTAL
CO2-39* BASE XS-11 INTUBATED-INTUBATED
[**2136-5-28**] 02:07PM LACTATE-3.0*
[**2136-5-28**] 02:00PM CK(CPK)-13*
[**2136-5-28**] 02:00PM cTropnT-<0.01
[**2136-5-28**] 02:00PM CK-MB-NotDone
[**2136-5-28**] 02:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.033
[**2136-5-28**] 02:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
Reports:
CT ABDOMEN WITH IV CONTRAST: The lung bases are clear without
evidence of nodules or effusions. There is symmetric thickening
of the esophageal wall measuring 12 mm, most likely consistent
with esophagitis, and this should be clinically correlated. A
G-tube is seen extending to the third portion of the duodenum.
The liver, gallbladder, spleen, adrenal glands, and pancreas are
unremarkable. The left kidney is unremarkable. A hyperdensity in
the right kidney may represent a hyperdense right kidney cyst,
however, cannot be further evaluated on this examination. There
is no free air or free fluid within the abdomen. There are no
pathologically enlarged mesenteric or retroperitoneal lymph
nodes. An IVC filter is collapsed and in unchanged position with
legs of the filter outside of the IVC. The aorta is calcified.
CT PELVIS WITH IV CONTRAST: There is air within the bladder,
likely secondary to the patient's Foley catheter. There is
sigmoid diverticulosis, without evidence of diverticulitis.
There is no free fluid within the pelvis. There are no
pathologically enlarged pelvic or inguinal lymph nodes.
OSSEOUS WINDOWS: Again demonstrate an exophytic lesion arising
from the right iliac crest that is unchanged in appearance
compared to the prior examination. Multiplanar reformatted
images confirm the above findings.
IMPRESSION:
1. Marked symmetric esophageal wall thickening, likely
consistent with esophagitis. This should be clinically
correlated.
2. No evidence of G-tube leak.
3. Right kidney hyperdensity may represent a cyst but can be
evaluated on ultrasound if clinically indicated.
4. Sigmoid diverticulosis without evidence of diverticulitis.
5. IVC filter in unchanged position.
CT head: No acute hemorrhage
CXR: No acute process.
GJ tube placement:
IMPRESSION: Unsuccessful placement of gastro jejunostomy tube
across the pylorus, due to gastroparesis. A gastrostomy tube was
placed instead.
Blood cultures:
[**5-28**]:AEROBIC BOTTLE (Final [**2136-6-1**]):
GRAM STAIN REPORTED BY PHONE TO [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 62709**] (CC7D) 1340
[**2136-5-29**].
STAPHYLOCOCCUS, COAGULASE NEGATIVE. OF TWO COLONIAL
MORPHOLOGIES.
ISOLATED FROM ONE SET ONLY SENSITIVITIES PERFORMED ON
REQUEST..
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
ANAEROBIC BOTTLE (Final [**2136-6-1**]):
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
[**2136-5-28**] 2:00 pm BLOOD CULTURE
AEROBIC BOTTLE (Final [**2136-6-1**]):
REPORTED BY PHONE TO [**Doctor First Name 62710**] GOOD [**2136-5-30**] 13:25.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
ANAEROBIC BOTTLE (Pending):
Brief Hospital Course:
48yo man with DM2, gastroparesis, GJ tube s/p recent revision,
who p/w n/v, found to have DKA, sepsis, hematemesis and seizure,
now well controlled.
##. Hematemesis: Patient's hematocrit remained stable after
transfusion of 2 units. Likely secondary to esophagitis. GI did
not feel need to repeat endoscopy at this time. Mr. [**Known lastname 6330**]
should continue PPI [**Hospital1 **] for 4 weeks and then can decrease to a
daily PPI.
##. Iron deficiency anemia: He was noted to have Iron deficiency
anemia and treated with IV iron replacement in the hospital. He
will continue on iron replacement as outpatient.
##. Hypotension and fever: Concerning for infection in setting
of positive blood cultures, however blood culture grew out
diphtheroids which infectious disease felt was contamination. No
clear source was ever identified by UA/CXR/CT scan.
##. Seizures: CT head negative on admit. Dilantin and depakote
were subtherapeutic. Neurology consulted and felt that these
were pseudoseizures after witnessing an episode (patient
conscious and talking throughout jerking movement). A bedside
EEG was attempted, but patient refused. Initially, dilantin load
was given and levels were followed closely. He was also
continued on dilantin. Further history from patient revealed
that he did not like to take dilantin or depakote due to side
effects (as demonstrated by levels on admission). After
consulation with neurology, he was changed to tegretol to
hopefully improve compliance. Dilantin and depakote were
discontinued. Of note, during hospitalization, his seizures
were only treated if they lasted longer than 5 minutes or he had
multiple seizures within an hour.
##. Gastroparesis s/p GJ Tube placement. Patient's GJ tube was
found to be out of position. It was replaced by CT guided
intervention on [**2136-6-1**]. He was continued on
Reglan and erythromycin per GI recs for gastroparesis. He
resumed solid diet on [**6-1**] after J tube placement without
events.
##. Depression. Concern was raised during the MICU stay for
suicidal ideation. There was a questionable history of multiple
suicide attempts in past, which was not able to be verified by
the psychiatry resident prior to discharge. Mr. [**Known lastname 6330**] was on 1:1
sitter while in ICU and initially on floor. He was continued on
his celexa. He was no longer suicidal prior to discharge.
Psychiatry was consulted and recommended that the patient follow
up with his outpatient psychiatrist.
##. DM2. ISS. FSQACHS. Blood sugars low initially while patient
NPO because of J tube misplacment.
##. Activity: As tolerated.
##. PPx: During the hospital stay, he was treated with PPI [**Hospital1 **],
pneumoboots for DVT prophylaxis, a bowel regimen and maintained
on seizure precautions.
##. Access: Right IJ triple lumen removed the day of discharge.
##. Comm: wife [**Name (NI) 8771**] [**Name (NI) 6330**] [**Telephone/Fax (1) 62711**]
##. Code: Full after discussion with wife
## pruritis- long standing. Could be due to diabetes, iron
deficiency or some other process. Would treat Iron deficiency
and reassess.
## esophagitis- should have another EGD with biopsy as a screen.
Medications on Admission:
-Lantus 95 U QAM, 55U QPM
-RISS
-Phenytoin 500 mg PO QHS
-Quetiapine 300 mg PO QHS
-citalopram 40 mg PO QHS
-Depakote 500 mg PO QHS
-Oxycontin SR 80 mg PO BID prn
-10mg percocet tid prn
-iron sulfate 325mg tid
-sucralfate 1g qid
-metoclopramide 10mg qid with meals
-[**Telephone/Fax (1) 44137**] 40mg qhs
.
ALLERGIES: Morphine, Augmentin, Ciprofloxacin all cause rash.
Discharge Medications:
1. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
[**Telephone/Fax (1) **]:*30 Capsule(s)* Refills:*6*
2. Quetiapine 300 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
[**Telephone/Fax (1) **]:*30 Tablet(s)* Refills:*1*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
[**Telephone/Fax (1) **]:*60 Capsule(s)* Refills:*2*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
[**Telephone/Fax (1) **]:*1 bottle* Refills:*2*
6. Oxycodone 40 mg Tablet Sustained Release 12HR Sig: Two (2)
Tablet Sustained Release 12HR PO Q12H (every 12 hours): 2 week
supply
refills through PCP.
[**Name Initial (NameIs) **]:*56 Tablet Sustained Release 12HR(s)* Refills:*0*
7. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
[**Name Initial (NameIs) **]:*60 Tablet(s)* Refills:*0*
8. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
[**Name Initial (NameIs) **]:*60 Tablet(s)* Refills:*1*
9. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for itching.
10. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
11. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
[**Name Initial (NameIs) **]:*120 Tablet(s)* Refills:*1*
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
[**Name Initial (NameIs) **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
13. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous QAM.
[**Name Initial (NameIs) **]:*0 0* Refills:*0*
14. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
15. Insulin
Please resume home insulin sliding scale.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Gatroparesis
J tube displacement
Diabetes Mellitus Type 2
Seizure Disorder
Iron deficiency anemia
Depression
Discharge Condition:
Stable
Discharge Instructions:
Please take all medications as directed. Your dilantin has been
replaced with Tegretol.
If you have recurrent nausea, vomiting, abdominal pain, fevers
or chills please call Dr. [**Last Name (STitle) 57930**] for urgent evaluation.
Your insulin was restarted at a lower dose. If your blood sugars
remain elevated, please call Dr. [**Last Name (STitle) 57930**] for dose adjustments of
your insulin.
Followup Instructions:
On Monday, please call your primary care physician , [**Last Name (NamePattern4) **].
[**Last Name (STitle) 57930**], to be seen in the office early next week.
You will need a referral to a neurologist for further evaluation
of your possible seizures. You can be seen here at [**Hospital1 18**] if you
would like. If so, please call [**Telephone/Fax (1) 40554**].
You will also need to follow up with Dr. [**First Name (STitle) 2643**] in
gastroenterology regarding your gastroparesis and ongoing need
for gastric and jejunal feeding tubes. Please call his office
MOnday for an appointment.
|
[
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"357.2",
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"530.19",
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"280.9",
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"995.94",
"038.9",
"401.9",
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icd9cm
|
[
[
[]
]
] |
[
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] |
icd9pcs
|
[
[
[]
]
] |
15131, 15180
|
9508, 12684
|
328, 360
|
15333, 15342
|
5841, 8538
|
15788, 16382
|
5247, 5325
|
13103, 15108
|
15201, 15312
|
12710, 13080
|
15366, 15765
|
5340, 5822
|
272, 290
|
9485, 9485
|
388, 4112
|
8547, 9456
|
4134, 4911
|
4927, 5231
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,632
| 177,050
|
53335
|
Discharge summary
|
report
|
Admission Date: [**2170-10-4**] Discharge Date: [**2170-11-20**]
Date of Birth: [**2107-10-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
abdominal pain, SOB
Major Surgical or Invasive Procedure:
Bronchoscopy c biopsy
History of Present Illness:
This is a 62 year old female with PMH significant for multiple
sclerosis presents with abdominal pain x 5 days, along with SOB.
Describes having constant epigastric pain that is burning in
nature and worsened with eating; however somewhat better with
milk. The pain is non-positional in nature and is not
exacerbated by recumbency. States that spicy food exacerbates
her pain. Reports some associated nausea but no vomiting and
also reports constipation. In addition, the patient has had
increasing dysphagia for both solids and liquids the last few
months, a video swallow study in [**6-7**] was largely unremarkable.
Denies recent weight loss and reports a good appetite.
Pt also reports feeling increasingly shortness of breath over
the past 3-4 months. As she is wheelchair bound, she can't say
for sure that this is exertional. Denies PND, orthopnea, h/o LE
edema. Feels that her SOB is worse when she experiences
swallowing difficulty. Denies chest pain, dizziness, fevers,
chills, night sweats. Does report a non-productive cough that is
chronic in nature but has increased in frequency in the past few
weeks.
In the ED, T 98.1 HR 101 BP 138/104 RR 18 O2 sat 98% on RA.
Given GI cocktail with improvement in abdominal pain. CXR
significant for RUL mass, sent for chest CT that revealed a 3.7
x 2.4 cm non-cavitating, enhancing mass in the RUL of the lung
abutting the R side of the mediastinum. Pt admitted to medicine
for further work-up of lung mass.
.
ROS otherwise negative. Reports negative PPD 2 months ago.
Past Medical History:
Multiple Sclerosis dx in [**2161**]-99 followed by [**Hospital1 **] [**Hospital1 **],
recently failed Avonex, cognitive decline over past year.
Chronic LBP s/p L5-S1 diskectomy [**2148**]
Breast Fibroadenoma
Distant h/o rheumatic fever in her 20s, no sequealae
Social History:
Second marriage. Divorced from first husband.
Originally from [**Male First Name (un) 1056**]. Now needs assistance in all ADL's
from husband. [**Name (NI) 1139**]: remote h/o of smoking 1 cigarette a day
for 20 yrs, 20 yrs ago
EtOH: 1 glass red wine qd
Drugs: no illicit substance use
Family History:
+DM, HBP, hyperlipidemia; negative for MS, negative for
carcinoma.
Several relatives with [**Name (NI) 5895**]
Fatal MI in mother (80's)
Physical Exam:
T 97.4 BP 130/90 HR 100 RR 20 O2 sat 98% on RA
Gen - NAD, thin appearing Hispanic female, alert, friendly,
speaks in full sentences but occ grunting.
HEENT - Sclerae anicteric, PER, MM slightly dry, no lesions.
Neck supple. no JVD appreciated.
CV - RRR, S1S2, no m/r/g appreciated
Lungs - B/L coarse breath sounds, fair air movement
Abd - Soft, Tender to palp in epigastric/RUQ area, no guarding
Ext - No ext edema, mild wasting
Skin - No lesion
Neuro - AAO x 3, Myoclonus L>R, hyperrefexic in brachiorad and
patellar reflexes
Pertinent Results:
[**2170-10-3**] 05:55PM WBC-7.5# RBC-4.86 HGB-15.8 HCT-45.0 MCV-93
MCH-32.4* MCHC-35.0 RDW-13.9
[**2170-10-3**] 05:55PM PLT COUNT-237
[**2170-10-3**] 05:55PM GLUCOSE-88 UREA N-21* CREAT-0.7 SODIUM-143
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-32 ANION GAP-14
[**2170-10-3**] 05:55PM ALT(SGPT)-26 AST(SGOT)-25 ALK PHOS-64
AMYLASE-89 TOT BILI-0.4
[**2170-10-3**] 05:55PM LIPASE-63*
[**2170-10-3**] 05:55PM ALBUMIN-4.9*
[**2170-10-4**] 12:01AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2170-10-4**] 12:01AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-TR
[**2170-10-4**] 12:01AM URINE RBC-0 WBC-[**5-12**]* BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2170-10-4**] 12:01AM URINE GRANULAR-[**2-4**]* HYALINE-1*
.
CXR - 1. No free intraperitoneal air.
2. 4-cm mass within the right upper lung zone. Further
evaluation of this with a CT scan should be obtained.
.
Chest CT - 1. Approximately 3.7 x 2.4 cm noncalcified,
noncavitating enhancing mass in right upper lobe abutting the
right side of the mediastinum, with possible area of assocaited
post- obstructive subsegmental atelectasis. There is no
pathologically enlarged mediastinal or hilar lymphadenopathy.
These findings are concerning for a primary bronchogenic
carcinoma that may be accessible to
tiisue diagnosis by transbronchial biopsy. 2. 4-mm nonspecific
noncalcified subpleural nodule within the right lower lobe.
Second possible smaller nodule in the right lower lobe. 3. Tiny
hypodensity in the right lobe of the liver is too small to
characterize.
Brief Hospital Course:
62 yo F c multiple sclerosis, chronic LBP, initially presents
with hypercarbic respiratory distress, then intubated, trached
and found to have NSCLC.
.
# Lung cancer - Biopsy of the right upper lobe mass result came
back as nonsmall cell lung cancer and it is Stage III by mass
size. Oncology saw patient while in house. No treatment will be
offered given her prognosis and co-morbidity. Her husband had
refused to talk to oncology as inpatient. No staging had been
done due to husband's refusal to talk about her cancer. She will
be followed by oncology as outpatient as necessary for possible
palliative treamtment in the future.
.
# Respiratory failure-Patient initiailly presents with
hypercarbic respiratory failure and aspiration due to multiple
sclerosis. SHe was eventually intubated. Weaning had been
unsuccessful due mostly to muscles weakness from multiple
sclerosis. She had tracheostomy while in ICU. SHe will require
long term ventilatory support since her multiple sclerosis is
progressive. She is on pressure support on discharge. Her trach
had been downsized to size 7 prior to discharge to faciliate
ventilator assisted speech. She does have a lot of anxiety,
needs ativan prn and needs reassurance and training with speech
and swallow.
.
# Dysphagia/aspiration - Patient has significant aspiration per
studies by speech and swallow. However, patient is very eager to
eat. GIven her bad prognosis from her lung cancer and multiple
sclerosis, she needs to be evaluated by speech and swallow
again. If she insists on eating, she needs to understand the
aspiration riskk and the potential mortality from that.
.
# Multiple Sclerosis - Per most recent [**Month/Day (1) **] note, pt with
progressive cognitive decline requiring assitance with most
ADLs. [**Month/Day (1) 878**] recommended to discontinue Avonex treatment
given no clear benefit. Continue supportive management.
.
# urinary tract infection
She was found to have enterobacter UTI and was started on
bactrim to complete 7 days course(d1= [**11-17**])
.
# Chronic LBP - Currently stable. Continue lidoderm patch.
.
# Code - Full, confirmed with pt and husband.
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Year (2) **]: One (1) ml
Injection TID (3 times a day).
3. Albuterol 90 mcg/Actuation Aerosol [**Month/Year (2) **]: Six (6) Puff
Inhalation Q6H (every 6 hours) as needed.
4. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Year (2) **]: Six (6)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
5. Senna 8.8 mg/5 mL Syrup [**Month/Year (2) **]: Five (5) ml PO BID (2 times a
day) as needed.
6. Docusate Sodium 150 mg/15 mL Liquid [**Month/Year (2) **]: One Hundred (100) mg
PO BID (2 times a day).
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month/Year (2) **]:
One (1) Adhesive Patch, Medicated Topical Q O 12 H (): apply to
lumbar spine .
8. Simethicone 80 mg Tablet, Chewable [**Month/Year (2) **]: 0.5 Tablet, Chewable
PO QID (4 times a day).
9. Quetiapine 25 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO QHS (once a
day (at bedtime)).
10. Lorazepam 0.5 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety.
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
12. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day): hold for SBP<100, HR<60 .
13. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Last Name (STitle) **]: One (1)
Tablet PO BID (2 times a day) for 4 days: d1= [**11-17**].
14. Phenazopyridine 100 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO TID (3
times a day) for 3 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
1. respiratory failure from muscle weakness
2. non small cell lung carcinoma
3. multiple sclerosis
4. ventilator associated pneumonia
5. urinary tract infection
Discharge Condition:
stable
Discharge Instructions:
Please return to the ED or call your doctor if you have high
fever, shortness of breath, chest pain, failing on ventilator or
if there are any other concerns
Followup Instructions:
1. Please follow up with PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 4775**] 2 weeks
after discharge
2. Please call ([**Telephone/Fax (1) 14703**] to schedule an appointment with
oncology should you change your mind about talking to oncology
3. Please call ([**Telephone/Fax (1) 2528**] to schedule an appointment with
[**Last Name (NamePattern4) 109736**] [**Last Name (NamePattern1) **], MD [**First Name (Titles) 767**] [**Last Name (Titles) **] as needed.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
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"162.3",
"724.2",
"340",
"599.0",
"518.84",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"33.27",
"96.6",
"33.26",
"46.39",
"96.04",
"33.24",
"31.1",
"96.72",
"00.17",
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] |
icd9pcs
|
[
[
[]
]
] |
8714, 8789
|
4850, 6988
|
335, 358
|
8994, 9003
|
3224, 4827
|
9209, 9826
|
2523, 2661
|
7011, 8691
|
8810, 8973
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9027, 9186
|
2676, 3205
|
276, 297
|
386, 1918
|
1940, 2202
|
2218, 2507
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,183
| 182,722
|
47354
|
Discharge summary
|
report
|
Admission Date: [**2137-6-7**] Discharge Date: [**2137-6-25**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Chest pain; aphasia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 1557**] is an 83 year-old man with a past medical history of
coronary artery disease and multiple recent admissions,
presenting with aphasia.
.
Of note, multiple recent admissions --
1. [**2137-2-21**] - [**2137-3-5**]: Admitted with a large STEMI (occluded
LAD, RCA, 90% circumflex. His course was complicated by LAD
in-stent thrombosis, vfib/vtach, cardiogenic shock, and right
sided femoral to popliteal DVT.
2. [**2137-3-13**] - [**2137-3-20**]: Admitted with chest pain and CHF.
3. [**2137-5-5**] - [**2137-6-3**]: Admitted with acute CHF. Course
complicated by cholecystitis. A percutaneous cholecystostomy
tube was placed, and he was treated with daptomycin, then
linezolid (after ARF) for VRE. He then underwent ERCP with
placement of stent in ampulla for stone in CBD. Of note, during
this admission, his blood pressures were consistently in the 80s
to 90s systolic.
.
On the morning of admission, patient awoke at 6am with
right-sided chest pain with mild shortness of breath. He was
given Maalox and SL nitro, the combination of which resolved his
pain. He was also noted at this time to have a systolic blood
pressure in the 80s, although this is his baseline. The patient
reports that approximately an hour later, when the physician
came to see him, he was initially "just out of it." After saying
something to the physician, [**Name10 (NameIs) **] was then unable to talk. This
period of aphasia lasted ~10 minutes and was not associated with
weakness or apparent sensory deficits. He was then transferred
to [**Hospital1 18**].
.
In the emergency room, initial vitals showed a HR of 68, BP
72/39, RR 18 and 94% on 2 liters. His blood pressure trended in
the 80-90s systolic. He received 1.5 of IVF and potassium
repletion
Past Medical History:
# Myocardial Infarction [**1-/2137**], s/p cath with PTCA and 2 stents
placed in proximal LAD. C/b cardiogenic shock and VT requiring
defibrillation/pacing for heart block
# Myocardial Infarction with two stents placed in the RCA in
[**2127**].
# RLE DVT [**3-1**]
# Diabetes: HA1c 6.4% on [**11-30**]. High grade proteinuria X 1 yr.
# Hypertension
# Hypercholesteremia
# Asthma
# Stage IV Chronic Kidney Disease (baseline creatinine 2.5 to
2.8)
Social History:
Social history is significant for a long standing history of
smoking prior to his myocardial infarction. He is now residing
at [**Hospital 100**] Rehab and is not currently smoking. He does not use
alcohol.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VITALS - T 98.2, HR 84, BP 95/45, 94% on 2 liters NC.
GEN - Elderly appearing male, lying
HEENT - No carotid bruits bilaterally.
CV - Regular. No murmurs. No S3/S4.
PULM - Bibasilar crackles. No wheezes.
ABD - Soft. Chole tube in place. Mild tenderness in RLQ, below
tube. No rebound/guarding. No tenderness otherwise.
EXT - Warm. Very thin extremities.
NEURO - Pupils are irregular and surgical. EOMI with mild
nystagmus on lateral movement. Otherwise normal cranial nerves.
Mildly diminished muscle bulk diffusely. Strength 5/5 in upper
and lower extremeties bilaterally. Sensation intact to light
touch throughout.
Pertinent Results:
ADMISSION LABS
---------------
[**2137-6-7**] 11:20AM BLOOD WBC-13.9* RBC-3.89* Hgb-9.8* Hct-30.3*
MCV-78* MCH-25.3* MCHC-32.5 RDW-17.3* Plt Ct-375
[**2137-6-7**] 11:20AM BLOOD Neuts-82.0* Lymphs-11.3* Monos-4.9
Eos-1.5 Baso-0.2
[**2137-6-7**] 11:20AM BLOOD PT-12.3 PTT-24.6 INR(PT)-1.0
[**2137-6-7**] 11:20AM BLOOD Glucose-123* UreaN-57* Creat-2.4* Na-138
K-4.5 Cl-99 HCO3-27 AnGap-17
[**2137-6-7**] 11:20AM BLOOD TotProt-6.5 Albumin-3.2* Globuln-3.3
Phos-4.5 Mg-2.2
ROMI
-----
[**2137-6-7**] 11:20AM BLOOD ALT-13 AST-28 LD(LDH)-310* CK(CPK)-39
AlkPhos-43 TotBili-0.4
[**2137-6-7**] 05:50PM BLOOD CK(CPK)-16*
[**2137-6-8**] 06:50AM BLOOD CK(CPK)-14*
[**2137-6-8**] 09:55AM BLOOD CK(CPK)-19*
[**2137-6-7**] 11:20AM BLOOD cTropnT-0.06*
[**2137-6-7**] 05:50PM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2137-6-8**] 06:50AM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2137-6-8**] 09:55AM BLOOD CK-MB-NotDone cTropnT-0.05*
OTHER LABS
----------
[**2137-6-10**] 05:00AM BLOOD TSH-1.7
[**2137-6-8**] 06:50AM BLOOD Triglyc-98 HDL-35 CHOL/HD-2.7 LDLcalc-38
[**2137-6-8**] 06:50AM BLOOD %HbA1c-5.6
MICRO
------
Blood culture, Urine culture-NGTD
Stool culture-c.diff positive
IMAGING
-------
[**6-7**] CT head: No hemorrhage, edema, or mass effect. Chronic
small vessel ischemic disease. Age-related parenchymal atrophy.
[**6-8**] MRI/MRA: No acute infarcts. Minimal amount of chronic
microangiopathic change and moderate degree of atrophy. Possible
irregularity of the basilar artery which may be artifactual due
to patient motion versus atherosclerotic disease. Limited
T2-weighted images of the head were obtained as the patient was
not able to tolerate the exam. There are scattered white matter
T2 hyperintensities, which likely represent
chronic microangiopathic change. There is generalized moderate
atrophy. The visualized major flow voids are grossly normal.
[**6-8**] Gallbladder US: Cholelithiasis, with a cholecystostomy tube
in place. Relatively decompressed gallbladder compared to [**5-21**], [**2136**] with mild
improvement in wall thickening.
[**6-8**] echo: The left atrium is mildly dilated. A left-to-right
shunt across the interatrial septum is seen at rest c/w a small
secundum atrial septal defect/stretched [**Doctor Last Name **] ovale. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is severely dilated with severe regional systolic
dysfunction and apical aneurysm. The basal inferolateral wall
contracts best. No masses or thrombi are seen in the left
ventricle. The right ventricular cavity is mildly dilated with
hypokinesis of the distal free wall. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Moderate to severe (3+) mitral regurgitation
is seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion. Compared with the prior study
(images reviewed) of [**2137-3-22**], the left ventricular cavity is now
larger with more severe systolic dysfunction. A small secundum
type atrial septal defect is now identified. The estimated
pulmonary artery systolic pressure is now lower.
[**6-10**] Abdominal CT: 1. No acute abnormality is seen. 2.
Questionable thickening of the distal sigmoid colon which likely
reflects the patient's known Clostridium difficile colitis. 3.
Abdominal aortic aneurysm. 4. Biliary stent and percutaneous
cholecystostomy tube identified. 5. Large bilateral pleural
effusions are seen.
[**6-10**] Carotid US: Left 60-69%, right <40%.
Brief Hospital Course:
83M with coronary artery disease, congestive heart failure,
chronic kidney disease, diabetes mellitus presenting with chest
pain and aphasia.
Aphasia:
Seen by the stroke service in the emergency room. Symptoms
possibly related to left hemisphere event, most probably in the
MCA distribution. Unclear what role hypotension plays given
that this has been a persistent problem; no watershed infarct
seen. Pt now fully communicative. Neuro believes it could have
been a TIA. MRI/MRA suboptimal as he moved; carotid US with
left side stenosis of 60-69% but likely symptomatic as he is
hypotensive at baseline (SBP 80-90). Dr. [**First Name (STitle) **] from Cardiology
evaluated patient on [**6-12**], felt that maximizing CHF treatment
and anti-coagulation would be the best course at this time
unless patient were to develop additional neurologic symptoms,
as potential difficulties with hypotension and bradycardia would
be concerning in this patient if he were to get a carotid stent.
He was continued on coumadin, aspirin and plavix. The INR was
3.3 on discharge and [**Hospital 100**] Rehab was given instructions to hold
Coumadin this evening and resume Coumadin 3mg daily on [**6-26**].
Pt should be getting a follow up INR drawn on [**6-26**] and every
three days thereafter following discharge.
Chest pain:
Patient has a history of single vessel disease and is s/p BMS to
LAD. He has been reporting intermittent chest/epigastric pain
(more epigastric and associated with his tube), but not felt to
be cardiac in nature. His ECGs have remained unchanged.
Troponins were followed and were elevated but stable; CK flat.
Systolic HF:
Patient with large anterior MI in [**Month (only) 956**] with in-stent
thrombosis. EF at the time was less than 20%; on this
admission, repeated study showed larger left ventricular cavity
with more severe systolic dysfunction. He had been on digoxin
and amiodarone as well as carvedilol but these were discontinued
on his last admission secondary to bradycardia. Although he was
started on low dose captopril for afterload reduction, he was
unable to tolerate this [**1-26**] ARF. The patient was admitted to
the CCU for diuresis with a lasix gtt and metalozone because his
BP was borderline low (Baseline SBP 80s) and could not tolerate
diuresis on the floor. Diuresis was subsequently transitioned
to Torsemide. He was started on Lisinopril 1.25 mg PO daily.
In addition, digoxin was restarted and dosed q3 days per
pharmacy. However, the digoxin was discontinued as pt was noted
to have paroxysmal atrial fibrillation with occaisional [**3-30**]
beats of asymptomatic junctional bradycardia.
Rhythm:
Patient has been in and out of afib throughout this admission,
as above; his heart rate is mainly in the 70s. He is on
amiodarone 400 daily (started [**6-10**]; plan for one month followed
by 200 daily). Beta-blocker was put on hold as pt was
susceptible to hypotension. Coumadin was resumed on [**6-18**] and INR
above. If heart rate increases significantly, can discuss with
PCP about restarting low dose metoprolol as tolerated.
C. diff diarrhea:
Patient with leukocytosis on admission and diarrhea. Flagyl was
started on [**6-10**] for empiric treatment of C. Diff. Diarrhea
worsened over the next few days. On [**6-14**], pt had a positive C.
diff toxin test, and Vancomycin was added to cover for resistant
C.Diff. Flagyl was discontinued on [**6-19**]. Pt is to complete 14
day course of Vancomycin following discharge (last dose on [**6-27**]).
Abdominal pain:
Imaging studies all negative. This has been a chronic issue
during his stay. LFTs have been WNL. Suspect that the etiology
of this pain was due to a combination of T tube versus from the
c. difficile infection. By the day of discharge his pain seems
to have improved. Pt does have drain in place from previous
acute CCY placed by surgery. Surgery was contact[**Name (NI) **] and pt has
follow-up appointment on [**7-5**] with Dr [**Last Name (STitle) **].
# CKD: Creatinine has fluctuated between [**1-27**], currently 1.9.
During diuresis, Cr levels continued to remain stable.
Medications were dosed renally during hospitalization.
.
# Urinary retention: Pt's home med Tamsulosin was held given
pt's hypotension during hospitalization. Pt had ongoing issues
with urinary retention and has an indwelling foley currently.
Pt will likely need a repeat voiding trial & follow-up with PCP
following discharge.
# Depression: Pt was continued on home medications of
Citalopram, Trazadone PRN, Lorazepam PRN during hospitalization.
.
# Diabetes: Pt was placed on RISS during stay, and to resume
home Glipizide following discharge.
Medications on Admission:
1. Clopidogrel 75 mg daily
2. Aspirin 325 mg daily
3. Atorvastatin 80 mg daily
4. Glipizide 2.5 mg daily
5. Tamsulosin 0.4 mg QHS
6. Citalopram 20 mg daily
7. Ferrous Sulfate 325 mg daily
8. Gabapentin 200 mg TID
9. Lorazepam 0.5 mg QHS PRN
10. Trazodone 25 mg QHS PRN
11. Calcium Carbonate 1000 mg [**Hospital1 **]
12. Torsemide 20 mg daily
13. Bisacodyl 10 mg daily
14. Senna 8.6 mg daily
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO BID (2 times a day).
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): Continue at this dose for one month starting [**6-10**], then
on [**7-10**] decrease dose to 200mg daily.
11. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO once a day.
12. Lisinopril 5 mg Tablet Sig: 0.25 Tablet PO DAILY (Daily).
13. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 8 days days: Take 1 tablet every day until last
dose on [**6-27**]. (14 day course).
14. Torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
15. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM: PLEASE DO NOT START UNTIL [**6-26**].
16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
17. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Primary:
TIA
acute systolic heart failure
Hypertension
Secondary:
Chronic kidney disease
Hyperlipidemia
Diabetes
Discharge Condition:
Good
Discharge Instructions:
You were admitted with chest pain, that is thought to be
non-cardiac and aphasia (difficulty speaking), which is due to a
TIA (transient ischemic attack-a small stroke). You were
treated for the TIA with coumadin. In addition you were treated
by cardiology for your heart failure.
We made the following changes to your medications: Amiodarone
and lisinopril were added.
Please call your PCP or return to the emergency room for chest
pain, shortness of breath, lightheadedness or any other
concerns.
Please do not start to smoke again. Information regarding
quitting smoking and staying smoke free was given to you at
discharge.
Followup Instructions:
1. You are on Coumadin, a medication that requires regular
monitoring. Please draw a PT/INR on [**6-27**] and every three
days thereafter and have the results faxed to your doctor at the
[**Month (only) 172**] (Phone: [**Telephone/Fax (1) 133**]. Fax: [**Telephone/Fax (1) 445**].)
an appointment within 1-2 weeks of discharge.
3. Please meet with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 2833**]
Date/Time:[**2137-7-5**] 9:00. He will assess the tube in your abdomen
and may remove it at this time.
|
[
"V45.02",
"427.31",
"412",
"V45.82",
"784.3",
"V12.51",
"428.0",
"511.9",
"250.00",
"493.90",
"428.22",
"355.8",
"110.1",
"703.8",
"311",
"285.21",
"272.0",
"403.90",
"788.20",
"414.01",
"008.45",
"585.4",
"433.10",
"584.9",
"458.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.27"
] |
icd9pcs
|
[
[
[]
]
] |
13737, 13822
|
7103, 11772
|
280, 286
|
13980, 13987
|
3521, 4705
|
14669, 15236
|
2786, 2868
|
12213, 13714
|
13843, 13959
|
11798, 12190
|
14011, 14317
|
2883, 3502
|
14347, 14646
|
221, 242
|
314, 2075
|
4714, 7080
|
2097, 2544
|
2560, 2770
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,130
| 146,524
|
44162
|
Discharge summary
|
report
|
Admission Date: [**2113-1-1**] Discharge Date: [**2113-1-13**]
Service: NEUROLOGY
Allergies:
Morphine
Attending:[**First Name3 (LF) 2518**]
Chief Complaint:
frontal ICH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 8494**] is an 88-year-old man with a history of a fib on
Coumadin who presents with speech difficulty and lethargy and
was found to have a left frontal intraparenchymal hemorrhage. He
was in his USOH until around 7 pm tonight. After dinner, he
complained to his wife of being tired. Shortly after, he stopped
talking and seemed very lethargic. He was not seen to have any
seizure activity. EMS was called, and he was transported to [**Hospital1 **]
[**Location (un) 620**]. There, NCHCT showed ~4 cm diameter left frontal
intraparenchymal hemorrhage. INR was found to be 3.4. He was
given 10 mg Vitamin K, 1 unit FFP, 2 inches of nitropaste (BP
178/81), and loaded with 1 gram of dilantin IV.
ROS not possible in detail; generally he says he feels "pretty
good" but does not elaborate.
Past Medical History:
Atrial fibrillation
HTN
BPH
GERD
TIAs (further information unavailable)
h/o frontal meningioma s/p resection [**2095**]
Social History:
Lives with wife in [**Hospital3 **]. Retired construction
engineer.
Family History:
NC
Physical Exam:
Vitals: T: 97.7 P: 80 R: 16 BP: 136/77 SaO2: 98%RA
General: Drowsy, cooperative, NAD.
HEENT: Two midline indentations from prior surgery, no scleral
icterus noted, MMM, no lesions noted in oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: Irregular, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Drowsy, difficult to keep awake. Says few words,
"okay," "Beacon" (for name of place); otherwise non-verbal.
Follows one-step commands slowly.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 3mm and brisk.
III, IV, VI: EOMI without nystagmus.
V: Not testable.
VII: Right facial droop.
VIII: Hard of hearing.
IX, X: Does not elevate palate.
[**Doctor First Name 81**]: Not tested.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Right pronator drift. No
adventitious movements noted. No asterixis noted.
Delt Bic Tri WrE IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5
R 4- 5 4+ 4+ 5 5 5 5 5
-Sensory: Not testable, although reacted in all 4 extremities.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 1 2 1
R 3 3 2 2 1
Plantar response was extensor on right, mute on left
-Coordination: Does not participate
-Gait: Not testable
Pertinent Results:
[**2113-1-1**] 09:07PM SODIUM-138
[**2113-1-1**] 09:07PM OSMOLAL-289
[**2113-1-1**] 09:06PM PT-17.5* PTT-30.1 INR(PT)-1.6*
[**2113-1-1**] 02:08PM SODIUM-140
[**2113-1-1**] 02:08PM OSMOLAL-295
[**2113-1-1**] 09:56AM PHENYTOIN-8.6* freepheny-0.8* %phenyfr-9
[**2113-1-1**] 08:01AM GLUCOSE-124* UREA N-10 CREAT-0.9 SODIUM-139
POTASSIUM-3.3 CHLORIDE-103 TOTAL CO2-29 ANION GAP-10
[**2113-1-1**] 08:01AM ALT(SGPT)-13 AST(SGOT)-20 LD(LDH)-165
CK(CPK)-37* ALK PHOS-84 TOT BILI-1.4
[**2113-1-1**] 08:01AM CK-MB-NotDone cTropnT-0.01
[**2113-1-1**] 08:01AM ALBUMIN-3.9 CALCIUM-8.8 PHOSPHATE-2.8
MAGNESIUM-1.8
[**2113-1-1**] 08:01AM OSMOLAL-295
[**2113-1-1**] 08:01AM PHENYTOIN-8.6*
[**2113-1-1**] 08:01AM WBC-10.1 RBC-3.98* HGB-11.3* HCT-34.8* MCV-87
MCH-28.3 MCHC-32.3 RDW-14.0
[**2113-1-1**] 08:01AM PLT COUNT-270
[**2113-1-1**] 08:01AM PT-17.7* PTT-29.6 INR(PT)-1.6*
[**2113-1-1**] 01:55AM GLUCOSE-161* UREA N-11 CREAT-1.0 SODIUM-141
POTASSIUM-3.3 CHLORIDE-101 TOTAL CO2-30 ANION GAP-13
[**2113-1-1**] 01:55AM estGFR-Using this
[**2113-1-1**] 01:55AM WBC-8.7 RBC-3.93*# HGB-11.3*# HCT-34.3*
MCV-87 MCH-28.9 MCHC-33.1 RDW-13.8
[**2113-1-1**] 01:55AM NEUTS-89.3* LYMPHS-7.3* MONOS-3.1 EOS-0.2
BASOS-0.1
[**2113-1-1**] 01:55AM PLT COUNT-257
[**2113-1-1**] 01:55AM PT-17.8* PTT-28.9 INR(PT)-1.6*
[**2113-1-3**] 03:10AM BLOOD PT-14.2* PTT-27.5 INR(PT)-1.2*
[**2113-1-3**] 03:10AM BLOOD Phenyto-11.2
[**2113-1-3**] 11:39AM BLOOD Osmolal-304
NCHCT [**2113-1-1**], 12:02 am:
FINDINGS: There is a large left frontal cerebral hemorrhage
measuring
approximately 4.9 x 4 cm with significant surrounding vasogenic
edema. There
is at least approximately 5 mm of midline shift and
effacement/mass effect
upon the ipsilateral and contralateral frontal horns of the
lateral
ventricles. There is effacement of the left mesencephalic
cistern worrisome
for early uncal herniation. Within the apex there is
hypoattenuation within
the subcortical white matter on the right. This may represent a
region of
post op-cystic encephalomalacia as patient has right craniotomy
changes in the
osseous structures of this region.
There is a left maxillary sinus mucus retention cyst. The
paranasal sinuses
and mastoid air cells are otherwise clear.
IMPRESSION:
1. Large left frontal lobe parenchymal hemorrhage with mass
effect upon the surrounding cortex and frontal horns of the
lateral ventricles. Effacement of the left perimesencephalic
cistern on the ipsilateral side is concerning for early uncal
herniation.
2. Hypoattenuation within the subcortical white matter of the
right parietal lobe is likely secondary to cystic
encephalomalacia from previous surgery.
MRI head [**2113-1-1**]:
FINDINGS:
Again noted is a large subacute hematoma in the left frontal
lobe causing
subfalcine herniation, of approximately 9 mm, which is unchanged
compared to the prior study. There is significant surrounding
edema and a small sliver of an extra-axial fluid collection.
No enhancing abnormality is seen to suggest an underlying mass.
There is restricted diffusion within the hematoma which can be
seen with
subacute hematomas.
There are a few scattered foci of signal dropout in a punctate
fashion in the left temporal and parietal lobes, which have
progressed since the prior study. These could be related to
amyloid angiopathy or old hypertensive microbleeds, if the
patient has the appropriate clinical history.
Again noted are changes from a right frontal craniotomy,
reportedly for
meningioma resection. There are encephalomalacic changes but no
evidence for recurrent or residual neoplasm.
No uncal herniation seen on this examination.
There are scattered small vessel ischemic sequelae in the
subcortical and
periventricular white matter and grossly stable since the prior
examination.
Intracranial flow voids are maintained.
There is a small left maxillary sinus mucous retention cyst.
IMPRESSION:
Large subacute left frontal hematoma with no definite underlying
mass noted.
Mild progression of punctate foci of signal dropout on the left
temporal and
parietal lobes with differential diagnostic considerations as
above.
Postoperative sequela in the right frontal lobe with no evidence
for residual
or recurrent neoplasm.
NCHCT [**2113-1-1**], 8:27 pm:
FINDINGS: There is no significant change in size, appearance,
or mass effect
of a large left frontal cerebral hemorrhage with surrounding
vasogenic edema.
No intraventricular hemorrhage or hydrocephalus is present.
There is
unchanged appearance to the intracranial cisterns.
NCHCT [**2113-1-2**]:
FINDINGS: Again seen is a large left frontal parenchymal
hemorrhage. There has been a gradual increase in the amount of
surrounding edema, as expected in the 24-48 hour period
following an acute hemorrhage. Subfalcine herniation remains
unchanged at approximately 6 mm. The cisterns remain normal.
Mass effect on the anterior [**Doctor Last Name 534**] of the left lateral ventricle
is also unchanged.
In addition, there has been no interval change in
encephalomalacia of the
right frontal lobe, adjacent to the old craniotomy.
IMPRESSION: Expected evolution of left frontal lobe parenchymal
hemorrhage, with small increase in surrounding edema. No other
interval change.
NCHCT [**2113-1-3**]:
FINDINGS: There has been no interval change in the large left
frontal
intraparenchymal hemorrhage with surrounding edema. Subfalcine
herniation is again unchanged, measuring approximately 6 mm.
Left lateral ventricle mass effect is also unchanged.
Again seen is scattered white matter hypodensities consistent
with
micro-endovascular disease, encephalomalacia in the right
frontal lobe
adjacent to the old craniotomy site, surgical changes in
bilateral globes
related to cataract surgery, and a retention cyst in the left
maxillary sinus.
IMPRESSION: No interval change in left frontal lobe
intraparenchymal
hemorrhage.
EEG [**2113-1-3**]:
Left hemispheric theta and delta slowing with bursts of
generalized slowing, no discharges or seizures seen (per initial
review, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]).
CXR [**2113-1-1**]:
Single portable radiograph of the chest demonstrates increased
airspace
opacity projecting over both lungs. There is blunting of the
bilateral
costophrenic angles, representing small pleural effusions.
Cardiomediastinal
contours are unchanged from [**2110-10-22**]. No pneumothorax. The
aorta is
tortuous. Deviation of the trachea from the midline to the
right is
attributable to the tortuous aorta. No consolidation is
evident.
IMPRESSION:
Pulmonary edema and small bilateral pleural effusions.
CXR [**2113-1-3**]:
Bilateral worsened perihilar opacity probably moderate pulmonary
edema.
New retrocardiac opacity with volume loss, likely represents
edema with
component of atectasis. Cannot exclude pneumonia. No
pnuemothorax. NGT okay position.
Brief Hospital Course:
Mr. [**Known lastname 8494**] is an 88 year old gentleman with hypertension, atrial
fibrillation on coumadin and prior R frontal meningioma
resection who presented with large left frontal lobe hemorrhage.
Given a hemorrhage in the setting of a supratherapeutic INR on
coumadin, the patient was admitted to the neurologic ICU for
closer observation and management. An MRI on [**2113-1-1**] showed no
underlying vascular abnormality or mass, but a few scattered
foci of signal dropout in a punctate fashion in the left
temporal and parietal lobes were suggestive of amyloid
angiopathy or old hypertensive bleeds. For correction of his
coagulopathy on warfarin, the patient received 2 units FFP and
10 mg Vitamin K on day 1 in the unit, and 1 unit FFP and 10 mg
more Vitamin K on day 2. His INR corrected to 1.3 on [**1-2**], then
to 1.2 on [**1-3**] with a third day and final day of Vitamin K. On
his first evening in the unit, the patient was noted to be more
lethargic, having more difficulty following commands, and with
further reduction in speech output. A repeat head CT showed no
significant change. He was continued on dilantin for seizure
prophylaxis, with therapeutic levels on [**2113-1-2**]. His poor mental
status persisted on [**2113-1-2**], and a repeat head CT showed a small
increase in his edema surrounding the lesion. His mannitol was
therefore increased to 50 grams q 6 on the morning of [**1-2**].
Given improved hypertensive control, nicardipine was dicontinued
on [**1-2**]. A urinalysis was suggestive of a UTI and the patient
was started on a course of bactrim on [**1-2**] (> 100,000 GNR). An
EEG performed on the morning of [**2113-1-3**] showed no discharges or
evidence of seizure, only left hemispheric slowing likely
associated with the hemorrhage. On attending rounds, the
patient seemed more awake and alert. He was following commands
with his extremities and holding both arms and legs antigravity.
Given some residual hypertension and tachycardia in the setting
of atrial fibrillation, the patient was started on a low dose
beta-blocker. The patient was not alert enough to pass a
bedside swallow exam, and an NG tube and tube feeds were begun.
A repeat CXR on [**2113-1-3**] showed bilateral worsened perihilar
opacity suspicious for pulmonary edema with atelectasis;
pneumonia could not be excluded. Given peristing low grade
fevers and an increasing WBC, he was empirically started on
levaquin for coverage of possible pneumonia. Over the next 24
hours, his WBC dropped and he remained afebrile. Given the
stability of the bleed, mannitol was tapered to 25 mg IV q 8
hours and heaprin SQ was started for venous thromboembolism
prophylaxis. He had a low phosphorus level, which was being
repleted with neutraphos. Hemoglobin A1c was within normal
limits and his lipid profile was satisfactory on a statin.
The [**Hospital 228**] hospital course did not reveal significant
improvement in his neurologic status despite maximum medical
management for elevated ICP and cerebral edema. EEG revealed
slowing and prior skull defect, but no epileptiform dishcharges.
He began to take small amounts of food by mouth prior to
discharge. Goals of care were discussed with the patient's
family and palliative care consultation was obtained. The
patient would not want life sustaining treatment without
reasonable expectation for meaningful recovery. Mr. [**Known lastname 29666**]
neurologic status may show signs of improvement while in hospice
care. However given the severity of hemorrhage and mass effect
he will likely remain aphasic with right hemiplegia/hemiparesis
as a best case scenario. Discussion with his family indicated
that the patient would not consider this an acceptable quality
of life. He was made DNR/DNI and transitioned to hospice care.
Medications on Admission:
Coumadin, unknown dose
Prozac, unknown dose
Ranitidine, unknown dose
Lipitor 10 mg po daily
Lisinopril 10 mg po daily
Discharge Medications:
1. Ativan 1 mg Tablet Sig: 1-2 Tablets PO every four (4) hours
as needed for anxiety or agitation.
Disp:*30 Tablet(s)* Refills:*2*
2. Oxycodone 20 mg/mL (1 mL) Concentrate Sig: [**5-16**] milliliters
PO q1hr as needed for pain or breathlessness.
Disp:*qs 14 day supply* Refills:*2*
3. Acetaminophen 650 mg Suppository Sig: [**12-28**] Rectal every six
(6) hours as needed for pain.
Disp:*30 tab* Refills:*2*
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for abulia.
Disp:*30 Tablet(s)* Refills:*2*
6. Phenytoin 100 mg/4 mL Suspension Sig: Four (4) ml PO three
times a day.
Disp:*30 day supply* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 14710**] House (Hospice Home) - [**Location (un) 620**]
Discharge Diagnosis:
Left Frontal Lobe Hemorrhage
Amyloid Angiopathy
Atrial Fibrillation
Discharge Condition:
Opens eyes to voice. Does not follow commands.
Discharge Instructions:
You were admitted for a large left frontal brain hemorrhage.
Followup Instructions:
Hospice care
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]
|
[
"486",
"427.31",
"V15.82",
"401.9",
"784.3",
"530.81",
"277.39",
"790.92",
"431",
"599.0",
"600.00",
"342.90",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
14681, 14781
|
9866, 13675
|
228, 234
|
14893, 14942
|
2931, 9843
|
15052, 15160
|
1318, 1322
|
13844, 14658
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14802, 14872
|
13701, 13821
|
14966, 15029
|
2067, 2912
|
1337, 1891
|
177, 190
|
262, 1072
|
1906, 2050
|
1094, 1216
|
1232, 1302
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,933
| 149,689
|
1476
|
Discharge summary
|
report
|
Admission Date: [**2120-1-14**] Discharge Date: [**2120-1-24**]
Service: MICU
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old man with
past medical history of hypertension, atrial fibrillation,
and bladder stones who was brought into the hospital with a
temperature of 101.5 and generalized fatigue.
In the ER he was found to be satting 78% on room air. His
fever increased to 103.4. He became delirious.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Benign prostatic hypertrophy.
3. Hypothyroidism.
4. Mild anemia.
5. Nephrolithiasis.
6. Atrial fibrillation.
7. Diverticulosis.
8. Coronary artery disease.
MEDICATIONS:
1. Accupril.
2. Proscar.
3. Synthroid.
4. Aspirin.
5. Lasix.
6. Hydrochlorothiazide.
7. Flomax.
8. Vitamin E.
9. Vitamin B.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He lived in an [**Hospital3 **] home. He is
a retired pulmonologist. Feeds himself but needs assistance
with all activities of daily living.
LABORATORY AND STUDIES DATA: Chest x-ray showed aspiration
pneumonitis versus acute pulmonary edema.
PHYSICAL EXAMINATION: Temperature is 103.4, blood pressure
and heart rate are stable, sat is 78% on room air which
increased to 100% on 6 liters. Exam: Cardiac: Irregular
rate; II/VI systolic murmur. Chest: Diffuse rhonchi
throughout; expiratory wheezes; no focal rales.
The patient was admitted to the Medical Intensive Care Unit.
HOSPITAL COURSE BY SYSTEMS:
1. Fevers: The patient was started on Clindamycin and
Levaquin. Blood cultures, urine cultures, sputum cultures
were sent. The patient also was cultured for influenza. It
ended up being positive. He was started on Amantadine, and
he completed a course of Amantadine as well as a seven-day
course of Clindamycin, Levaquin, and Ceftriaxone.
2. Desaturation: The patient was intubated for hypoxic
respiratory failure. He was extubated on [**2120-1-24**] as he
and his family decided to make him comfort measures only.
3. Hypertension: The patient had episode of hypertension
with his acute hypoxia. He was started on Accupril and
Lasix. During his hospital course he had to be placed on a
nitro drip for blood pressure control. The nitro drip was
discontinued on [**2120-1-23**].
For his atrial fibrillation he was continued on aspirin and
beta blocker. For his benign prostatic hypertrophy he was
continued on his Proscar and Flomax.
The patient passed away on [**2120-1-24**] when the family decided
that he had been optimally medically managed, and they felt
that he would not make meaningful recovery. The patient was
pronounced at 3:56 p.m. on [**2120-1-24**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Name8 (MD) 8736**]
MEDQUIST36
D: [**2120-3-18**] 16:16
T: [**2120-3-20**] 22:25
JOB#: [**Job Number 8737**]
|
[
"518.81",
"410.91",
"584.9",
"599.7",
"707.0",
"507.0",
"038.9",
"427.31",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.72",
"38.93",
"96.6",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
1462, 2903
|
1117, 1434
|
117, 438
|
460, 830
|
847, 1094
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,156
| 176,300
|
18708
|
Discharge summary
|
report
|
Admission Date: [**2160-10-3**] Discharge Date: [**2160-10-7**]
Date of Birth: [**2074-6-3**] Sex: M
Service: NEUROLOGY
Allergies:
Iodine-Iodine Containing
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Stroke in the setting of cardiac cath
Major Surgical or Invasive Procedure:
cardiac catheterization, failed angioplasty
History of Present Illness:
Mr. [**Known lastname 34909**] is an 86 year old man with a hx of CAD s/p CABG in
[**2143**], PCI with DESx3 to SVG-OM in [**2157**] who was referred for
urgent cardiac cath in the setting of increasing anginal
symptoms. Per OMR, the patient has been experiencing chest and
back pain for the past month occurring at rest and with
exertion.
He was seen by Dr. [**Last Name (STitle) **] in early [**Month (only) **] and his Imdur was
increased to 120mg daily. Since then he has continued to have
increasing chest pain at rest, including 2 episodes on [**2160-10-2**]
requiring several nitroglycerin for relief. Dr. [**Last Name (STitle) **] was
notified and has recommended urgent urgent catheterization. Per
the patient's family, he has otherwise been in his usual state
of health lately.
.
In the cath lab, balloon angioplasty was performed to the OM2,
an intervention was about to be performed on the OM1, but the
patient suddenly woke up and was aphasic. Stroke team called,
patient sent for CTA of the head, which showed no bleed or
visible occlusion. In the cath lab, he was started on a
bivalirudin drip, but transitioned to a heparin drip at the
advice of the stroke team.
Upon stroke consult, initial exam was remarkable for
significantly impaired speech with some preserved repetition of
short words but otherwise unintelligible. Also had R facial
droop and some difficulty with fine movements of R hand but
otherwise full strength throughout. CT head showed no acute
intracranial process and CTA showed no major vessel occlusion.
MRI performed [**10-4**] showed bilateral partial small middle
cerebral artery territorial infarcts. Transferred to the
neurology service for further management.
Past Medical History:
. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CABG: CABG [**2143**] at [**Hospital1 1774**], LIMA to LAD, SVg to D1 (known
occluded), SVG to PDA (known occluded), SVg sequential to
OM1-OM2
- PERCUTANEOUS CORONARY INTERVENTIONS: [**12-11**] s/p stenting of
SVG to OM with 3 drug eluting stents
3. OTHER PAST MEDICAL HISTORY:
atrial fibrillation - on Coumadin
bph s/p turp x2 c/b post operative hemorrhage
[**9-/2147**] TIA
[**2142**] cholecystectomy
[**4-11**] CT of chest: pleural changes c/w asbestos exposure
inguinal hernia repair x 3
hard of hearing
cataract surgery bilaterally
CHF
asbestosis
s/p flu shot last week
emergency appendectomy [**2-15**] in [**State 108**]; since then having some
short term memory issues
Social History:
Lives with his wife, is a retired driver for the T.
- Tobacco history: none
- ETOH: wife denies
- Illicit drugs: none
Family History:
son with ASD and stroke. father with a stroke in his 40s.
Physical Exam:
Admission Exam
VS: T=96.1 BP=188/58 HR=70s RR18 O2 sat 97% on RA
GENERAL: elderly male, NAD, well-nourished, cooperative
HEENT: NCAT. EOMI. mild, right sided facial droop.
CARDIAC: irregularly irregular, S1, S2. No murmurs appreciated
LUNGS: CTAB anteriorly
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. right femoral cath site with no hematoma
or bruit
Neuro: moves all four extremities equally, normal tone, no
pronator drift
PULSES: DP pulses dopplerble b/l
Exam upon neurology transfer:
SBP 190 HR 90 RR 16 Sat 95% RA
General: well nourished, well kept, calm, cooperative
Heart: no murmurs heard
Lungs clear
Abd soft to palpation
Neurological exam:
MS: awake, alert
Speech: anarthric
Language: sounds, cannot comprehend. Follows commands crossing
midline. cannot repeat. Can write basic things.
CN: Pupils are 3 mm, round and reactive although surgical.
Recognizes waiving hands bilaterally by pointing. Patient can
track light source with preserved lateral gaze. R facial
weakness. Tongue protrudes to the right.
Motor: Strength is [**5-8**] in all four extremities (difficult to
test
the RLE due to femoral access). Tone is normal. No drift.
DTRs symmetrical on biceps and knees
[**Last Name (un) **]: LT seems preserved, including face
Coord:: No dysmetria on UEs
Plantar responses flexor b/l
GAIT: deferred
Exam upon discharge:
GENERAL: elderly male, NAD, very pleasant
HEENT: NCAT. EOMI. +right sided facial droop.
CARDIAC: irregularly irregular, S1, S2. No murmurs appreciated
LUNGS: CTAB anteriorly
ABDOMEN: Soft, NTND. +BS
EXTREMITIES: No c/c/e.
General: well nourished, well kept, calm, cooperative
Heart: no murmurs heard
Lungs clear
Abd soft to palpation
Neurological exam:
Mental status: Alert and oriented x 3. Language significantly
improving, able to produce some spontaneous words and short
sentences. Still difficult to understand due to significant
dysarthria. Comprehension and repetition intact.
Follows commands well.
CN: Pupils 3mm to 2mm bilaterally. EOMI, VFF. +R lower facial
weakness. Tongue protrudes to the right.
Motor: Strength is [**5-8**] throughout. Tone is normal. No drift.
DTRs symmetrical on biceps and knees
[**Last Name (un) **]: intact to light touch
Coord:: No dysmetria on UEs
Plantar responses flexor b/l
GAIT: ambulates steadily with assistance
Pertinent Results:
[**2160-10-3**] 10:20AM BLOOD WBC-7.6 RBC-4.63 Hgb-13.3* Hct-39.8*
MCV-86 MCH-28.6 MCHC-33.3 RDW-15.0 Plt Ct-126*
[**2160-10-3**] 10:20AM BLOOD Neuts-58.4 Lymphs-28.4 Monos-5.3 Eos-7.3*
Baso-0.5
[**2160-10-3**] 10:20AM BLOOD PT-18.3* PTT-29.5 INR(PT)-1.6*
[**2160-10-3**] 10:20AM BLOOD Glucose-104* UreaN-28* Creat-1.6* Na-142
K-4.5 Cl-105 HCO3-29 AnGap-13
[**2160-10-3**] 10:44PM BLOOD Calcium-8.7 Phos-3.5 Mg-2.1
CT/CTA [**2160-10-3**]:
1. Head CT shows no evidence of hemorrhage. No definite loss of
[**Doctor Last Name 352**]-white
matter differentiation seen. Small vessel disease and brain
atrophy noted.
2. CT angiography of the neck demonstrates calcification in both
carotid
bifurcations, but no evidence of high-grade stenosis. The right
vertebral
artery is only faintly visualized.
3. CT angiography of the head demonstrates some evidence of
decreased
branching in the region of left middle and left sylvian fissure
which could be secondary to an evolving infarct or slow flow in
the region. Subsequent MRI can help for further assessment to
exclude infarct in this location and clinical correlation is
also recommended. There is no evidence of occlusion of main
vascular structures seen. Calcification is seen in the left
vertebral artery and mild atherosclerotic disease is seen in the
basilar artery.
Brain MRI [**2160-10-4**]: There are areas of restricted diffusion seen
bilaterally in the frontal lobes in the distribution of the
middle cerebral artery indicative of small bilateral partial
middle cerebral artery territorial infarcts. There is no
evidence of hemorrhage seen. There is brain atrophy seen. There
is no midline shift. Soft tissue changes seen in the right
maxillary sinus.
TTE 10/3/1:
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function. Mild-moderate aortic
regurgitation. Mild-moderate mitral regurgitation. Pulmonary
artery hypertension. Dilated thoracic aorta. No definite cardiac
source of embolism identified.
Brief Hospital Course:
Mr. [**Known lastname 34909**] was admitted on [**10-3**] and was brought to the cardiac
cath lab for angioplasty to relieve anginal symptoms. In the
cath lab, he developed difficulty speaking and the procedure was
halted before the angioplasty was completed. The stroke service
was consulted.
Upon stroke consult, initial exam was remarkable for
significantly impaired speech with some preserved repetition of
short words but otherwise unintelligible. Also had R facial
droop and some difficulty with fine movements of R hand but
otherwise full strength throughout. CT head showed no acute
intracranial process and CTA showed no major vessel occlusion.
MRI performed [**10-4**] showed bilateral partial small middle
cerebral artery territorial infarcts. Transferred to the
neurology service for further management.
He was started on a heparin drip due to the likely cardioembolic
source for his stroke. His exam remained stable with some
improvement of his aphasia during his stay. He continued to have
a right facial droop but no significant strength deficits. TTE
showed mild symmetric left ventricular hypertrophy with
preserved systolic function with EF >55%. He was continued on
pravastatin for his hyperlipidemia. HbA1c was 6.5%; he was
maintainted on insulin sliding scale during his admission. Per
discussion with his cardiologist he was transitioned from the
heparin drip to Pradaxa 150mg [**Hospital1 **]. He was continued on aspirin
81mg daily.
He was seen by PT, OT, and speech therapy who recommended
discharge to acute rehab. A video swallow study showed
aspiration of thin liquids and he was started on a heart healthy
diet with regular solids and nectar thick liquids.
He was discharged on [**2160-10-7**] in good condition. He will follow
up with his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] as well as Dr. [**Last Name (STitle) **] in stroke
clinic. Pharmacy recommended monitoring of his renal function on
Pradaxa as his Cr was slightly high on admission. This has now
resolved and we have advised him to have an electrolyte panel
drawn at his follow-up visit with his PCP.
Medications on Admission:
FUROSEMIDE [LASIX] - 40 mg Tablet - 1 Tablet(s) by mouth daily
alternating with 60mg
ISOSORBIDE MONONITRATE - - 120 mg Tablet Extended Release 24 hr
- 1 Tablet(s) by mouth qam
LOSARTAN - 100 mg Tablet daily
METOPROLOL SUCCINATE - 25 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth twice a day
MOM[**Name (NI) **] [[**Name2 (NI) **] TWISTHALER] - (Prescribed by Other
Provider)
- Dosage uncertain
NITROGLYCERIN - (Prescribed by Other Provider) - Dosage
uncertain
OMEPRAZOLE - 20 mg Capsule, 1 Capsule(s) by mouth twice a day
POTASSIUM CHLORIDE [KLOR-CON 10] - 10 mEq Tablet Extended
Release - 1 Tablet(s) by mouth daily
PRAVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth qpm
WARFARIN - 2 mg Tablet - 1 Tablet(s) by mouth daily last dose
[**10-1**]
ASPIRIN - 81 mg Tablet,
Chewable - 1 Tablet(s) by mouth qam
CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - 1000 mg monthly
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or fever.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
9. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
12. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
13. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Bilateral middle cerebral artery strokes
Discharge Condition:
Condition: good
Mental status: improving nonfluent aphasia, comprehension intact
Ambulatory status: ambulates with assistance
Discharge Instructions:
Dear Mr. [**Known lastname 34909**],
You were admitted to [**Hospital1 69**] on
[**2160-10-3**] due to difficulty speaking after a heart procedure. You
were found to have small strokes on both sides of your brain.
The stroke on the left side is likely responsible for your
speech difficulties. Your speech should improve with time and
appropriate rehabilitation.
We made the following changes to your medications:
STARTED Pradaxa 150mg twice a day
We held some of your blood pressure medications during your
admission to help maintain good blood flow to your brain in
light of your stroke. These may be slowly started back as per
your primary care physician after your discharge.
If you experience any of the below listed danger signs, please
call your doctor or go to the nearest Emergency Department.
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
You have an appointment with your primary care doctor Dr. [**Last Name (STitle) **]
on [**10-16**] at 11am. You need to have an electrolyte panel
drawn at this appointment to check your kidney function.
[**Hospital 4038**] clinic follow-up:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2160-11-7**] 2:00
**You need to call the office prior to this appointment in order
to update your information in the system**
|
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5,060
| 151,109
|
24312+57395
|
Discharge summary
|
report+addendum
|
Admission Date: [**2183-1-11**] Discharge Date: [**2183-1-14**]
Date of Birth: [**2144-9-28**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5123**]
Chief Complaint:
Abdominal pain, EtOH withdrawl
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 24927**] is a 38-year-old homeless male with long history of
EtOH and heroin abuse, prior EtOH withdrawals, HCV, HBV, and
depression who presented to the ED complaining of abdominal
pain. Of note, he has presented to the ED numerous times with
withdrawal, last discharged on [**2182-11-12**] with similar complaint.
Hx of alcohol seizures, DTs. Also history of exaggerating
symptoms so he can obtain more diazpeam per previous psychiatry
notes.
In the emergency room the patient's vitals were 97 117 168/126
18 99.
He received 20mg IV diazepam, 10mg PO diazepam, 1mg IM dilaudid
x2, and PO dilaudid for abdominal pain in addition to a banana
bag. CT abdomen/pelvis obtained with wet read: Mild gastric wall
thickening could reflect gastritis. No perforation or bowel
abnormalities. Fatty liver. Labs notable for elevated AST/ALT
to mid 200's, ETOH 366 and + benzos. Lipase 78 but consistently
elevated on prior admissions. Lactate 5.2, but down to 3.1 on
repeat. ABG 7.6/20. Admitted to ICU initially for further
management.
Past Medical History:
Polysubstance abuse (alcohol, heroin, IVDU, benzodiazapines)
Hepatitis C
Hepatitis B
Anxiety
Depression
Seizures from alcohol withdrawal
Compartment syndrome of RLE in [**2171**]
Chronic bilateral hand swelling
hx of ?scabies or another form of eczematous/irritant
dermatitis [**2182-5-26**]
Social History:
From Mass originally. Not in contact with any family members,
never married, no children. Homeless, lives at [**Location (un) 7073**] T
station. Panhandles for money; has SSI and rep-payee, [**Doctor First Name **] at
Community Action in Cities in [**Location (un) **] and she in turns sends him
a check for $125/week to [**Location (un) 33316**] House. Currently drinks one
fifth of listerine and [**2-8**] fifths rum daily. Substance use hx:
Long and severe hx of alcohol with self-reported withdrawal
seizures and DTs; states that when he can't use alcohol he will
use other "medications" including BZPs and narcotics. Multiple
detoxes, multiple Section 35s. Also history of opiates and IVDU.
Family History:
He reports his father had depression, alcoholism and
questionable OCD. Mother had diabetes. Otherwise, patient
refusing to answer additional family questions medical history
Physical Exam:
On Admission:
HEENT: Sclera slightly icteric, slightly dry MM, extremely poor
dentition.
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: Patient appears to be making abdominal muscles rigid.
Grimaces with palpation, but not consistently.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
On Discharge:
GEN: sleeping, uncooperative, not in apparent distress,
breathing comfortably
Lungs: CTA b/l
CV: RRR
Abd: soft, no HSM, no distention
Ext: Trace nonpitting edema
Pertinent Results:
[**2183-1-11**] 06:55PM WBC-5.4# RBC-4.52* HGB-12.6* HCT-38.7* MCV-86
MCH-27.9 MCHC-32.6 RDW-14.9
[**2183-1-11**] 06:55PM NEUTS-39.3* LYMPHS-50.6* MONOS-3.7 EOS-5.1*
BASOS-1.3
[**2183-1-11**] 06:55PM PLT COUNT-234#
[**2183-1-11**] 06:55PM GLUCOSE-161* UREA N-14 CREAT-0.9 SODIUM-145
POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-21* ANION GAP-20
[**2183-1-11**] 06:55PM GLUCOSE-162* LACTATE-5.2* NA+-147 K+-3.7
CL--108 TCO2-20*
[**2183-1-11**] 06:55PM ALT(SGPT)-203* AST(SGOT)-249* ALK PHOS-122*
TOT BILI-0.4
[**2183-1-11**] 06:55PM LIPASE-78*
[**2183-1-11**] 06:55PM ALBUMIN-4.5
[**2183-1-11**] 06:55PM ASA-NEG ETHANOL-366* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2183-1-11**] 09:16PM LACTATE-3.1*
CT abd/pelvis: Suggestion of gastric wall thickening, which
could be related to underdistension, or gastritis. Fatty liver.
Brief Hospital Course:
38 yr old male h/o ETOH abuse and withdrawl seizures presenting
with ETOH withdrawal and abdominal pain.
.
# ETOH withdrawal: H/o polysubstance abuse and multiple previous
admits for detox/drug seeking behavior. Initially presented
intoxicated, agitated in the ED requiring multiple sedating
medications including valium (received 20mg IV, 10mg PO) however
on admission to the MICU he did not require further benzos. No
evidence of withdrawl objectively, evaluated by psych and not
felt to be in active withdrawl. Pt has h/o malingering and knows
how to manipulate CIWA scale. Patient received banana bag, IVF
resuscitation while in ICU. Since has been able to tolerate PO
and not required futher benzos while on floor. Given MVI and
folate daily.
.
# Abdominal Pain: Unclear etiology, initial exam with epigastric
tenderness. Had a CT demonstrating gastritis likely secondary
to ingestion of listerine, alcohol. Also may have a component
of pain related to his ongoing chronic HBV/HCV and ETOH
ingestion, given his fatty liver demonstrated on CT and mild
transaminits on admission. These trended down during his
hospitalization. He also had an elevated lipase, however he has
had similar levels on previous admissions so this appears to be
a chronic problem. Additionally, abdominal pain is difficult to
interpret given patient's frequent complaints and refusal to
allow physical exam. He initially refused medications for
gastritis including PPI and GI cocktail. He was also given
sucralfate but took this only intermittently. On admission,
foley placement resulted in UOP of 500cc and there was initial
concern about urinary retention, however since foley d/c, pt has
been able to void on his own.
.
# Suicidal Ideation: Reported SI while intoxicated in the ED.
Seen and cleared by psychiatry. No SI at this time, no clear
plan. No sitter required, does not meet criteria for section
12.
.
# Anemia: HCT near baseline. Likely anemia of chronic disease.
Normal MCV. Hct stable throughout admission.
.
# FEN: Magnesium and potassium repleted in ICU. Pt is
tolerating PO fluids.
Medications on Admission:
None
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Gastritis
Alcohol intoxication
Secondary diagnosis:
Alcohol abuse
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive although
uncooperative
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted to the hospital with abdominal pain and for
protection from alcohol withdrawl. You had a CT scan that
demonstrated that you have inflammation of your stomach called
gastritis. Also there is some evidence of damage to your liver,
which is also refleted by some abnormalities in your labs. This
is related to your heavy alcohol consumption. You did not
experience alcohol withdrawal seizures during this
hospitalization and therefore did not need medications for that.
It is important that you stop drinking because it is damaging
to your health and if you continue to drink heavily you will
die.
You were started on several new medications for your abdominal
pain and for your alcohol use.
Followup Instructions:
You will have an appointment scheduled with a physician within
the next week. Please call [**Telephone/Fax (1) 250**] to set this up.
Name: [**Known lastname 5188**],[**Known firstname 801**] Unit No: [**Numeric Identifier 11140**]
Admission Date: [**2183-1-11**] Discharge Date: [**2183-1-14**]
Date of Birth: [**2144-9-28**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 11141**]
Addendum:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11142**] at [**Hospital1 2239**] -> home care for homeless knows this
patient and has followed him previously as PCP. [**Name10 (NameIs) **] clinic
Thursday am, which pt knows about.
clinic [**Telephone/Fax (1) 11143**]
pg [**Telephone/Fax (1) 11144**]
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11145**] MD [**MD Number(2) 11146**]
Completed by:[**2183-1-14**]
|
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|
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8738, 8903
|
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|
303, 309
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63,351
| 154,914
|
8738
|
Discharge summary
|
report
|
Admission Date: [**2103-1-28**] Discharge Date: [**2103-2-1**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
IR guided Dobhoff N-J tube
Left arm casting
History of Present Illness:
This is a [**Age over 90 **] year-old female with a history of dementia, HTN who
had a recent fall on [**1-22**] complicated by L humerus fracture
presents with aspiration pneumonia. The patient was in her
usual state of health until she had a fall at rehab during a bed
transfer. She had a head laceration and was brought to the ED
on [**1-22**] with negative CT head/neck and received sutures to her
laceration. The patient was discharged back to her rehab, but
was noted to have swelling of her left arm with associated pain.
She was brought back to the ED and x-rays revealed a oblique
supracondylar fracture involving the distal humerus without
articular extension or displacement. The patient was seen by
ortho and was managed non-operatively with a splint.
.
On [**1-26**] the patient had a witnessed aspiration event at rehab
and then was febrile to 101. A CXR obtained at rehab showed a
RLL opacity and she was started on CTX. The patient had
worsening hypoxia with desats to 85-92%, cough and mental
status. The patient has documentation for DNR/DNI/DNH per prior
records. The facility called the son and wanted her to be
brought to [**Hospital1 18**].
.
In the ED, 97.2 56 106/61 24 94% NRB. She had a CXR that showed
RLL opacity. She was treated empirically with
Zosyn/Vanco/Levofloxacin. His labs were significant for a
leukocytosis of 13.5. Additionally, her sodium was 157. She
received 1L NS and 500cc D5. The patient's HCP (son- [**Name (NI) **] was
contact[**Name (NI) **] and stated that she has had a dramatic decline since
her fall. He wanted "aggressive" measures taken including
intubation, however, did not want chest compressions. The
patient stated that he was taking a flight from [**State 4565**] and
will arrive at 11pm tonight. VS prior to transfer were: 97.4
120/60 87 20 94% NRB.
.
I called the patient's HCP prior to him departing for his flight
and confirmed that he wanted intubation and other procedures
such as CVL. He did not want any of her "bones broken" during
CPR and therefore confirmed she is DNR. Given he was boarding
his flight we could not fully discuss Ms. [**Last Name (Titles) 30572**] goals of care,
but agreed we would address them when he arrived. In the mean
time she will remain DNR, but able to be intubated.
.
ROS:
Unable to obtain
.
Past Medical History:
Dementia
HTN
HL
Gastritis
Social History:
The patient lives at [**Hospital 100**] Rehab and does not perform any ADL's
Family History:
mom with stroke
Physical Exam:
On Admission:
GEN: using some accessory muscle use, eyes closed and does not
respond to voice and only minimally to pain
HEENT: 3mm pupils b/l, sclera anicteric, no epistaxis or
rhinorrhea, dry MM
NECK: No JVD, no cervical lymphadenopathy, trachea midline
COR: difficult to hear heart sounds over rhonchi, RRR, normal S1
S2
PULM: diffuse and coarse rhonchi thoughtout no W/R
ABD: umbilical hernia, soft, NT, ND, +BS
EXT: No C/C/ trace edema
NEURO: does not respond to voice. only minimally responds to
painful stimuli. CN II ?????? XII grossly intact.
SKIN: deep tissue ulcer over the coccyx
Pertinent Results:
[**2103-1-28**] 01:50PM WBC-13.5* RBC-2.91* HGB-8.4* HCT-26.7* MCV-92
MCH-28.8 MCHC-31.4 RDW-14.7
[**2103-1-28**] 01:50PM PLT COUNT-299
[**2103-1-28**] 01:50PM NEUTS-86.7* LYMPHS-8.8* MONOS-4.0 EOS-0.1
BASOS-0.3
[**2103-1-28**] 12:20PM GLUCOSE-319* UREA N-70* CREAT-1.0 SODIUM-157*
POTASSIUM-4.7 CHLORIDE-120* TOTAL CO2-24 ANION GAP-18
[**2103-1-28**] 12:20PM LD(LDH)-351* TOT BILI-0.5 DIR BILI-0.2 INDIR
BIL-0.3
[**2103-1-28**] 06:33PM GLUCOSE-340* LACTATE-1.8 NA+-153* K+-3.7
CL--120*
[**2103-1-28**] 06:00PM URINE HOURS-RANDOM
[**2103-1-28**] 06:00PM URINE OSMOLAL-597
[**2103-1-28**] 06:00PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.019
[**2103-1-28**] 06:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-70 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2103-1-28**] 06:00PM URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-1
[**2103-1-28**] 06:00PM URINE GRANULAR-1* HYALINE-1*
.
Micro:
URINE CULTURE (Final [**2103-1-29**]): NO GROWTH.
.
Legionella Urinary Antigen (Final [**2103-1-29**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
.
Blood cx: NGTD
.
[**2103-1-29**] 9:28 am SPUTUM Source: Expectorated.
**FINAL REPORT [**2103-1-29**]**
GRAM STAIN (Final [**2103-1-29**]):
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
.
Imaging:
Left Upper Extremity Plain film
IMPRESSION: Overall limited study as detailed above. There is an
obvious
oblique supracondylar fracture involving the distal humerus with
no
intra-articular extension and displacement as above. Grossly,
the shoulder
and wrist joints are intact.
.
CT-head [**1-22**].
IMPRESSION:
1. No acute intracranial process.
2. Global atrophy and chronic small vessel ischemic change.
3. Laceration over the right frontal scalp.
.
CT C-spine [**1-22**]
IMPRESSION:
1. No acute fracture or change in alignment of the cervical
spine.
2. Multilevel cervical spondylosis with mild to moderate central
canal
narrowing.
CXR: [**1-31**]
FINDINGS: In comparison with the study of [**1-30**], the monitoring
and support
devices remain in place. The area of opacification at the right
base may be increasing with poor definition of the
hemidiaphragm. This suggests worsening of the previously
described pneumonia and possible associated pleural effusion.
The left lung remains essentially clear.
.
CXR: [**1-28**]
INDICATION: [**Age over 90 **]-year-old woman with desaturations.
COMPARISON: Chest radiograph from [**2103-1-23**].
ONE VIEW OF THE CHEST: The lungs are low in volume and
evaluation is limited secondary to rotation. Within these
limitations there is a new right middle lobe opacity. The
cardiac silhouette is normal. The mediastinal silhouette shows
calcifications within it which may represent calcified lymph
nodes. The hilar contours and pleural surfaces are normal. No
pleural effusions are present.
IMPRESSION: Right middle lobe opacity, likely pneumonia. Repeat
radiography after therapy recommended to document resolution.
Calcified aorticopulmonary window lymph nodes are unchanged.
Brief Hospital Course:
This is a [**Age over 90 **] year-old female with a history of dementia, HTN who
had a recent fall on [**1-22**] complicated by L humerus fracture
presents with hypoxia likely secondary to an aspiration
pneumonia.
.
Plan:
#. ASpiration pneumonia/healthcare associated pneumonia: Pt with
witnessed aspiration event on [**1-26**] with new radiographic
evidence of a RLL infiltrate. On arrival patient was hypoxic,
saturating 94% on a NRB. She has been febrile at rehab. Labs
notable for elevated leukocytosis of 13.5. Urine legionella
negative. Sputum culture sent but poor quality (>10 epithelial
cells)Patient broadly covered on admission with Zosyn,
Vancomycin and Ciprofloxacin. Ciprofloxacin later discontinued
and patient maintained on Vanc, Zosyn for planned 8day course to
be completed on [**2103-2-4**]. Patient weaned off NRB and saturating
well on NC. At time of transfer to floor patient saturating >95%
4L NC. Oxygenation also improved after diuresis with IV lasix on
[**1-30**]. LOS fluid balance 4.8L.
.
# Left humerus fracture. Patient s/p fall on [**1-22**] with
radiographic evidence of fracture. Pain control with tylenol.
Underwent casting on [**2103-2-1**] by orthopedics. She needs to have
an Xray in 2 weeks. This Xray can be sent to orthopedics from
[**Hospital 100**] Rehab, patient herself does not have to physically
present for follow-up.
.
#. Hypernatremia: On admission patient's free H2O deficit
calculated to be 4.6L. Patient received IV hydration and Na
slowly corrected.
.
#. Anemia: Pt Hct is 26.7 which is below her baseline of low
30's. There is no evidence of active bleeding, but she did have
a recent fall. No evidence of large hematoma on exam, imaging
without evidence of bleeding. Hemolysis labs negative. Stools
guaiac negative. HCT did slowly down trend throughout ICU stay.
She received 1u of pRBCs on [**1-31**] with appropriate increase in
her hct. Iron studies pending, but were sent after transfusion
so interpretation may be limited.
.
#. Altered Mental Status: Likely from her dementia, but worsened
given her infection and hypernatermia. Pt with neg head CT-head
on [**1-22**] without new trauma. Patients infection and
hypernatremia treated with little change in mentation
.
#. Leukocytosis: Likely source is pneumonia as above. Currently
hemodynamically stable. UA/UCx negative. Blood cultures NGTD.
Leukocytosis improving with treatment of PNA.
.
# HTN: Largely normotensive in ICU while holding home BB given
infection. Restarted after transfer to floor at atenolol 25mg
daily, may increase to 50 mg daily (her usual dose) if bp
tolerates.
.
# FEN: IVF prn/ repelete electrolytes/ NPO, nutrition consulted
for TF, reccomended Fibersource at goal 45cc/hr (1296kcal);
doboff placed on [**1-31**] with post-pyloric placement by IR on [**2-1**].
Per report, plan was to keep this in place x 21 days and then
reasses swallowing while at rehab.
.
#. Goals of Care: Pt with documentation of DNR/DNI/DNH. However,
after speaking with her HCP her code status has been reverse to
DNR but ok to intubate. Plan to transfer back to [**Hospital 100**] Rehab
MACU
# Access: PICC in right arm
.
# PPx: heparin sq/ bowel regimen
.
# Code: DNR, but OK to intubate. See goals of care as above.
.
# Comm: HCP [**Name (NI) **] [**Name (NI) **]) [**Telephone/Fax (1) 30573**]. [**Name2 (NI) **]ter-in-law:
[**Telephone/Fax (1) 30574**]
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheeze.
7. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
8. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED): as per sliding scale.
9. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
previously on 50mg daily, can increase as tolerated.
10. piperacillin-tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q6H (every 6 hours) for 4 days: last day
[**2-4**].
11. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours) for 4 days: last day [**2-4**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Pneumonia, aspiration and healthcare associated
Dysphagia
Dementia
Anemia
Hypertension, benign
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to the hospital for a pneumonia that developed
after an aspiration event. You were treated with IV antibiotics
and should complete an 8 day course, to be finished on [**2103-2-4**].
Since you are aspirating, you should not take/receive anything
by mouth and a dobhoff feeding tube has been placed. This is a
temporary tube and your swallowing will be reassessed in several
weeks. you were also anemic and received 1 unit of blood while
in the hospital
Followup Instructions:
with Rehab physician
|
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icd9cm
|
[
[
[]
]
] |
[
"38.97",
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icd9pcs
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[
[
[]
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258, 303
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11538, 11538
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3448, 6685
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2835, 2835
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211, 220
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331, 2642
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2849, 3429
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11553, 11650
|
2664, 2692
|
2708, 2787
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,294
| 181,403
|
28709
|
Discharge summary
|
report
|
Admission Date: [**2128-3-8**] Discharge Date: [**2128-3-18**]
Date of Birth: [**2062-9-4**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Obstructive Jaundice
Major Surgical or Invasive Procedure:
Successful placement of an 8-Fr internal-external biliary drain
through an anomalous R biliary duct.
PTBD placed in the left biliary system internal-external drain.
Right PTBD removed
IR Celiac Plexus Block
Exploratory Laparotomy
History of Present Illness:
This is a 65 year old female with a history of T3N1 pancreatc
Adenocacinoma s/p Whipple by Dr. [**Last Name (STitle) 468**] in 8/[**2125**]. She is s/p
chemo and radiation and recently had asecond round of chemo.
She presents with obstructive jaundice. She is s/p ERCP on
[**2128-3-8**], but they were not able to cannulate her duct.
Past Medical History:
Pancreatic CA s/p chemo and radiation
hyperlipid, asthma, smoker, chronic cough and mild dyspnea
PSH: BSO, ankle [**Doctor First Name **]
Social History:
Smoked two packs per day. quit in [**2125**].
No ETOH
Former Waitress - currently not working
Family History:
There is no familial history of pancreatic cancer.
Physical Exam:
AVSS
Gen: tired, A+O x 3. Normal communication.
HEENT: slight scleral icterus
CV: RRR
Chest: diminished at bases, crackles heared at bases. Productive
cough.
Abd: soft, tender to epigastric, minimally distended, +BS.
Previous surgical scar noted.
Ext: +2 pulses bilat.
Pertinent Results:
[**2128-3-12**] 09:30AM BLOOD WBC-10.0 RBC-3.10* Hgb-8.6* Hct-26.2*
MCV-85 MCH-27.9 MCHC-33.0 RDW-20.0* Plt Ct-180
[**2128-3-12**] 09:30AM BLOOD Glucose-86 UreaN-8 Creat-0.7 Na-142 K-3.4
Cl-105 HCO3-28 AnGap-12
[**2128-3-8**] 08:50AM BLOOD ALT-49* AST-75* AlkPhos-203* Amylase-15
TotBili-5.2* DirBili-1.8* IndBili-3.4
[**2128-3-11**] 06:35AM BLOOD ALT-46* AST-36 AlkPhos-166* Amylase-14
TotBili-4.8*
[**2128-3-8**] 08:50AM BLOOD Lipase-20
[**2128-3-11**] 06:35AM BLOOD Lipase-16
[**2128-3-11**] 06:35AM BLOOD Albumin-2.2* Calcium-7.6* Phos-2.5*
Mg-2.2
.
Reason: Please place PTC and stent
IMPRESSION: Cholangiogram demonstrates moderate dilation of the
intrahepatic biliary ducts as well as partial obstruction at the
level of the confluence of an anomalous right bile duct and the
right and left hepatic ducts. The exact appearance of the
obstuction may be better delineated by pull- back
cholangiography after the ducts have decompressed in [**1-18**] days.
Successful placement of an 8-French internal-external biliary
drain through an anomalous right biliary duct.
.
CTA ABD W&W/O C & RECONS [**2128-3-10**] 9:03 AM
IMPRESSION:
1. Heterogeneous pancreatic mass extending into the root of the
mesentery as above, compatible with recurrent pancreatic
adenocarcinoma.
2. Ascites, prominent enhancing mesenteric lymph nodes as above.
3. Tiny bilateral pleural effusions with associated airspace
disease, likely reflecting atelectasis.
.
IR Biliary Drain [**2128-3-12**]
Biliary obstruction appears to be secondary to narrowed, encased
Roux loop, which we were unable to cross distally to stent.
Successful placement of 8 Fr left internal-external biliary
drain with the tip positioned within the Roux loop, connected to
a bag for external drainage. This should decompress the left and
right bile ducts as well as the obstructed roux loop.
The previously placed biliary drain through the right anomalous
biliary duct was removed and the tract was embolized with
Gelfoam.
Brief Hospital Course:
This is a 65 year old female with recurrence of pancreatic tumor
who presented with abdominal and back pain and obstructive
jaundice.
ERCP was unsuccessful in cannulating her duct to relieve the
obstruction.
She went to IR for a PTC and had dilated intrahepatic ducts, and
successful placement of an 8-Fr internal-external biliary drain
through an anomalous R biliary duct.
A CT showed recurrent pancreatic cancer.
She then went to IR for stent placement on [**3-12**]. However, the
biliary obstruction appears to be secondary to narrowed, encased
Roux loop, which we were unable to cross distally to stent.
Successful placement of 8 Fr left internal-external biliary
drain with the tip positioned within the Roux loop, connected to
a bag for external drainage. This should decompress the left and
right bile ducts as well as the obstructed roux loop.
The previously placed biliary drain through the right anomalous
biliary duct was removed and the tract was embolized with
Gelfoam.
Chronic Pain was consulted for a Celiac Plexus Block. she went
for this procedure on [**2128-3-15**] and had some expectant relief.
She developed clear evidence of precipitace recurrent disease.
She has a large [**Location (un) 21851**] at the root of the root of the
mesentery on CT scan. It is
obstructing her full pancreaticobiliary efferent limb rendering
her jaundice and bilirubin rising each day. She has a mild
septic picture and now comes to the operating room on [**2128-3-17**] for
an attempt to decompress this obstructive pancreaticobiliary
rim. This is a last ditch effort change in the patient but
clear aggressive recurrent pancreatic cancer with a hope at
palliation.
Upon opening she had ischemic infarcted small bowel.
Her family was contact[**Name (NI) **] and her abdomen was closed. She was
made CMO and passed away early the next morning.
Medications on Admission:
Haldol 1mg q8prn, Megestrol 400mg, Omeprazole 20mg, Oxycodone,
oxycontin 40 [**Hospital1 **], Paxil 10mg qd, Senna, prochlorperazine 10mg
prn
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Pancreatic Cancer recurrence
Obstructive Jaundice
Chronic Pain
Infarcted Small bowel
Death
Discharge Condition:
Death
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2128-3-22**]
|
[
"789.51",
"576.2",
"197.6",
"V10.09",
"557.0",
"272.4",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.23",
"97.55",
"51.98",
"54.11"
] |
icd9pcs
|
[
[
[]
]
] |
5643, 5652
|
3571, 5421
|
332, 564
|
5787, 5794
|
1575, 3548
|
5847, 5882
|
1218, 1270
|
5613, 5620
|
5673, 5766
|
5447, 5590
|
5818, 5824
|
1285, 1556
|
272, 294
|
592, 928
|
950, 1090
|
1106, 1202
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,208
| 136,044
|
39778
|
Discharge summary
|
report
|
Admission Date: [**2173-9-8**] Discharge Date: [**2173-9-23**]
Date of Birth: [**2129-9-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Percocet / Vicodin / Levofloxacin / Oxycodone
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
43M with R flank pain and recent chest pain
Major Surgical or Invasive Procedure:
[**2173-9-17**]
1. Coronary artery bypass grafting x4 with left internal mammary
artery to left anterior descending coronary artery; reverse
saphenous vein single graft from the aorta to the first diagonal
coronary artery; reverse saphenous vein single graft from aorta
to the second
obtuse marginal coronary artery; as well as reverse saphenous
vein graft to the distal right coronary artery.
2. Endoscopic left greater saphenous vein harvesting.
[**2173-9-14**]
Cardiac Catheterization
History of Present Illness:
43 year old male with h/o DMII, HTN,
Hyperlipidemia and recent nephrolithiasis who was admitted to
[**Hospital1 18**] [**9-8**] with recurrent right flank pain and chest pain.
He was originally admitted to [**Location (un) 8973**] Hospital one week prior
and found to have a right 8mm UPJ stone and 9mm lower pole stone
in the kidney. He underwent right ureteral stent placement. He
has continued to have right flank pain and hematuria and
returned
to the emergency [****].
In the ED, he experienced a 3 hour episode of substernal chest
pressure. He reports it started shortly after eating breakfast.
It was accompanied by nausea, which he feels may be related to
the pain medication he was given. He also reports associated
shortness of breath.This resolved prior to the resolution of the
chest pain. He denies pain radiation,vomiting or diaphoresis.
He has multiple risk factors for CAD including HTN, T2DM, fatty
liver, and recent significant family stress. In addition, his
ECGs are concerning for coronary ischemia given the dynamic
changes with his episode of chest pressure. His troponin
also elevated somewhat from his admission troponin, and on [**9-13**]
+Stress Test. Cardiac cath was performed on [**9-14**]. Significant
coronary artery disease was revealed. Cardiac surgery was
consulted for revascularization.
Past Medical History:
DMII (diet controlled)
Hypertension
Hyperlipidemia
Fatty liver
H/o alcohol abuse(quit 23 years ago)
H/o renal colic in the past
Right ureteral stent placement [**8-/2173**] due to right sided
nephrolithiasis
PSH:
cystogram
retrograde pyelogram- R stent-[**2173-9-9**]
Social History:
Lives in [**Location (un) 8973**] City with his fiancee.
He works as an administrator at a recovery facility for
alcoholics and people with drug abuse problems. [**Name (NI) **] himself used
to be an alcoholic, but had his last drink 23 years ago.
He also used to smoke 2ppd for 21 years, but quit 9 years ago.
He also used illicit drugs, but never IVDU.
Family History:
Uncles with MI.
Parents with DM and HTN.
Older borther with kidney stones.
Physical Exam:
Vitals: T:97 BP:145/86 P:76 R:18 O2:95%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, tongue midline
and pink
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, +mild suprapubic tenderness, otherwise nt/nd,
bs+; liver edge 1cm below costal margin by percussion and
palpatation
Back: no CVA tenderness, no paraspinal tenderness
Ext: WWP, no peripheral edema, 2+ pulses
Pertinent Results:
Admission Labs:
- [**2173-9-8**] 08:40PM GLUCOSE-91 UREA N-9 CREAT-0.7 SODIUM-135
(repeat 5.6*) POTASSIUM-8.0* CHLORIDE-102 TOTAL CO2-23 ANION
GAP-18
- [**2173-9-8**] 08:40PM WBC-8.8 RBC-5.03 HGB-15.6 HCT-44.3 MCV-88
MCH-31.0 MCHC-35.2* RDW-14.2 PLT COUNT-336
- [**2173-9-8**] 05:47PM URINE COLOR-Straw APPEAR-Clear SP
[**Last Name (un) 155**]-1.008 BLOOD-LG NITRITE-NEG PROTEIN-75 GLUCOSE-NEG
KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD RBC->50
WBC-[**6-3**]* BACTERIA-FEW YEAST-NONE EPI-0-2
[**2173-9-9**] 09:00AM BLOOD cTropnT-<0.01
[**2173-9-9**] 04:00PM BLOOD cTropnT-0.02*
[**2173-9-11**] 11:51AM BLOOD %HbA1c-6.3* eAG-134*
Discharge Labs:
[**2173-9-22**] 03:56AM BLOOD WBC-6.9 RBC-2.97* Hgb-8.9* Hct-26.4*
MCV-89 MCH-29.9 MCHC-33.6 RDW-15.5 Plt Ct-416
[**2173-9-22**] 03:56AM BLOOD Plt Ct-416
[**2173-9-20**] 02:10AM BLOOD PT-13.5* PTT-24.7 INR(PT)-1.2*
[**2173-9-22**] 03:56AM BLOOD Glucose-125* UreaN-18 Creat-0.6 Na-140
K-3.7 Cl-101 HCO3-31 AnGap-12
[**2173-9-14**] 06:49PM BLOOD ALT-48* AST-38 LD(LDH)-203 AlkPhos-104
Amylase-53 TotBili-0.9
Radiology
[**2173-9-8**] KUB: Renal stent in proper position.
Radiology Report CHEST (PA & LAT) Study Date of [**2173-9-21**] 3:13 PM
[**Hospital 93**] MEDICAL CONDITION: 44 year old man with s/p cabg
REASON FOR THIS EXAMINATION: eval for effusion POD 4 s/p cabg
Final Report FINDINGS: Right middle lobe opacification with
sharp lateral edge is again seen and stable since [**2173-9-9**],
possibly atelectasis versus fibrosis. Slight reduction in
retrocardiac opacification likely due to decrease in left
pleural effusion and atelectasis. Stable postoperative
mediastinal widening. Stable moderate-to-large cardiac
silhouette. Hilar contours are normal.
IMPRESSION: Decreased retrocardiac opacity likely due to
decreased effusion and atelectasis. Stable right mid lung
opacification of unclear etiology may represent scarring.
Consider chest CT to better evaluate when patient clinically
appropriate.
DR. [**First Name (STitle) 10900**] BISHOP
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Date/Time: [**2173-9-17**] at 10:11 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.7 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 4.0 cm
Left Ventricle - Fractional Shortening: 0.30 >= 0.29
Left Ventricle - Ejection Fraction: 55% >= 55%
Left Ventricle - Stroke Volume: 66 ml/beat
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Ascending: 2.3 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.1 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 5 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 3 mm Hg
Aortic Valve - LVOT VTI: 21
Aortic Valve - LVOT diam: 2.0 cm
Aortic Valve - Valve Area: *2.8 cm2 >= 3.0 cm2
Mitral Valve - MVA (P [**12-26**] T): 3.3 cm2
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.4 m/sec
Mitral Valve - E/A ratio: 1.75
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: 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 ascending aorta diameter. Normal descending aorta
diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: No MVP. No MS. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications. Results were personally reviewed with the MD
caring for the patient.
Conclusions
Pre CPB:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage.
No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation.
There is no mitral valve prolapse. Trivial mitral regurgitation
is seen.
Dr. [**Last Name (STitle) 914**] was notified in person of the results.
Post CPB:
Preserved biventricular systolic function. LVEF 55%
Intact thoracic aorta.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2173-9-17**] 18:35
Brief Hospital Course:
43 year old male who was admitted to [**Hospital1 18**] [**9-8**] with recurrent
right flank pain and chest pain.
Originally admitted to [**Location (un) 8973**] Hospital one week prior found
to have a right 8mm UPJ stone and 9mm lower pole stone in the
kidney. He underwent right ureteral stent placement. He has
continued to have right flank pain and hematuria and returned
to the emergency [****].
In the ED, he experienced a 3 hour episode of substernal chest
pressure. His ECGs were concerning for coronary ischemia. His
troponin was elevated somewhat on [**9-13**] he had a +Stress Test.
Cardiac cath was performed on [**9-14**]. Significant coronary artery
disease was revealed. Cardiac surgery was consulted for
revascularization.
He was brought to the operating room on [**9-17**] for coronary artery
bypass grafting.
Please see operative report for details, in summary he had:
1. Coronary artery bypass grafting x4 with left internal mammary
artery to left anterior descending coronary artery; reverse
saphenous vein single graft from the
aorta to the first diagonal coronary artery; reverse
saphenous vein single graft from aorta to the second obtuse
marginal coronary artery; as well as reverse
saphenous vein graft to the distal right coronary artery.
2. Endoscopic left greater saphenous vein harvesting.
His BYPASS TIME was 89 minutes with a CROSSCLAMP TIME of 74
minutes. He tolerated the operation well and post-operatively
was transferred to the cardiac surgery ICU in stable condition.
He remained hemodynamically stable in the immediate post-op
period. On the day of surgery he woke neurologically intact and
was extubated. He required low dose Neosynephrine to support his
blood pressure and stayed in the ICU on POD1. All tubes lines
nad drains were removed per cardiac surgery protocol.
After his chest tubes were removed he developed white out of the
left side and a chest tube was placed, it subsequently drained
1.5L of serosang fluid. On POD 3 he was transferred from the ICU
to the stepdown floor. Once on the stepdown floor he worked with
the nursing and physical therapy staff to regain his strenghth
and mobility. The remainder of his post-operative course was
uneventful.
He was discharged home with services on POD6. He is to follow up
with Dr [**Last Name (STitle) 914**] in 3 weeks.
Medications on Admission:
Simvastatin 40mg po daily
ASA 81 mg po daily
MVI
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) for 2
weeks.
Disp:*14 Adhesive Patch, Medicated(s)* Refills:*0*
9. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 2
weeks.
10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
11. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) patch
Transdermal every seventy-two (72) hours for 2 weeks.
Disp:*4 patches* Refills:*0*
12. Ibuprofen 600 mg Tablet Sig: Six Hundred (600) mg PO Q8H
(every 8 hours) as needed for pain.
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
s/p coronary bypass graft x4
PMH:
Coronary Artery disease
DMII (diet controlled)
Hypertension
Hyperlipidemia
Fatty liver
H/o alcohol abuse(quit 23 years ago)
H/o renal colic in the past
Right ureteral stent placement [**8-/2173**] due to right sided
nephrolithiasis
PSH: cystogram
retrograde pyelogram R stent-[**2173-9-9**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral Dilaudid/Fentanyl patch
Incisions:
Sternal - healing well, no erythema or drainage
Leg: Left -healing well, no erythema or drainage.
Edema: 1+ bilaterally
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) 914**] on [**10-12**] at 1:30pm
Cardiologist: need to identify cardiologist
Please call to schedule appointments with your
Primary Care Dr.[**First Name8 (NamePattern2) 3095**] [**Last Name (NamePattern1) **] in [**3-29**] weeks
Urologist as needed
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2173-9-23**]
|
[
"401.9",
"571.0",
"250.00",
"303.93",
"998.11",
"592.0",
"592.1",
"414.01",
"E878.2",
"530.81",
"272.4",
"412",
"511.89",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"34.04",
"39.61",
"36.13",
"88.56",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
12656, 12712
|
8860, 11187
|
354, 845
|
13081, 13332
|
3560, 3560
|
14172, 14699
|
2891, 2967
|
11287, 12633
|
4806, 4836
|
12733, 13060
|
11213, 11264
|
13356, 14149
|
4226, 4769
|
2982, 3541
|
271, 316
|
4868, 8511
|
873, 2210
|
3577, 4210
|
2232, 2503
|
2519, 2875
|
8521, 8837
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,187
| 177,446
|
19856
|
Discharge summary
|
report
|
Admission Date: [**2200-4-11**] Discharge Date: [**2200-4-17**]
Date of Birth: [**2162-7-8**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamides) / Latex
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Hepatic masses, abdominal pain
Major Surgical or Invasive Procedure:
[**2200-4-11**] extended right hepatectomy
History of Present Illness:
Per Dr.[**Name (NI) 1369**] note: 37-year-old female with a history of right
upper quadrant abdominal pain and periumbilical abdominal pain,
along with a history
of enlarging liver masses thought to represent either hepatic
adenoma or focal nodular hyperplasia. She underwent an MRI
with BOPTA at [**Hospital1 18**] on [**2200-3-26**]. This demonstrated
a large, rounded, lobulated, 5.7 x 6.6-cm solid lesion in
segment [**Year (4 digits) 7060**] extending into segment [**Doctor First Name 690**] and segment I, the
caudate lobe. The bulk of the lesion was situated between the
right and middle hepatic veins. This was higher-intensity due
to the underlying hepatic parenchyma on T2 weighted images,
and the lesion contained a central scar. On the delayed
BOPTA images, there was some central washout from the
dominant central lesions, as well as some small arterial
enhancing lesion in the inferior aspect of the right lobe
with residual peripheral right of contrast. This was thought
to be slightly unusual, but still most left compatible with
FNH. There is a second solid, 1.7-cm lesion in the inferior
aspect of the right lobe thought to represent FNH, and is a
3.1-cm hemangioma in the inferior and lateral aspect of the
right lobe. These lesions were increased in size. The largest
mass measured 3.8 cm in [**2194**].
Due to the patient's symptoms, the enlarging mass, and its
difficult location should it continue to enlarge and require
resection, the patient has elected to proceed with hepatic
resection. She has provided informed consent and is now
brought to the operating room for possible right hepatic
lobectomy, caudate lobe resection, segment [**Doctor First Name 690**] resection, or
possible segment [**Doctor First Name 7060**] and [**Doctor First Name 690**] resection depending on the
intraoperative findings.
Past Medical History:
abdomiinal pain, htn, hyperlipidemia, allergic rhinitis, atopic
disease, depression, irritable bowel syndrome, anxiety, hiatal
hernia, and hepatic lesions noted in the history
Hysterectomy, bunionectomy of right 1st toe, right arthroscopic
knee surgery, ear tubes as a child
Social History:
Denies cigarette or recreational drugs, one ETOH beverage per
day.
Married
Physical Exam:
T HR 94 RR 16 BP 118/65 98% RA
A&O
anicteric,
Lungs clear
abd soft, NT/ND, no masses palp
ext no edema
Pertinent Results:
[**2200-4-17**] 05:15AM BLOOD WBC-18.9* RBC-2.97* Hgb-8.9* Hct-27.4*
MCV-93 MCH-30.1 MCHC-32.6 RDW-15.6* Plt Ct-364
[**2200-4-12**] 01:05AM BLOOD PT-14.8* PTT-34.7 INR(PT)-1.3*
[**2200-4-16**] 05:30AM BLOOD ALT-105* AST-42* AlkPhos-93 TotBili-0.4
Brief Hospital Course:
On [**2200-4-11**] she underwent
extended right hepatic lobectomy, segment [**Doctor First Name 690**] resection,
cholecystectomy, caudate lobe resection, and intraoperative
ultrasound for mass in segments [**Last Name (LF) 7060**], [**First Name3 (LF) 690**], and caudate lobe.
Surgeon was Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Please see operative note for
further details. A single JP was placed. EBL was 5 liters and
this was replaced with 4 units PRBC, cellsaver, FFP and
crystalloid. She remained intubated due to large fluid
replacement and was transferred intubated to the SICU over
night. She was extubated without event and transferred out of
the SICU.
Diet was slowly advanced and IV fluid stopped. The JP drainage
was serosanguinous and the incision remained without erythema or
drainage. The foley was removed on pod 3. Pain was well
controlled. Vital signs remained stable. BP remained on the low
side with sbp's in the 90's. Her usual home meds included
toprol,lisinopril and caduet. Cadue and lisinopril were held.
Lopressor was continued without dizziness.
LFTs trended down. Hct stabilized at 26-27 from 31 immediately
postop. Preop hct was 41. The JP was removed on pod 5 when
output averaged 100cc/day.
Of note, the wbc trended up on pod 3 to 11.8. This continued to
increase each day up to 18.9. CVL was removed on pod 4. A UA
was negative and urine culture was contaminated. She remained
afebrile and breath sounds were only slightly diminished in
bases. The urine culture was repeated on pod 6.
She also experienced bilateral leg edema for which iv lasix was
administered x1. The right leg appeared slightly more edematous
than the left. Non-invasive u/s studies were done on [**4-17**]. This
was negative for any DVT.
She was discharged home in stable condition tolerating a regular
diet and ambulatory.
Medications on Admission:
Xanax 0.5"', caduet 1', wellbutrin-XL 450', lexapro 30',
zestril 10', lithium carbonate 600', toprol 25', nortriptyline
25', tylenol prn, maalox prn, hyocyamine 0.5"'prn, gas-x prn
.
Discharge Medications:
1. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
2. Escitalopram 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Lithium Carbonate 300 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
4. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
5. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
6. Wellbutrin XL 300 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO once a day.
7. Wellbutrin XL 150 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO once a day.
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Hepatic FNH
Discharge Condition:
good
Discharge Instructions:
Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, inability to take medications/food, increased
abdominal pain, jaundice, constipation, incision
redness/bleeding/drainage or any concerns
No heavy lifting
No driving while taking pain medications
[**Month (only) 116**] shower
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2200-6-20**] 11:20
[**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**], RN will call you with follow up appointment
([**Telephone/Fax (1) 673**]) to schedule follow up appointment with Dr. [**Last Name (STitle) **]
in 1 week.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2200-4-17**]
|
[
"782.3",
"401.9",
"228.04",
"553.3",
"477.9",
"458.29",
"272.4",
"V45.89",
"564.1",
"300.4",
"790.01",
"751.69"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.00",
"99.07",
"50.3",
"99.04",
"88.76",
"51.22"
] |
icd9pcs
|
[
[
[]
]
] |
6017, 6023
|
3072, 4974
|
317, 362
|
6079, 6086
|
2759, 3007
|
6466, 7004
|
5209, 5994
|
6044, 6058
|
5001, 5186
|
6110, 6443
|
2631, 2740
|
247, 279
|
390, 2225
|
2247, 2524
|
2540, 2616
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,679
| 195,414
|
43014
|
Discharge summary
|
report
|
Admission Date: [**2137-7-21**] Discharge Date: [**2137-7-24**]
Date of Birth: [**2065-7-10**] Sex: M
Service: MEDICINE
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Dyspnea on exertion, R>L claudication
Major Surgical or Invasive Procedure:
Cardiac catheterization
Peripheral [**First Name3 (LF) 1106**] angiography
Pneumovax
History of Present Illness:
HPI: 71 M with PMH PVD, DM, HTN, hyperchol, CAD (CABG [**2131**],
PTCA/stent), accepted from the CCU. The patient was admitted
[**2137-7-21**] for AA angiogram with Dr. [**First Name (STitle) **], for pre-procedure
hydration and prep. Pt had been having DOE for past 4 mo, LE
color changes, skin dryness. No CP, SOB, orthopnea, PND, F/C.
ROS neg.
.
Pt had flushing and warmth with contrast, will document that pt
may need pretreatment with steroids, benadryl, pepcid in case of
contrast in future.
.
Pt had cath yesterday, with LMCA stent and LCx balloon. Pt has
no CP, no SOB, no palpitations, no dizziness, ROS neg. MRI
L-spine showed spinal stenosis. Pt will attempt ambulating
today and be monitored o/n for hypotension/arrhythmia.
Past Medical History:
PMH:
1) Hypertension.
2) Hyperlipidemia.
3) Diabetes with neuropathy.
4) Coronary disease status post bypass surgery in [**2131**] placing
a LIMA to the LAD and separate vein grafts to the PDA, and a
vein graft to the diagonal artery.
5) Preserved left ventricular systolic function.
6) Status post multiple PCIs, most recently [**2132-7-1**] under
the care of Dr. [**Last Name (STitle) **], placing a 2.75 x 13 Penta stent
in the left circumflex with vein grafts, as well as a patent
LIMA.
7) Peripheral [**Last Name (STitle) 1106**] disease, lower extremity claudication
Rutherford Class II, status post lower extremity angioplasty
in [**2130**] under the care of Dr. [**First Name4 (NamePattern1) 1158**] [**Last Name (NamePattern1) 1274**], now with right
lower extremity claudication status post aortoiliac
reconstruction, starting with the right, later
with the left stage procedure, most recently in [**7-4**].
8) CRI - baseline creat 1.7
Social History:
SH: Past smoker (quit 17 yrs ago after ~80pack yrs), etoh - quit
17 yrs ago when dx with DM
Family History:
FH: Non-contributory
Physical Exam:
EXAM:
Vitals: 97.8, 124/98 (L), 122/67 (R), 82, 22, 92% RA
G: NAD, comfortable
H: No LAD/facial flushing. Neck supple
C: RRR, no murmur appreciated, PMI non-displaced, JVD flat at
90deg
L: Bibasilar crackles - clear with cough
A: Soft, obese, NT, ND, +BS
E: No edema, pulses: DP 1+ L, 0 R; PT 0 L, 1+ R. Dry, hairless
skin with venous stasis color changes
Pertinent Results:
EKG [**2137-7-21**] (post-cath):
Sinus rhythm with first degree atrio-ventricular conduction
delay. Diffuse
non-diagnostic repolarization abnormalities. Compared to the
previous tracing of [**2136-7-25**] multiple abnormalities as previously
noted persist without major change.
.
Cardiac cath [**2137-7-22**]:
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. All vein grafts widely patent.
3. Widely patent iliac artery stents.
4. Widely patent renal artery stent.
5. Successful PTCA and atherectomy of the proximal LCX.
6. Successful Perclose.
.
CXR [**2137-7-23**]:
1. The patient has had median sternotomy. Heart remains
moderately enlarged.
2. Thoracic aorta is generally large and the contour of the
descending portion raises the possibility of aneurysm.
3. Lungs are clear. No pleural effusion.
.
Abdominal aortogram:
Results sent separately.
.
[**2137-7-21**] 08:55PM GLUCOSE-292* UREA N-32* CREAT-1.4* SODIUM-139
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-26 ANION GAP-16
[**2137-7-21**] 08:55PM CALCIUM-9.6 MAGNESIUM-1.9
[**2137-7-21**] 08:55PM WBC-9.3 RBC-4.99 HGB-14.5 HCT-42.9 MCV-86
MCH-29.1 MCHC-33.8 RDW-13.7
[**2137-7-21**] 08:55PM PLT COUNT-178
[**2137-7-21**] 08:55PM PT-13.1 PTT-23.1 INR(PT)-1.1
Brief Hospital Course:
A/P: 71 yr old male with known PVD and hx of CABG, admitted for
AA angiogram and cath:
.
## CAD:
The patient has a past history of CABG. Cardiac catheterization
showed 3VD. The LMCA was heavily calcified with a 60% taper and
was stented. The LCX was non-dominant and showed a 99% lesion,
and underwent PTCA and rotational atherectomy, but a stent could
not be placed. In the cath lab, the patient required dopamine
to maintain his BP. The patient was weaned off of dopamine
prior to arrival in the CCU, and the patient was subsequently
transferred to the floor. The abdominal aortogram showed CIA
bilaterally with stents that are patent. The left renal artery
stent is widely patent. The patient was maintained on ASA,
plavix, bb, acei, integrilin for 18 hrs post-cath, and a statin
was added. The patient's BP stayed stable, without hypotensive
episodes and without arrhythmia post-stenting on tele.
Post-cath check was uneventful.
.
NOTE: Patient needs pre-medication of steroids, benadryl, PPI
before contrast administration. Pt had flushing and warmth with
contrast on this admission.
.
## PVD:
Per Dr. [**First Name (STitle) **] Note, "lower extremity claudication Rutherford
Class II, status post lower extremity angioplasty in [**2130**] under
the care of Dr. [**First Name4 (NamePattern1) 1158**] [**Last Name (NamePattern1) 1274**], now with right lower extremity
claudication status post aortoiliac reconstruction under my
care, starting with the right, later with the left stage
procedure, most recently in [**7-4**]."
.
## HTN:
The patient was continued on his home regimen of Felodipine,
Metoprolol, and Lisinopril.
.
## DM2:
The patient was maintained on an insulin sliding scale during
admission. On the day before discharge, Metformin and glyburide
were restarted without complication.
.
## CRI:
Baseline creat 1.7, now Cr 1.3. The patient's CRI is likely due
to DM2 and HTN. The pt's Cr continued to trend down post-cath.
He was discharged on Lasix 40 PO QD. HCTZ was discontinued,
since pt's BP was well-controlled on Felodipine, Metoprolol,
Lisinopril.
Medications on Admission:
Medications:
Aspirin a day,
Zocor 20 mg once a day,
Plavix once a day,
metformin b.i.d., ---------HOLDING
glyburide 5 mg b.i.d ------HOLDING
atenolol 25 mg once a day,
lisinopril 10 mg once a day,
hydrochlorothiazide 25 mg once a day,
insulin per protocol
Discharge Medications:
1. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime) as needed for insomnia.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Felodipine 5 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO DAILY (Daily).
5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane
PRN (as needed). Lozenge(s)
10. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO twice a day.
12. Metformin 500 mg Tablet Sig: Two (2) Tablet PO twice a day.
13. Insulin Regular Human 100 unit/mL Solution Sig: per home
scale scale Injection four times a day.
14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig:
34am/40pm units Subcutaneous twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Peripheral [**Date Range 1106**] disease
Coronary artery disease
Secondary:
1) Hypertension.
2) Hyperlipidemia.
3) Diabetes with neuropathy.
4) Coronary disease status post bypass surgery in [**2131**] placing
a LIMA to the LAD and separate vein grafts to the PDA, and a
vein graft to the diagonal artery.
5) Preserved left ventricular systolic function.
6) Status post multiple PCIs, most recently [**2132-7-1**] under
the care of Dr. [**Last Name (STitle) **], placing a 2.75 x 13 Penta stent
in the left circumflex with vein grafts, as well as a patent
LIMA.
7) Peripheral [**Last Name (STitle) 1106**] disease, lower extremity claudication
Rutherford Class II, status post lower extremity angioplasty
in [**2130**] under the care of Dr. [**First Name4 (NamePattern1) 1158**] [**Last Name (NamePattern1) 1274**], now with right
lower extremity claudication status post aortoiliac
reconstruction under my care, starting with the right, later
with the left stage procedure, most recently in [**7-4**].
8) CRI - baseline creat 1.7
Discharge Condition:
Fair, with no shortness of breath or chest pain
Discharge Instructions:
Please all your doctor or return to the ED for chest pain,
shortness of breath, pain or weakness in your legs, abdominal
pain, bleeding, or other concerning symptoms.
Followup Instructions:
Please see Dr. [**First Name (STitle) **] in [**1-3**] weeks; call [**Telephone/Fax (1) 2207**] to make an
appointment.
.
Please see you PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] in the next month; call
[**Telephone/Fax (1) 19968**] to make an appointment.
.
Keep appointments as below:.
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2137-7-29**] 9:20
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51535**], M.D. Where: [**Hospital6 29**]
DERMATOLOGY Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2137-8-29**] 1:15
.
Provider: [**Name10 (NameIs) **] STUDY Where: CC CLINICAL CENTER RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2137-11-14**] 10:00
Completed by:[**2137-9-4**]
|
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28,001
| 153,232
|
32288
|
Discharge summary
|
report
|
Admission Date: [**2198-12-5**] Discharge Date: [**2198-12-18**]
Date of Birth: [**2118-7-10**] Sex: M
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
[**3-4**] wk feeling unsteady
Major Surgical or Invasive Procedure:
[**12-7**] Brain Biopsy
[**12-13**] Left sided craniotomy
History of Present Illness:
Patient is a 80 yo man with PMH of HTN, hyperlipid, h/o
afib, osteoporosis, DM2, low testosterone, prostate ca s/p
radiation who is transferred from [**Hospital3 **] with a necrotic brain
lesion in the left parietal/occipital area. Reports that he went
to his PCP recently with 3-4 weeks of spells of unsteadiness. He
describes it as feeling as if he is going to tip over. There is
no dizziness or vertigo with this. His PCP ordered the CT and
he
was admitted for further work up including a non contrast MRI.
Notes mention both primary and secondary as possibilities, but
there is no official report. CT torso mentioned as negative but
no official repport.
ROS: Denies HA, fever, chills sweats. Reports that he has had
[**12-15**] lb planned wt loss over 6 mo with diet/excercise. He is
unsure if his vision has changed, but poor at baseline. No N/V,
vertigo or bladder or bowel changes. Small cough which is new
and dry.
Past Medical History:
-HTN
-hyperlipid
-h/o afib
-osteoporosis
-DM2
-low testosterone
-prostate ca s/p radiation
-chronic dry eyes.
Social History:
Pt is a retired school superintendent. Pt quit smoking 40 [**Month/Year (2) 1686**]
ago, reports drinking 6 [**Last Name (un) 75470**]/week. Pt lives alone since
wife died 2 [**Name2 (NI) 1686**] ago. Daughter lives on [**Location (un) 945**] and son lives
in [**Name (NI) **].
Family History:
Father died at 78 and mother in 90s both of MI.
Physical Exam:
T- 98.0 BP- 176/80 HR- 80 RR- 12 O2Sat 97 RA
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, says
[**Doctor Last Name 1841**] backwards. Speech is fluent with normal comprehension and
repetition; naming intact. No dysarthria. [**Location (un) **] and writing
intact. Registers [**3-4**], recalls [**3-4**] in 5 minutes. No right left
confusion. No evidence of apraxia or neglect. No agraphesthesia
in left hand.
Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Visual fields are full to confrontation. Catarcts
bilaterally left > right. Unable to visualize disc left but
intact right. Extraocular movements intact bilaterally, no
nystagmus. Sensation intact V1-V3. Facial movement symmetric.
Hearing intact to finger rub bilaterally. Palate elevation
symmetrical. Sternocleidomastoid and trapezius normal
bilaterally. Tongue midline, movements intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch, cold, vibration throughout. No
extinction to DSS on hands, but extinguishes right foot
consistently.
Reflexes:
+2 and symmetric throughout.
Toes down right and up left (?)
Coordination: finger-nose-finger normal, heel to shin normal,
RAMs normal.
Gait: Narrow based, steady.
Romberg: retropulses
Pertinent Results:
RADIOLOGY Final Report
MR HEAD W & W/O CONTRAST [**2198-12-14**] 7:37 PM
MR HEAD W & W/O CONTRAST
Reason: follow up on postop residual tumor. please do before
midnigh
[**Hospital 93**] MEDICAL CONDITION:
80 year old man with s/p craniotomy for tumor resection.
REASON FOR THIS EXAMINATION:
follow up on postop residual tumor. please do before midnight
[**2198-12-14**].
CONTRAINDICATIONS for IV CONTRAST: None.
EXAM: MRI brain.
CLINICAL INFORMATION: Patient status post craniotomy for tumor
resection for postoperative evaluation.
TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and
diffusion axial images of the brain were acquired before
gadolinium. T1 sagittal, axial and coronal images were obtained
following gadolinium. Comparison was made with the previous
study of [**2198-12-13**].
FINDINGS: Since the previous study, the patient has undergone
resection of enhancing brain lesion in the left parietal
convexity region. Small amount of blood products is seen in this
region with surrounding edema. Following gadolinium, enhancement
is seen along the medial margin of the resection site as well as
inferior margin of the resection site indicating some residual
enhancement. There is also evidence of small area of slow
diffusion seen adjacent to the surgical site which could be
related to surgery. There is pneumocephalus identified. There is
no midline shift or hydrocephalus seen. There is moderate brain
atrophy.
IMPRESSION: Status post resection of the left parietal convexity
enhancing intra-axial brain lesion. Small amount of residual
enhancement is seen immediately and inferior to the resection
site. No large hematoma seen, midline shift or hydrocephalus
identified. No change in the surrounding edema noted.
DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**]
Approved: SAT [**2198-12-15**] 5:38 PM
RADIOLOGY Final Report
MR HEAD W/ CONTRAST [**2198-12-13**] 5:39 AM
MR HEAD W/ CONTRAST
Reason: pre-op for tumor resection, please do at 5:00 am on
[**2198-12-13**]
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
80 year old man brain tumor
REASON FOR THIS EXAMINATION:
pre-op for tumor resection, please do at 6:00 am on [**2198-12-13**],
prior to OR time
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Brain tumor, preoperative for tumor resection.
COMPARISON: MRI head dated [**2198-12-7**].
TECHNIQUE: Multiplanar T1- post-gadolinium images were obtained
including axial MP-RAGE images.
MRI HEAD WITH CONTRAST: Enhancing peripheral mass in the left
posterior parietal lobe is again demonstrated and unchanged
compared to [**2198-12-7**]. Surrounding signal abnormality on
T1-weighted images is also again demonstrated and not
significantly changed. Ventricles are stable in size. No other
enhancing lesions within the brain are seen.
IMPRESSION: Enhancing left parietal mass without significant
change compared [**2198-12-7**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**]
Approved: SAT [**2198-12-15**] 9:10 PM
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2198-12-13**] 6:39 PM
CT HEAD W/O CONTRAST
Reason: rule out postop ICH. please do before 7pm [**12-13**].
[**Hospital 93**] MEDICAL CONDITION:
80 year old man with s/p craniotomy for tumor resection.
REASON FOR THIS EXAMINATION:
rule out postop ICH. please do before 7pm [**12-13**].
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: Status post left parietal lobe tumor resection.
Evaluate for postoperative hemorrhage.
Comparison is made to [**2198-12-13**] MRI and [**2198-12-8**]
head CT.
NON-CONTRAST HEAD CT.
FINDINGS: There is expected air within the left parietal
surgical bed and expected postoperative pneumocephalus and
adjacent subcutaneous emphysema and swelling adjacent to the
high right parietal craniotomy site. No postoperative
intraparenchymal or extra-axial hemorrhage is identified.
Stable-appearing vasogenic edema within the left parietal lobe.
The appearance of the head CT is otherwise unchanged with stable
mild mucosal thickening within the right maxillary sinus.
IMPRESSION:
Expected postoperative changes with no evidence of hemorrhage.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
DR. [**First Name8 (NamePattern2) 11136**] [**Last Name (NamePattern1) 11137**]
Approved: FRI [**2198-12-14**] 5:52 PM
Cardiology Report ECG Study Date of [**2198-12-8**] 1:59:38 AM
Probable idioventricular rhythm with prolonged QTc interval at a
rate
of 56 beats per minute. Compared to tracing #3 idioventricular
rhythm is now
evident. QTc interval is more polonged. Clinical correlation is
suggested.
TRACING #4
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] S.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
56 0 178 514/507 0 -42 114
RADIOLOGY Final Report
CHEST (PA & LAT) [**2198-12-6**] 8:46 AM
CHEST (PA & LAT)
Reason: please do in AM.man with new brain mass
[**Hospital 93**] MEDICAL CONDITION:
80 year old man with new brain mass
REASON FOR THIS EXAMINATION:
please do in AM.man with new brain mass
HISTORY: An 80-year-old male with new brain mass.
CHEST, PA AND LATERAL: There are no prior studies for
comparison. Heart size is normal. The hilar and mediastinal
contours are normal. Lungs are clear. There is a tiny 2-mm
rounded opacity projecting over the left second anterior rib,
likely represents a vessel. No pleural effusions are seen.
Fracture deformities of the right fourth, fifth, and sixth
posterior ribs are seen. No pneumothorax identified.
IMPRESSION: No evidence of intrathoracic malignancy.
jr
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: FRI [**2198-12-7**] 4:33 PM
Test Name Value Units Reference Range
[**2198-12-16**] 06:25AM
COMPLETE BLOOD COUNT
White Blood Cells 11.6* K/uL 4.0 - 11.0
PERFORMED AT WEST STAT LAB
Red Blood Cells 4.49* m/uL 4.6 - 6.2
PERFORMED AT WEST STAT LAB
Hemoglobin 14.1 g/dL 14.0 - 18.0
PERFORMED AT WEST STAT LAB
Hematocrit 42.5 % 40 - 52
PERFORMED AT WEST STAT LAB
MCV 95 fL 82 - 98
PERFORMED AT WEST STAT LAB
MCH 31.5 pg 27 - 32
PERFORMED AT WEST STAT LAB
MCHC 33.3 % 31 - 35
PERFORMED AT WEST STAT LAB
RDW 13.7 % 10.5 - 15.5
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count 142* K/uL 150 - 440
PERFORMED AT WEST STAT LAB
Test Name Value Units Reference Range
[**2198-12-16**] 06:25AM
RENAL & GLUCOSE
Glucose 127* mg/dL 70 - 105
PERFORMED AT WEST STAT LAB
Urea Nitrogen 36* mg/dL 6 - 20
PERFORMED AT WEST STAT LAB
Creatinine 0.9 mg/dL 0.5 - 1.2
PERFORMED AT WEST STAT LAB
Sodium 140 mEq/L 133 - 145
PERFORMED AT WEST STAT LAB
Potassium 4.8 mEq/L 3.3 - 5.1
PERFORMED AT WEST STAT LAB
Chloride 101 mEq/L 96 - 108
PERFORMED AT WEST STAT LAB
Bicarbonate 31 mEq/L 22 - 32
PERFORMED AT WEST STAT LAB
Anion Gap 13 mEq/L 8 - 20
Test Name Value Units Reference Range
[**2198-12-6**] 06:40AM
RENAL & GLUCOSE
Glucose 189* mg/dL 70 - 105
PERFORMED AT WEST STAT LAB
Urea Nitrogen 25* mg/dL 6 - 20
PERFORMED AT WEST STAT LAB
Creatinine 0.9 mg/dL 0.5 - 1.2
PERFORMED AT WEST STAT LAB
Sodium 139 mEq/L 133 - 145
PERFORMED AT WEST STAT LAB
Potassium 3.9 mEq/L 3.3 - 5.1
PERFORMED AT WEST STAT LAB
Chloride 102 mEq/L 96 - 108
PERFORMED AT WEST STAT LAB
Bicarbonate 30 mEq/L 22 - 32
PERFORMED AT WEST STAT LAB
Anion Gap 11 mEq/L 8 - 20
ESTIMATED GFR (MDRD CALCULATION)
Estimated GFR (MDRD equation)
Using this patient's age, gender, and serum creatinine value
of 0.9,
Estimated GFR = >75 if non African-American (mL/min/1.73 m2)
Estimated GFR = >75 if African-American (mL/min/1.73 m2)
For comparison, mean GFR for age group 70+ is 75 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
ENZYMES & BILIRUBIN
Alanine Aminotransferase (ALT) 28 IU/L 0 - 40
PERFORMED AT WEST STAT LAB
Asparate Aminotransferase (AST) 17 IU/L 0 - 40
PERFORMED AT WEST STAT LAB
Lactate Dehydrogenase (LD) 200 IU/L 94 - 250
PERFORMED AT WEST STAT LAB
Alkaline Phosphatase 109 IU/L 39 - 117
PERFORMED AT WEST STAT LAB
Amylase 46 IU/L 0 - 100
PERFORMED AT WEST STAT LAB
Bilirubin, Total 0.6 mg/dL 0 - 1.5
PERFORMED AT WEST STAT LAB
OTHER ENZYMES & BILIRUBINS
Lipase 29 IU/L 0 - 60
PERFORMED AT WEST STAT LAB
CHEMISTRY
Albumin 3.9 g/dL 3.4 - 4.8
PERFORMED AT WEST STAT LAB
Calcium, Total 8.9 mg/dL 8.4 - 10.2
PERFORMED AT WEST STAT LAB
Phosphate 2.7 mg/dL 2.7 - 4.5
PERFORMED AT WEST STAT LAB
Magnesium 2.5 mg/dL 1.6 - 2.6
PERFORMED AT WEST STAT LAB
PITUITARY
Thyroid Stimulating Hormone 0.41 uIU/mL 0.27 - 4.2
Hematology
GENERAL URINE INFORMATION Type Color Appear Sp [**Last Name (un) **]
[**2198-12-11**] 11:09PM Yellow Clear 1.027
Source: CVS
DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub
Urobiln pH Leuks
[**2198-12-11**] 11:09PM NEG NEG NEG 1000 NEG NEG 4* 6.5 NEG
Source: CVS
[**2198-12-11**] 11:09PM
Source: CVS
06:37a
Other Blood Chemistry:
%HbA1c: 5.8
Comments: %HbA1c: [**Doctor First Name **] Recommendations:; <7% Goal Of Therapy; >8%
Warrants Therapeutic Action
Other Blood Chemistry:
Cryoglb: Negative
TSH:0.44
Other Blood Chemistry:
T4: 4.6
PEP: No Specific Abnormalities Seen;Interpreted By [**Name6 (MD) 1158**] [**Name8 (MD) **], Md
HCV-Ab: Negative
SED-Rate: 1
[**Hospital1 69**]
[**Location (un) 86**], [**Telephone/Fax (1) 15701**]
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 75471**],[**Known firstname **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 3947**] [**2118-7-10**] 80 Male [**-7/4824**]
[**Numeric Identifier 75472**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dif
SPECIMEN SUBMITTED: Brain tumor.
Procedure date Tissue received Report Date Diagnosed
by
[**2198-12-8**] [**2198-12-8**] [**2198-12-14**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/tcc
DIAGNOSIS:
Brain, stereotactic core biopsies, seven:
1. "-3" (A): Anaplastic Oligoastrocytoma, grade III (see
note).
2. "-2": Glial neoplasm.
3. "-1" (B): Anaplastic Oligoastrocytoma, grade III (see
note).
4. "0": Glial neoplasm.
5. "+1" (C): Anaplastic Oligoastrocytoma, grade III (see
note).
6. "+2": Glial neoplasm.
7. "+3" (D): Anaplastic Oligoastrocytoma, grade III (see
note).
Note: The tumor shows areas with microgemistocytes and halos
suggesting an oligodendroglial differentiation. Other areas
show clear fibrillary processes positive for GFAP
(immunohistochemistry) suggesting astroglial differentiation.
LCA immunohistochemistry identifies macrophages in this tumor.
Clinical: "Brain tumor."
Gross: The specimen is received in seven containers, labeled
with the patient's name "[**Known firstname **] [**Initial (NamePattern1) **]. [**Known lastname 14039**]" and the medical record
number.
Part 1 is received in formalin additionally labeled "-3" and
consists of a tan white fragment of tissue measuring 0.1 x 0.1 x
0.1 cm. The specimen is entirely submitted in A.
Part 2 is received fresh and additionally labeled "-2" and
consists of a tan white fragment of tissue measuring 0.1 x 0.1 x
0.1 cm. An intraoperative consultation was performed and the
entire specimen was smeared onto a slide. Intraoperative smear
diagnosis (SM -2) is "glial neoplasm" by Dr. [**First Name (STitle) 4223**].
Part 3 is received in formalin and additionally labeled "-1" and
consists of a tan white fragment of tissue measuring 0.1 x 0.1 x
0.1 cm. The specimen is entirely submitted in B.
Part 4 is received fresh and additionally labeled "0" and
consists of a tan white fragment of tissue measuring 0.1 x 0.1 x
0.1 cm. An intraoperative consultation was performed and the
entire specimen is smeared onto a slide. Intraoperative smear
diagnosis (SM TP) is "glial neoplasm" by Dr. [**First Name (STitle) 4223**].
Part 5 is additionally labeled "+1" and consists of a fragment
of tan white tissue measuring 0.1 x 0.1 x 0.1 cm. The specimen
is entirely submitted in C.
Part 6 is received fresh and is additionally labeled "+2" and
consists of a tiny tan white fragment of tissue that measures
0.1 x 0.1 x 0.1 cm. An intraoperative consultation was performed
and the entire specimen is smeared onto a slide. Smear
diagnosis (SM +2) is "glial neoplasm" by Dr. [**First Name (STitle) 4223**].
Part 7 is received in formalin and is additionally labeled "+3"
and consists of a tan white fragment of tissue measuring 0.1 x
0.1 x 0.1 cm. The specimen is entirely submitted in D.
Brief Hospital Course:
Patient is a 80 yo man with PMH of HTN, hyperlipid, h/o
afib, osteoporosis, DM2, low testosterone, prostate ca s/p
radiation who is transferred from [**Hospital3 **] with a necrotic brain
lesion in the left parietal/occipital area. There is nothing on
physical exam to suggest mass effect. In [**Hospital3 **] his Coumadin
was held, and he was started on Keppra and Decadron which we
have continued. He has recent diagnosis and treatment of
prostate CA, however this does not metastasize to the brain
parenchyma. Primary neoplasm such as GBM, less likely CNS
lymphoma. He had a repeat MRI with gad.
On [**12-7**] he underwent a brain biopsy; pathology report:
Anaplastic Oligoastrocytoma, grade III
On [**12-13**] he underwent a craniotomy for removal of the left
parietal mass. Post operatively he spent the night in the SICU
to monitor his BP he required a Nitro drip intermittently.
Neurologically he was intact.
He was transferred to the surgical floor on [**12-14**]. PT saw the
patient and recommended rehab; OT was also consulted and
recommended short term rehab.
Medications on Admission:
Vytorin [**10-20**] daily
Januvia 100 daily
Miacalcin nasal spral 200 IU alternating each nostril QOD
Androgel 5% 2 pumps daily, shoulders and chest
Protonix 40mg PO BID
Oscal with Vit D 500 [**Hospital1 **]
Diovan 160 daily
Rythmol SR 225 Po BID
Astelin [**Hospital1 **]
Keppra 500 [**Hospital1 **]
Decadron 4mg IV or PO Q6hrs
RISS
ALL: sulfas? redness with HCTZ.
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
2. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
200 units Nasal DAILY (Daily).
3. Testosterone 1 %(50 mg/5 gram) Gel in Packet Sig: 1% /2pumps
50mg/5gm Transdermal daily (): apply transdermal to chest and
shoulders.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
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).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Propafenone 150 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
13. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H () as needed.
15. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
17. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
18. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
19. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours) as needed for SBP>140.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 11057**] Nursing & Rehabilitation Center - [**Location (un) 3320**]
Discharge Diagnosis:
Left Temporal Parietal Mass
Anaplastic Oligoastrocytoma, grade III
Discharge Condition:
Neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
PLEASE HAVE YOUR STAPLES/SUTURES REMOVED BETWEEN [**2198-12-23**] TO
[**2198-12-26**] IN REHAB FACILITY OR DR[**Doctor Last Name **] OFFICE (PLEASE CALL
([**Telephone/Fax (1) 11314**] FOR APPOINTMENT)
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 4 WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST PRIOR TO
APPT.
Appointment with Dr [**Last Name (STitle) 4253**] in brain tumor clinic on [**12-21**] (Friday) at 1pm on the [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building, [**Location (un) **].
If you need to cancel or reschedule the appt., please call
[**Telephone/Fax (1) 1844**]
Completed by:[**2198-12-18**]
|
[
"733.00",
"V45.89",
"401.9",
"272.4",
"375.15",
"191.3",
"V10.46",
"276.1",
"427.31",
"250.00",
"342.90",
"427.89",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"99.07",
"01.13"
] |
icd9pcs
|
[
[
[]
]
] |
20153, 20260
|
16960, 18039
|
316, 376
|
20371, 20395
|
3767, 3940
|
21681, 22397
|
1784, 1834
|
18457, 20130
|
9028, 9064
|
20281, 20350
|
18065, 18434
|
20419, 21658
|
1849, 2204
|
247, 278
|
9093, 16937
|
404, 1336
|
2688, 3745
|
2243, 2672
|
2228, 2228
|
1358, 1470
|
1486, 1768
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,845
| 118,082
|
45730
|
Discharge summary
|
report
|
Admission Date: [**2112-4-10**] Discharge Date: [**2112-4-14**]
Date of Birth: [**2044-3-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Chest pain/palpatations
Major Surgical or Invasive Procedure:
Dual chamber pacemaker placement
History of Present Illness:
68y/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4746**] w/ a PMH of CAD s/p 4V CABG, HTN, PAF, ulcerative
colitis, and hypercholesterolemia who presented today with
complaints to chest pain and palpatations x 2.5hrs. He had been
in his USOH until ~10am when the above symptoms developed
acutely. He describes his pain as a pleuritic substernal pain
that is still present currently. He denies any radiation of the
pain or SOB, nausea, or diaphoresis. This pain is quite
different from his previous anginal equilivant of DOE and
pressure type CP. He notes some mild flu-like symptoms yesterday
evening (muscle aches, chills, and diarrhea) but states that
these have resolved since. His normal BM pattern is [**2-7**] loose BM
daily and his last bloodly BM was ~3wks ago. He denies excessive
EtOH intake (had 1 drink overnight) or caffeine intake outside
of 1 cup of coffee daily. He is not always symptomatic with
afib.
.
Of note, the patient was admitted in [**2109**] with similar
complaints and developed complete heart block with ~10 second
pauses after being given IV metoprolol (5mg x3) and diltiazem
(5mg x1) for rate control. He was sent to the CCU at this time
where a DC cardioversion was planned but deferred given that he
was noted to have sinus beats breaking his pauses. He
spontaneously converted to NSR ~3-4 hours after admission to the
CCU and remained in sinus rhythm for the remainder of his
hospitalization. He has not been anticoagulated given his
diagnosis of UC.
.
In the ED, the patient was noted to be in atrial fibrillation
with a rapid ventricular response in the 150s. He was given IV
metoprolol 5mg x3 without response and was sent to the ICU for
further management.
Past Medical History:
1. Ulcerative Colitis [**2106**] (s/p polypectomy w/ high grade
dysplasia)
2. 4V CABG '[**00**] (LIMA->LAD, SVG->RCA, SVG->D1, SVG->OM/RI)
3. Hypercholesterolemia
4. HTN
5. GERD
6. Diverticulosis
7. Inguinal hernia
8. Internal Hemorrhoids
9. Paroxysmal Atrial Fibrillation - first noted post-op '[**00**] and
c/b CHB w/ 10s pauses following metoprolol/diltiazem pushes in
[**2109**]
10. Benign prostatic hypertrophy
Social History:
The patient lives with his sister in [**Name (NI) 11209**]. He has about
one to two alcoholic drinks per week. He quit cigarettes about
35 years ago. The patient was employed as an electrical
engineer, recently retired ~1 year ago.
Family History:
The patient's father as well as two of his uncles had coronary
artery disease. His maternal aunt had [**Name2 (NI) 499**] cancer. There is no
family history of premature coronary artery disease or sudden
death.
Physical Exam:
100.0, 153/79, 135, 20, 97% 3L
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. O/P clear w/out
exudate or erythema
Neck: Supple
CV: Tachycardic and irregular. No m/r/g. No thrills, lifts. No
S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, mildly distended but non-tender. No HSM appreciated
but exam limited by body habitus. No abdominial bruits.
Ext: Trace LE edema bilaterally. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Femoral 2+ DP 2+ PT 2+
Left: Femoral 2+ DP 2+ PT 2+
Pertinent Results:
EKG demonstrated atrial fibrillation ~ 140 without obvious
ischemic changes and no overall significant change compared with
prior dated [**6-9**].
.
2D-ECHOCARDIOGRAM performed on [**10-8**] demonstrated: Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Regional left ventricular wall motion is
normal. The mitral valve leaflets are mildly thickened. There is
mild mitral annular calcification. Mild (1+) mitral
regurgitation is seen
.
ETT performed on [**10-8**] demonstrated: The patient exercised for 6
minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol and stopped for fatigue. No anginal
symptoms or significant ST segment changes at the achieved
workload. No ECG or 2D echocardiographic evidence of inducible
ischemia to
achieved workload.
.
CXR [**2112-4-10**]: No overt infiltrates or CHF.
.
CXR [**2112-4-14**] s/p PPM placement:
Analysis is performed in direct comparison with a preceding
chest examination of [**2112-4-10**]. During the interval, the
patient received a permanent pacer in left anterior axillary
position. Dual-electrodes system is identified and termination
points correspond to right atrial appendage and apical portion
of right ventricle correspondingly. There is no pneumothorax or
any other placement-related complication. Chest findings are
unaltered. A small blunting of the left posterior pleural sinus
is identified but review of a more older PA and lateral
examination of [**2110-6-9**], showed this blunting already. Thus,
there is no evidence of acute pleural effusion. IMPRESSION:
Uncomplicated placement of dual-electrode permanent pacemaker.
Brief Hospital Course:
Pt is a 68y/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4746**] w/ a PMH significant for CAD s/p CABG, HTN,
PAF, UC, and hyperlipidemia who presents with chest pain and
palpitations, found to be in Afib/RVR.
.
1) CAD: s/p 4V CABG in [**2100**] with a normal stress ECHO in [**2107**].
Complained of CP starting the morning of admission in the
setting of a fib with RVR. There were no ischemic changes on EKG
and he ruled out for MI with 3 sets of negative CE. The
patient's chest pain resolved when his tachycardia was
controlled and after he converted to NSR he remained chest pain
free. He was continued on his outpatient cardiac regimen
including aspirin/statin/metoprolol.
.
2) Atrial fibrillation: Patient has had a least 3 previous
episodes of atrial fibrillation and was quite sensitive to CCB
during his previous admission. He was hemodynamically stable on
admission despite a HR of 140s. He had no response to metoprolol
5mg IV x4 in the ED. He was not a good cardioversion subject as
is occassionally asymptomatic when in Afib per both the patient
and Dr. [**Last Name (STitle) 911**]. Given the unknown length of his afib he was
started on heparin gtt. He was admitted to the CCU given his
previous long pauses following BB and diltiazem in the past. He
was started on an esmolol gtt and titrated to maximum dose with
no improvement. This was discontinued and the patient was given
an IV bolus of diltiazem and started on a dilt gtt. He
initially responded to the dilt with HR in 110s-120s however he
quickly returned to HR 140s-160s. He was given his home dose of
metoprolol and later his rate slowed down, followed by
spontaneous conversion to NSR with rate 50s-60s. He was started
on coumadin with heparin bridge for stroke prevention. He then
developed another episode of Afib without any symptoms including
chest pain. 15mg Diltiazem IV was given twice with minimal
effect, followed by Dilt drip without effect. Patient received
regular dose of PO metoprolol (50MG) and finally converted after
additional dose of 5mg IV metoprolol while still being on Dilt
drip. He remained in NSR since then and was started on
Amiodarone. After EP consult, it was decided to place a
dual-chamber PPM given that he developed another pause after the
conversion to NSR from the second Afib episode. After PPM
placement, he was switch to Sotalol given its better side effect
profile compared to Amiodarone. Coumadin was started prior
discharge. He was discharged in NSR without any symptoms. He
should take Keflex for one day after discharge to complete a
three-day course of abx coverage for prophylaxis after PPM
placement (he already received two doses of Vancomycin IV while
in hospital). A follow-up appointment in the device clinic was
scheduled for one week after discharge. In addition, he is going
to see Dr. [**Last Name (STitle) **] from EP five weeks after discharge for
follow-up.
.
3) Pump: only ECHO in [**2107**] was in setting of a stress ECHO but
normal EF at that time. The patient had no overt signs of
failure on exam or cxr. He was continued on BB as above.
.
4) Hyperlipidemia: continued statin and fibrate.
.
5) HTN: Patient's BP was on lower side following administration
of multiple medications in attempt to rate control him, so his
valsartan was initially held in this setting. He was discharged
on his BB and on 80mg of Valsartan to be taken daily.
.
6) Ulcerative colitis: currently stable and w/ normal bowel
movement pattern. Per the patient, his GI doctor recently said
he was a candidate for anticoagulation should he require it. He
was continued on colazal 2.25g tid.
.
7) Acute renal failure: The patient had a small bump in his Cr
following admission. This was thought to be pre-renal etiology
in the setting of poor forward flow and decreased PO intake.
His Cr normalized back to baseline following improvement in his
Po intake.
.
8) FEN: cardiac diet, repleted lytes prn
.
9) PPX: heparin drip, coumadin, PPI
.
10) Access: PIV x2
.
11) Code: FULL
Medications on Admission:
Toprol 50 mg p.o. b.i.d.
TriCor 48 mg qd
Colazal 2250mg tid
Omeprazole 20 mg a day
Folic acid 1mg qd
Simvastatin 40 mg qd
Valsartan 160 mg qd
Aspirin 162 mg qd
Flomax
MVI
Ca2+/Vit D
Discharge Medications:
1. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO
daily ().
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
4. Balsalazide 750 mg Capsule Sig: Three (3) Capsule PO tid ().
5. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Keflex 500 mg Capsule Sig: One (1) Capsule PO once for 1
doses: One dose on [**4-15**] .
Disp:*1 Capsule(s)* Refills:*0*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain for 5 doses.
Disp:*5 Tablet(s)* Refills:*0*
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
12. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Atrial fibrillation
2. s/p pacemaker placement for sinus pauses during conversion
from atrial fibrillation to normal sinus rhythm
3. Coronary artery disease s/p four vessel CABG in [**2100**]
.
Secondary diagnosis:
1. Hypertension
2. Hypercholesterolemia
3. Ulcerative colitis
4. Acute renal failure
Discharge Condition:
Afebrile. Hemodynamically stable. Ambulating. Tolerating PO.
Discharge Instructions:
You had two episodes of atrial fibrillation with a rapid heart
rate during this admission. During conversion from atrial
fibrillation to normal sinus rhythm, you had a 7-second pause.
You were started on a medication, Sotalol, to help keep you in
normal sinus rhythm. Because of the pauses you had during
conversion, a pacemaker was placed.
.
You should take an antibiotic (keflex) for one dose after
discharge for prophylaxis after pacemaker placement (you already
have received two doses of another intravenous antibiotic while
you were in the hospital).
.
Please call your primary doctor or return to the ED with fever,
chills, chest pain, shortness of breath, near-fainting,
palpitations, nausea/vomiting, spontaneous bleeding or any other
concerning symptoms.
.
Please take all your medications as directed.
.
Please keep you follow up appointments as below.
Followup Instructions:
* DEVICE CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2112-4-20**] 2:00
* Dr. [**Last Name (STitle) **] (for pacer check): [**Last Name (LF) 766**], [**5-16**] at 9am;
Phone:[**Telephone/Fax (1) 285**]
* [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6925**] Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2112-6-1**] 3:00
|
[
"V15.82",
"562.10",
"427.31",
"530.81",
"414.00",
"556.9",
"401.9",
"584.9",
"427.81",
"550.90",
"600.00",
"455.0",
"V45.81",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.74",
"37.83"
] |
icd9pcs
|
[
[
[]
]
] |
10968, 10974
|
5522, 9535
|
338, 372
|
11340, 11403
|
3839, 5499
|
12322, 12673
|
2816, 3028
|
9768, 10945
|
10995, 10995
|
9561, 9745
|
11427, 12299
|
3043, 3820
|
275, 300
|
400, 2111
|
11232, 11319
|
11014, 11211
|
2133, 2551
|
2567, 2800
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,231
| 118,600
|
48388
|
Discharge summary
|
report
|
Admission Date: [**2129-4-5**] Discharge Date: [**2129-4-12**]
Date of Birth: [**2077-10-3**] Sex: M
Service: MICU
CHIEF COMPLAINT: Increased secretions.
HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old
male with severe restrictive lung disease secondary to polio
and severe right kyphoscoliosis and paraplegia, COPD on
chronic steroids, status post trach, who presents with a
chief complaint of increased secretions. The patient reports
that within the last few days he has been experiencing some
shortness of breath and increased secretions and requested
assistance by calling EMS. The patient has a home vent which
is set at pressure support of 15 by 5 and FIO2 of 21% by
EMTs. He was brought to the Emergency Room where chest x-ray
was performed which was unremarkable for infiltrate. The
patient was suctioned with medium amount of white sputum.
While in the Emergency Room the patient was noted to have
increased congestion and transient saturation to 90%. The
patient's saturation improved while being bagged. He was
suctioned and his blood pressure elevated to 200/100. He was
given Hydralazine and transferred to medical ICU for further
evaluation.
PAST MEDICAL HISTORY: 1) Restrictive lung disease secondary
to kyphosis, polio. No pulmonary function tests available.
2) Chronic obstructive pulmonary disease. 3) Bronchiectasis
status post multiple pneumonias. 4) Chronic tracheostomy.
Patient reports he is vented at night and is able to tolerate
trach mask during the day. 5) Hypertension. 6) History of
DVT in 11/92. 7) History of C. diff in 7/94. 8) Chronic
pain syndrome. 9) Obesity. 10) Recent admission to [**Hospital1 2025**] with
treatment with high dose steroids tapered and Levaquin.
ALLERGIES: No known drug allergies.
MEDICATIONS: On admission, Methyldopa 250 mg [**Hospital1 **], Nexium 300
mg q d, KCL, Lasix 40 mg po q d, Singular 10 mg q d,
Prednisone 10 mg being tapered down per script, Levaquin 500
mg, Slo-[**Hospital1 **] 300 mg q d, Tylenol #3 for back pain prn, Bactrim
q d.
REVIEW OF SYSTEMS: Significant for back pain, cough with
sputum that is yellowish, reported low grade fevers, no
chills or shakes, no abdominal pain, diarrhea, constipation
or dysuria.
SOCIAL HISTORY: Patient lives at home and has VNA services
provided 8 hours per day. VNA phone number is [**Telephone/Fax (1) 101906**].
His stent is serviced by [**Last Name (un) 55557**] [**Telephone/Fax (1) 101907**].
PHYSICAL EXAMINATION: Generally patient is a chronically ill
appearing man with trach. Marked obesity, especially of the
neck. Vital signs, temperature 100.5, pulse 96, blood
pressure 171/68, respiratory rate 16, O2 saturation 98% on
21% FIO2, set at pressure support of 15 and PEEP of 5.
HEENT: Pupils round and reactive to light, JVD unable to
assess secondary to neck obesity, mucus membranes moist.
Heart, regular rate and rhythm, no murmur, rub or gallop,
hyperdynamic PMI. Lungs rhonchorus bilaterally without
wheezes. Abdomen soft, nontender, non distended with well
healed midline scar. Extremities with 1+ bilateral edema.
Neuro, alert and oriented times three, bilateral hand grip
with normal strength, 1+ strength in lower extremities, deep
tendon reflexes 0-1+ throughout.
LABORATORY DATA: On admission revealed white count of 10.2
with differential of 68 neutrophils, 20 lymphs, 9 monos,
hematocrit 42.5, and platelet count 316,000. His sodium was
141, potassium 2.6, chloride 105, CO2 24, BUN 10 and
creatinine 0.2, glucose 87. PTT 22.1, INR 1.2.
EKG showed normal sinus rhythm at 97 beats per minute, normal
intervals, axis 97 degrees, right atrial enlargement, poor R
wave progression, 1 PAC, T wave flattening and T wave
inversion in V1 to V3, right bundle branch block appearing.
This was the EKG in the Emergency Room. On arrival to the
floor the patient was also noted to have ST depression of 1
mm in 3 and F with heart rate at 116 and blood pressure of
213/89.
Chest x-ray showed severe right kyphoscoliosis, no effusion,
no infiltrate, difficult to assess heart size.
HOSPITAL COURSE: In summary, the patient is a 51-year-old
man with chronic restrictive lung disease secondary to polio
and musculoskeletal abnormalities, COPD, on chronic
ventilation through a trach, presenting with increased
congestion and low grade fevers. His issues during this
hospitalization included:
1. Cardiovascular: The patient was noted to be hypertensive
to 200/100. At the time of admission he was not symptomatic,
however, his EKG showed ST depressions in leads 3 and F. For
his hypertensive emergency the patient was started on
Labetalol with normal elevation of his blood pressure to
120's and reversal of EKG changes to baseline. In addition,
patient was ruled out for myocardial ischemia with serial CKs
and troponin which were normal.
2. Pulmonary: The patient did present with congestion and
shortness of breath. He did not appear to be in congestive
heart failure and there was no evidence of pneumonia on his
chest x-ray. However, patient was started on Zithromycin for
possible bronchitis. He completed the course of antibiotics
while in the hospital. After initial low grade fever
recorded on admission, the patient remained afebrile. The
patient did not appear to be in COPD exacerbation so there
was no indication for high dose steroids.
3. Fluids, Electrolytes & Nutrition: On presentation the
patient was hyperkalemic and hypermagnesemic. It was thought
to be due to the diuretic use without potassium replacement.
The patient's potassium was repleted by mouth within a few
days. The delay was caused by patient's refusal to take
medication.
4. Prophylaxis during this hospitalization. The patient was
maintained on subcu Heparin and Protonix.
5. Social issues: Per patient report, he lives
independently in [**Hospital1 778**] Apartments with daily VNA services.
Social work was involved in patient's management in addition
to the case manager to clarify the services he obtains.
There was an issue of vent cleaning-apparently patient
prohibited the VNA to clean his vent, partially leading to
his difficulties ventilating. The patient appears to be more
compliant with his care at present time. On admission
patient's VNA was notified of patient's hospitalization and
promptly reassigned his services. His discharge was delayed
due to the lack of staff to provide VNA services for him.
FOLLOW-UP: The patient has a follow-up appointment with his
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 101908**], [**Telephone/Fax (1) 101909**] at [**Hospital1 2025**] on
[**5-20**] at 3:30 p.m. In addition he was scheduled to see a
pulmonologist, Dr. [**Last Name (STitle) **] on Thursday, [**4-28**] at 9:15 a.m. on
the [**Location (un) 1773**] of [**Hospital Ward Name 23**] Building.
On [**4-11**] the care of this patient was transferred to Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) **] who will dictate an addendum to this discharge summary
that will include the discharge medications.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4428**], M.D. [**MD Number(1) 4429**]
Dictated By:[**Last Name (NamePattern1) 1762**]
MEDQUIST36
D: [**2129-4-10**] 22:56
T: [**2129-4-11**] 20:23
JOB#: [**Job Number 101910**]
|
[
"518.81",
"V44.0",
"401.9",
"334.1",
"V46.1",
"737.41",
"138",
"278.00",
"491.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.56"
] |
icd9pcs
|
[
[
[]
]
] |
4093, 7346
|
2493, 4075
|
2079, 2246
|
150, 173
|
202, 1194
|
1217, 2059
|
2263, 2470
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,680
| 133,948
|
16700
|
Discharge summary
|
report
|
Admission Date: [**2138-1-4**] Discharge Date: [**2138-2-3**]
Date of Birth: [**2117-5-5**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 20 year old
female whose left lower extremity was run over by a bus at
about 02:30 a.m. on [**2138-1-4**]. The patient was reported to
have been running along a bus that was moving slowly at about
5 mph when she fell in the midst of a crowd of people. The
bus ran over her left leg from the knee downward and actually
stopped on her for about 15 seconds before pulling forward.
The patient was transported to the [**Hospital1 190**] for evaluation and treatment.
The patient had no trauma to the head and no loss of
consciousness.
PAST MEDICAL HISTORY: Right knee pain.
PAST SURGICAL HISTORY: Right anterior cruciate ligament
repair in [**2132**].
MEDICATIONS: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient smoked approximately one pack
per day and consumed alcohol. The patient was a single
college student.
PHYSICAL EXAMINATION: On presentation, the patient was on a
stretcher in no apparent distress. Her vital signs were 95.4
F.; 116/65; 18; and 100% saturated on room air. HEENT: The
patient had no trauma to the head. Pulmonary clear to
auscultation bilaterally. Cardiovascular: The patient was
tachycardic but with a regular rhythm. Abdomen: Soft,
nontender, nondistended with positive bowel sounds.
Extremities: The patient's left lower extremity was markedly
swollen below the knee with no active dorsiflexion of the
left ankle. Extensors of the large toe and second through
fifth toes were also not active. The patient's foot was
resting at about 35% plantar position. There was no open
wound. There was an eschar versus burn on the medial aspect
of the distal tibia. There was a palpable gap at the medial
malleolus. There was pain on passive dorsiflexion of her
foot to neutral. A dorsalis pedis was palpable at two plus
with brisk capillary refill. Her posterior tibialis was also
palpable at two plus. All the patient's toes were plantar
flexed. There was dirt from the road notable on her left
lower extremity. The patient's sensation was markedly
diminished over the anterior compartment. The patient could
feel deep pressure. Sensation was markedly diminished to the
left dorsum but the patient could feel light touch over the
superficial peroneal distribution.
HOSPITAL COURSE: On arrival in the Emergency Department,
the patient was seen by Vascular Surgery as well as
Orthopedic Surgery. X-rays obtained in the Emergency
Department confirmed that the patient had a displaced left
medial malleolar fracture. Given the severity of the
patient's crush injury on clinical examination and concern
for impending or ongoing compartment syndrome, the patient
was emergently taken to the Operating Room for compartment
release of the left leg and nine compartment release of the
foot with open reduction and internal fixation of her medial
malleolar fracture.
In the Operating Room the patient was found to have avulsed
anterior compartment muscles. The muscles were found to be
essentially non-viable. There was disruption of the soft
tissues of the left foot but the muscles of the lateral, deep
superficial and posterior compartments appeared viable on
first inspection. The patient was thereafter transferred to
the Trauma Intensive Care Unit for continued management. She
was on a PCA for pain control. Vacuum dressings had been
applied to her wounds.
Plastic Surgery involvement was requested regarding further
management of the patient's wounds. The patient was returned
to the Operating Room for further debridement on [**2138-1-6**].
Vascular surgery intra-operative consultation was requested
and the patient was found to have essentially normal vascular
function.
On [**2138-1-7**], the patient was noted to have a hematocrit of
24.5, down from 39.2 on admission, and received transfusions
with three units of packed red blood cells over the course of
the day. The patient was returned to the Operating Room on
[**2138-1-10**] for further cleanout and debridement. The patient
was thereafter transferred back to the floor with a wound VAC
in place. At this time, 90 to 95% of the patient's anterior
compartment muscles had been debrided. No new areas of
muscle necrosis were noted.
The patient's lateral compartment muscles appeared intact and
viable. Posterior compartment muscles also appeared intact
and viable. The wounds were beginning to appear clean with
largely viable tissue with skin bridge between the two
fasciotomy incisions with viable appearing tissue. The
patient remained on Kefzol and Levaquin.
The patient was returned to the Operating Room on [**2138-1-14**],
for further debridement and washout. The patient was found
to have some greenish purulent looking tissue in her wounds
and the decision was therefore made to not place a VAC
dressing but to manage the wound with wet-to-dry dressings
with Dakin solution. There was also some concern some
Pseudomonas infection and cultures were sent to the
Microbiology laboratory.
The patient began ambulating with Physical Therapy on
[**2138-1-16**]. Following four days with wet-to-dry dressings
with [**Last Name (un) 47263**] solution, wound care was changed to twice a day
dressing changes of wet-to-dry gauze dressings with normal
saline on [**2138-1-18**].
The patient was returned to the Operating Room on [**2138-1-20**]
for further washout and debridement. The patient's wound
appeared improved with largely healthy viable tissue and a
VAC dressing was once again placed. On [**2138-1-24**], the
patient was once again returned to the Operating Room for
further debridement of her leg wounds as well as a VAC
dressing change.
While in the Operating Room, dark eschar that had been
present on the anterior surface of the patient's foot was
debrided and found to be relatively [**Name2 (NI) 47264**] with healthy
viable subcutaneous tissue and no exposed tendon. A VAC
dressing was also placed to this new wound. The patient
continued to have sessions of Physical Therapy during which
she was able to ambulate but with non-weight bearing on her
left foot. The patient was followed by the Acute Pain
Service and was intermittently on PCA analgesia as well as
analgesics by mouth. She also received intravenous analgesia
for breakthrough pain.
By [**2138-1-30**], the patient was ambulating relatively
comfortably with crutches. She continued to be seen by the
Orthopedics Surgery Service with the plan being for the
patient to remain non-weight bearing for six weeks from the
date of her open reduction and internal fixation.
By [**2138-1-31**], the decision was made to make arrangements for
the patient to be transferred to her home city in [**State **] for
further management of her wounds by a Plastic Surgeon there.
Dr. [**Last Name (STitle) 13797**], the Plastic Surgeon on staff at the [**Hospital1 346**], made contact with a plastic surgeon
in [**Name (NI) **], who agreed to accept [**Known firstname **] [**Known lastname 47265**] as a patient.
Arrangements were made for transportation of the patient to
[**State **] via ambulance.
It was expected that the patient's wound VAC would remain in
place and functioning during the transfer. The patient had a
final change in her wound VAC on [**2138-2-2**], at the [**Hospital1 1444**]. By this time, the patient's
wound beds were largely healthy, pink and granulating well.
The wound beds had failed significantly over the course of
the patient's hospitalization. The patient's wound culture
from [**2138-1-14**] had grown Acinetobacter baumannii which was
sensitive to all antibiotics on the sensitivity panel except
for trimethoprim sulfa and Methisazone.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Dilaudid 8 to 16 mg p.o. q. four hours p.r.n.
2. Dilaudid 2 mg subcutaneously q. three to four hours
p.r.n. for breakthrough pain.
3. Morphine sulfate SR 15 mg p.o. twice a day.
4. Gabapentin 300 mg p.o. q. h.s.
5. Dulcolax 10 mg p.r. q. h.s. p.r.n.
6. Ceftazidime 1 gram intravenously q. eight.
7. Levofloxacin 500 mg p.o. q. day.
8. Colace 100 mg p.o. twice a day.
9. Heparin 5000 units subcutaneously twice a day.
10. Zofran 2 to 4 mg intravenously q. six hours p.r.n.
DISCHARGE INSTRUCTIONS: The patient is to receive care at
[**Hospital6 34976**] in her home town under the care of Dr.
[**Last Name (STitle) 47266**].
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. [**MD Number(1) 20990**]
Dictated By:[**Name8 (MD) 997**]
MEDQUIST36
D: [**2138-2-2**] 16:26
T: [**2138-2-2**] 20:31
JOB#: [**Job Number **]
|
[
"824.0",
"958.8",
"928.10",
"928.20",
"E814.7",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.57",
"83.14",
"83.65",
"79.36",
"77.67",
"86.28",
"83.45",
"86.22"
] |
icd9pcs
|
[
[
[]
]
] |
7847, 8332
|
2437, 7789
|
8356, 8743
|
774, 890
|
1048, 2418
|
157, 709
|
732, 750
|
908, 1024
|
7815, 7824
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,434
| 106,405
|
14756
|
Discharge summary
|
report
|
Admission Date: [**2126-1-21**] Discharge Date: [**2126-1-28**]
Date of Birth: [**2052-8-6**] Sex:
Service:
CHIEF COMPLAINT: This man came in with a chief complaint of
chest and neck pain and shortness of breath.
HISTORY OF PRESENT ILLNESS: A 73-year-old man with past
medical history significant for CAD, status post three-vessel
CABG, AVR, and pacer, who presented with chest pain which
started approximately 1 week prior to admission. Described
it as soreness which comes at rest and activity. The patient
also complained of shortness of breath, beginning in [**Month (only) **] or
[**Month (only) 205**] which previously is his main complaint. The patient
also has neck pain with exertion, which abates at rest. Last
week prior to admission, the patient had increasing shortness
of breath and "neck pain" which escalated and prompted his
visit to his PCP. [**Name10 (NameIs) **] patient did lie flat and denies PND.
Chest pain started over the prior week but increased
shortness of breath prompted an ETT, which showed a large
mild reversible defect. Because of this result, the patient
escalating systems the primary care doctor referred the
patient to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for possible intervention.
REVIEW OF SYSTEMS: Negative for cough and fever. Negative
for overindulgence in food and alcohol over the holidays.
Positive rash. Fair appetite, which is approximately stable.
No abdominal pain, nausea, vomiting or diarrhea. Positive
occasional monocular loss of vision in the left eye, maybe
the right eye too. Carotid ultrasound "okay" per the
patient.
PAST MEDICAL HISTORY: CAD (CABG three-vessel and AVR [**2124-7-17**], reason positive ETT).
Status post pacer placement in the context of unclear
disorder ? heart block for AAA repair, [**2123-6-18**].
Status post cardioversion [**Month (only) 116**] or [**2125-6-17**] but felt return of
neck pain in [**2125-9-17**].
Hypothyroidism.
AAA repair 4 to 5 years prior to admission.
Borderline hypertension.
Chronic renal insufficiency.
Kyphosis.
ALLERGIES: NKDA.
MEDICATIONS:
1. Aspirin 81 mg p.o. q.d.
2. Synthroid 75 mg p.o. q.d.
3. Lotrel 510 mg q.d.
SOCIAL HISTORY: The patient was an electric technician,
retired, and lives with his wife and son who is 39 years old.
The patient has 1 to 2 drinks a day. Former smoker, quit in
[**2090**].
FAMILY HISTORY: Mother died at 97 of unclear causes. Father
died at 65 with ? CAD but the father is a World War I veteran
with many exposures. He has three children who are alive and
well and he is the only child himself.
PHYSICAL EXAMINATION: VITAL SIGNS: The patient had a heart
rate of 107, blood pressure 138/74, saturating 96 percent on
room air, and respiratory rate is 21. GENERAL: He is an
elderly man, alert, and mildly tachypneic in no apparent
distress. HEENT: Bilateral ear lobe creases, mottled nose,
and anicteric sclerae. NECK: JVP approximately 6 cm.
HEART: A 2/6 systolic murmur at the left sternal border and
apex. Regular rhythm and tachycardic. No gallops or rubs
appreciated. LUNGS: Clear bilaterally. CHEST: Soft 3 to 4
cm mass above the left nipple. ABDOMEN: Soft, nontender,
and nondistended. No hepatosplenomegaly. Multiple surgical
scars. EXTREMITIES: Same with no CCE and 2 plus DP pulses
bilaterally. NEUROLOGIC: Cranial nerves II through XII
intact. Moves all extremities well.
LABORATORY DATA: Admission labs are notable for eosinophil
percentage of 10.9 percent and creatinine of 2.9. CK on
admission was 77 with a troponin of less than 0.01. The
patient's recent stress SPECT showed a large valvular
reversible defect in the inferior lateral apex, EF of 67
percent (positive for large inferolateral and inferoapical
ischemia with normal EF.) Echo on [**2126-1-11**] outside
hospital showed mild LVH, EF 55 percent, mild thickened MV
with trace MR, dilated ascending aorta, normal aortic valve,
normal right ventricular size and function but with mild-to-
moderate tricuspid regurgitation, and no pericardial
effusion. Chest x-ray on admission also showed no acute
cardiopulmonary process or change from [**2124-8-10**].
BRIEF SUMMARY OF HOSPITAL COURSE: A 73-year-old man with
history significant for coronary artery disease status post
three-vessel CABG, AVR, and pacer, who had 6 months' history
of increasing shortness of breath and neck pain. It is
angina equivalent. The patient presented in the context of
positive stress and escalating pain over the last 1-1/2
weeks. The patient was catheterized and found to have
diffuse disease. Given chronic renal insufficiency on
dialysis, the patient was reassessed on the second
catheterization to avoid giving him too much contrast with
one procedure per his attending, Dr. [**Last Name (STitle) **]. However, the
patient had a vagal episode and vague UTI at the outside of
the second catheterization with anginal chest pain. The
patient had a short stay in the CCU as a result. The patient
no longer considered to be a catheterization candidate and
remaining options include medical management and ? of repeat
CABG. The plan therefore changed to send the patient home
for outpatient evaluation after carotid ultrasound read.
Given that the carotid ultrasound showed complete occlusion
of the right ICA and 40 percent of the left ICA, the patient
was sent home. This will be detailed below.
PROBLEM LIST: Cardiovascular rhythm, no changed tachycardiac
event as before. Continue beta-blocker. The patient will
also have a pacemaker interrogated by EP which showed normal
pacemaker function. It should be slowed only with beta
blockade to control the underlying cause of sinus
tachycardia, which was performed during the course of his
admission. CAD, the patient underwent cardiac
catheterization as discussed above. He was continued on beta
blockade, statin, and aspirin and thus consideration given to
Isordil treatment as an outpatient will be decided on
followup. The patient has decreased EF to 40 percent. The
patient was continued on beta blockade but never had symptoms
of clinical CHF on exam.
Renal failure. The patient had improved creatinine over the
course of the admission. The patient only had a small bump
in his creatinine to 3.0 from baseline in mid to high 2s with
his cardiac catheterization. However given that his chronic
renal insufficiency had never been adequately explained,
renal ultrasound was performed. These results were as
follows:
Normal appearance of the left kidney and urinary bladder.
Right kidney which appeared atrophic and 1 to 2 cm cystic
stricture present in the right renal bed. Functionally, the
patient has unilateral kidney and ACE inhibitor was therefore
held.
Hypercholesterolemia. There is no significant increase in
LDL but the patient had reduced HDL, so statin was continued
given his known coronary artery disease.
Hypothyroidism, outpatient Synthroid regimen was continued.
Rash, the patient developed a maculopapular rash over the
face and torso, which improved with steroid cream. Is to
question as to whether this rash is related to metoprolol,
there is a question of discontinuing this drug but Cardiology
input was to continue this protective drug given his coronary
artery disease unless the symptoms became terribly
bothersome.
Question TIA during cardiac catheterization. The patient
developed right hand numbness and weakness, speech slurring,
and hypotension during cardiac catheterization. The symptoms
resolved with the administration of atropine. The patient
had positive amaurosis in the left eye in the past. He also
has nausea and vomiting with these episodes. Vascular and
Neurology consults were called in regards to this and as a
result the patient had a CT head which showed no acute
hemorrhage or infarct, chronic small vessel disease.
Ultrasound of the carotids were also performed, which showed
complete occlusion of the right ICA and 40 percent of the
left ICA. The Vascular consults recommended MRA but given
that the patient has the pacemaker, he cannot have an MRI.
The other alternative would be CT angiograms with the
carotids but given his high creatinine, this was also
rejected as an option. Given the patient's comorbidities and
asymptomatic state, the Vascular Service recommended starting
Plavix and follow up with Dr. [**Last Name (STitle) **]. In light of this
result, the patient was discharged to home in stable
condition.
DISCHARGE INSTRUCTIONS: To return to the ER. Call his
cardiologist for any chest or neck pain, increasing shortness
of breath, dizziness or unusual sweating.
DIAGNOSES: Coronary artery disease.
Renal insufficiency.
Heart failure.
Hypothyroidism.
Carotid stenosis.
FOLLOW UP: Follow up with primary care physician [**Name Initial (PRE) 176**] 1 to
2 weeks.
Follow up with Dr. [**Last Name (STitle) **] within 1 to 2 weeks.
Follow up with Dr. [**Last Name (STitle) **], Vascular Surgery, within next 4
weeks.
CONDITION ON DISCHARGE: The patient was discharged home in
stable condition.
DISCHARGE MEDICATIONS:
1. Synthroid 75 mcg p.o. q.d.
2. Aspirin 325 mg p.o. q.d.
3. Lipitor 10 mg p.o. q.d.
4. Metoprolol 12.5 mg p.o. b.i.d.
5.
Fluocinolone cream b.i.d. p.r.n. rash.
6. Plavix 75 mg p.o. q.d.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8158**], [**MD Number(1) 8159**]
Dictated By:[**Last Name (NamePattern1) 25972**]
MEDQUIST36
D: [**2126-6-20**] 13:22:30
T: [**2126-6-21**] 09:23:09
Job#: [**Job Number **]
|
[
"414.01",
"411.1",
"V45.01",
"593.9",
"244.9",
"996.72",
"V42.2",
"584.9",
"435.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.23",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
2420, 2629
|
9098, 9557
|
8501, 8749
|
8761, 8996
|
4225, 5421
|
2652, 4196
|
1304, 1646
|
145, 234
|
263, 1284
|
5436, 8476
|
1669, 2210
|
2227, 2403
|
9021, 9075
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,568
| 114,783
|
5910
|
Discharge summary
|
report
|
Admission Date: [**2156-1-10**] Discharge Date: [**2156-1-19**]
Date of Birth: [**2071-4-23**] Sex: M
Service: MEDICINE
Allergies:
Robitussin Pediatric / Hytrin / Hydrochlorothiazide
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
HD line placement, intubation
History of Present Illness:
84 year old male with hx of HTN, CVA, cirrhosis, known ascites,
presents s/p fall. Patient says that he got up from his couch,
felt unsteady, and fell on his right shoulder and back. Says he
may have felt a little dizzy prior to falling, but is not sure.
The fall was unwitnessed. Patient doesn't think that he hit his
head or lost consciousness, but son reported that there was LOC.
He had had a beer and a sip of brandy prior to getting up off
the couch. He's had [**4-3**] other falls in the past. The most recent
of which was 1 week ago. Says that he had gotten his foot caught
on the carpetting and fell. Has felt slightly weaker in the past
week. Denies chest pain, SOB, palpitations, n/v.
.
Patient also complains of having diarrhea off and on. He had
diarrhea starting this morning, saying that he's had [**1-14**]
episodes of diarrhea already. Last incidence of diarrhea was
about 1-2 weeks prior to this one. Denies any fevers, abdominal
pain, nausea, vomiting.
.
In the ED, a bedside abdominal ultrasound was done to check for
abdominal bleeding, which returned positive. This prompted a CT
of the torso which showed no bleed. He received 2 L of fluids in
the ED for a lactate of 2.2. Lactate improved to 0.9.
Orthostatics reported to be normal. He was also noted to be
hyponatremic at 125.
.
On the floor patient is feeling comfortable. Not complaining of
anything other than a little soreness in his shoulder and back
from where he fell.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting,
constipation or abdominal pain. No dysuria. Denied arthralgias
or myalgias.
Past Medical History:
HTN
BPH
h/o ascites
CVA - [**2140**] visual field loss right eye. ?amaurosis. By report,
no etiol found. [**4-8**] ? h/o one week of right facial weakness.
Subtle
asymmetry on exam. Began ASA. Carotid U/S shows <40% stenosis
bilat. [**8-8**] branch retinal artery occlusion, Rx conservatively
(Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23333**]). Previous w/u for embolic source neg.
Resumed ASA.
Cirrhosis - [**8-7**] U/S suggestive of fibrosis
Allergic rhinitis
B12 deficiency anemia
EtOH abuse
Social History:
Drinks 5 beers and has a "couple of shots" of brandy a day, 12
pack year smoking hx quit [**2103**].
Retired, worked as a police officer
Recently widowed
Family History:
Sister had rectal cancer, brother with a history of brain
cancer.
Physical Exam:
On admission:
Vitals: 98.1, 174/87, 81, 20, 100%4L
General: AAOx3, NAD
HEENT: PERRLA, EOMI, OP clear, no JVD, no LAD, neck supple
Lungs: slight dullness to auscultation in right lower lobe,
otherwise clear breath sounds, no w/r/r
CV: S1S2, RRR, no m/r/g
Abd: soft, distended, +ascites, nontender, +BS
Ext: no e/c/c, 1+ peripheral pulses
Neuro: no nystagmus, CN II-XII grossly intact, 5/5 strength
throughout, good coordination
On discharge:
Pertinent Results:
[**2156-1-10**] 02:50PM GLUCOSE-94 UREA N-14 CREAT-1.5* SODIUM-125*
POTASSIUM-4.3 CHLORIDE-93* TOTAL CO2-19* ANION GAP-17
[**2156-1-10**] 02:50PM ALT(SGPT)-13 AST(SGOT)-38 ALK PHOS-204* TOT
BILI-0.4
[**2156-1-10**] 02:50PM ETHANOL-25*
[**2156-1-10**] 02:50PM WBC-6.7 RBC-3.82* HGB-10.5* HCT-31.3* MCV-82
MCH-27.5 MCHC-33.6 RDW-15.1
[**2156-1-10**] 02:50PM PT-13.2 PTT-29.4 INR(PT)-1.1
[**2156-1-10**] 02:55PM LACTATE-2.2*
[**2156-1-19**] 02:42AM BLOOD Hct-18.2*#
[**2156-1-19**] 09:42AM BLOOD Hct-26.7*
[**2156-1-19**] 05:44AM BLOOD PT-22.8* PTT-57.0* INR(PT)-2.2*
[**2156-1-19**] 03:24AM BLOOD Glucose-105* UreaN-75* Creat-5.7* Na-131*
K-4.7 Cl-97 HCO3-17* AnGap-22*
[**2156-1-19**] 03:24AM BLOOD ALT-11 AST-24 LD(LDH)-145 AlkPhos-134*
TotBili-5.9* DirBili-4.5* IndBili-1.4
[**2156-1-19**] 03:24AM BLOOD Albumin-3.3* Calcium-7.5* Phos-3.9 Mg-2.1
[**2156-1-19**] 05:47AM BLOOD Type-ART Temp-35.5 pO2-146* pCO2-33*
pH-7.30* calTCO2-17* Base XS--8 Intubat-INTUBATED
Micro:
[**2156-1-19**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-PRELIMINARY INPATIENT
[**2156-1-19**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2156-1-18**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2156-1-17**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
[**2156-1-17**] Rapid Respiratory Viral Screen & Culture
Respiratory Viral Culture-FINAL; Respiratory Viral Antigen
Screen-FINAL INPATIENT
[**2156-1-17**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2156-1-16**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2156-1-16**] URINE Legionella Urinary Antigen -FINAL
INPATIENT
[**2156-1-15**] Rapid Respiratory Viral Screen & Culture
Respiratory Viral Antigen Screen-FINAL; Respiratory Viral
Culture-FINAL INPATIENT
[**2156-1-15**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2156-1-14**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2156-1-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2156-1-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2156-1-13**] PLEURAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-PRELIMINARY INPATIENT
[**2156-1-13**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2156-1-13**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-PRELIMINARY INPATIENT
[**2156-1-13**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2156-1-13**] BLOOD CULTURE Blood Culture, Routine-FINAL
{STAPH AUREUS COAG +}; Anaerobic Bottle Gram Stain-FINAL;
Aerobic Bottle Gram Stain-FINAL INPATIENT
[**2156-1-12**] URINE URINE CULTURE-FINAL INPATIENT
[**2156-1-12**] BLOOD CULTURE Blood Culture, Routine-FINAL
{STAPH AUREUS COAG +}; Aerobic Bottle Gram Stain-FINAL;
Anaerobic Bottle Gram Stain-FINAL INPATIENT
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
[**2156-1-10**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT
[**2156-1-10**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
Brief Hospital Course:
MEDICAL FLOORS COURSE:
Mr [**Known lastname 23334**] is an 84 M with HTN, h/o prior CVA, EtOH abuse who
presented s/p fall, subsquently found to have MSSA bacteremia,
SBP and transuduative pleural effusion; transferred to MICU on
[**1-17**] with altered mental status.
.
# Fall. Per report appears to have syncopized in setting of
hypovolemia (poor PO intake as well as diarrhea in days
preceding hospitalization). No indication of seizure activity
(no incontinence, no post-itcal state) No evidence of cardiac
cause as telemetrey monitored without evident, biomarkers
negative. CT head: negative.
.
# Cirrhosis/ascites/sbp. Regarding risk factors patient with
known h/o EtOH abuse as well as hep B infection which had been
cleared based on serologies. Hep C negative. Patient without
formal diagnosis of cirrhosis in past though hypothesized due to
[**2153**] US with nodular liver characterized. On admission physical
patient with signs of cirrhosis: tense peri-hepatic ascites,
bilateral peripheral edema, splenomegaly, spider angiomas,
Duputrons contractures. Diagnostic paracentitis performed with
peritoneal fluid consistent with SBP. Patient started on
ceftriaxone which was later switched to cipro/flagyl. Patient
received albumin per SBP protocal. Liver consulted for
assistance in management. Due to preserved synthetic function
there was question regarding etiology of ascites ? cirrhosis vs
cardiac however [**Year (4 digits) **] demonstrated preserved systolic function
with EF>55%. RUQ US obtained which demonstrated nodular hepatic
architecture, no focal liver lesion, no
biliary dilatation, mild splenomegaly, no e/o portal vein
thrombosis.
.
# Cough. Patient with 3-4months of productive cough which he
attributed to allergies.
Admission CT with moderate right pleural effusion with adjacent
compressive atelectasis. Patient found to be dyspneic on Day 2.
Diuresis with IV Lasix 20mg attempted without improvement of
symptoms. Decision made to proceed with diagnostic and
therapeutic thoracentitis. Fluid consistent with exudate
?parapneumonic. Urine legionella negative. Repeat CXR with
improved effusion with RLL opacity: atelectasis/fluid though
underlying consolidation could not be ruled out. Patient
initially treated for commmunity-acquired pneumonia with
ceftriaxone and azithromycin. ID consulted. In setting of
multiple infections drug regimen transitioned to naficillin,
azithromycin, cipro/flagyl. Due to nature of cough concern for
pertussis for which the patient was placed in isolation and
treated with a 5day course of azithromycin.
.
# MSSA bacteremia. Patient spiked a fever on [**1-12**]. Cultures
with gram positive cocci. Patient initially placed on
vancomycin. Switched to nafcillin when speciated out to MSSA on
[**1-14**]. ?Source: endocarditis vs skin source as patient with
several areas of excoriation on forearm and shins. TEE ordered
however patient unable to tolerate procedure to examine for
vegatations. Physical on the floor notable for stable, unchanged
murmur, negative for additonal exam findings consistent with
endocarditis. ID consulted. Recommended treating with IV
Nafcillin for likely 6weeks as endocarditis could not be ruled
out.
.
# Acute kidney injury. Patient with baseline chronic kidney
disease with creatinine at baseline 1.6. On admission,
creatinine 1.6. Bump in creatinine from 1.6 -> 2.2 noted on
[**1-14**]. Urine labs notable for negative eosinophilia, lytes
notable for Fena<.1 consistent with pre-renal vs hepatorenal
syndrome. Renal US negative for hydronephrosis ruling out
post-renal obstruction. Primary team concerned for hepatorenal
syndrome. Liver and renal consulted for question hepatorenal
syndrome especially in setting of SBP. At that time patient
without signs of decompensated liver failure via laboratory
data. Patient continued on albumin. Octreotide and midodrine
were not started. Renal suggested fluid challenge of 1-2L to
rule out pre-renal etiology also question contrast-induced
nephropathy as patient received CTA on [**1-10**]. Unable to spin
urine to assess for presence of casts. Patient did not respond
appropriately to fluids and became anuric on [**1-16**]. Decision
made to place a HD catheter on [**1-16**] in anticipation of renal
replacement.
.
# HTN - Patient continued on home amlodipine and atenolol on
admission. Atenolol switched to [**Hospital1 **] metoprolol in setting of
[**Last Name (un) **].
.
# Diarrhea. Per report patient with multiple episodes of
diarrhea on day prior to admission. C. diff negative and stool
studies negative in house. Diarrhea resolved in house.
# h/o CVA. Residual deficits: mild dysarthria. CT head negative
on admission for new stroke. Patient continued on ASA on the
floor.
.
MICU course:
1. Altered Mental Status: Patient was initially transferred to
MICU for concern of stroke, though upon discussion with neuro
and radiology, imaging did not suggest this. Seizure not
suspected. More likely toxic metabolic in the setting of liver
failure, multiple infections, renal failure, SBO, and GI bleed.
Patient intubated on early morning of [**1-19**] for airway
protection in setting of AMS.
2. Sepsis: Patient known to have MSSA bacteremia of unclear
source (negative [**Name (NI) **], refused TEE), for which he had been on
vancomycin-->nafcillin. Also with SBP, treated with
ceftriaxone-->cipro/flagyl. Patient hypothermic and hypotensive
to systolic pressures in 60's in MICU. Also ? evidence of
retrocardiac opacity on CXR. Would have broadened treatment to
cover for HCAP but family soon after decided not to pursue
aggressive measures. Transiently on peripheral dopamine before
family decided to make patient CMO.
3. Acute drop in hematocrit: Patient noted to have 10 point Hct
drop from evening of [**1-18**] to [**1-19**], also in setting of
coagulopathy (due to liver failure versus early DIC). He
received a total of 3 units PRBC and 1 bag of FFP. NG lavage
with blood tinged fluid, no gross blood. No plans to scope for
GI bleed in setting of critical illness and multiorgan failure
by AM of [**1-19**].
4. Acute renal failure: Thought initially to be due to contract
induced nephropathy, though urine sediment never obtained as pt
was oliguric during MICU stay. Urine lytes with Na<10, certainly
possible that he developed HRS in the setting of SBP and acute
liver decompensation. CVVH was not pursued based on goals of
care discussion.
5. Liver failure: Patient with e/o cirrhosis given nodularity of
liver and splenomegaly on ultrasound, in addition to presence of
ascites. On admission bilirubin 0.4 and INR 1.1, which
progressed to bilirubin peaking at 7 and INR peaking at 2.5,
suggesting acute liver decompensation. Possible precipitants may
have been sepsis causing cholestatic picture versus antibiotic
effect (ceftriaxone, nafcillin) in a poor substrate. Patient not
a candidate for transplant per liver team given critical illness
and multiorgan failure.
6. Goals of care discussion: Per discussion with HCP, son,
[**Name (NI) **], patient was full code for first 24 hours of course in
MICU. On [**1-19**], family meeting held with 3 children including
HCP, and given critical illness/multiorgan failure as well as
low likelihood of meaningful recovery, patient was made comfort
measures only at 10am on [**2156-1-19**] and expired later in the day.
Medications on Admission:
amlodipine 5 mg daily
atenolol 100 mg daily
finasteride 5 mg daily
Vitamin B12
ASA 81 mg daily
Iron supplement
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
|
[
"518.0",
"276.52",
"511.89",
"790.01",
"787.91",
"780.2",
"348.30",
"438.13",
"486",
"567.23",
"287.5",
"995.92",
"286.9",
"584.5",
"585.9",
"789.59",
"572.8",
"038.11",
"403.90",
"V15.88",
"305.01",
"428.0",
"560.9",
"571.5",
"572.4",
"276.1",
"276.2",
"518.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"34.91",
"96.71",
"96.04",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
14335, 14344
|
6814, 7394
|
317, 348
|
14395, 14404
|
3450, 6791
|
14460, 14562
|
2906, 2973
|
14303, 14312
|
14365, 14374
|
14167, 14280
|
14428, 14437
|
2988, 2988
|
3431, 3431
|
1848, 2173
|
273, 279
|
376, 1829
|
7403, 11564
|
3002, 3416
|
11579, 14141
|
2195, 2718
|
2734, 2890
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,281
| 171,807
|
39264
|
Discharge summary
|
report
|
Admission Date: [**2159-4-28**] Discharge Date: [**2159-5-5**]
Date of Birth: [**2094-12-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Aspirin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest and back pain/Hypotension
Major Surgical or Invasive Procedure:
[**Date range (1) 86880**] - Repair of acute type A aortic dissection with
28-mm Dacron interposition graft from the sinotubular junction
to the beginning portion of the aortic arch using deep
hypothermic circulatory arrest.
History of Present Illness:
y/o male presented to outside hospital with 10/10 epigastric
pain. Subsequently developed right lower extremity pain
followed
by right lower extremity numbness. Emergency CT scan showed
dissection of ascending aorta with ? involvement of aortic root
extending to both iliacs. Patient emergently transferred to
[**Hospital1 18**] OR. Patient with 10/10 epigastric pain in OR. TEE showed
+2 aortic regurgitation. In the OR, no pulses felt in right
lower extremity. +3 pulses in left femoral/DP/PT. Underwent
emergency repair of ascending aortic dissection.
Past Medical History:
Hypertension
Tobacco use
Social History:
Works as a physician. [**Name10 (NameIs) 13802**] with wife. [**Name (NI) **] is an active smoker.
Family History:
N/C
Physical Exam:
Intubated on OR table, unable to fully examine
Right foot mildly cool but pink. No palpable pedal pulses right
(examined from under drape)
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RLE Femoral: faintly palpable prior to going on bypass.
LLE Femoral: P.
Pertinent Results:
[**2159-4-28**] ECHO
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
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.
A mobile density is seen in the ascending aorta consistent with
an intimal flap/aortic dissection. A mobile density is seen in
the aortic arch consistent with an intimal flap/aortic
dissection. A mobile density is seen in the descending aorta
consistent with an intimal flap/aortic dissection. There is no
pericardial effusion.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Moderate (2+) aortic regurgitation is
seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. No mitral regurgitation is seen. There is
no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of
the results on [**Known lastname 27735**] before surgical incision.
Post_Bypass:
There is no aortic insufficiency.
Thoracic aorta is intact.
Minimal MR, TR.
Biventricular systolic functioni s good. LVEF 55%.
[**2159-4-30**] Carotid Ultrasound
Impression:
Right ICA with no stenosis .
Left ICA with no stenosis .
RCCA true lumen appears re-expanded with complete collapse of
flase lumen comared to pre-op CTA from outside hospital.
[**2159-5-5**] 03:45AM BLOOD WBC-15.2* RBC-3.36* Hgb-10.7* Hct-30.6*
MCV-91 MCH-31.8 MCHC-34.9 RDW-14.3 Plt Ct-348
[**2159-5-4**] 04:40AM BLOOD WBC-13.9* RBC-3.30* Hgb-9.9* Hct-30.3*
MCV-92 MCH-30.1 MCHC-32.7 RDW-14.5 Plt Ct-268
[**2159-5-5**] 03:45AM BLOOD Glucose-98 UreaN-21* Creat-0.9 Na-138
K-3.7 Cl-104 HCO3-25 AnGap-13
Brief Hospital Course:
Mr. [**Known lastname 27735**] was admitted to the [**Hospital1 18**] on [**2159-4-28**] for emergency
repair of his type A aortic dissection. He as taken immediately
to the operating room where he underwent repair of acute type A
aortic dissection with 28-mm Dacron interposition graft from the
sinotubular junction to the beginning portion of the aortic arch
using deep
hypothermic circulatory arrest. A vascular surgery consult was
obtained intraoperatively as he had diminished pulses in his
right lower extremity however following his operation, his
pulses improved to normal. Postoperatively he was taken to the
intensive care unit for monitoring. On postoperative day one, he
self extubated himself requiring reintubation. He was noted to
be quite agitated and somewhat confused. On postoperative day
four, he was successfully extubated and was neurologically
intact. He was later transferred to the step down unit for
further recovery. He developed atrial fibrillation which
converted with amiodarone and beta blockade. Amiodarone was
increased to three times a day on post operative day 7 for
increased premature atrial beats. He is to be discharged on an
amiodarone taper and is to receive no anticoagulation per Dr.
[**Last Name (STitle) 914**]. He worked with physical therapy daily. Gentle diuresis
was initiated.
He continued to make steady progress and was discharged home on
postoperative day 7. He will follow-up with Dr. [**Last Name (STitle) 914**] and his
primary care physician and cardiologist as an outpatient.
Medications on Admission:
Aspirin
Discharge Medications:
1. Lopressor 50 mg Tablet Sig: 1.5 Tablets PO twice a day.
Disp:*90 Tablet(s)* Refills:*0*
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO every twenty-four(24)
hours for 7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
3. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*28 Patch 24 hr(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
8. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO three times a
day for 1 weeks: decrease to 400 mg [**Hospital1 **] after 1 week then 400 mg
QD x 1 week then 200 mg QD ([**1-20**] tab) x 2 weeks.
Disp:*50 Tablet(s)* Refills:*0*
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain. Tablet(s)
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Aortic dissection
Hypertension
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with Ultram prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) 914**] on [**2159-6-5**] 1:30PM [**Telephone/Fax (1) 170**]
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10940**] in [**1-20**] weeks ([**Telephone/Fax (1) 86881**]
Cardiologist Dr. [**Last Name (STitle) 86882**] [**Telephone/Fax (1) 9219**] in 2 weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2159-5-5**]
|
[
"443.22",
"997.1",
"424.1",
"518.5",
"441.01",
"427.31",
"348.30",
"401.9",
"E878.2",
"305.1",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"38.91",
"39.61",
"38.93",
"38.45",
"35.11"
] |
icd9pcs
|
[
[
[]
]
] |
6435, 6493
|
3531, 5069
|
304, 531
|
6568, 6662
|
1607, 3508
|
7203, 7706
|
1305, 1310
|
5127, 6412
|
6514, 6547
|
5095, 5104
|
6686, 7180
|
1325, 1588
|
233, 266
|
560, 1125
|
1147, 1173
|
1189, 1289
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,074
| 174,826
|
31626
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 74335**]
Admission Date: [**2101-6-5**]
Discharge Date: [**2101-6-13**]
Date of Birth: [**2101-6-5**]
Sex: M
Service: Neonatology
IDENTIFICATION: Baby [**Name (NI) **] [**Known lastname 74336**] is a 7-week-old at term
infant who is being discharged from the neonatal intensive
care unit at the [**Hospital1 69**]
following evaluation for fever and desaturation episodes.
HISTORY: Baby [**Name (NI) **] [**Known lastname 74336**] was born on [**2101-6-5**] as the
4275 gm product of a 37 and [**5-12**] week gestation pregnancy to a
27-year-old gravida 1, para 0-1 mother with [**Name (NI) 37516**] of [**2101-6-20**]. Prenatal Lab Corp studies included blood type A+,
antibody negative, RPR nonreactive, rubella-immune, hepatitis
B surface antigen negative and group B streptococcus
negative. Maternal history and prenatal course were notable
for asthma, gestational diabetes mellitus and pregnancy-
induced hypertension. Maternal medications included insulin
and albuterol. The infant was delivered by C-section due to
macrosomia. No sepsis risk factors were identified. At
delivery the infant was vigorous with Apgars of 9 and 9. He
was well-appearing, but initial D-sticks were noted to be
under 30. Infant was also found to be mildly hypothermic and
to turn dusky during 1st feeding attempt; due to these
concerns the infant was brought to the NICU.
HOSPITAL COURSE BY SYSTEMS: Respiratory: Infant remained
comfortable on room air throughout admission without evidence
of significant respiratory distress. However, occasional
desaturation episodes were noted; these were primarily with
feeding attempts, although were occasionally seen at rest as
well. Desaturations episodes gradually improved with
improvement in feeding skills and by the time of discharge
the infant has been free of desaturation episodes at rest for
over 5 days and free of desaturation episodes with feedings
for over 3 days. Overall, feedings are noted to be much more
coordinated by the time of discharge than were seen in the
1st few days after birth.
Cardiovascular: The infant has remained hemodynamically
stable throughout admission. No cardiovascular concerns have
been noted.
Fluids, electrolytes, nutrition: The infant has been
maintained on ad lib feeding throughout hospitalization of
breast milk and Similac 20. Total intake has been adequate
and urine and stool output has been normal throughout. As
mentioned, the infant was hypoglycemic shortly after birth
with 2 blood sugar values under 40; however, with routine
feeding these normalized and blood sugars remained within
normal range subsequently. As mentioned above, initial
feedings were described as somewhat discoordinated resulting
in frequent desaturation; these gradually improved with time
and by the time of discharge the infant is feeding well
without difficulty. Birth weight was 4275; weight at the time
of discharge was 4110g.
GI: Infant experienced mild physiologic jaundice. Bilirubin
level on day of life 3 was 8.7/0.3, phototherapy was not
necessary.
Hematology: The infant's hematocrit was measured on day of
life 2 and was found to be 56. No other hematologic issues
have been identified.
Infectious disease: No perinatal sepsis risk factors were
identified. On day of life 2 however, the infant was noticed
to have developed a temperature to 101. Infant gradually
defervesced, but did have mildly elevated temperatures above
100 for the next 12-24 hours. A sepsis evaluation was
performed including a CBC that was unremarkable and CSF
analysis that was also reassuring. Blood and CSF cultures
were subsequently negative. The infant was begun on
ampicillin, gentleman and acyclovir. Antibiotics were
discontinued at 48 hours. CSF was sent for HSV, PCR, this
returned negative on day of life 6, at which time acyclovir
was discontinued. Of note, a transient exanthem was noted the
day following the fever; overall course is most suggestive of
a viral illness.
Neurology: The infant had maintained a normal urologic exam
throughout admission. Hearing screen was performed with
automated auditory brainstem responses and was passed
bilaterally.
CONDITION AT DISCHARGE: Stable, on room air with mature
respiratory and feeding patterns.
DISCHARGE DISPOSITION: Infant is being discharged to home.
PRIMARY PEDIATRICIAN: Dr. [**First Name5 (NamePattern1) 25897**] [**Last Name (LF) 74337**], [**First Name3 (LF) 392**]
Pediatrics, [**Telephone/Fax (1) 42643**].
PHYSICAL EXAMINATION AT DISCHARGE: Weight 4110g, head
circumference 37.5cm, length 53.5cm. Infant is a well-developed
infant in no distress. Infant is comfortable and reactive with
exam. Fontanelles are soft and flat. Ears and nares are normal.
Red reflex is present bilaterally. Palate is intact. Neck is
supple. Chest is clear to auscultation without grunting,
flaring or retractions. Cardiac exam is regular rate and
rhythm without murmur. Abdomen is soft and nondistended with
active bowel sounds. Genitalia that of a normal male, testes
are descended bilaterally, anus is patent. Hips and back are
normal. Tone and activity are appropriate.
CARE AND RECOMMENDATIONS:
1. Feeds: Breast milk or Similac 20 ad lib.
2. Medications: None.
3. Car seat position screening: Car seat safety screening
was performed and was passed.
4. State newborn screening: Newborn State screen was sent on
day of life 3 as per protocol. No abnormal results have
been reported to date.
5. Immunizations received: Hepatitis B vaccine was given on
[**2101-6-10**], day of life 5.
6. Immunizations recommended:
1. Influenza immunization is recommended annually in the
fall for all infants at least 6 months of age; before
this age, and for the first 24 months of the child's
life, immunization against influenza is recommended
for household contacts and out of home caregivers.
2. This infant has not received rotavirus vaccine. The
American Academy of Pediatrics recommends initial
vaccination of preterm infants at or following
discharge from the hospital if they are clinically
stable and at least 6 weeks or fewer than 12 weeks of
age.
7. Followup: Infant will followup with primary pediatrician
within 3 days of discharge.
DISCHARGE DIAGNOSES:
1. At term gestation.
2. Hypoglycemia.
3. Sepsis evaluation.
4. Viral illness.
5. Feeding immaturity.
6. Apnea.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 37928**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2101-6-12**] 19:42:08
T: [**2101-6-12**] 20:40:02
Job#: [**Job Number 74338**]
|
[
"V30.01",
"V50.2",
"775.0",
"079.99",
"V05.3",
"771.89",
"770.81",
"774.6",
"V29.0",
"779.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"64.0",
"99.55",
"99.21",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
4270, 4493
|
6310, 6682
|
5146, 5557
|
1425, 4164
|
4508, 5120
|
5588, 6289
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,181
| 116,876
|
48831
|
Discharge summary
|
report
|
Admission Date: [**2185-9-14**] Discharge Date: [**2185-9-23**]
Service: MEDICINE
Allergies:
Codeine / Penicillins / Aspirin / Fentanyl
Attending:[**First Name3 (LF) 2605**]
Chief Complaint:
Foreign body aspiration
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
81yo F w/ MMP including lung cancer s/p RML and LUL lobectomies,
with new L hilar mass and R base mass, who was eating lunch at
her [**Hospital3 **] facility today when she aspirated what she
thought was a piece of lamb. She was seen in the nursing station
at her [**Hospital3 **] facility and was felt to be doing OK, so
was sent to her room. However 15 mins later, the pt's aide noted
that she had a lot of frothy white sputum, was abdominal
breathing, and was not talking much. Her color also looked off.
Her O2 sats were only 70% at the time and she was unable to talk
(her speech was very garbled). She was taken to the [**Hospital1 18**] ER for
evaluation by EMS. EMS had her on 15L by NRB. On arrival to the
hospital, her sats were only in the 60s on a NRB. She was given
another combivent nebulizer w/o improvement. CXR revealed no
radioopaque objects in her trachea. Her sats began to drop into
the 50s and she was tachypneic to the 30s, usuing accessory
muscles of respiration. She was noted to be AAOx3 and agreed to
be intubated. She was given ativan, etomidate, and
succinylcholine. After intubation, her sats improved to the 90s
and she was stabilized on the vent. She was transferred to the
MICU for bronchoscopy and retrieval of the foreign body.
Bronchoscopy revealed an object lodged in the R main bronchus.
Multiple attempts were made at obtaining the food particles, but
2 mushrooms were eventually dislodged. She continued to do well
post-bronchscopy but the decision was made to keep her intubated
in case repeat bronchoscopy was needed in the AM to insure that
all food particles had been retrieved.
Past Medical History:
# Lung cancer
- s/p RUL lobectomy in [**2169**] for bronchoalveolar carcinoma
- s/p segemental resection of posterior segment of LUL in [**2173**]
- path = adenoca NOS, moderately differentiated features, neg LN
- repeat mass found in LUL in [**2183**] -> bronchoscopy -> developed
resp failure post bronch requiring ventilation (? [**1-20**] muscle
rigidity from fentanyl)
- path of [**2184-1-22**] mass = infiltrating adenoca w/ papillary
features
- then found L hilar mass -> 6 cycles chemo w/ navelbine + XRT
- L hilar mass enlarged, plus new mass at R lung base (20 x
13mm)
- opted for no further treatment
# COPD
- last PFTs in [**2173**] - FEV1 1.80, FVC 2.05, FEV1/FVC 88 (125%)
# hypothyroidism
# h/o TIA/CVA
- MRA in [**2172**] showed 80%+ stenosis of [**Doctor First Name 3098**], 90%+ of [**Country **]
- s/p L CEA in [**2172**] (h/o R CEA in past)
- [**2182**]: R ICA w/ 70-79% stenosis L ICA w/ 60-69% stenosis
- MRA in [**2182**] showed subacute vs. acute infarct L internal
capsule
- per neuro notes, strokes have been bilateral and had residual
L sided hemiparesis (though not noted on neuro exams)
# Parkinson's
# PVD and claudication
# Cervical stenosis
- s/p anterior cervical disk excision and fusion of screws
# HTN
# Osteoarthritis and osteoporosis
# s/p R THR in [**2171**] for OA
- then had R hip dislocation in [**2181**], s/p closed reduction
# OSA - not on CPAP
# h/o PUD
# Depression
# CRI - baseline Cr is 1.7 - 3.2 in last 2 yrs
Social History:
Lives at [**Location 5583**] House x 2 yrs. 90 pack-yr smoker. h/o EtOH
abuse. Widowed, husband died in [**2171**].
Family History:
NC
Physical Exam:
VS - T 97.2, BP 173/73, HR 86, RR 26, sats 100% on AC 450x12,
PEEP 10, FiO2 60%
Gen: Thin, cachetic elderly female, sedated and intubated.
HEENT: Sclera anicteric. L pupil 5mm, reactive, R pupil 3mm,
reactive. Neck supple, no JVD.
CV: RR, normal S1, S2. No m/r/g.
Lungs: CTA anteriorly, no wheezes/rhonchi/crackles. Unable to
sit pt up to listen posteriorly.
Abd: Soft, NTND. + BS. No masses.
Ext: 2+ DP, radial pulses bilaterally.
Neuro: Sedated. Withdraws all 4 extremities to painful stimuli.
Upgoing toes bilaterally.
Pertinent Results:
LABS on admission:
WBC 9.7, Hct 36.8, Plt 351, MCV 93
(diff: 83.9N, 12.6L, 2.8M, 0.6E, 0.1B)
PT 11.9, PTT 29.1, INR(PT) 1.0
Na 142, K 4.3, Cl 102, HCO3 26, BUN 30, Cr 1.9, Glu 145
CK(CPK) 12*, CK-MB NotDone, trop <0.01
ABG pO2-32* pCO2-46* pH-7.39 calTCO2-29 Base XS-1
EKG: sinus, rate 90, normal intervals, normal axis, LAE
(biphasic P waves in V1-V2), no Q waves, no ST or TW changes
.
CXR [**2185-9-14**]: Compared with [**2184-12-8**], the patchy infiltrates in
the right lung have cleared, but the region of clustered linear
opacities in the left upper lung field are still present, either
more confluent or smaller in size. No acute infiltrates or
obvious CHF or effusions.
The patient is status post lower anterior cervical spine fusion,
with her chin somewhat low in position at this time. Whether
this is a fixed posture or not is uncertain.
.
CXR [**2185-9-14**]: (my read) R line clear, L hilar mass, ETT 2 mm
above carina, normal heart size
.
[**2185-9-14**] 02:35PM BLOOD WBC-9.7 RBC-3.94* Hgb-12.4 Hct-36.8
MCV-93 MCH-31.4 MCHC-33.7 RDW-14.7 Plt Ct-351
[**2185-9-15**] 06:03AM BLOOD WBC-9.3# RBC-3.48* Hgb-11.1* Hct-33.2*#
MCV-95 MCH-32.0 MCHC-33.6 RDW-14.6 Plt Ct-282
[**2185-9-16**] 04:31AM BLOOD WBC-9.7 RBC-3.34* Hgb-10.9* Hct-31.3*
MCV-94 MCH-32.5* MCHC-34.7 RDW-14.7 Plt Ct-256
[**2185-9-18**] 04:34AM BLOOD WBC-9.7 RBC-3.71* Hgb-12.2 Hct-35.3*
MCV-95 MCH-32.9* MCHC-34.6 RDW-14.9 Plt Ct-292
[**2185-9-19**] 07:05AM BLOOD WBC-7.2 RBC-3.57* Hgb-11.5* Hct-33.8*
MCV-95 MCH-32.2* MCHC-34.0 RDW-14.9 Plt Ct-341
[**2185-9-20**] 05:35AM BLOOD WBC-7.4 RBC-3.38* Hgb-10.9* Hct-31.7*
MCV-94 MCH-32.3* MCHC-34.5 RDW-15.3 Plt Ct-326
[**2185-9-21**] 09:44AM BLOOD WBC-7.4 RBC-3.36* Hgb-11.2* Hct-31.5*
MCV-94 MCH-33.2* MCHC-35.4* RDW-15.1 Plt Ct-319
[**2185-9-14**] 02:35PM BLOOD PT-11.9 PTT-29.1 INR(PT)-1.0
[**2185-9-14**] 02:35PM BLOOD Glucose-145* UreaN-30* Creat-1.9* Na-142
K-4.3 Cl-102 HCO3-26 AnGap-18
[**2185-9-15**] 03:47AM BLOOD Glucose-77 UreaN-25* Creat-1.2* Na-143
K-3.0* Cl-115* HCO3-19* AnGap-12
[**2185-9-15**] 06:03AM BLOOD Glucose-93 UreaN-29* Creat-1.8* Na-142
K-3.9 Cl-108 HCO3-25 AnGap-13
[**2185-9-16**] 04:31AM BLOOD Glucose-87 UreaN-19 Creat-1.5* Na-145
K-3.5 Cl-112* HCO3-23 AnGap-14
[**2185-9-17**] 04:55AM BLOOD Glucose-96 UreaN-19 Creat-1.5* Na-145
K-3.5 Cl-109* HCO3-21* AnGap-19
[**2185-9-18**] 04:34AM BLOOD Glucose-97 UreaN-21* Creat-1.5* Na-145
K-3.9 Cl-109* HCO3-22 AnGap-18
[**2185-9-19**] 07:05AM BLOOD Glucose-110* UreaN-17 Creat-1.2* Na-144
K-3.3 Cl-107 HCO3-25 AnGap-15
[**2185-9-20**] 05:35AM BLOOD Glucose-96 UreaN-17 Creat-1.3* Na-139
K-3.6 Cl-105 HCO3-26 AnGap-12
[**2185-9-21**] 09:44AM BLOOD Glucose-134* UreaN-20 Creat-1.6* Na-148*
K-3.9 Cl-105 HCO3-26 AnGap-21*
[**2185-9-21**] 05:00PM BLOOD Glucose-95 UreaN-23* Creat-1.5* Na-138
K-4.1 Cl-105 HCO3-21* AnGap-16
[**2185-9-14**] 02:35PM BLOOD CK(CPK)-12*
[**2185-9-14**] 02:35PM BLOOD cTropnT-<0.01
[**2185-9-14**] 02:35PM BLOOD CK-MB-NotDone
[**2185-9-15**] 03:47AM BLOOD Calcium-6.1* Phos-2.7 Mg-1.6
[**2185-9-16**] 04:31AM BLOOD Calcium-8.2* Phos-4.2 Mg-1.7
[**2185-9-18**] 04:34AM BLOOD Calcium-9.6 Phos-3.0 Mg-1.9
[**2185-9-19**] 07:05AM BLOOD Calcium-9.3 Phos-2.9 Mg-1.5*
[**2185-9-14**] 02:47PM BLOOD pO2-30* pCO2-58* pH-7.31* calTCO2-31*
Base XS-0
[**2185-9-14**] 02:49PM BLOOD pO2-32* pCO2-46* pH-7.39 calTCO2-29 Base
XS-1
Brief Hospital Course:
81 yo F w/ h/o lung cancer not amenable to treatment, dementia
and prior CVAs s/p mult. aspirations, htn, CRI presented w/
hypoxic respiratory failure [**1-20**] aspiration now moving towards
palliative care management.
In the MICU, she continued to do well post-bronchoscopy and was
extubated on [**2185-9-15**]. She has had excellent O2 saturations
averaging 96% on room air during the day. However, she has
required 2L NC overnight while in the MICU. Her MICU course has
been significant for hypertension. She has been NPO with h/o
recurrent aspirations in the past and has had an NG tube in
which she has removed several times, not because she is delerius
but because she doesn't like it. When she is given her po blood
pressure medications, her BP runs in the 130s. However, when NG
is not in, she has required IV hydralazine and SL isordil with
BPs in the 150s-180s. She has not yet had a speech and swallow
evaluation as her mental status would not tolerate until
recently.
HTN: Patient's MICU stay was complicated by hypertension as she
was NPO for aspiration risk and would not maintain an NG tube.
On IV hydralazine, SL isosorbide, BPs were in the 160s-180s. IV
lopressor was added and BPs decreased slightly but persisted in
180s at times. Patient failed video swallow again and a family
meeting was held with the geriatrics team. [**Hospital **] healthcare
proxy along with patient and family input decided that patient
should be made DNR/DNI and should be allowed to be fed for
improved quality of life. Patient's diet was advanced and
patient did well without evidence of respiratory compromise.
Her affect greatly improved after starting to eat again. All
of her IV blood pressure medications were stopped and she was
started back on her home dose norvasc and isosorbide dinitrate.
She had improved BP control back on her oral medication regimen.
.
# ASPIRATIONS: She failed repeat swallow evaluation but family
determined that patient's code status should be changed and
patient should be allowed to eat and take medications as
described above given her poor prognosis to improve the quality
of her life. Staff were instructed to take comfort measures
only if patient were to aspirate including O2, suctioning,
nebulizers, and morphine. All medications given were crushed.
As well, all unnecessary medications including fexofenadine,
donepazil, flonase, simvastatin, and pletal were discontinued.
Palliative care was consulted and were actively involved in the
goals of her care.
.
# INCREASED SECRETIONS- patient has had increased secretions
post extubation in MICU which persisted on the floor. These were
managed with bedside suctioning, frequent suctioning by nurses,
and hyoscyamine which was changed from prn to QID standing
doses.
.
# HYPOXIC RESPIRATORY FAILURE: Likely due to foreign body
aspiration.(2 mushrooms were found in the R main bronchus).
Extubated on [**9-15**] and then saturated well on room air with only
occasional dips into the low 90s overnight when not on her CPAP
machine.
.
# OSA: She normally uses CPAP outside of hospital and was
started on CPAP [**9-18**] with improved overnight O2 saturations.
.
# h/o TIA/STROKE: No change in neurologic exam. No active
issues. Pletal was d/c'ed as above
.
# CRI- baseline Creatinine in last year seemed to be between
1.5-2.0. Patient persisted at former baseline with infrequent
gentle IV hydration to supplement po intake.
.
# DEMENTIA: No acute issues. Aricept d/c'ed as above.
.
# HYPOTHYROIDISM: No active issues. She was restarted on her
home dose levothyroxine once po medications restarted.
.
# DEPRESSION: She initially had a flattened affect which
improved once patient's diet was advanced. She was continued on
her lexapro throughout admission.
.
# PUD- No acute issues. She was initially managed on protonix
which was changed to her home med prevacid once diet was
advanced as patient was receiving crushed meds and protonix
could not be crushed
Medications on Admission:
MVI 1 tab PO QD
Flonase 1 spray INH QD
Levsin elixir .125mg PO Q4-6 prn
Norvasc 10mg PO QHS
Aricept 10mg PO QHS
Prevacid 30mg PO BID
Albuterol inhalers 1-2 puffs INH Q4 prn
Tessalon perles 100mg PO TID
Lexapro 20mg PO QD
Levoxyl 50mcg PO QD
Cilostazol (pletal) 100mg PO QD
simvastatin 40mg PO QHS
Isosorbide 10mg PO TID
Loratidine 10mg PO QD
.
** only med NOT on list is Ritalin 10mg PO TID - ordered [**8-23**],
reordered [**7-24**] **
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
3. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
6. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day as needed for constipation: hold for loose stools.
Disp:*60 Tablet(s)* Refills:*2*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Disp:*120 Tablet(s)* Refills:*2*
8. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO twice a day.
10. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual QID (4 times a day).
Disp:*120 Tablet, Sublingual(s)* Refills:*2*
11. CPAP
at night per previous settings
12. Morphine Concentrate 20 mg/mL Solution Sig: 1-20 mg PO Q1hr
SL as needed for pain or respiratory distress.
Disp:*qs * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Hospice of the good [**Doctor Last Name 9995**]
Discharge Diagnosis:
Primary:
1. hypoxic respiratory failure
2. aspiration
3. dysphagia
.
Secondary
1. lung cancer
2. hypertension
3. hypothyroidism
4. COPD
5. hyperlipidemia
6. obstructive sleep apnea
7. depression
8. chronic renal failure
Discharge Condition:
stable
Discharge Instructions:
Please take all medications as prescribed.
.
Please follow up with Dr. [**First Name8 (NamePattern2) 712**] [**Name (STitle) 713**] as listed below.
.
Please call your doctor or return to the hospital if you
experience chest pain, shortness of breath, difficulty
swallowing, fevers, chills, abdominal pain, or any other
concerns.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 713**] as below:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2185-10-4**]
8:30
.
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2185-11-22**]
2:00
.
.
Please follow up with orthopedics as below:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Date/Time:[**2186-7-7**] 11:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2608**] MD, [**MD Number(3) 2609**]
|
[
"403.90",
"244.9",
"311",
"327.23",
"E911",
"V10.11",
"518.81",
"585.9",
"934.1",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"98.15",
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
13190, 13269
|
7499, 11450
|
274, 288
|
13533, 13542
|
4136, 4141
|
13920, 14632
|
3574, 3578
|
11938, 13167
|
13290, 13512
|
11476, 11915
|
13566, 13897
|
3593, 4117
|
211, 236
|
316, 1940
|
4155, 7476
|
1962, 3425
|
3441, 3558
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,797
| 147,974
|
49556
|
Discharge summary
|
report
|
Admission Date: [**2109-8-29**] Discharge Date: [**2109-9-20**]
Date of Birth: [**2027-4-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Abdominal Pain UTI, Hypotension, Giant Stool ball
Major Surgical or Invasive Procedure:
Stool Disimpaction Under Anesthesia
PICC line placement
History of Present Illness:
This is an 82 y/o F with PMHx of demenia oriented x1 at
baseline, peripheral neuropathy and depression who presents from
NH long term care facility with abdominal pain and distension.
Per nursing home notes abdominal distension and pain first noted
on [**8-27**]. KUB at facility reportedly unremarkable though noted to
have leukocytosis and guaiac + brown stool. Per the patient's
sister, she has not had a BM in a long time and she noted that
the patient was nauseated with food intake. The NH reports
documented small BMs daily for the past few weeks. Per the
patient's sister, the patient has been complaining of belly pain
for weeks. Her NH reports weight loss and poor PO intake for the
past month, but unable to give weight loss estimate.
.
On arrival to T 98.2 HR 66 BP 94/55 RR 20 Sats 95%. Pt underwent
CT abd which revealed a large stool ball and UA which was
grossly positive. She received Cipro/Flagyl and approx 3L of IVF
for SBPs in 80-90. Lactate was notably elevated at 3, SBPs
remained in the 80-90s despite IVF and pt was admitted to the
MICU for hypotension.
.
On arrival to the ICU, the patient complained of significant
abdominal pain. Oriented to first name only.
.
On the floor, patient .
Review of systems:
(+) Per NH, patient has been loosing weight.
(-) unable to obtain [**1-21**] mental status
Past Medical History:
# Dementia - baseline oriented to person only.
# Hypertension
# Depression/Anxiety
# essential tremor and some concern re: parkinson's disease but
no formal diagnosis
# CVA per [**Name (NI) **] - son denies h/o CVA
# peripheral neuropathy
# left breast cancer
# hyperlipidemia
# h/o squamous cell cancer.
# ulcerations on heals and buttocks - since [**2109-6-19**]
Social History:
Pt lives at [**Hospital3 2558**] NH. Per their report the patient is
non-ambulatory at baseline. She is generally a 2 person assist
and requires assistances for all ADLs. She has been evaluated
for swallow safety at OSH and did not have any swallowing
problems. [**Name (NI) 8389**] placed on [**8-27**] at NH after pt noted to have
abdominal distension.
Family History:
Unable to obtain from patient
Physical Exam:
General: Alert, oriented to name only. no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, tender to light palpation diffusely, distended, +
bowel sounds present, no rebound tenderness or guarding.
Rectal: lack of rectal tone, guiac postive, large rectal cavity,
unable to palpate stool ball.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
skin: 2cm ulceration on left buttock that is approx 4 cm deep.
heel ulceration stage 2.
neuro: a&0x1, follows commands. wiggles toes, plantarflexion
intact bilat & grib intact but would not comply with full
strength testing. sensation intact to light touch. babinski mute
bilat.
Pertinent Results:
Labs on admission:
[**2109-8-29**] 11:55AM GLUCOSE-96 UREA N-23* CREAT-0.7 SODIUM-145
POTASSIUM-3.3 CHLORIDE-109* TOTAL CO2-28 ANION GAP-11
[**2109-8-29**] 11:55AM CALCIUM-8.4 PHOSPHATE-3.3 MAGNESIUM-2.1
[**2109-8-29**] 11:55AM WBC-14.4* RBC-2.85* HGB-8.4* HCT-27.6* MCV-97
MCH-29.4 MCHC-30.5* RDW-13.6
[**2109-8-29**] 11:55AM PLT COUNT-317
[**2109-8-29**] 01:39AM URINE BLOOD-LG NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-8.0 LEUK-MOD
[**2109-8-29**] 01:39AM URINE RBC->50 WBC-[**5-29**]* BACTERIA-FEW
YEAST-NONE EPI-0
[**2109-8-29**] 12:22AM LACTATE-3.0*
[**2109-8-29**] 12:15AM cTropnT-0.02*
[**2109-8-29**] 12:15AM CK-MB-2
[**2109-8-29**] 12:15AM PT-12.0 PTT-26.1 INR(PT)-1.0
Micro:
[**2109-9-3**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
[**2109-9-3**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2109-9-2**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2109-8-30**] URINE URINE CULTURE-FINAL INPATIENT
[**2109-8-29**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2109-8-29**] URINE URINE CULTURE-FINAL INPATIENT
[**2109-8-29**] BLOOD CULTURE Blood Culture, Routine-PRELIMINARY
{STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Aerobic Bottle Gram
Stain-FINAL EMERGENCY [**Hospital1 **]
[**2109-8-29**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
Imaging:
CT head: No acute intracranial process. MR is more sensitive in
the
detection of acute stroke.
CT abd/pelvis:
1. Massive fecal ball in the rectum mass with significant fecal
loading
throughout the large bowel.
2. Pulmonary nodule does not require follow up in a low risk
patient. If
high risk recommend chest CT in 12 months [**First Name8 (NamePattern2) **] [**Last Name (un) 8773**]
guidelines.
3. Liver hypodensity too small to characterize, likely a cyst.
4 Right renal hypodensities, too small to characterize,
statistically likely to be simple cysts.
5. Degenerative changes in the spine including essential
vertebral planar at L1, likely chronic in etiology. There is
also a compression deformity at L4. Correlate clinically.
CXR: IMPRESSION: Aside from retrocardiac atelectasis, no new
focal consolidation or edema.
KUB: IMPRESSION: Slightly decreased fecal retention.
Transthoracic echo [**9-9**]:
IMPRESSION: Suboptimal image quality. Moderate aortic
regurgitation with thickened leaflets but no discrete vegetation
(does not exclude). Mild pulmonary artery systolic hypertension.
Normal biventricular cavity sizes with preserved global
biventricular systolic function. Dilated aorta.
.
Most Recent Labs:
[**2109-9-18**] 05:45AM BLOOD WBC-4.9 RBC-3.00* Hgb-9.2* Hct-28.9*
MCV-96 MCH-30.7 MCHC-31.9 RDW-15.6* Plt Ct-219
[**2109-9-17**] 06:30AM BLOOD Neuts-38.5* Lymphs-54.0* Monos-4.1
Eos-2.5 Baso-1.0
[**2109-9-17**] 06:30AM BLOOD PT-19.6* PTT-38.9* INR(PT)-1.8*
[**2109-9-18**] 05:45AM BLOOD Glucose-86 UreaN-5* Creat-0.3* Na-140
K-3.5 Cl-109* HCO3-24 AnGap-11
[**2109-9-11**] 06:58AM BLOOD ALT-12 AST-16 AlkPhos-57 TotBili-0.6
[**2109-9-17**] 06:30AM BLOOD Calcium-9.0 Phos-3.0 Mg-2.0
Brief Hospital Course:
82F with severe dementia who presented with hypotension, UTI and
large stool impaction.
.
# Hypotension: Patient initially hypotensive on arrival in the
setting of several weeks of poor PO intake. The initial
differential included Sepsis vs hypovolemia. Patient was
repeatedly bolused and maintained on IVF, but still required
pressors. She was weaned off pressors prior to transfer from
MICU, with SBP in the 90's (c/w her baseline as per outside
facility records and excellent urine output (>2500cc/day)).
There was concern about both urinary and gut bacteria for
possible evolving sepsis. She was maintained on cipro, flagyl,
and cefepime given fact that she is a nursing home resident and
wanted broad spectrum coverage. Pt remained afebrile and
cultures were negative. She was also started on vancomycin for
Gram positive cocci in [**12-23**] bottles, but this was thought to be a
contaminant as her clinical picture improved so this was
discontinued. Her ciprofloxacin was discontinued on [**2109-9-2**] but
she was maintained on IV flagyl and cefepime for a two week
course, which was completed on [**2109-9-12**]. Her blood pressures
remained stable in the high 90's and low 100s.
.
# Coag Neg Staph Bacteremia: After the patient was transfered
out of the MICU to the medicine floor she initially did well.
Unfortunately she soon started to spike fevers above 101. Coag
negative staph was again found in [**1-21**] cultures of her blood
after the vancomycin was stopped. It was thought this time that
the bacteremia was real so she was restarted on vancomycin. A
transesophageal echo was performed to rule out heart vegitations
as she has a known murmur. The Echo was negative for
vegetations but noted to be a poor study. She was continued on
the vanc for a full 2 week course. Subsequent blood cultures
were negative.
.
# Stool Impaction - The patient presented with an extremely
large stool ball not-responsive to manual disimpaction or enema.
Manual disimpaction was attempted but unable to fully disimpact
due to pain. General surgery took the patient to the OR for
disimpaction under anesthesia, and was able to disimpact to the
point that patient was able to have loose stools afterwards. She
was maintained on mirolax, colace, senna, and PR bisocodyl. She
received water enemas PRN. She was given IV morphine for pain.
.
# Ischial Stage 4 Skin Ulceration - Buttocks and heel
ulcerations. Buttock ulceration very deep and concern re:
possible abscess/fistula. She is s/p wound debridement to
bloody tissue (did not go down to bone). She received cefepime
and flagyl for two weeks as above. The wound was cleaned twice
daily while in house and later decreased down to once daily
secondary to patient discomfort.
.
# Aspiration Risk: The patient initially evaluated by speech and
swallow that determined the patient was at high risk for
aspiration. The patient was kept on a diet of pureed solids and
thin liquids with meds crushed in puree, and a 1:1 feeder. The
patient had numerous episodes concerning for aspiration. After
these episodes the patient was suctioned and Chest X ray was
unrevealing for aspiration pneumonia. The patient was repeatedly
re-evaluated by speech and swallow that noted progressive
deconditioning of her muscles. Following discussions with the
patients son, the decision was made not have the pt undergo a
procedure such as a feeding tube. The patient was made CMO
during her hospital course, and thus her food restrictions were
lifted. The patient was not asking for food or water at the time
of her discharge.
.
# Failed Voiding Trials: Pt is now dependent on foley and was
retaining urine for unclear etiology. The patient failed
multiple voiding trials.
.
# GOALS OF CARE: The patient presented to [**Hospital1 18**] as Full Code.
During the [**Hospital **] hospital course, palliative care, ethics
and social work were consulted. During extensive phone
conversations between the primary team and the patients son
[**Doctor First Name **] [**Name (NI) 103658**], the patients HCP), the decision was made to make
the patient DNR/DNI. Later during her course, given her mental
deterioration and inability to take POs, the patient was made
CMO. The patients life expectancy at the time of discharge was
anticipated to be days to weeks given her lack of nutrition.
Medications on Admission:
Atenolol 25 mg PO daily
Lasix 40 mg PO daily
Lexapro 10 mg PO daily
MVI 1 tab daiy
Vitamin B1 100mg PO daily
Calcium 600 / Vitamin D 400mg PO BID
Triam/HCTZ 37.5-25 1 tab po daily
Mirtazapine 15 mg PO qhs
Depakote 250mg PO daily
Colace 100mg PO BID
Senna 2 tabs PO QHS
KCl 40 meq PO daily
Seroquel recently d/c'ed
Discharge Medications:
1. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal [**Hospital1 **] (2 times a day) as needed for rectal pain.
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
5. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for fever/pain.
6. Morphine 10 mg/5 mL Solution Sig: [**12-21**] 10mg PO four times a
day as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 169**]- Heathwood
Discharge Diagnosis:
Primary diagnosis:
-Septic shock
-Fecal impaction
-Abdominal pain
-Urinary tract infection
-Decubitus ulcer
-Dementia
Discharge Condition:
Poor. Patient refusing POs. Oriented x 0-1. Bed bound.
Discharge Instructions:
You were admitted to the hospital with abdominal pain,
constipation, and low blood pressures. Your constipation was
also aggressively treated and your abdominal pain has also
improved. You developed problems swallowing and had difficulty
eating foods. You also developed a blood infection for which
you received IV antibiotics.
.
Followup Instructions:
Please followup with your doctors at your nursing home upon
arrival.
|
[
"300.4",
"272.4",
"785.52",
"788.20",
"599.0",
"560.39",
"294.8",
"995.92",
"401.9",
"707.05",
"356.9",
"707.24",
"707.07",
"038.9",
"564.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.38",
"86.22"
] |
icd9pcs
|
[
[
[]
]
] |
11842, 11903
|
6551, 10874
|
365, 423
|
12065, 12121
|
3466, 3471
|
12503, 12575
|
2553, 2584
|
11239, 11819
|
11924, 11924
|
10900, 11216
|
12145, 12480
|
2599, 3447
|
1683, 1776
|
276, 327
|
451, 1664
|
4831, 6528
|
11943, 12044
|
3485, 4822
|
1798, 2165
|
2181, 2537
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,309
| 176,130
|
39923
|
Discharge summary
|
report
|
Admission Date: [**2112-9-18**] Discharge Date: [**2112-10-4**]
Service: MEDICINE
Allergies:
Zosyn
Attending:[**First Name3 (LF) 10682**]
Chief Complaint:
Nausea and vomiting
Major Surgical or Invasive Procedure:
intubation
extubation
ERCP with biliary stent placement
Percutaneous cholecystostomy tube placement by IR
History of Present Illness:
[**Age over 90 **]M with CHF, HTN, CKD recently hospitalized for CHF
exacerbation who had been at rehab until recently who developed
RUQ abdominal pain 3 days PTA when discharged home and developed
N/V and worsening abdominal pain last couple days.
.
At OSH, labs were significant for elevated transaminase, bili,
and lactate. RUQ U/S revealed distended GB, CBD 8mm, no
pericholecystic fluid or thickened wall. He was given Dilaudid,
Unasyn, Cipro, Flagyl, and Gentamycin and sent to [**Hospital1 18**] for
possible ERCP vs surgical management of presumed biliary
obstruction.
.
In the ED, initial vs were: 99.2 121 129/76 26 95%. He received
2L NS. SBPs dropped to 80s as well as HR 80s. He received an
additional 500cc with improvement in BP to 94/46. Labs
significant for lactate 7.2, WBC 5K with 33% bands, T bili 6.3,
ALT 220, AST 167, AP 310. He was seen by surgery and ERCP with
recommendation for ERCP in am. At transfer: T 97.1 BP 94/46 HR
88 97%4L.
.
On the floor, he reports pain is [**9-11**] in severity.
Past Medical History:
CHF (recent exacerbation)
Hypercholesterolemia
Renal disease
Gait disturbance
HTN
Anemia
GERD
Bradycardia
Social History:
Lives with wife although was recently at rehab until day of
admission. Has 14 grandchildren. Formerly worked odd jobs and as
a grocer.
- Tobacco: Denies
- Alcohol: Denies
- Illicits: Denies
Family History:
not relevant to this admission.
Physical Exam:
on ICU admission:
General: Somnolent but arousable, oriented x 3, appears to be in
pain
HEENT: Sclera icteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased BS in bases with faint crackles. No wheezes
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Slightly distended. Tender in RUQ and RLQ, positive
[**Doctor Last Name 515**]. Involuntary guarding, no rebound. Absent BS.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission labs:
[**2112-9-18**] 04:13AM BLOOD WBC-12.2*# RBC-3.15* Hgb-9.2* Hct-28.4*
MCV-90 MCH-29.2 MCHC-32.4 RDW-13.5 Plt Ct-122*
[**2112-9-30**] 06:40AM BLOOD WBC-4.6 RBC-3.17* Hgb-8.8* Hct-27.4*
MCV-87 MCH-27.7 MCHC-32.0 RDW-13.5 Plt Ct-453*#
[**2112-9-17**] 11:00PM BLOOD Glucose-134* UreaN-56* Creat-2.5* Na-142
K-4.5 Cl-106 HCO3-18* AnGap-23*
[**2112-9-19**] 05:27AM BLOOD Glucose-128* UreaN-71* Creat-3.5* Na-139
K-5.0 Cl-108 HCO3-21* AnGap-15
[**2112-9-30**] 06:40AM BLOOD Glucose-118* UreaN-33* Creat-1.5* Na-135
K-4.4 Cl-106 HCO3-22 AnGap-11
[**2112-9-17**] 11:00PM BLOOD ALT-220* AST-167* AlkPhos-310*
TotBili-6.3* DirBili-5.6* IndBili-0.7
[**2112-9-26**] 06:50AM BLOOD ALT-31 AST-15 LD(LDH)-237 AlkPhos-111
TotBili-0.6
[**2112-9-17**] 11:00PM BLOOD Lipase-198*
[**2112-9-22**] 03:49AM BLOOD Lipase-21
[**2112-9-18**] 09:45PM BLOOD CK-MB-49* MB Indx-2.7 cTropnT-0.27*
[**2112-9-19**] 03:09PM BLOOD CK-MB-20* MB Indx-2.2 cTropnT-0.32*
[**2112-9-22**] 03:49AM BLOOD CK-MB-4 cTropnT-0.31*
[**2112-9-30**] 06:40AM BLOOD Phos-3.9 Mg-1.6
[**2112-9-23**] 06:00AM BLOOD %HbA1c-6.2* eAG-131*
[**2112-9-17**] 11:08PM BLOOD Lactate-7.4*
[**2112-9-20**] 09:53PM BLOOD Lactate-1.1
Discharge labs, [**9-30**]:
135 106 33
----------------< 118
4.4 22 1.5
Mg 1.6, Phos 3.9
4.6>-----<453
27.4
Micro:
[**2112-9-25**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST- +
CLOSTRIDIUM DIFFICILE
URINE CULTURE-Negative
Blood Culture, Routine-Negative x7
[**2112-9-20**] Bile FLUID CULTURE- ESCHERICHIA COLI, pan-sensitive
[**2112-9-18**] MRSA SCREEN MRSA SCREEN- No MRSA isolated
Cardiac Echo Conclusions:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). There is mild (non-obstructive)
focal hypertrophy of the basal septum. There is considerable
beat-to-beat variability of the left ventricular ejection
fraction due to an irregular rhythm/premature beats. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened. There is mild
aortic valve stenosis (valve area 1.2-1.9cm2). 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. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild calcific aortic stenosis. Mild mitral and moderate
tricuspid regurgitation. Moderate pulmonary artery systolic
hypertension.
Renal Ultrasound IMPRESSION: No evidence of hydronephrosis,
masses, or stones. Echogenic kidneys with evidence of chronic
renal disease. Limited doppler examination shows patent renal
arteries and renal veins bilaterally. Doppler waveforms indicate
increased bilateral resistance to diastolic flow.
UNILAT UP EXT VEINS US Study Date of [**2112-10-3**]
IMPRESSION:
1. No evidence of deep vein thrombosis in the left upper
extremity.
2. Superficial thrombus noted in the left cephalic vein, below
the level of the left antecubital fossa.
3. Subcutaneous edema in the region of the left antecubital
fossa
________________________________________________
ERCP Procedures: A 9cm by 10FR Cotton [**Doctor Last Name **] biliary stent was
placed successfully in the main duct due to the high suspicion
for cholangitis. No [**Known firstname **] pus was seen exiting the papilla
following stent placement.
Impression: Successful biliary cannulation.
Normal biliary tree and anatomy.
Normal size CBD given patient's age.
No pus seen exiting the papilla.
No evidence of extrinsic compression, no ductal abnormalities,
and no filling defects.
Cystic duct slowly filled with contrast and the gallbladder was
partially visualized.
Successful placement of 9cm x 10F Cotton [**Doctor Last Name **] biliary stent due
to the high LFTs, clinical suspicion for cholangitis, and
possibility of a small stone being missed on cholangiogram
contributing to symptoms.
Otherwise normal ercp to third part of the duodenum.
Recommendations: Please call Dr.[**Name (NI) 2798**] office at
[**Telephone/Fax (1) 2799**] with any further questions or concerns.
Please call the on call ERCP fellow at [**Telephone/Fax (1) 2756**] with any
immediate concerns such as fever, abdominal pain, bleeding,
following your procedure.
Return in 4 weeks for repeat ERCP with Dr. [**Last Name (STitle) **] for stent
pull and re-assessment of the duct.
____________________________________________
Brief Hospital Course:
[**Age over 90 **]M with CHF, CKD, and HTN trasnferred from OSH with N/V,
hyperbilirubinemia, and bandemia consistent with biliary sepsis
s/p ERCP with stent placement s/p percutaneous drain placement.
.
# Septic shock from cholangitis: Patient presenting with sepsis
(elevated bands and tachycardia in setting of likely infection)
and cholestatic pattern of elevated LFTs as well as RUQ U/S with
distended GB consistent with biliary obstruction. Underwent
successful ERCP [**9-19**] with stent placement and his LFTs have
been trending down. IR drain placed [**9-20**]. In terms of his
sepsis, lactates have trended down to normal, and no longer with
a pressor requirement. Vancomycin was added to zosyn on [**9-19**]
for broader coverage. Bile culture grew pan sensitive e.coli an
antibiotics were tailored to cipro/flagyl to complete a 2 week
course. Given his ongoing pain, a cholecystostomy tube was
placed by Interventional Radiology. The cholecystostomy tube
will need to remain in place for at least 3 weeks, per Surgery.
Pt will f/u with ACS [**Doctor First Name **] Service Clinic after discharge. He had
no abdominal pain upon discharge.
.
#Aspiration pneumonitis: Patient developed an evolving right
lower lobe infiltrate on CXR. Afebrile with nl WBC. Pt with
diffuse rhonchi on [**9-24**] and therefore vanco/zosyn continued.
However, pt rapidly improved and antibiotics were changed to
cipro/flagyl as above. There was no further evidence of
pneumonia.
.
#C.diff colitis: Pt developed loose stools on [**9-25**]. His stools
were tested and were found to be C.diff toxin positive. He was
continued on flagyl however he continued to have ongoing
frequent stooling. Due to the lack of significant improvement
in the frequency of his stools, oral vancomycin was added to his
regimen. This was discussed with Infectious Disease, and the pt
meets criteria for severe c. diff based on frequency of BM and
age, and therefore warrants addition of po vancomycin. Pt's BM's
frequency is improving on dual therapy. Patient is to continue
flagyl as per above through [**10-13**] (14 day course from the
addition of vanc) and continue po vanc 125 mg po Q6hr through
[**10-13**] (14 day course).
.
# Acute renal failure on CKD: Pt presenting with elevated Cr
with baseline 1.4. most likely ATN in setting of sepsis with
prolonged hypotension. Urine lytes checked and Fena is 1.2%
with 12 granular casts on sediment arguing for intrinsic renal
pathology likely in setting of prolonged hypotension, likely
ATN. His renal function continued to improve throughout the
hospitalization.
.
# chronic diastolic congestive heart failure: Pt was recently
hospitalized with CHF exacerbation. Echo: EF 55-60%. His fluid
balance was carefully monitored throughout the hospitalization.
.
# Elevated Cardiac enzymes: Elevated enzymes likely demand
ischemia and renal failure. EKG did not show changes concerning
for MI.
.
# Hypertension: His blood pressure medications were initially
held in the setting of hypotension, and his amlodipine was added
back as his blood pressure rose. His hydrochlorothiazide
remains held at this time, as the patient is at risk for
dehydration considering his frequent stooling from c-diff
infection. Please consider adding back his hydrochlorothiazide
25 mg po q day once his diarrhea has resolved.
.
# Hypercholesterolemia: his statin was initially held in the
setting of elevated LFT's. His simvastatin was resumed once his
LFT's normalized.
.
# Superficial venous thrombosis of L upper extremity: Pt was
noted to have LUE swelling on [**10-3**]. No DVT on ultrasound. No
indication for anticoagulation. Keep elevated.
.
#DVT Prophylaxis: Heparin 5000 units TID
#COMMUNICATION: wife [**Name (NI) 22362**] [**Telephone/Fax (1) 87794**]
Medications on Admission:
Updated [**9-23**] based on fax from PCP.
[**Name Initial (NameIs) 87795**] 2.5-0.025 tablet. 1-2 tabs po QID prn diarrhea
Roxicet 5-325 mg tab. One tab po q 8 hr prn.
HCTZ 25 mg po q day
Sulindac 150 mg po BID
B12 injection 1000 mcg q month
MVI 1 tab po q day
omeprazole 20 mg po q day
simvastatin 20 mg po q HS
amlodipine 10 mg po q day
Discharge Medications:
1. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. multivitamin Tablet Sig: One (1) Tablet PO once a day.
5. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One
(1) inj Injection once a month.
6. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 10 days.
7. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 10 days.
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) inj
Injection TID (3 times a day): for DVT prophylaxis given
decreased mobility.
10. insulin lispro 100 unit/mL Solution Sig: 2-10 units
Subcutaneous ASDIR (AS DIRECTED).
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation & Nursing Center - [**Location (un) **]
Discharge Diagnosis:
sepsis due to biliary obstruction
C.diff diarrhea
aspiration pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with an infection in your gallbladder. You had
a drain placed in your gallbladder and were given antibiotics
and your symptoms improved. You also had an infection in your
stool and were given antibiotics for this as well.
.
Medication changes
1.ciprofloxacin
2. flagyl
3. oral vancomycin
.
Discontinued:
1. hydrochlorothiazide (until follow up with PCP)
Please follow up with the appointments below and take your
medications as prescribed.
Followup Instructions:
Name: Dr [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) 519**], General Surgeon
Location: [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Bldg, [**Location (un) 470**]
Phone: [**Telephone/Fax (1) 6554**]
Appt: [**10-10**] at 9:30am
Return in 4 weeks for repeat ERCP with Dr. [**Last Name (STitle) **] for stent
pull and re-assessment of the duct.
Please follow up with your primary care physician after
discharge from rehab.
|
[
"286.9",
"585.3",
"008.45",
"575.0",
"250.00",
"272.0",
"403.90",
"530.81",
"576.1",
"453.81",
"584.5",
"416.8",
"038.9",
"785.52",
"576.2",
"507.0",
"518.81",
"276.2",
"995.92",
"428.32",
"428.0",
"397.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.87",
"38.93",
"96.71",
"96.04",
"38.91",
"51.01"
] |
icd9pcs
|
[
[
[]
]
] |
12313, 12410
|
7160, 9957
|
234, 341
|
12525, 12525
|
2335, 2335
|
13190, 13650
|
1745, 1778
|
11324, 12290
|
12431, 12504
|
10961, 11301
|
12708, 13167
|
1793, 2316
|
9974, 10935
|
175, 196
|
369, 1390
|
2351, 7137
|
12540, 12684
|
1412, 1519
|
1535, 1729
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,971
| 133,665
|
19938
|
Discharge summary
|
report
|
Admission Date: [**2108-11-6**] Discharge Date: [**2108-11-7**]
Date of Birth: Sex:
Service: Trauma surgery
HISTORY OF PRESENT ILLNESS: This was a 69-year-old man who
was struck by a motor vehicle while crossing the street as a
pedestrian. He was brought to our emergency room by [**Location (un) 7622**]
with massive head trauma. During his resuscitation, he
underwent a cricothyroidotomy in the trauma room because of
the inability to obtain an airway. He also had placement of
bilateral chest tubes because of his instability and
ultimately was found to have a small left apical
pneumothorax.
He underwent CT scanning of the head and abdomen. He had
massive brain injury with subarachnoid blood, diffuse
contusions, and impending herniation. He had bilateral
pulmonary contusions. Some fluid was seen above the liver,
which was of unclear significance. He had no correctable
injury in the abdomen.
HOSPITAL COURSE: The patient was admitted to the intensive
care unit. His initial hematocrit had been 40. Later that
evening, he was found to have his hematocrit fall to 17. At
that point, his neurologic prognosis was thought to be
extremely poor. He was transfused with 4 units of blood to a
hematocrit of 30. However, he then proceeded to deteriorate
further from the neurological perspective and ultimately was
made CMO status in consultation with the neurosurgery service
and was allowed to expire on the second hospital day.
DISCHARGE DIAGNOSES:
1. Blunt trauma with massive cerebral contusion and
intracerebral hemorrhage.
2. Blood loss anemia.
3. Bilateral pulmonary contusions.
CONDITION: Discharged deceased.
DISPOSITION: Deceased.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern4) 1779**]
MEDQUIST36
D: [**2109-4-12**] 11:23
T: [**2109-4-12**] 15:41
JOB#: [**Job Number 53781**]
|
[
"836.50",
"803.25",
"414.00",
"E814.7",
"V45.81",
"967.1",
"518.0",
"E849.5",
"861.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"38.91",
"34.04",
"79.76"
] |
icd9pcs
|
[
[
[]
]
] |
1484, 1957
|
949, 1463
|
164, 931
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,765
| 154,125
|
41097
|
Discharge summary
|
report
|
Admission Date: [**2125-4-11**] Discharge Date: [**2125-4-12**]
Date of Birth: [**2072-10-3**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / morphine / NSAIDS / IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
coronary artery catheterization
History of Present Illness:
52 year old female with a hx of CAD s/p IMI in [**2112**] with
stenting at [**Hospital1 336**], and hx of ASA allergy (hives) who presents for
ASA desensitization prior to cath. Also has a similar rx to
NSAIDS, morphine, and IVP dye (on clarification had myelogram
that caused severe pain). Pt said that she had been doing well
for many years, but about 1.5 years ago she had an episode of
substernal chest pressure described as "a baby sitting on her
chest". The pain radiated to the left shoulder and jaw with
associated nausea and diaphoresis. Initially, the pain was
occuring infrequently and with exertion. She was not taking any
medications to alleviate the symptoms, but they would go away
after some time. The symptoms increased in frequency and she
presented to OSH in [**2124-12-13**] for CP that radiated to her
jaw and left arm the day after she was sick with the flu. She
left AMA and since that time because she did not want to be
hospitalized at that particular hospital. Since then her angina
has become more regular and is now occuring daily both at rest
and with exertion. She also has become increasingly short of
breath and now cannot fold her sheets without becoming short of
breath. However, she has no SOB associated with the chest pain.
She also has a stabbing chest pain with no associated symptoms
that has been worked up in the outpatient and unclear etiology,
but her cardiologist does not believe it to be cardiac in
origin. She has a chronic history of syncope and is treated with
fiorocet. She is known to be orthostatic on multiple visits to
her PCP. [**Name10 (NameIs) **] has no palpitations, vomiting, abdominal pain,
diarrhea. She is scheduled for a Cardiac Catheterization on
[**2125-4-12**] with Dr. [**Last Name (STitle) 7047**].
.
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.
Past Medical History:
1. CARDIAC RISK FACTORS:
-Dyslipidemia
-Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS:
[**2112**] had stent placed of unknown location
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
-cervical radiculopathy.
-hysterectomy [**2093**]
-cyst removal of the neck [**2098**]
-PNA ([**2124**])
-Emphysema (diagnosed on CXR)
-Abnormal Pap
Social History:
'Works at a homeless shelter doing multiple jobs.
-Tobacco history: Quit 5 years ago, smoked 10 pack year history
-ETOH: Rarely, does not remember last alcoholic drink
-Illicit drugs: None
Family History:
No family history of early MI, arrhythmia, cardiomyopathies
Father: Died of ruptured AAA at the age of 63. Had HTN
Brother/Sisters: have HTN
One brother has PVD
Physical Exam:
VS: T=99.0 BP=139/70 HR= 66 RR= 18 O2 sat=98%
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No
oralpharyngeal leasions. No xanthalesma.
NECK: Supple with no elevated JVP.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: belly button ring in place, Soft, NTND. No HSM or
tenderness. No abdominal bruits.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ radial 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Radial 2+ Popliteal 2+ DP 2+ PT 2+
Neuro: A&Ox3, CN II-XII intact, sensation intact on face, slight
hyperesthesia on the right compared to the left, sensation equal
to light tough of lowwer extremities bilaterally, Right upper
extremity slightly weaker than left, lower extremity [**5-17**]
bilaterally, gait normal.
Pertinent Results:
CBC:
[**2125-4-11**] 05:47PM BLOOD WBC-5.4 RBC-3.51* Hgb-11.7* Hct-34.1*
MCV-97 MCH-33.4* MCHC-34.4 RDW-12.7 Plt Ct-254
[**2125-4-12**] 05:30AM BLOOD WBC-5.7 RBC-3.59* Hgb-12.4 Hct-35.0*
MCV-97 MCH-34.6* MCHC-35.6* RDW-12.6 Plt Ct-233
.
DIFF:
[**2125-4-11**] 05:47PM BLOOD Neuts-46.3* Lymphs-46.4* Monos-5.0
Eos-1.6 Baso-0.7
.
CMP:
[**2125-4-11**] 05:47PM BLOOD Glucose-117* UreaN-15 Creat-0.7 Na-140
K-3.9 Cl-106 HCO3-26 AnGap-12
[**2125-4-12**] 05:30AM BLOOD Glucose-153* UreaN-17 Creat-0.7 Na-136
K-5.3* Cl-103 HCO3-24 AnGap-14
[**2125-4-11**] 05:47PM BLOOD Calcium-9.6 Phos-3.2 Mg-2.3
[**2125-4-12**] 05:30AM BLOOD Calcium-9.4 Phos-3.4 Mg-2.3
.
##########################################################
CARDIAC CATH: PENDING
NO INTERVENTION NEEDED
Brief Hospital Course:
52 year old female with a hx of CAD s/p IMI in [**2112**] with
stenting at [**Hospital1 336**], and hx of ASA allergy (hives) who presents for
ASA desensitization prior to cath scheduled on [**2125-4-12**].
.
# Aspirin allergy: The patient successfully underwent aspirin
desensitization with minor itching requiring 25mg of benadryl.
Otherwise there were no complications and she tolerated her full
dose aspirin well. She will be sent home on aspirin and she
understands that she cannot miss a dose or she may have an
allergic reaction to the medication.
.
# Dye allergy: Has questionable dye allergy. She said she had
severe pain during a myelogram many years ago and then developed
meningitis. No reported rash, hives, angioedema or swelling of
any kind. Pt will be receiving dye during cath so will also
receive steroids as per protocol for dye reaction despite this
uncertain allergic reaction. She received Prednisone 50mg 13, 7
and 1 hour prior to Catheterization as well as benadryl 50mg PO
1 hour prior to procedure. She had her catheterization with no
incidence.
.
# CORONARIES: Pt has known coronary disease s/p MI with stent
placement in [**2112**]. She has been having progressively worsening
anginal symptoms that appear to have been unstable for a couple
of months now. She is currently asymptomatic. EKG showed Q waves
in the inferior leads. She was NPO overnight and went for
cardiac catheterization on [**2125-4-12**]. The cath report is pending,
but she was ready for discharge post-cath. She will follow up
with her cardiologist for further work up of her chest pain. We
also advised her to stop her premarin since it can increase her
risk for CAD and MI.
.
# PUMP: Last ECHO showed normal EF with no signs of systolic or
diastolic disease although has some apical akinesis. Pt is on
crestor, but no other cardioprotective medications. She stopped
her plavix because of increased incidence of bruising.
Continued Crestor 10mg PO QHS
.
# Cervical radiculopathy: Pt has history of cervical
radiculopathy and has chronic right arm pain. She also seems to
have hyperesthesia of the right arm. We continued Oxycontin
40mg PO Q12H
.
# Syncope: Pt has history of orthostasis and syncopal events.
She said she has been worked up in the outpatient setting, and
her physician has her on fiorocet 1 tab Q4H for these symptoms
and she says it has been working well. We continued her home
medications and this was not an active issue.
.
# HLD: No labs, but patient says is well controlled. Will be
followed in the outpatient setting. Continued crestor 10mg PO
QHS.
.
CODE: Full (confirmed)
.
COMM: [**Name (NI) **], Husband [**Doctor Last Name **] [**Telephone/Fax (1) 89578**])
Medications on Admission:
Crestor 10mg PO QHS
Fiorocet 1 tab Q4H
Oxycontin 40mg PO BID
Premarin 0.625mg PO Daily
Xanax 1mg PO QHS
MVI 1 tab PO DAILY
BIOTIN 1 tab PO Daily
B-Complex 1 Tab PO Daily
Discharge Medications:
1. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q4H (every 4 hours).
2. oxycodone 20 mg Tablet Extended Release 12 hr Sig: Two (2)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
3. alprazolam 0.25 mg Tablet Sig: Four (4) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. B complex vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
6. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
7. 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*
8. biotin 1 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
aspirin allergy
chest discomfort
Secondary Diagnosis:
hypertension
hyperlipidemia
coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for an elective cardiac
catheterization. Because you had a history of allergy to
aspirin, you underwent an aspirin desensitization prior to the
procedure. Your cardiac catheterization showed no evidence of
significant narrowing in the coronary vessels. You should
continue to take aspirin EVERY day to help prevent heart attacks
in the future. If you miss a day of aspirin, you will need to
undergo aspirin desensitization again.
Please make the following changes to your medication regimen:
1. START aspirin 325mg daily
2. STOP premarin: this medication can increase your risk of
heart attacks
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **] [**1-14**] weeks
Please follow up with your cardiologist in 1 -2 weeks. In
particular, you should discuss whether or not to continue
premarin
|
[
"E947.8",
"E935.3",
"401.9",
"414.01",
"272.4",
"412",
"723.4",
"786.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"88.55"
] |
icd9pcs
|
[
[
[]
]
] |
8883, 8889
|
5180, 7874
|
326, 360
|
9059, 9059
|
4403, 5157
|
9867, 10096
|
3130, 3293
|
8095, 8860
|
8910, 8910
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7900, 8072
|
9210, 9844
|
3308, 4384
|
2608, 2724
|
276, 288
|
388, 2513
|
8984, 9038
|
8929, 8963
|
9074, 9186
|
2755, 2906
|
2535, 2588
|
2922, 3114
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,250
| 160,285
|
44595
|
Discharge summary
|
report
|
Admission Date: [**2105-7-27**] Discharge Date: [**2105-8-7**]
Date of Birth: [**2034-10-10**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Darvon / Codeine
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Unresponsive, s/p intubation
Major Surgical or Invasive Procedure:
Endotrachial intubation with mechanical ventilation
PICC line placement
History of Present Illness:
70 year old female with a PMH significant for anklyosing
spondylitis, HTN, HLD, and CAD who was admitted to the ICU
secondary to unresponsiveness on [**7-27**], she was found to have
hypercarbic respiratory failure. The patient had been
discharged from [**Hospital1 **] after treatment for CAP with azithromycin and
levofloxacin. The patient also had been treated for C diff
after her recent discharge, she was treated with flagyl. In
this setting she developed a fever of 101.8 and tachypnea, in
addition to fatigue and weakness. The patient then had mental
status depression, slurred speech and confusion- EMS was called
and she was found to be hypoxic (88% on 100% NRB), she was
intubated due to respiratory failure and brought to the ER. In
the ER she was following commands and was extubated, she then
slowly became unresponsive and hypoxic again and re-intubated
(this time nasally due to kyphosis). She had some seizure
activity as reported by ER attending, and was given 2mg IV
ativan. She was then admitted to the [**Hospital Unit Name 153**] on [**2105-7-27**].
[**Hospital Unit Name 153**] course:
The patient was initially treated with vancomycin, meropenem and
also on acyclovir for presumed cellulitis / sepsis versus PNA.
Acyclovir and meropenem were discontinued on HD # 2, vancomycin
was continued for total 8 day course, no + culture data (with
the exception of 1+ GPCs in Pairs on endotracheal sputum sample
on [**2105-7-29**]). She was intubated for a total of 6 days, she was
then extubated on [**2105-8-1**]. Due to sinus tachycardia small
boluses of fluid were given (500cc x 2 on [**8-3**]) and metoprolol
was started at 12.5mg po bid, amlodpine discontinue to allow
more BP room to uptitrate metoprolol.
Currently the patient feels well, no SOB, productive cough of
yellow sputum following extubation. No orthopnea or PND
although has been sleeping nearly sitting up. Has pedal edema
which is new over past 2 weeks. Last BM was formed and was 1
day ago. No N/V, good appetite, no abdominal pain. No other
symptoms. No F/C/NS currently, rest of ROS is negative.
Past Medical History:
Anklyosing spondylitis
Chronic kidney disease
Hypertension
HLD
Coronary artery disease - MI in her 30s ("pulmonary" MI in
setting of a bad cold)
Arthritis
Shingles - right flank
Social History:
Lives with husband, independent in [**Name (NI) 12210**]. Tobacco - none, quit
18 years ago. 3 ppd x 18 years. EtOH - social. Denies IV,
illicit, or herbal drug use.
Family History:
Mother - multiple [**Name (NI) 11011**] events (DVT and PE). Father with MI in
50s, brother with MI in 30s.
Physical Exam:
Vitals: T 98.7 BP 120/70 HR 92 RR 20 O2 95% on 2L, 85% on RA
GEN: NAD, AOX3
HEENT: MMM, OP Clear, JVP 12cm
CARD: RRR, + S3, no murmurs
PULM: diminished breath sounds at bases, good effort, no ronchi
or rales
ABD: soft, NT, ND, no masses or organomegaly
EXT: WWP, 2+ pitting edema to thighs, also pitting edema of
sacrum
NEURO: AOx3, [**6-3**] stregnth of UE bicep, tricep, grip, delt. [**5-4**]
strength LE quad, hams, plantarflexion/dorsiflexion,
abduction/adduction at hip, no saddle anesthesia.
Pertinent Results:
[**2105-7-27**] LOWER EXT ULTRASOUND:
1. No evidence of DVT.
2. Fluid tracking along the intermuscular plane in the right
popliteal fossa to the calf, could represent a ruptured [**Hospital Ward Name 4675**]
cyst versus hematoma.
[**2105-7-28**] CT HEAD W/O CONTRAST:
No evidence of acute intracranial process; somewhat limited
study.
[**2105-8-2**] CXR:
Extremely low lung volumes persist. Technically limited study
makes it extremely difficult to determine whether an
endotracheal tube is
indeed present. No nasogastric tube is appreciated. Large hiatal
hernia is
again seen. There may well be some patchy atelectasis at the
bases on this
extremely limited study.
HCT at discharge: 26.9
Creatinine at discharge: 0.9
Bicarbonate at discharge: 40
Brief Hospital Course:
1. HYPERCARBIC RESPIRATORY FAILURE: At baseline, has poor
reserve given Ankylosing spondylitis and severe kyphosis as well
as hiatal hernia. Unclear what the precipitant was in this
case. Long-term, patient is DNR but okay to intubate. Dr.
[**Last Name (STitle) **], her PCP, [**Name10 (NameIs) **] continue discussions with patient and
husband regarding goals of care.
2. CLOSTRIDIUM DIFFICILE INFECTION: Plan to continue treatment
through [**8-17**]; remained with little to no diarrhea during
stay.
3. VOLUME OVERLOAD: Significant anasarca post-ICU. Diuresed
with IV lasix in-house and discharged with plans for stockings
use daily.
4. QUESTION OF SEIZURE ACTIVITY: Witnessed in ER in the setting
of PCO2 of 100.
5. SINUS TACHYCARDIA: A chronic issue per old notes, likely
related to restrictive lung disease. At discharge, HR in the
90s.
6. HTN: Discharged on propranolol and lisinopril; amlodipine was
not restarted but could be in follow-up.
Medications on Admission:
HOME MEDICATIONS
Propanalol 10 mg po bid
Lisinopril 20 mg daily
Pravastatin 40 mg daily
Amlodipine 5 mg daily
Benefiber
Flagyl 500 mg
TRANSFER MEDICATIONS:
Acetaminophen prn
Famotidine 20 mg po daily
Lisinopril 20 mg po daily
Metoprolol Tartrate 12.5 mg po bid
Albuterol 0.083% Neb q6hrs prn
MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
Heparin 5000 UNIT SC TID [**7-27**] @ [**2105**] View
Discharge Medications:
1. Propranolol 10 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. Benefiber (Guar Gum) Oral
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 11 days: Last day [**2105-8-17**].
Disp:*33 Tablet(s)* Refills:*0*
6. oxygen
Home oxygen @ 2 LPM continuous via nasal cannula.
Conserving device for portability
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Hypercarbic respiratory failure
Clostridium difficile colitis
Anasarca
Anemia of chronic disease
Anklyosing spondylitis
Coronary artery disease
Discharge Condition:
Hemodynamically stable with blood pressure 139/78 and heart rate
in the 90s.
O2 drops to 86% on room air with ambulation.
Discharge Instructions:
You were admitted with breathing failure requiring use of the
ventilator. It is not entirely clear what caused the failure
though things have improved since your admission to the ICU.
Regarding your medications, we have STOPPED your amlodipine.
The visiting nurses will check your blood pressure after
discharge to ensure that it is not elevated.
For the fluid accumulation, please wear stockings as directed.
Followup Instructions:
Primary Care Physician Appointment
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
When: WEDNESDAY, [**8-19**], 1PM
Location: [**Hospital6 5242**] CENTER
Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 798**]
|
[
"682.6",
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"285.9",
"414.01",
"008.45",
"720.0",
"780.39",
"038.9",
"275.2",
"553.3",
"518.81",
"275.3",
"403.90",
"788.5",
"416.0",
"427.89",
"737.10",
"995.92",
"782.3",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6248, 6306
|
4354, 5318
|
320, 394
|
6493, 6616
|
3578, 4251
|
7077, 7359
|
2930, 3039
|
5753, 6225
|
6327, 6472
|
5344, 5479
|
6640, 7054
|
3054, 3559
|
4327, 4331
|
251, 282
|
5501, 5730
|
422, 2528
|
2550, 2730
|
2746, 2914
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,531
| 119,794
|
1184
|
Discharge summary
|
report
|
Admission Date: [**2179-10-16**] Discharge Date: [**2179-10-21**]
Date of Birth: [**2150-5-14**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p MVC vs tree
Major Surgical or Invasive Procedure:
None
History of Present Illness:
29 year-old male, unrestrained driver, who was brought in by EMS
after his car collided with a tree; questionable LOC. Positive
for ETOH. Airbags were activated and windshield was starred. He
was positive for ETOH. He was extricated and transported to
[**Hospital1 18**].
Past Medical History:
Pectus excavatum
ADD
Depression
Anxiety
Social History:
Consumes about 5 beers/week. Smokes tobacco occasionally, for
past 13 years. Occasionally smokes marijuana.
Family History:
Non-contributory
Physical Exam:
VS: on admission to trauma bay: T 98.8 HR 78 BP 109/52 RR 18
Sat 97%
GCS 15
Gen: Smells of EtOH, intoxicated
HEENT: NC/AT, EOM intact, PERRLA.
Neck:C-collar present, trachea midline.
Chest: CTA bilaterally. Equal breath sounds Pectus excavatum.
Well-healed transverse lower sternal scar.
CV: RRR, S1, S2
Abd: Soft BS, slightly distended. Mild TTP. No guarding No
rebound
Rectum: Normal tone, guaiac negative
Back: No stepoffs, no tenderness
Motor: 5/5 strength
Neuro: A & O x3
Pertinent Results:
[**2179-10-16**] 10:13PM HCT-33.6*
[**2179-10-16**] 04:22PM GLUCOSE-108* UREA N-8 CREAT-1.0 SODIUM-142
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-29 ANION GAP-11
[**2179-10-16**] 04:22PM CALCIUM-8.9 PHOSPHATE-4.6*# MAGNESIUM-2.1
[**2179-10-16**] 04:22PM HCT-35.7*
[**2179-10-16**] 10:24AM HCT-37.9*
[**2179-10-16**] 05:15AM CALCIUM-9.3 PHOSPHATE-2.4* MAGNESIUM-1.6
[**2179-10-16**] 05:15AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2179-10-16**] 05:15AM WBC-17.5*# RBC-4.28* HGB-13.4* HCT-38.4*
MCV-90 MCH-31.3 MCHC-34.9 RDW-12.3
[**2179-10-16**] 05:15AM PLT COUNT-334
[**2179-10-16**] 02:31AM PH-7.37 COMMENTS-GREEN TOP
[**2179-10-16**] 02:31AM LACTATE-2.1* NA+-140 K+-3.5 CL--101 TCO2-26
[**2179-10-16**] 02:31AM freeCa-1.19
[**2179-10-16**] 02:29AM AMYLASE-28
[**2179-10-16**] 02:29AM ASA-NEG ETHANOL-32* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2179-10-16**] 02:29AM WBC-7.7 RBC-4.63 HGB-15.3 HCT-41.4 MCV-90
MCH-33.0* MCHC-36.9* RDW-12.5
[**2179-10-16**] 02:29AM PLT COUNT-308
[**2179-10-16**] 02:29AM PT-13.1 PTT-23.3 INR(PT)-1.1
[**2179-10-16**] 02:29AM FIBRINOGE-190
CT ABDOMEN W/CONTRAST [**2179-10-16**] 2:37 AM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: injury
Field of view: 38 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
29 year old man with trauma
REASON FOR THIS EXAMINATION:
injury
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Trauma.
No prior studies are available for comparison.
TECHNIQUE: Multidetector CT scanning of the abdomen and pelvis
was performed following intravenous administration of 150 cc of
Optiray contrast. Coronal and sagittal reformations were also
obtained.
CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The visualized lung
bases demonstrate minor linear atelectatic changes. There is
noted of a large amount of gas within the right ventricles,
estimated at 10-20 cc. Note is made of a pectus deformity. There
is a large laceration involving the superior aspect of the
spleen, with adjacent acute extravasation of contrast. There is
adjacent high-density free fluid extending along the left
paracolic gutter into the pelvis consistent with hemoperitoneum.
A small amount of high- density free fluid is also seen in the
deep pelvis and in the right lower quadrant. There is also note
of small focal area of fluid, with a triangular configuration,
within the mesentery adjacent to a loop of jejunum in the left
mid abdomen (best appreciated series 3, image 43). No associated
bowel wall thickening is identified. The liver, gallbladder,
adrenals, pancreas, and opacified loops of large are otherwise
within normal limits. There is no free intraperitoneal air.
CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The distal ureters,
urinary bladder, rectum, prostate, and seminal vesicles are
within normal limits. The bladder is distended with urine. There
is no pelvic or deep inguinal lymphadenopathy.
BONE WINDOWS: There are no fractures identified. Note is again
made of a pectus deformity. No suspicious lytic or sclerotic
lesions are identified.
CT RECONSTRUCTIONS: The above findings were confirmed with
coronal and sagittal reformations.
IMPRESSION:
1. Large laceration involving the superior aspect of the spleen
with associated active extravasation of contrast material and
hemoperitoneum.
2. Small triangular focus of fluid tracking along the mesentery
associated with loops of jejunum in the left mid abdomen. This
finding is unusual despite the associated hemoperitoneum and
raises concern for a mesenteric or small bowel injury.
3. Air within the right ventricle, estimated around 10-20 cc.
This was likely introduced through a venous line, as it was also
evident in the neck veins on the non-contrast CT scan of the
c-spine. Precautionary positioning would be advised.
Brief Hospital Course:
On arrival at [**Hospital1 18**], the patient was hemodynamically stable,
with complaints of epigatsric tenderness. He was admitted under
the trauma service to the Trauma intensive care unit. His
intitial evaluation revealed a large splenic laceration and
thickened small bowel with free abdominal fluid. He was admitted
under the trauma service to the Trauma Intensive Care Unit for
monitoring of the splenic laceration and serial hematocrits. His
hematocrit remained stable during his hospital course His Hct on
[**2179-10-21**] was 33. He was kept on bedrest at first and physical
activities were advanced slowly, along with his diet. Social
work was consulted for his ETOH use.
Medications on Admission:
Xanax 0.5mg [**Hospital1 **]
Celexa 40mg qd
Valtrex 400mg [**Hospital1 **]
Discharge Medications:
1. Citalopram Hydrobromide 20 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
2. Valacyclovir 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for unknown (prior medication).
3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for breakthrough pain.
Disp:*45 Tablet(s)* Refills:*0*
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) as needed.
6. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours) as needed
for pain.
Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
status-post motor vehicle collision
Splenic laceration
Discharge Condition:
Stable
Discharge Instructions:
It is important you complete all the medications as directed.
You [**Known lastname **] continue to take your pre-admission medications. You
should not drive or operate heavy machinery while on any
narcotic pain medication such as oxycodone as it can be
sedating. You [**Known lastname **] take colace to soften the stool as needed for
constipation, which can be caused by narcotic pain medication.
AVOID any physical/contact sports for next 6-8weeks to not cause
injury to your spleen.
You should call a physician or come to ER if you have worsening
pains, fevers, chills, nausea, vomiting, shortness of breath,
chest pain, redness or drainage about the wounds, or if you have
any questions or concerns.
Followup Instructions:
Follow up in Trauma Clinic in 2 weeks, call [**Telephone/Fax (1) 6439**] for an
appointment.
Completed by:[**2179-10-21**]
|
[
"314.00",
"300.4",
"865.03",
"E816.0",
"868.03"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6767, 6773
|
5251, 5936
|
331, 337
|
6872, 6880
|
1383, 2692
|
7639, 7764
|
846, 864
|
6061, 6744
|
2729, 2757
|
6794, 6851
|
5962, 6038
|
6904, 7616
|
879, 1364
|
276, 293
|
2786, 5228
|
365, 640
|
662, 703
|
719, 830
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,965
| 145,872
|
48642
|
Discharge summary
|
report
|
Admission Date: [**2109-9-2**] Discharge Date: [**2109-9-4**]
Date of Birth: [**2035-6-12**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
74 y/o F presents from OSH s/p fall down 13 stairs. Patient
states that she had to use the bathroom and because of the
recent storm had no electricity in her home and fell down her
stairs. She does not recall if she lost consciousness, but
reports bilateral numbness and tingling. She states that the
numbness and
tingling start in her fingers, mostly in the thumbs, and
radiates towards her neck L arm and to the elbow in her R arm.
She denies any pain in her neck or bowel/bladder incontinence.
CT chest reveals spinous process fractures at C7 and T1 that are
minimally displaced.
Past Medical History:
osteoporosis
Social History:
Lives and takes care of husband, denies ETOH or tobacco
use.
Family History:
non-contributory
Physical Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: normocephalic
Pupils: PERRL EOMs: tracking
Neck: In hard cervical collar, neck tender to palpation
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T IP Q H AT [**Last Name (un) 938**] G
R 4 4+ 4+ 5- 5- 5- 5- 5- 5-
L 4- 4- 4+ 5 5 5 5 5 5
Sensation: decreased sensation in the L forearm
On Discharge:
Motor:
D B T IP Q H AT [**Last Name (un) 938**] G
R 4 4+ 4+ 5- 5- 5- 5- 5- 5-
L 3 4- 5- 5 5 5 5 5 5
Hard c-collar in place
Pertinent Results:
CT TORSO: [**2109-9-2**]- IMPRESSION:
1. Minimally displaced fractures of C7 and T1. No other
fractures, or
traumatic injury is present.
2. Fibroid uterus.
MRI C-Spine [**2109-9-2**]- IMPRESSION
1. Multiple fractures of the spinous process of C4, C7 and T1,
not as well
visualized on this study as CT.
2. Large prevertebral or retropharyngeal hematoma, 2.3 cm in
AP-width,
extends from skull base to C4 causing partial effacement of the
airway
3. Central canal stenosis at levels C5, C6 and C7.
4. Increased STIR signal in the interspinous ligaments of C2-C3
and C4-C5
suggestive of ligamentous injury.
Brief Hospital Course:
Pt was admitted to the ICU on the neurosurgery service for close
neurological observation and to monitor airway status secondary
to her retropharyngeal hematoma. An MRI of the C-spine was
completed and revealed cervical fractures, ligamentous injury
and the retropharyngeal hematoma. She was started on high dose
PO steroids.
The patient remained neurologically stable overnight and was
cleared for transfer to the stepdown unit on [**9-3**]. Decadron was
weaned and SBP was allowed to auto-regulate. On [**9-4**], she was
transferred to the floor and PT recommended rehab. She was
discharged to rehab on [**9-4**] after eating and voiding
appropriately.
Medications on Admission:
MVI, caltrate, aspirin QOD
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
5. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
7. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO q8 () for 1
days.
8. dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO q8 () for
1 days.
9. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO q8 () for 1
days.
10. dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO q8 () for
1 days.
11. dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO q12 ()
for 1 days.
12. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Cervical Spine Fractures
Spinal Cord Injury
Retropharyngeal hematoma
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:
?????? Do not smoke.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? You are required to wear your cervical collar at all times
?????? 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.
Followup Instructions:
Follow Up Instructions/Appointments
??????Please return to the office in [**7-14**] 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 4 weeks.
??????You will need an MRI c-spine w/ and w/o contrast
Completed by:[**2109-9-4**]
|
[
"806.00",
"E849.0",
"780.09",
"806.05",
"E880.9",
"920",
"806.20",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4291, 4388
|
2479, 3135
|
315, 322
|
4501, 4501
|
1850, 2456
|
5511, 6127
|
1067, 1085
|
3213, 4268
|
4409, 4480
|
3161, 3190
|
4684, 5488
|
1100, 1251
|
1620, 1831
|
267, 277
|
350, 935
|
4516, 4660
|
957, 972
|
988, 1051
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,760
| 168,303
|
8481
|
Discharge summary
|
report
|
Admission Date: [**2167-1-14**] Discharge Date: [**2167-1-14**]
Date of Birth: [**2097-10-23**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Evaluation of OSH transfer for ICH
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
69 yo with a history of afib on anticoagulation,
hypertension, and CHF who awoke this morning with left sided
weakness. He was last seen normal at 11:30PM the day prior when
he was in the living room watching TV and his wife had gone to
bed. She thinks that he likely went upstairs to go to bed at
midnight. This morning around 7:50AM, his right arm hit her and
she woke up. She went to him and noticed that his right arm and
leg were flailing. He was mumbling, "[**Last Name (un) **] pee" several times,
then said "too late" and became incontinent. She noticed that
his left side wasn't moving, he had a right facial droop, and
that his speech was slurred.
She called 911 and EMS transported him to [**Hospital 1474**] Hospital. En
route, he declined and became unresponsive. Initial blood
pressure was 205/114. At [**Hospital1 1474**], he was given Esmolol and
?Dilantin (on nursing chart, but no time or dose noted). He was
given Lidocaine, Vecuronium, Succ, Etomidate, Ativan 2mg and
intubated. He was then also given Vitamin K 10mg. Notable labs
include an INR of 3.5. A head CT was done, which showed a right
temporal parietal lobe hemorrhage with 17mm right to left shift
with subfalcine herniation. The hemorrhage extends into the
lateral ventricles. He had an EKG that showed he was in Afib
with a slow ventricular rate. He was then transported to the
[**Hospital1 18**] ED for further care.
Since arrival, his systolic blood pressure has been in the 150s
to 160s. Prior to the start of sedation, his pupils were
reportedly fixed and dilated. He has been givein Vitamin K 10mg
(2nd dose), FFO x 2 units, Proplex x 4 vials, and started on
Propofol for sedation.
In review of systems, his wife states that two weeks ago, his
blood pressure was a little higher than usual 140-150/80-90.
One
week ago, he saw his sleep doctor and at the clinic visit, his
blood pressure was 155/95. However, at home, his blood pressure
was 140/89. His cardiologist was contact[**Name (NI) **] who said to continue
to same medications until follow up with his regular doctor. He
has not had any fevers, chest pain, shortness of breath,
abdominal pain.
Past Medical History:
Central sleep apnea on CPAP, CHF, HTN, diabetes, prostate
CA diagnosed in [**2164**] and treated with radiation which ended in
[**2166-3-6**], Afib on anticoagulation, basal cell CA at the right
ear and back.
Social History:
Not available
Family History:
Not available
Physical Exam:
VS: OSH: T 96.7 HR 51 BP 205/114 RR 18 Sat 100% NRB % on RA
PE: General NAD
HEENT AT/NC, MMM no lesions, ETT in place
Neck Supple, no bruits
Chest CTA B
CVS irregularly irregular, no murmur noted
ABD soft, NTND, + BS
EXT no C/C/E, no rashes or petechiae
NEUROLOGICAL
MS:
General: not responsive to voice, withdraws to noxious in all
extremities (not antigravity in UE). no localizing. spontaneous
movement of LE bilaterally.
CN: off propofol X 10 min
II,III: no blink to threat. pupils 5 mm unresponsive
bilaterally to light
III,IV,V: no movement of eyes with OCR
V: no corneal reflexes bilaterally
Motor/Sensory: Normal bulk and tone; no tremor
- as noted above. withdraws to noxious in all extremities -
extension in UE bilatreally, purposeful/flexion in LE
bilaterally
Reflex:
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 2 2 2 1 0 Extensor
R 2 2 2 1 0 Extensor
Pertinent Results:
[**2167-1-14**] 03:36PM GLUCOSE-287* UREA N-25* CREAT-1.4* SODIUM-144
POTASSIUM-3.1* CHLORIDE-101 TOTAL CO2-31 ANION GAP-15
[**2167-1-14**] 03:36PM ALT(SGPT)-19 AST(SGOT)-26 LD(LDH)-242
AMYLASE-120* TOT BILI-1.4
[**2167-1-14**] 03:36PM LIPASE-228*
[**2167-1-14**] 03:36PM ALBUMIN-4.4 CALCIUM-9.7 PHOSPHATE-1.8*
MAGNESIUM-2.2
[**2167-1-14**] 03:36PM OSMOLAL-327*
[**2167-1-14**] 03:36PM PT-16.2* INR(PT)-1.4*
[**2167-1-14**] 11:15AM GLUCOSE-264* UREA N-25* CREAT-1.3* SODIUM-139
POTASSIUM-2.8* CHLORIDE-97 TOTAL CO2-30 ANION GAP-15
[**2167-1-14**] 11:15AM estGFR-Using this
[**2167-1-14**] 11:15AM CALCIUM-8.9 PHOSPHATE-1.9* MAGNESIUM-2.1
[**2167-1-14**] 11:15AM WBC-9.8# RBC-4.45* HGB-14.3 HCT-42.0 MCV-94
MCH-32.2* MCHC-34.1 RDW-14.0
[**2167-1-14**] 11:15AM NEUTS-86.9* LYMPHS-7.5* MONOS-4.5 EOS-0.9
BASOS-0.2
[**2167-1-14**] 11:15AM PLT COUNT-136*
[**2167-1-14**] 11:15AM PT-24.2* PTT-32.9 INR(PT)-2.4*
[**2167-1-14**] 03:36PM BLOOD PT-16.2* INR(PT)-1.4*
[**2167-1-14**] 03:36PM BLOOD Glucose-287* UreaN-25* Creat-1.4* Na-144
K-3.1* Cl-101 HCO3-31 AnGap-15
[**2167-1-14**] 03:36PM BLOOD ALT-19 AST-26 LD(LDH)-242 Amylase-120*
TotBili-1.4
[**2167-1-14**] 03:36PM BLOOD Albumin-4.4 Calcium-9.7 Phos-1.8* Mg-2.2
[**2167-1-14**] 03:36PM BLOOD Osmolal-327*
NCHCT [**2167-1-14**]:
FINDINGS: Since the prior study from approximately 3-1/2 hours
ago, there is
further increase in size of a right intraparenchymal hemorrhage
centered at
the right basal ganglia with now further extension into the
right thalamus and
possibly also involving the mid brain at the level of the
superior cerebellar
peduncle. There is increase in shift of normally midline
structures with a
subfalcine herniation of approximately 1.7 cm. Additionally,
there is
increased intraventricular extension with hemorrhage seen in the
lateral,
third, and fourth ventricles. Enlargement of the contralateral
lateral
ventricle is seen, suggesting an increase in trapping and
obstruction of the
ventricular system. Hemorrhage is also seen within the
subarachnoid space,
which is new since prior study.
There is obliteration of the suprasellar and ambient cisterns
consistent with
uncal and downward transtentorial herniation. There is also
early
left tonsillar herniation.
These findings are most consistent with hypertension in the
setting of
anticoagulation.
IMPRESSION:
1. Increased size of intraparenchymal hemorrhage centered at
the right basal
ganglia, with extension into the right thalamus, and possible
involvement of
the midbrain.
2. Increased subfalcine herniation, with uncal, downward
transtentorial
and early tonsillar herniation.
3. Marked increase in intraventricular hemorrhage with
increased trapping and
obstruction of the ventricular system.
CXR [**2167-1-14**]:
FINDINGS: Limited single bedside AP examination labeled
"semi-erect" and no
comparisons. The tip of the newly inserted ET tube lies some 3.7
cm proximal
to the carina, and the side-hole and tip of the endogastric tube
lie in the
gastric fundus, directed cephalad. Allowing for the numerous
tubes and
monitoring electrodes overlying the upper thorax, other than
left basilar
subsegmental atelectasis, the lungs are clear. The heart size
and pulmonary
vessels are likely within normal limits with no evident pleural
effusion (in
this position). There are atherosclerotic changes involving the
thoracic
aorta. Noted are gas-filled bowel loops in the left central
upper abdomen.
IMPRESSION:
1. ET and NG tubes in satisfactory position.
2. Left basilar atelectasis, with no other acute process.
Brief Hospital Course:
The patient was admitted to the neurologic ICU for further
observation and management. Given the extent of the hemorrhage
and the patient's clinical state (only with Gag relex and some
extremity posturing to noxious), the neurologic team relayed the
patient's extremely poor prognosis to the family. The patient
was screened for organ donation, and only deemed a candidate to
donate his corneas, which would be done post-mortem. The family
decided to make the patient comfort measures only; he was thus
extubated on the evening of admission. The patient died
comfortably in the evening.
Medications on Admission:
Aspirin 81mg QD
Glyburide 1.25mg QD
Allopurinol 300mg QD
Lasix 40mg [**Hospital1 **]
Carvedilol 50mg [**Hospital1 **]
Lisinopril 40mg QD
KCl 40mEq QD
Niaspan 1000mg QD
Coumadin 1mg Tu/Th/Sa/[**Doctor First Name **]
2mg M/W/F
Digoxen 125mcg QD
Discharge Medications:
Not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
Intraparenchymal hemorrhage
Discharge Condition:
Expired
Discharge Instructions:
Not applicable
Followup Instructions:
Not applicable
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"428.0",
"402.91",
"348.4",
"V10.46",
"V58.61",
"425.8",
"250.00",
"431",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
8332, 8341
|
7398, 7990
|
351, 363
|
8412, 8421
|
3796, 7375
|
8484, 8593
|
2834, 2849
|
8293, 8309
|
8362, 8391
|
8016, 8270
|
8445, 8461
|
2864, 3777
|
277, 313
|
391, 2554
|
2576, 2787
|
2803, 2818
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,791
| 100,230
|
45668
|
Discharge summary
|
report
|
Admission Date: [**2148-3-19**] Discharge Date: [**2148-3-25**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Placement of single chamber pacemaker (ventricular)
History of Present Illness:
88 yo M with a history of paroxysmal a fib, CHF, ASD, goiter,
PVD, polycythemia [**Doctor First Name **], chronic GIB on warfarin and recently
started on atenolol, admitted with complaints of shortness of
breath found to have profound bradycardia with high degree heart
block.
.
The patient is a poor historian. A recent discharge summary from
an admission starting on [**2148-3-12**] at [**Hospital3 **]
describes symptomatic shortness of breath noted by [**Name Initial (MD) **] home NP.
The patient was treated for worsening anemia (Hct 23 on
admission down from previous baseline of 35 in [**2147-11-13**]) in
the setting of supratherapeutic INR. The patient's hematocrit
improved to 27 and INR to 2.4 after 4 U PRBCs and 2U FFP. EGD
during this hospitalization revealed non-bleeding ulcers in the
stomach and Barrett's esophagus. Colonoscopy was negative. The
patient was also diuresed at that time for likely acute on
chronic CHF exacerbation. His dry weight at discharge was 83kg.
Echo revealed EF>60%. The patient was newly started on atenolol
25mg daily at the time of discharge. ACEi was not started
because of acute on chronic renal failure (Cr of 1.9 up from
previous 1.5 many months prior). Heart rate was 60-80 prior to
discharge. The patient was discharged to rehab.
.
The patient was at rehab for approximately 1 week. At rehab on
the day of admission, the patient was noted to have oxygen
saturations down to 80% on RA with subjective SOB. 4L nc was
applied w/ improvement in sats to 88%. HR was found to be 35-42.
.
The patient initially presented to [**Hospital1 **] [**Location (un) 620**] prior to transfer
to [**Location (un) 86**]. In the ED, the patient was persistently bradycardic
to 30-40 with complete heart block vs. high degree AV block on
EKG. The patient was evaluated by electrophysiology consult team
and started on isoproterenol with improvement in HR to 50-60
range. The patient was hemodynamically stable throughout with
sbp 100-130 and asymptomatic.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
Cardiac Risk Factors: Diabetes
.
Cardiac History:
Prior CAD, OSH records not currently available
CHF
ASD
RBBB
PVD
.
Other:
Multinodular goiter
GERD with esophagitis and non-bleeding gastric ulcers on recent
EGD ([**2-20**])
Polycythemia [**Doctor First Name **]
DM, diet controlled
Nephrolithiasis
Social History:
Lived alone and administered his own meds prior to recent
hospitalization. Had home NP. No tob or EtOH.
Family History:
Family history noncontributory.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
97.2 51-59 138-143/58-64 18 96% 6L NC
Gen: Well-appearing elderly man in NAD.
Integumentary: Chronic venous stasis changes in the bilateral
lower extremities.
HEENT: PERRL. Pink, moist oral mucosa without lesions.
CV: Regular rhythm, bradycardic with normal S1 and S2. [**4-18**]
systolic murmur at the right upper sternal border. Pansystolic
mrumur at the apex.
Pulm: Bibasilar crackles L>R.
Abd: Soft, nondistended, no masses or organomegaly.
Ext: No edema.
Pertinent Results:
ADMISSION LABS:
[**2148-3-18**] 05:20PM BLOOD WBC-3.7* RBC-3.06* Hgb-8.5* Hct-27.6*
MCV-90 MCH-27.8 MCHC-30.8* RDW-20.6* Plt Ct-176
[**2148-3-18**] 05:20PM BLOOD Neuts-55.1 Bands-0 Lymphs-32.2 Monos-9.1
Eos-2.9 Baso-0.7
[**2148-3-18**] 05:20PM BLOOD Hypochr-3+ Anisocy-3+ Poiklo-1+
Macrocy-3+ Microcy-2+ Polychr-OCCASIONAL Ovalocy-1+ Target-2+
[**2148-3-18**] 05:20PM BLOOD PT-22.5* PTT-42.7* INR(PT)-2.2*
[**2148-3-18**] 05:20PM BLOOD Glucose-97 UreaN-40* Creat-1.8* Na-145
K-4.7 Cl-109* HCO3-25 AnGap-16
[**2148-3-18**] 05:20PM BLOOD Calcium-8.3* Phos-3.0 Mg-2.5 Iron-24*
[**2148-3-20**] 03:20AM BLOOD TSH-0.46
CARDIAC ENZYMES:
[**2148-3-18**] 05:20PM BLOOD cTropnT-0.05*
[**2148-3-18**] 11:57PM BLOOD CK-MB-NotDone
[**2148-3-18**] 11:57PM BLOOD cTropnT-0.05*
[**2148-3-19**] 08:15AM BLOOD cTropnT-0.06*
[**2148-3-19**] 08:15AM BLOOD CK(CPK)-85
[**2148-3-18**] 11:57PM BLOOD CK(CPK)-96
[**2148-3-18**] 05:20PM BLOOD CK(CPK)-95
[**2148-3-18**] EKG: Sinus bradycardia at a rate of 34 with likely atrial
tachycardia with high grade AV block vs. CHB. Also right bundle
branch block. Downgoing T's in V4-V6. No prior for comparison.
[**2148-3-18**] CXR:
Pulmonary edema; the markedly abnormal cardiac silhouette
suggests either underlying cardiomyopathy or pericardial
effusion (or both).
2D-ECHOCARDIOGRAM ([**2147-3-20**]): The left atrium is markedly
dilated. The right atrium is markedly dilated. A secundum type
atrial septal defect is present with right to left shunting.
There is mild symmetric left ventricular hypertrophy. Overall
left ventricular systolic function is normal (LVEF>55%). The
estimated cardiac index is depressed (<2.0L/min/m2). The right
ventricular cavity is markedly dilated with depressed free wall
contractility. [Intrinsic right ventricular systolic function is
likely more depressed given the severity of tricuspid
regurgitation.] There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Severe [4+] tricuspid regurgitation is seen. There is
severe pulmonary artery systolic hypertension. The pulmonic
valve leaflets are thickened. The main pulmonary artery is
dilated. There is a small pericardial effusion. There are no
echocardiographic signs of tamponade. Echocardiographic signs of
tamponade may be absent in the presence of elevated right sided
pressures.
Brief Hospital Course:
The patient was admitted with bradycardia with high degree heart
block. Atenolol use in the setting of acute renal failure
likely worsened his bradycardia, but it was felt that his
underlying conduction disorder had worsened and that he would
benefit from placement of a pacemaker. He was on a dopamine
drip prior to placement of the pacemaker but was weaned off
after the procedure. A single chamber ventricular pacemaker was
placed on [**2148-3-22**]. He had significant blood losses during the
procedure, requiring transfusion of one unit of PRBC's. His Hct
remained stable after the transfusion. Heparin for his AFib was
restarted the morning after the procedure, and coumadin was
restarted 48 hours after pacer placement. eh was also started
on aspirin 81 mg QD.
On admission, his heart failure had been exacerbated by the
bradycardia, and he had evidence of volume overload with
crackles on lung exam. He was aggressively diuresed and had
improvement in his volume status. he was discharged on lasix 40
mg QD, to be further adjusted as an out-patient.
He was admitted with acute on chronic renal failure likely
secondary to hypoperfusion with his bradycardia (Cr 2.0 on
admission; baseline uncertain but pt has history of DM and
vascular disease). Creatinine improved somewhat with control of
his CHF exacerbation and placement of the pacemaker. He was
discharged with Cr 1.3.
ISSUES FOR FOLLOW-UP:
(1) Please measure daily weights. Mr. [**Known lastname 97347**] cardiologist
will make adjustments to his lasix medication according to his
weights.
(2) Please check INR, CBC, and chem-10 on [**2148-3-28**] at the rehab
facility. Please fax results to Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **] (cardiologist) at
[**Telephone/Fax (1) 25173**]. He will make any needed changes to Mr. [**Known lastname 97347**]
medications.
Medications on Admission:
HOME MEDICATIONS (at time of most recent discharge [**3-22**]):
Warfarin 3mg Daily
KCl 10mEq Daily
Lasix 40mg TThSaSu, 60mg MWF
Protonix 40mg twice daily - newly prescribed
Atenolol 25mg Daily - newly prescribed
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO every twelve (12) hours.
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
For your blood pressure. .
3. Warfarin 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)): Please adjust dosage to INR goal of 2.0 - 3.0. .
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): For your blood pressure. .
5. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 2 days: Please continue through [**2148-3-26**] (last dose
to be given on [**2148-3-26**]).
6. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Aspirin 81 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 Diagnoses:
Bradycardia
Secondary Diagnoses:
Congestive heart failure-- diastolic
Gastroesphageal reflux disease
Diabetes mellitus-- diet controlled
Discharge Condition:
Stable-- heart rate in the 50 - 60's; satting in the mid to
upper 90's on 2 Liters supplemental oxygen; breathing
comfortably.
Discharge Instructions:
You were admitted for a slow heart rate and received a
pacemaker. Because your heart rate was low, you had an
exacerbation of your heart failure, requiring removal of fluid
from your body with medications.
Several changes were made to your medications while you were in
the hospital:
(1) You should no longer take atenolol.
(2) You were started on two new medicines (amlodipine and
metoprolol) to control your blood pressure.
(3) Your Coumadin (also called warfarin) was increased to 5 mg
each night. This will need to be adjusted to your blood levels,
which should be followed closely.
(4) You were put on three days of cephalexin (an antibitoic)
after your procedure. You only need to take this through
[**2148-3-26**].
(5) Your lasix dose is now 40 mg daily. You shoud follow-up
with yoru cardiologist to see how this medicine should eb
adjusted accoridng to how much fluid you are retaining.
(6) You were started on aspirin, to help prevent clotting.
Followup Instructions:
You have the following appointments:
(1) Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**]
Date/Time:[**2148-3-29**] 9:30 -- this is to follow-up on your new
pacemaker.
(2) You have appointment to see Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **], your
cardiologist, on Wednesday, [**2148-4-3**] at 2:30 pm. Their phone
number is ([**Telephone/Fax (1) 97348**].
(3) You will have blood work drawn on [**2148-3-28**] and faxed to Dr. [**Name (NI) 97349**] office. He will make any neccessary changes to your
medications after he sees these results.
|
[
"250.00",
"428.0",
"745.5",
"424.0",
"584.9",
"428.33",
"288.50",
"426.0",
"530.81",
"585.9",
"427.31",
"424.2",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.82",
"37.71"
] |
icd9pcs
|
[
[
[]
]
] |
9428, 9506
|
6528, 8404
|
281, 334
|
9707, 9836
|
3902, 3902
|
10844, 11453
|
3341, 3375
|
8666, 9405
|
9527, 9559
|
8430, 8643
|
9860, 10821
|
3390, 3400
|
9580, 9686
|
3422, 3883
|
4533, 6505
|
222, 243
|
362, 2883
|
3918, 4516
|
2905, 3204
|
3220, 3325
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,892
| 162,530
|
667
|
Discharge summary
|
report
|
Admission Date: [**2137-10-31**] Discharge Date: [**2137-11-5**]
Date of Birth: [**2090-7-30**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Iodine; Iodine Containing
Attending:[**Last Name (NamePattern1) 5062**]
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
47yo F with metastatic breast cancer with bone and liver mets
s/p recent 2nd dose of Gemzar([**10-28**]) and XRT presents with c/o
fever to 102 at home x 2d. +malaise, f/c, L ear "pulsating", n/v
3d ago and x 1 tonight. No CP, SOB, cough, sore throat,
congestion, rhinorrhea, postnasal gtt, dysuria, diarrhea, abd
pain, rash. Reports 3 kids had URI sxs last week, though she did
not. Here in ED T 101, borderline hypotensive with SBP in 80s,
low wbc without neutropenia, hct 23 and guiaic positive brown
stool. Blood cultures x 2 were sent from the portacath and
peripherally. U/A which was neg and ucx were sent. She received
cefepime 2g x 1, anzemet, oxycontin 80 mg, and 2L NS. GI c/s
requested for heme + stool and anemia, but rec cont. IVF and
prbc resuscitation, no role for scoping. Given the borderline
BP, she was admitted to [**Hospital Unit Name 153**] o/n for observation.
.
Past Medical History:
onc hx:
Primary Onc: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Metastatic Breast ca- in past, undewent chemo w/
adriamycin/cytoxan, then taxol. Then, she received
5FU/leukovorin and Zometa. Her course has been complicated by
compression fractures in T1-T6 and T9. She underwent radiation
treatment for T1 and developed more pain and T6 then was found
to have a compression fracture with cord compression. She was
hospitalized while she started radiation treatment. The decision
had initially been made to continue her chemotherapy through her
radiation treatment as a radiation sensitizer; however, the
patient had episodes of severe nausea and vomiting and diarrhea
resulting in additional hospitalizations. She is finishing off
her radiation treatments with the omission of 5-FU leucovorin.
She was restarted weekly taxol on [**2137-5-23**] until [**9-30**]. Pt was
switched to gemzar since [**10-22**] due to apparent progression of
disease. CT on [**10-18**] showed progression in size of liver mets and
development of new right sided pulmonary nodules. PET [**10-21**]
showed widespread metastatic bone lesions which were stable in
intensity and number.
.
Past medical hx:
s/p ccy
ovarian clot- requiring coumadin
hypertrigylceridemia
pancreatitis
Social History:
Married with 3 children. Denies any T/A/D
Family History:
Aunt with breast cancer on father's side. Mother with bladder
cancer. Uncle with unknown type of cancer.
Physical Exam:
PE: VS T 100.6, BP 101/51 (90s/50s), HR 87, R 16, O2 96% RA
Gen: Pleasant pale F in NAD
HEENT: Short hair, PERRLA though 2 mm pupils, no photophobia,
dry mm
Neck: No LAD or masses. No nuchal rigidity.
Chest wall portacath c/d/i, no erythema/ttp
CV: RRR nl S1, S2 no m/r/g
Pulm: CTA bilat
Abd: Soft NABS, ND/NT
Extr: No c/c/e
Neuro: AAO x 3, neg Kernig/Brudzinski's signs, nl strength
throughout in all extremities, nl sensation to light touch, nl
gait
Pertinent Results:
[**2137-10-31**] 01:55PM WBC-4.5# RBC-2.77* HGB-8.6* HCT-23.8* MCV-86
MCH-30.9 MCHC-36.0* RDW-15.4
[**2137-10-31**] 01:55PM NEUTS-89.2* LYMPHS-9.6* MONOS-0.4* EOS-0.7
BASOS-0.1
[**2137-10-31**] 01:55PM POIKILOCY-1+
[**2137-10-31**] 01:55PM PLT COUNT-137*
[**2137-10-31**] 01:55PM PT-13.6* PTT-23.9 INR(PT)-1.2
[**2137-10-31**] 01:43PM GLUCOSE-103 LACTATE-1.4 NA+-138 K+-3.2*
CL--111 TCO2-21
[**2137-10-31**] 01:55PM LIPASE-12
[**2137-10-31**] 01:55PM GLUCOSE-103 UREA N-10 CREAT-0.6 SODIUM-137
POTASSIUM-3.3 CHLORIDE-106 TOTAL CO2-21* ANION GAP-13
[**2137-10-31**] 01:55PM ALT(SGPT)-108* AST(SGOT)-125* ALK PHOS-48 TOT
BILI-1.4
[**2137-10-31**] 05:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2137-10-31**] 05:30PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
.
DATA:
[**10-31**] CXR: The heart is of normal size. The mediastinal and hilar
contours are within normal limits. The pulmonary vasculature is
normal without evidence of CHF. There is a right chest wall
Port-A-Cath with the tip in the cavoatrial junction. There are
again noted surgical clips overlying the left breast. There is a
patchy opacity in the right perihilar region and infrahilar
region with nodular densities, which is likely due to post-
radiation changes. No definite evidence of pneumonia is seen.
There is a stable compression fracture of T6 and T9 vertebral
bodies. There are surgical clips in the gallbladder fossa and
subcutaneous tissues in the left abdomen. The patient is status
post TRAM flap. The patient is status post left mastectomy.
IMPRESSION:
1. Post-radiation changes. No evidence of pneumonia.
2. Stable compression fractures of T6 and T9 vertebral bodies.
.
Ultrasound of abdomen [**2137-11-4**]: FINDINGS: Gallbladder is not
seen as patient is status post cholecystectomy. Common duct is
not dilated. The liver appears echogenic consistent with fatty
liver. Multiple rounded hypoechoic lesions are seen within the
liver, the largest measuring 2.5 cm in largest dimension. The
right kidney measures 11.2 cm. The left kidney measures 11.6 cm.
There is no hydronephrosis or stones. The pancreas and spleen
appear unremarkable. The aorta is of normal caliber throughout.
IMPRESSION:
1. Multiple hypoechoic lesions seen within the liver
corresponding to findings on CT performed [**2137-10-18**]. These
findings are suggestive of liver metastases.
2. The liver is echogenic consistent with fatty liver. However,
other forms of liver disease and more advanced liver disease,
including significant hepatic fibrosis/cirrhosis, cannot be
excluded on the study.
3. Status post cholecystectomy.
.
CXR [**2137-11-4**]: History of metastatic breast cancer with fever.
Right subclavian CV line is in distal SVC. No pneumothorax.
Right para mediastinal post-radiation changes as previously
demonstrated. No new pulmonary consolidation or pleural
effusions.
IMPRESSION: No evidence for pneumonia or other change since
prior film of [**2137-10-31**].
.
Labs at discharge:
[**2137-11-5**] 04:43AM BLOOD WBC-3.6* RBC-3.84* Hgb-11.2* Hct-30.7*
MCV-80* MCH-29.2 MCHC-36.5* RDW-16.3* Plt Ct-73*
[**2137-11-5**] 04:43AM BLOOD Neuts-44* Bands-7* Lymphs-25 Monos-10
Eos-1 Baso-0 Atyps-4* Metas-9* Myelos-0 NRBC-1*
[**2137-11-5**] 04:43AM BLOOD Gran Ct-2140*
[**2137-11-5**] 04:43AM BLOOD Glucose-96 UreaN-11 Creat-0.7 Na-139
K-4.2 Cl-103 HCO3-21* AnGap-19
[**2137-11-5**] 04:43AM BLOOD ALT-102* AST-88* LD(LDH)-365* AlkPhos-62
TotBili-1.2
[**2137-11-5**] 04:43AM BLOOD Albumin-4.0 Calcium-10.0 Phos-4.1 Mg-2.0
[**2137-11-4**] 05:11AM BLOOD Triglyc-578*
.
UCX [**2137-10-31**]: No growth (final)
BCX [**2137-10-31**]: No growth (final)
BCX [**2137-11-3**]: No growth (final)
Brief Hospital Course:
A/P: 47 yo F w/metastatic breast ca s/p multiple regimens of
chemo and XRT, most recently Gemzar [**2137-10-28**], p/w fever to 102
and mild hypotension.
.
1. Fever of unclear etiology/hypotension: In the [**Hospital Unit Name 153**], the
patient was empirically covered with cefepime, vancomycin, and
azithromycin. Her hypotension responded to IVF and 2 units of
PRBCs. Pt was transferred to the floor on [**2137-11-2**] in a stable
condition. The patient did not require any IVF and maintained
her SBP in the 90s with good PO intake. The vancomycin and
cefepime were subsequently discontinued as the patient remained
afebrile, not neutropenic, and cultures remained negative, and
switched to Levaquin. The source of fever remains unclear as
final urine and blood cultures are negative and repeat x-ray
showed no pneumonia(Port-A-Cath was a concern although the site
looked clean, but the patient remained afebrile off of
vancomycin).
.
2. Anemia/guiaic + stool: Pt's hct was 23.8 (baseline 30) and
stool was heme + in the ED. In the ED hct over several hours
stayed stable. New anemia was felt likely due to chemotherapy
as other cell lines also decreased. The patient received 2 units
of PRBC in the [**Hospital Unit Name 153**], resulting in appropriate rise in hct to
32.2. Her hct remained stable on the floor. For GI consulted in
ED and no acute recs for colonoscopy/ imaging. Of note, the
patient has chronic + heme since Xeloda induced colitis.
.
3. Elevated LFTs- Was felt to be secondary to liver mets and/or
Gemzar. Pt did not have any abdominal complaints. U/S of abdomen
showed echogenic liver with multiple hypoechoic lesions
consistent with corresponding to findings on CT performed
[**2137-10-18**].
.
4. Metastatic breast ca- s/p Gemzar [**2137-10-28**]. The patient was
continued on neurontin and oxycontin for peripheral neuropathy.
.
5. Hypertriglyceridemia: Continued tricor. Since the patient has
a h/o pancreatitis with elevated TG, triglyceride was rechecked
and was improved to 578 ([**6-30**] 1397) The patient had normal
amylase and lipase during this hospitalization.
.
6. H/o R ovarian v clot: Continue coumadin (unclear effect as
INR 1.2)
7. Depression/anxiety: Continued Wellbutrin and Lexapro. Ativan
for sleep prn.
.
8. FEN: Received IVF for hydration and regular diet
.
9. Proph: PPI, pneumoboots; on coumadin.
Medications on Admission:
Wellbutrin 150 [**Hospital1 **], Lexapro 10 qd, OxyContin 80 [**Hospital1 **], Protonix,
TriCor 145 mg qd, coumadin 1 mg a day, neurontin 300 mg qd,
Ativan as needed, vicodin, zometa.
Discharge Medications:
1. Bupropion 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
qd ().
4. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: Four (4)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
7. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
10. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic breast cancer
Fevers
Discharge Condition:
Afebrile, stable to go home.
Discharge Instructions:
Return to the emergency department or call your primary care
physician if you develop fever, chills, intractable
nausea/vomiting, dizziness, bright red blood per rectum,
shortness of breath, chest pain, or any other worrisome
symptoms.
.
Take your antibiotics as prescribed.
.
Have your hematocrit checked at your oncology appointment.
.
Please, call radiology and schedule an appointment to get a CT
of abdomen and follow up with Dr. [**First Name (STitle) **] with the result.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Date/Time:[**2137-11-12**] 9:00
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/ONCOLOGY-CC9
Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2137-11-12**] 9:00
Provider: [**Name10 (NameIs) 26**] [**Name8 (MD) 28**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2137-11-12**]
9:30
|
[
"780.6",
"E933.1",
"287.4",
"V10.3",
"197.7",
"198.5",
"285.9",
"V58.61",
"197.0",
"356.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10474, 10480
|
6997, 9350
|
313, 320
|
10556, 10587
|
3217, 6260
|
11114, 11535
|
2622, 2729
|
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10501, 10535
|
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|
2744, 3198
|
267, 275
|
6279, 6974
|
348, 1237
|
1259, 2546
|
2562, 2606
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,460
| 108,751
|
41223
|
Discharge summary
|
report
|
Admission Date: [**2126-5-24**] Discharge Date: [**2126-5-25**]
Date of Birth: [**2062-10-18**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 29055**]
Chief Complaint:
presyncope / elective PVI
Major Surgical or Invasive Procedure:
pulmonary vein isolation
History of Present Illness:
63 year old man with history of paroxysmal atrial fibrillation
diagnosed in [**2117**], s/p 3+ CVs with recurrence of presyncopal
symptoms who is transferred to CCU s/p PVI earlier today in
setting of relative hypotension (SBP min 77mmHg) during the
procedure.
.
His PAF has been distressing to him since onset with symptoms of
dizziness, lightheadedness and feeling like he is going to fall
down and a sensation of the "jello heart." He has been in/out
of afib every couple of years, most of the time lasting several
days and requiring a CV. He was on Propafenone in the past,
however had signfiicant bradycardia and near syncope thus this
was stopped.
.
Over the last 2 months, he had 3 occurences of Afib. [**4-1**]
requiring DCCV and [**4-6**] lasting 3 days, undergoing Stress/ECHO
and then undergoing DCCV. His last episode was in early [**Month (only) 958**],
when he noted a feeling of lightheadedness and and then syncope
while shopping at Sears. LOC lasted ~ 45 seconds. He noted
history of dehydration and exhaustion prior to this episode.
This Afib episode lasted for 2.5 days and terminted on its own.
.
In addition he reports having symptoms of "atrial fibrillation"
while straining on the toilet and in setting of dehydration, but
not during exertion while wt. lifting. He denied episodes of
difficulty with language, weakness, clumsiness, numbness or
tingling or visual deficits. He has never had urinary retention
or balance difficulties. He was treated with ASA 325mg for Afib
utnil ~ 2 wks ago when he was started on Pradaxa.
.
Prior to PVI, he had undergone an evaluation including TTE
([**3-/2125**]) showing nl EF, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 13385**] of 3.8cm and a trileaflet
aortic valve with a small pericardial effusion w/o "evidence of
hemodynamic compromise." He had also undergone a adenosite
imaging stresss, which was normal.
.
Today, while undergoing PVI, had an episode of atrial
tachycardia with SBP to 77 from 90s, underwent DCCV x2, received
2.6L NS and has remained in SR after PVI. Given his low normal
BPs, he was admitted to CCU for monitoring. Pre-PVI EKG at 8am
was NSR at 65.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
In the CCU, patient feels comfortable and has no complaints. He
feels a little confused after having received Dilaudid in the
PACU. No CP, no SOB.
Past Medical History:
1. CARDIAC RISK FACTORS: None
2. CARDIAC HISTORY:
-CABG: NA
-PERCUTANEOUS CORONARY INTERVENTIONS: NA
-PACING/ICD: NA
- PAF s/p CV x 3+, s/p PVI.
.
3. OTHER PAST MEDICAL HISTORY:
- Tonsillectomy as a child.
- Multiple MSK surgeries (shoulder, knee)
Social History:
He is a retired teacher, quit 5 yrs ago, now substituting.
Lives at home with with his wife. 3 kids, one passed away from
cancer. He is a competitive water skier.
Family History:
Father's brother, grandfather and multiple cousins w/ Afib.
Both parents lived to mid 90s, no early CAD or cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
.
Physical Exam:
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 12 cm.
CARDIAC: PMI at apex. At 2 RICS there are a systolic and a
diastolic murmur each [**3-24**]. No S3.
RR, normal S1, S2. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Trace crackles
bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits. R groin site C/D/I,
no murmur.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP dopplerable.
Left: DP dopplerable.
Pertinent Results:
Labs at admission:
[**2126-5-24**] 08:57AM GLUCOSE-104* UREA N-23* CREAT-1.1 SODIUM-139
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-25 ANION GAP-14
[**2126-5-24**] 08:57AM estGFR-Using this
[**2126-5-24**] 08:57AM WBC-4.6 RBC-3.63* HGB-11.7* HCT-32.8* MCV-90
MCH-32.1* MCHC-35.6* RDW-12.8
[**2126-5-24**] 08:57AM NEUTS-61.1 LYMPHS-26.0 MONOS-8.4 EOS-3.6
BASOS-0.8
[**2126-5-24**] 08:57AM PLT COUNT-315
[**2126-5-24**] 08:57AM PT-14.0* INR(PT)-1.2*
Imaging:
ECHO
[**2126-5-24**]
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The estimated pulmonary artery systolic pressure is normal.
There is a small pericardial effusion. There are no
echocardiographic signs of tamponade.
IMPRESSION: Small circumferential pericardial effusion without
echocardiographic signs of tamponade physiology.
ECHO
[**2126-5-24**]
The left atrium is elongated. The right atrium is moderately
dilated. A left-to-right shunt across the interatrial septum is
seen at rest. A small secundum atrial septal defect is present.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. Trivial mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is a small pericardial effusion. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade.
IMPRESSION: Small circumferential pericardial effusion without
echo signs of tamponade. Small secundum ASD.
ECHO
[**2126-5-25**]
- Wet read : no increase in pericardial effusion; increase in TR
Brief Hospital Course:
63 year old man with history of paroxysmal atrial fibrillation
diagnosed in [**2117**], s/p 2 CVs with recurrence of presyncopal
symptoms who is transferred to CCU s/p PVI earlier today in
setting of relative hypotension (SBP min 77 mmHg) during the
procedure.
.
# PUMP: Nl LV and RV fx and EF. Small circumferential effusion
(note on prior TTE), no evidence of tamponade. Normotensive,
normal pulsus. Has systolic/diastolic murmur at 2 RICS likely
s/p procedure. He had stable heart rate and BP. Repeat ECHO did
not reveal worsening effusion, it did reveal slightly worsened
TR.
.
# RHYTHM: PAF s/p multiple CVs and now PVI. Currently in SR. We
restarted Pradaxa which he will continue at home. Pt was
instructed on the use of a "[**Doctor Last Name **] of heart" monitor. He will call
to make a f/u outpatient EP appointment
.
# Anemia. Normocytic. HD stable, HCT 32, no priors. Etiology
unclear.[**Name2 (NI) **] studies were sent but patient was discharged prior
to results, he should have outpatient follow up of this issue.
Medications on Admission:
Pradaxa 150mg [**Hospital1 **]
Vitamin C 1g daily
Glucosamine-Chondroit-VitC
Centrum Ultra Men
Fish Oil [**Telephone/Fax (1) 89797**] daily
Discharge Medications:
1. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
2. ascorbic acid 250 mg Tablet, Chewable Sig: Four (4) Tablet,
Chewable PO DAILY (Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Atrial Fibrillation
Secondary:
Pericardial effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the [**Hospital3 **] Medical Center for a PVI
procedure. During the procedure you had transient low blood
pressure. An echocardiogram also noted that you had an
accumulation of fluid around your heart. Given these two
findings, you were admitted to the Cardiac Intensive Care Unit
for close monitoring. Overnight your blood pressures were within
a normal range and your repeat echocardiogram did not show
worsening fluid accumulation around your heart.
You were discharged home with a heart monitor that you should
wear for 2 weeks.
No changes were made to your medications please continue to take
all your medications including Pradaxa.
Please call your doctor or return to the emergency room if you
have chest pressure or pain or feel lightheaded or dizzy.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 5448**], cardiologist.
|
[
"423.9",
"285.9",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.61",
"37.27",
"37.34"
] |
icd9pcs
|
[
[
[]
]
] |
7940, 7946
|
6374, 7411
|
300, 326
|
8052, 8052
|
4629, 6351
|
9010, 9084
|
3627, 3808
|
7601, 7917
|
7967, 8031
|
7437, 7578
|
8203, 8987
|
3823, 4610
|
3228, 3327
|
235, 262
|
354, 3156
|
8067, 8179
|
3358, 3429
|
3178, 3208
|
3445, 3611
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,447
| 183,103
|
46789+58943+58944
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2193-7-4**] Discharge Date: [**2193-7-10**]
Date of Birth: [**2121-6-29**] Sex: M
Service: MEDICINE/[**Hospital1 **]
COVERING RESIDENT: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 99294**], MD. Pager #: [**Numeric Identifier 99295**].
HISTORY OF THE PRESENT ILLNESS: This is a 72-year-old man
with severe coronary artery disease, AICD, hypertension, and
a history of alcoholism, who presents unresponsive with a
head laceration. On [**2193-7-4**], the patient was found at
home by his wife in bed, bleeding from the scalp after having
crawled after a fall. He was able to ambulate at that time,
but soon after, he was found unresponsive in a pool of blood.
He remembers only walking from the living room to the
bedroom, then blacking out. He reports having had a single
drink of vodka with cranberry juice that day. The EMS was
called and the patient was found hypotensive, intubated in
field and brought to the ED still unresponsive. In the ED,
Mr. [**Known lastname **] received packed red blood cells and 4.5 liter
normal saline for resuscitation. He received a total of 8
units of packed red blood cells and two units of fresh frozen
plasma for the ICU stay. He also received Cefazolin one gram
IV and methylprednisolone IV. CT scan of the head showed no
hemorrhage or fracture, only significant right-sided soft
tissue swelling. CT scan of the spine showed only stable old
C2 fracture and slight anterior C4-C5 listhesis, for which
she was put in a collar. The right facial avulsion was
sutured and stapled. Mr. [**Known lastname **] was admitted to the
Trauma Surgery ICU, where he continued to receive fluids and
he was started on Dopamine. The ethanol level was measured
at 247. He was started on Ativan for alcohol withdrawal.
AICD was interrogated by the on call electrophysiology fellow
and showed no events. The fall was presumed to be secondary
to alcohol intoxication. Dopamine was weaned off and the
patient was transiently given an IV nitroglycerin drip for
hypertension and fluid overload, as well as Furosemide IV.
His course was also complicated by metabolic acidosis, mixed
anion gap and nonanion gap, which was resolving on transfer
to the [**Hospital **] Medical Team.
PAST MEDICAL HISTORY:
PROBLEM #1: Coronary artery disease status post CABG in
[**2190**] (LIMA LAD, SVG-OM, SVG-PDA. Coronary catheterization on
[**7-8**], [**2193**], after loss of consciousness showed
three-vessel CAD (LM 50-60, LAD T.O., LIMA-LAD patent with
50% to 60% stenosis and retrograde LAD, LCX 70-80, proximal
OM1 high grade times two, OM2 70-8, SVG-OM2 patent, RCA T.O.
SVG-PDA 60%). Stents to the left main coronary artery and
ramus intermedius placed at [**Hospital1 756**] [**Hospital5 **] [**Hospital6 44770**] Hospital on
[**2193-6-19**].
PROBLEM #2: Left ventricular dysfunction. Transthoracic
echocardiogram on [**2193-6-17**] after loss of consciousness showed
LV ejection fraction 25%, septal and apical wall motion
abnormalities, moderate MR, tricuspid valve gradient of 37
indicating moderate pulmonary hypertension.
PROBLEM #3: Ventricular arrhythmia with automatic internal
cardiac defibrillator placed. Defibrillator by EMS in the
field on 7/[**2192**]. Details unavailable, but the patient was
started on Amiodarone at that time. On [**2193-6-16**], the
patient was admitted to [**Hospital 21811**] [**Hospital6 **] after
loss of consciousness. No arrhythmia was documented, but EKG
showed on incomplete right bundle branch block. CT angiogram
did not reveal pulmonary embolism. Transthoracic
echocardiogram and catheterization as above. AICD placed on
[**2193-6-21**].
PROBLEM #4: Aspiration pneumonia diagnosed on
hospitalization earlier this month, treated with Levofloxacin
and Clindamycin for ten days.
PROBLEM #5: Peripheral vascular disease with right femoral
tibial bypass on [**2193-6-12**], complicated at that time by wound
infection requiring prolonged hospitalization.
PROBLEM #6: Bilateral carotid artery disease.
PROBLEM #7: Ethanol abuse with past withdrawal episodes.
PROBLEM #8: Positive PPD in [**2190**] with no related
abnormalities on chest x-ray at that time.
PROBLEM #9: Hypertension.
PROBLEM #10: Peptic ulcer disease.
PROBLEM #11: C1, C2 spinal fusion.
ADMISSION MEDICATIONS:
1. EC ASA 325 mg p.o.q.d.
2. Enalapril 10 mg p.o.q.d.
3. Multivitamin, thiamine 100 mg p.o.q.d.
4. Folate 100 mg p.o.q.d.
5. Magnesium gluconate 500 mg p.o.t.i.d.
6. Metoprolol 50 mg p.o.b.i.d.
7. Clopidogrel 75 mg p.o.q.d.
8. Omeprazole 20 mg p.o.q.d.
9. Amiodarone 200 mg p.o.q.d.p.r.n.
10. Nitroglycerin.
11. Oxycodone-APAP.
ALLERGIES: The patient has question of reaction to
Oxycodone-APAP.
SOCIAL HISTORY: The patient has ethanol abuse with multiple
past falls and withdrawal episodes. Tobacco smoker, 1?????? packs
per day for 50 years, lives with his wife. She has four
children and he has three, who are apparently somewhat
estranged.
PHYSICAL EXAMINATION: Examination revealed the following:
VITAL SIGNS: Temperature 98.2, pulse 52 to 60, blood
pressure 131/28 to 158/56, respirations 16 to 24, oxygen
saturation 97 to 100% on five liters face tent. GENERAL: In
general, the patient is pleasant, appropriate, fatigued.
HEENT: Pharyngeal, but no scleral icterus. Mucous membranes
moist with no oropharyngeal lesions. Conjunctivae were pale.
Facial laceration neatly stapled and sutured with no
surrounding erythema or discharge. Neck was supple. No JVD.
CHEST: Poor air movement throughout with rales in the left
base. CARDIAC: Very faint heart sounds due to barrel chest.
ABDOMEN: Normal bowel sounds, obese, soft, with no
tenderness other than a mildly tender 2-cm hepatomegaly. No
[**Doctor Last Name **] sign. EXTREMITIES: Marked bilateral upper extremity
edema, mild palmar erythema, no spider angiomata.
EXTREMITIES: Warm with normal capillary refill. There are
multiple bruises on the face, arms, and legs.
LABORATORY DATA: Laboratory data: On admission the WBC was
8.6, hematocrit 24, platelet count 347,000, PT 13.4, INR 1.3,
PTT 37.4, fibrinogen 221, sodium 136, potassium 4.3, chloride
105, CO2 20, BUN 9, creatinine 1.3, glucose 95, inonized
calcium 1.08, phosphate 3.4, magnesium 1.5, amylase 38,
lipase 18, serum ethanol 247, urine toxicology screen
negative. ABG revealed the pH of 7.30, pCO2 46, pO2 34. On
transfer to the Medicine Service, white blood cells were
17.8, hematocrit 36, platelet count 157, PT 12.4 with INR of
1.1, PTT 34.1, sodium 137, potassium 4.9, chloride 107, CO2
20, BUN 15, creatinine 1.3, glucose 178, ionized calcium
1.22, phosphate 5.7, magnesium 2.0, albumin 2.4, arterial
blood gases revealed the pH of 7.27, pCO2 46, pO2 148 on 5
liter face tent. Serum osmolarity; 293. Urinalysis on
[**2193-7-4**] showed specific gravity greater than 1.003, pH 5.0,
protein 30, RBC 3 to 5, WBC less than 1, urine sodium of 12,
creatinine 90 and osmolality 484. Creatinine kinases were 44
and 52 with cardiac troponin I less 0.3 times two. Imaging:
CT of the head on [**2193-7-4**] showed no intracranial bleeding,
midline shift or skull fracture, right sided soft tissue
swelling with subcutaneous emphysema. CT of the cervical
spine on [**7-4**] showed surgical screws and wires at C1 through
C2. Grade I C4 through C5 anterolisthesis. CT of the
abdomen and pelvis on [**7-4**] showed 1.9 cm left kidney cyst,
several small right kidney cysts, no fractures or signs of
acute injury. Chest x-ray on [**7-5**] revealed left basilar
atelectasis, no pneumothorax, pulmonary artery
catheterization correctly placed. CT of the abdomen and
pelvis on [**7-4**] showed bilateral pleural effusions, right
greater than left, right inferior pubic irregularities
consistent with old fracture. Chest x-ray on [**7-5**] showed
interval development of mild congestive heart failure. Chest
x-ray on [**7-6**] showed retrocardiac opacification.
HOSPITAL COURSE: The patient was transferred to the Medicine
Service on [**2193-7-6**]. The course from then on was as
follows:
PROBLEM #1. ETHANOL ABUSE: The patient received Diazepam 5
mg p.o.t.i.d. through [**7-8**]. He received one extra dose of
Diazepam on the evening of [**7-7**] for mild withdrawal symptoms.
On [**7-9**] it was felt that the patient was not withdrawing and
Diazepam was changed to 10 mg p.o.q.h.s. Unfortunately, he
still complained of insomnia on that evening and required
additional zolpidem to sleep. Vitamin supplementation and
electrolyte repletion was provided by the
hospitalization/substance abuse nurse specialist,
[**First Name8 (NamePattern2) 2411**] [**Last Name (NamePattern1) 2412**], RN consulted and her recommendations are
pending at the time of this summary. However, it is notable
that the patient adamantly feels that ethanol is not a
problem for him and he has no interest in ethanol-abuse
treatment.
PROBLEM #2. BLOOD LOSS ANEMIA: As noted above, the patient
required a total of eight units of packed red blood cells to
restore the hematocrit to greater than 30. This remained
stable after repletion and felt to be resolved entirely
confirmed by the head laceration.
PROBLEM #3. CORONARY ARTERY DISEASE: With suspicion for
ventricular arrhythmias, as noted above, the patient's AICD
was interrogated on [**2193-7-5**] and found to have no
arrhythmias recorded. The patient was felt to have suffered
a fall in the setting of alcohol abuse rather than a cardiac
event. Outpatient cardiac medications including clopidogrel
were resumed although Metoprolol was decreased to 25 mg p.o.
b.i.d. and Enalapril increased to 20 mg p.o.q.d. for
bradycardia and hypertension respectively.
PROBLEM #4. RETROCARDIAC OPACIFICATION: It was noted that
the patient was treated for aspiration pneumonia starting
[**2193-6-19**]. Retrocardiac opacification was stable on chest
x-ray and felt to be consistent with resolving process. He
has not developed symptoms of pneumonia during his
hospitalization. He was not hypoxic on discharge. Swallow
evaluation was performed at the bedside and showed no swallow
abnormalities.
PROBLEM #5: METABOLIC ACIDOSIS: This appeared to correlate
well with elevated serum lactate levels and rapid normal
saline expansion and had entirely resolved by [**2193-7-7**].
PROBLEM #6: FLUID OVERLOAD: This was transient in the
setting of aggressive crystalloid repletion, hypertension and
prerenal azotemia at the beginning of Mr. [**Known lastname **]
hospital stay. He was additionally on Furosemide, but not
continuing to require this medicine during the second half of
his hospital stay. On discharge, the BUN and serum
creatinine were within normal limits.
PROBLEM #7: MILD PROTEINURIA: This was noted as an
incidental finding and should be followed as an outpatient.
DISPOSITION: The patient was evaluated by the Department of
Physical Therapy and felt not to be safe for discharge to
home in the setting of impaired balance, functional mobility,
and endurance. He was initially resistant to [**Hospital 3058**]
rehabilitation, but ultimately agreed to go to physical
therapy, re-emphasizing that he had no interest in inpatient
alcohol treatment.
DISCHARGE CONDITION: Stable, preparing for transfer to
[**Hospital 3058**] rehabilitation facility.
DISCHARGE MEDICATIONS:
1. EC ASA 325 mg p.o.q.d
2. Enalapril 20 mg p.o.q.d.
3. Metoprolol 25 mg p.o.b.i.d.
4. Omeprazole 20 mg p.o.q.d.
5. Clopidogrel 75 mg p.o.q.d.
6. Amiodarone 200 mg p.o.q.d.
7. Multivitamin q.d.
8. Thiamine 100 mg p.o.q.d.
9. Folate 1 mg p.o.q.d.
10. Magnesium gluconate 500 mg p.o.t.i.d.
11. P.r.n. sublingual nitroglycerin and noxazepam.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6384**], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 99296**]
MEDQUIST36
D: [**2193-7-10**] 14:36
T: [**2193-7-10**] 14:46
JOB#: [**Job Number **]
Name: [**Known lastname 15655**], [**Known firstname **] Unit No: [**Numeric Identifier 15893**]
Admission Date: [**2193-7-4**] Discharge Date: [**2193-7-11**]
Date of Birth: [**2121-6-29**] Sex: M
Service:
DISCHARGE SUMMARY ADDENDUM:
DISCHARGE DIAGNOSIS:
1. Alcohol abuse.
2. Head laceration.
3. Blood loss anemia.
4. Old pneumonia.
[**First Name4 (NamePattern1) 168**] [**Last Name (NamePattern1) 1030**], MD [**MD Number(1) 1031**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2193-7-10**] 22:28
T: [**2193-7-12**] 09:54
JOB#: [**Job Number 15894**]
Name: [**Known lastname 15655**], [**Known firstname **] Unit No: [**Numeric Identifier 15893**]
Admission Date: [**2193-7-4**] Discharge Date: [**2193-7-11**]
Date of Birth: [**2121-6-29**] Sex: M
Service:
DISCHARGE SUMMARY ADDENDUM:
ADDENDUM TO HOSPITAL COURSE:
Ankle Pain - The patient complains of ankle pain with
ambulation. He was examined and found to have a hematoma over
the medial aspect of his right ankle with mild tenderness
posterior to the medial malleolus. There was no point
tenderness over any of the bones. This was felt to be most
likely a sprain. X-rays of the ankle are pending at the time
of this summary.
[**First Name4 (NamePattern1) 168**] [**Last Name (NamePattern1) 1030**], MD [**MD Number(1) 1031**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2193-7-11**] 13:42
T: [**2193-7-12**] 10:06
JOB#: [**Job Number 15895**]
|
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"285.1",
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] |
icd9cm
|
[
[
[]
]
] |
[
"37.26",
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"86.59",
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] |
icd9pcs
|
[
[
[]
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11229, 11309
|
11332, 12212
|
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|
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|
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|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,304
| 126,719
|
18287
|
Discharge summary
|
report
|
Admission Date: [**2190-9-17**] Discharge Date: [**2190-9-27**]
Date of Birth: [**2117-6-1**] Sex: F
Service: BMT
HISTORY OF PRESENT ILLNESS: The patient is a 73 year-old
white female who presents as a transfer from [**Hospital 1474**]
Hospital for further evaluation and management of acute
leukemia. The patient states she was in her usual state of
health until one week prior to admission. At that time she
began to feel a generalized weakness and fluid like symptoms.
After about two to three days of these symptoms she called
her primary care physician who advised her to go to the
hospital. At [**Hospital 1474**] Hospital the patient had a CBC, which
showed pancytopenia. Further workup included a bone marrow
biopsy, which showed large numbers of blasts cells. The
patient received several red blood cell transfusions and had
intermittent fevers at the outside hospital. Chest x-ray at
the outside hospital showed possibility of infiltrates so the
patient was started on Rocephin. CBC on admission at the
outside hospital showed a white blood cell count of 700 and a
hematocrit of 24. The patient denies fevers or chills,
rigors prior to admission. She also denies weight loss,
bleeding, easy bruising, headaches or visual changes.
PAST MEDICAL HISTORY:
1. Osteoporosis.
2. Gastroesophageal reflux disease.
3. Umbilical hernia repair 15 years ago.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs temperature
102.1. Pulse 112. Respiratory rate 16. Blood pressure
112/60. General the patient was alert and oriented times
three and in no acute distress appearing stated age. Head
examination normocephalic, atraumatic. Pupils are equal,
round and reactive to light. Extraocular movements intact.
Sclera anicteric and not injected. Oropharynx was clear
without lesions, erythema or exudate. Neck was supple. No
JVD. No bruits. No cervical, submandibular,
supraclavicular, axillary or inguinal lymphadenopathy. Lungs
crackles bilaterally most pronounced at the bases.
Cardiovascular regular rate and rhythm. Normal S1 and S2.
No murmurs, rubs or gallops. Abdominal examination soft,
nontender, nondistended. Normoactive bowel sounds. No
organomegaly. No bruits. Well healed low midline scar.
Extremities no clubbing, cyanosis or edema. Distal pulses 1+
bilaterally. Skin no rashes. Antecubital ecchymosis.
Neurological intact. Cranial nerves II through XII intact.
Motor strength 5 out of 5 throughout.
LABORATORIES ON ADMISSION: CBC shows a white blood cell
count of 1.3, hematocrit 34.8, platelets 39. Differential on
the white count 31% neutrophils, 2% bands, 47% lymphocytes,
2% atypical cells. Chemistries were within normal limits.
INR was 1.3. Liver function tests were within normal limits.
HOSPITAL COURSE: 1. AML: The patient's bone marrow
biopsy from [**Hospital 1474**] Hospital was reviewed and was consistent
with acute myelogenous leukemia-AML . The patient was not
started on any immediate treatment for the AML as she was not
symtomatic. Her hematocrit was fairly
stable and though her platelets were low she did not require
any platelet transfusions. The patient was also started on
Danazol for possible effect of treating her thrombocytopenia.
2. Infectious disease: The patient was febrile on admission
as well as neutropenic, therefore she was started on Cefepime
2 grams q 8 for gram negative bacteria coverage. The patient
also had a chest CT done to evaluate for infectious etiology.
The CT showed patchy infiltrates suggestive of the
possibility of pneumonia as well as some emphysematous
changes. The patient was started on Levaquin for treatment
of community acquired pneumonia after which she defervesced
and had no further fevers. The patient had blood cultures
and urine cultures taken during the admission, which were
negative. Once the patient had been afebrile for over 48
hours the Cefepime was discontinued. She was maintained on
Levaquin and discharged on Levaquin for a total two week
course.
3. Cardiovascular: During the third day of admission the
patient complained of chest discomfort and palpitations. An
electrocardiogram was done, which showed atrial fibrillation.
Vital signs showed hypotension. The patient was given .5 mg
of Digoxin intravenous push without significant effect. She
was then transferred to the Intensive Care Unit for further
management. In the Intensive Care Unit the patient was
loaded with Amiodarone and started on an Amiodarone drip.
Her vital signs stabilized and the following day she was
electrically cardioverted from atrial fibrillation into a
normal sinus rhythm. She remained stable in the Intensive
Care Unit after the cardioversion and was then transferred
back to the floor. The next day after returning to the floor
the patient developed atrial fibrillation once again shown on
telemetry. At this time she was asymptomatic and her blood
pressure and other vital signs were stable. Her heart rate
ranged from 100 to 130. After several hours of atrial
fibrillation the patient's rhythm spontaneously converted
back to normal sinus. Cardiology was consulted regarding
further management of the patient. Per cardiology consult
the patient was switched from Amiodarone to Sotalol for
prophylaxis of arrhythmias. She was initially started on 80
mg t.i.d. of Sotalol. After one day of monitoring the
patient's electrocardiogram her QT interval corrected
prolonged to approximately 480 milliseconds. At this time it
was felt that the Sotalol dose should be decreased to avoid
prolongation of her QT interval. Her dose was decreased to
80 mg b.i.d. On this her electrocardiograms showed a QTC
interval within normal limits and she was maintained on this
dose. In addition, while in the Intensive Care Unit the
patient had an echocardiogram, which showed a moderate
pericardial effusion. The etiology of this was unclear, but
possibly to be due to her pneumonia. A repeat echocardiogram
was done two days after the initial one, which showed that
the pericardial effusion had been reduced in size and was now
small. The patient never showed any signs or symptoms of
cardiac tamponade. The patient would be followed up by Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**] cardiology attending as an outpatient
following discharge. The patient was not anticoagulated
despite her paroxysmal atrial fibrillation due to the fact
that her platelets remained low below 50 during the admission
secondary to her disease.
4. Gastrointestinal: The patient was initially put on
Zantac for history of reflux disease as this was her
outpatient medication. She was switched to Pepcid during the
hospitalization.
CONDITION ON DISCHARGE: Good, afebrile, hemodynamically
stable, tolerating po and ambulating without difficulty.
DISCHARGE STATUS: The patient is to be discharged to home.
DISCHARGE INSTRUCTIONS: The patient was instructed to call
if she developed fevers, chest pain, palpitations. She was
instructed to follow up with Dr. [**First Name (STitle) 1557**] in the outpatient
clinic in two days. She was also told that she will follow
up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**] of cardiology as an outpatient if
not contact[**Name (NI) **] by Dr.[**Name (NI) 12467**] secretary for an
appointment. She was given the phone number to call and make
an appointment.
DISCHARGE DIAGNOSES:
1. AML.
2. Atrial fibrillation.
3. Pneumonia.
DISCHARGE MEDICATIONS:
1. Levaquin 500 mg once a day for seven days after
discharge.
2. Sotalol 80 mg twice a day.
3. Pepcid 20 mg twice a day.
4. Danazol 200 mg twice a day.
5. Fosamax continuing outpatient dose.
[**Last Name (LF) **],[**First Name3 (LF) 1730**] B. M.D. [**MD Number(2) 10997**]
Dictated By:[**Name8 (MD) 5709**]
MEDQUIST36
D: [**2190-9-28**] 03:12
T: [**2190-9-29**] 06:35
JOB#: [**Job Number 50429**]
|
[
"205.00",
"423.9",
"486",
"733.00",
"492.8",
"427.31",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.31",
"99.61"
] |
icd9pcs
|
[
[
[]
]
] |
7413, 7463
|
7486, 7931
|
2779, 6689
|
6890, 7392
|
160, 1266
|
2488, 2761
|
1288, 1407
|
6714, 6865
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,629
| 182,981
|
23086
|
Discharge summary
|
report
|
Admission Date: [**2120-12-29**] Discharge Date: [**2121-1-14**]
Date of Birth: [**2046-6-1**] Sex: F
Service: MEDICINE
Allergies:
Ceftazidime / Zosyn
Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
respiratory failure, hypotension, sepsis
Major Surgical or Invasive Procedure:
irrigation and debridement of right hip
History of Present Illness:
74 y/o F with h/o COPD, CAD s/p CABG [**2113**], CHF (last echo [**11-11**]
with EF 45-50%), with septic Right hip s/p hardware
removal/irrigation on [**12-5**] at OSH, subsequent abx coverage with
6 weeks of Vanc/Levo (until [**1-19**]). Discharged to rehab
initially where she was noted to have a new 02 requirement (not
on oxygen at home previously), and presented from rehab on [**12-23**]
to [**Hospital3 1280**] w/ acute SOB. Pt improved with diuretics and O2,
but worsened over 24hrs and was transferred to [**Location (un) 620**] ICU on
[**12-25**]. As pt had acute renal failure, no PE workup was done. Pt
did not respond to Lasix or Natrecor. Pt developed fever to 101
on [**12-27**], with leukocytosis and was C diff positive. She was
placed on Ceftaz in addition to coverage with Vanc/Levo, and
rash developed, so ceftaz was discontinued. Repeat echo showed
depressed EF at 30%. Pt had two episodes of chest pain where CE
cycled and neg x 3 no EKG changes. BNP measured and noted to be
increased to 1500, creatinine peak at 2.8 from baseline 1.3, and
AIN was suspected in the setting of the reaction to Ceftaz. On
[**12-29**] pt had an episode of hypotension and was started on
dopamine because she was already so fluid overloaded. Pt was
intubated at that time for persistant dyspnea and respiratory
decline.
Past Medical History:
1. Cardiac: HTN, CHF, CAD s/p CABG [**2113**], most recent cath in
[**2119**] with patent grafts; ECHO [**2120-12-5**] EF 45-50% 1+ MR, [**3-12**]+TR,
Pulmonary HTN, hx of NSVT
2. Septic R hip, frank purulence discovered in OR on [**2120-12-5**]
hardware removed at [**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) 3549**] Hospital, on Vanc/Levo until
[**1-19**]
3. PVD: s/p AAA repair [**2114**]
4. CVA w/ no residual deficitsm, on coumadin for anticoagulation
5. Breast CA s/p R mastectomy in [**2110**]
6. COPD
7. Hypothyroidism
8. Anemia
9. Gout
Social History:
at rehab recently after removal of hardware from right hip.
Family History:
non-contributory
Physical Exam:
on admission to [**Hospital1 18**] MICU:
VS: 100.4 80 101/35 12 98%
on dopamine 5, on AC 600/12/80/10
Gen: elderly female, intubated, sedated, opens eyes to voice,
unable to follow commands
HEENT: JVP to 10cm; R high pitched bruit
CV: RRR, nl S1/S2, no murmurs
Resp: good air movement, + scant crackles posteriorly
Abd: active BS, soft, obese, + guarding with palpation of RUQ,
no masses
Ext: 2+ edema, 1+ PT pulses bilaterally, toes downgoing
Access: L PICC
on discharge from [**Hospital1 18**]:
VS: 98.5 53 130/60 24 96% on 2L NC
GEN: elderly female, in NAD, alert and oriented, pleasant with
no complaints of chest pain, dyspnea, or calf pain
HEENT: PEERL, EOMI, OP clear
PULM: crackles at bases bilaterally but with good air movement
in upper lung fields
CV: RRR, nl S1/S2 no murmurs
ABD: active BS, soft, obese, non-tender
EXT: [**2-9**]+ edema, Right hip incision clean, dry, intact with no
drainage or evidence of infection, no erythema
Access: L PICC
Pertinent Results:
HIP UNILAT MIN 2 VIEWS RIGHT [**2120-12-30**] 9:52 AM
IMPRESSION: Presumed right prosthesis removal, with near total
destruction of the right proximal femur, possibly consistent
with an ongoing septic arthritis. Clinical correlation and joint
tap if necessary are recommended.
ECHO Study Date of [**2120-12-30**]
1.The left atrium is mildly dilated. The left atrium is
elongated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. Overall left ventricular systolic function is
moderately
depressed (30-35% ) Resting regional wall motion abnormalities
include basal
inferior, inferoseptal and inferolateral akinesis . The views
are limited but
the anterior wall appears hypokinetic. 3.Right ventricular
chamber size is
normal. Right ventricular systolic function is normal.
4.The aortic root is mildly dilated.
5.The aortic valve leaflets are mildly thickened. No aortic
regurgitation is
seen.
6.The mitral valve leaflets are mildly thickened. There is mild
mitral
stenosis.There is trace MR.
7.There is mild to moderate pulmonary artery systolic
hypertension.
8.There is no pericardial effusion.
BILAT LOWER EXT VEINS PORT [**2121-1-6**] 1:12 PM
No evidence of DVT within both lower extremities.
[**2121-1-14**] 05:40AM BLOOD WBC-11.2* RBC-3.16* Hgb-9.5* Hct-29.4*
MCV-93 MCH-30.1 MCHC-32.3 RDW-15.7* Plt Ct-190
[**2121-1-14**] 05:40AM BLOOD Plt Ct-190
[**2121-1-14**] 05:40AM BLOOD Glucose-135* UreaN-57* Creat-1.2* Na-142
K-5.5* Cl-108 HCO3-29 AnGap-11
[**2120-12-29**] 10:44PM BLOOD ALT-16 AST-15 LD(LDH)-212 CK(CPK)-67
AlkPhos-149* TotBili-0.4
[**2120-12-29**] 10:44PM BLOOD Lipase-11
[**2121-1-14**] 05:40AM BLOOD Calcium-8.0* Phos-3.1 Mg-2.0
[**2121-1-13**] 03:59AM BLOOD TSH-0.67
[**2121-1-11**] 03:31AM BLOOD [**Doctor First Name **]-POSITIVE Titer-1:1280
Cntromr-POSITIVE
[**2121-1-14**] 05:40AM BLOOD Vanco-19.0*
[**2121-1-11**] 03:41AM BLOOD Type-ART Temp-36.9 O2 Flow-5 pO2-63*
pCO2-45 pH-7.42 calHCO3-30 Base XS-3
Brief Hospital Course:
74 y/o F, admitted to the [**Hospital1 18**] Intensive Care Unit on [**2120-12-29**]
intubated secondary to respiratory failure in the setting of
sepsis secondary to right hip infxn with hypotension requiring
dopamine for BP support. Hospital course complicated by
1. Respiratory failure: Etiology multifactorial [**3-11**] COPD, CHF,
fluid overload, in the setting sepsis. CXR sent w/ pt on
transfer [**12-29**] notable for bilateral infiltrates [**3-12**] way up both
lung fields. Concern for pulm edema and CHF on top of baseline
COPD. ABG at time of intubation revealed a respiratory acidosis.
The patient remained intubated until [**1-3**] when she was
successfully extubated. Post extubation the patient continued to
have intermitent episodes of tachypnea and hypoxia requiring
additional oxygen supplementation in the form of a face mask and
nasal cannula. These were thought to be related to fluid
overload and flash pulmonary edema related to increased
activity. She improved quickly after onset of these episodes
when she received treatment with IV lasix, albuterol nebs, and
morphine. At the time of discharge she was stable on 2 L NC but
had additional supplemental O2 requirements during exertion. She
was started on CPAP the night of [**1-8**] and was able to tolerate
this intermittently. She was not using this therapy on a regular
basis but it could potentially be useful in the future. She may
require a formal sleep study on an outpatient basis to determine
if she does indeed require CPAP.
2. CV: Patient with known CAD s/p CABG with reportedly patent
grafts by cath [**2119**]. During her hospital stay, patient initially
required blood pressure support with dopamine in the setting of
initial sepsis. She was quickly weaned off pressors and did not
require any additional BP support during her stay. A Swan-Ganz
catheter was placed soon after her initial arrival to the ICU in
order to differentiate the nature of her shock (cardiogenic vs.
septic). She had Cardiac output of 9 with low SVR of 460 showing
a picture more consistent with septic as opposed to cardiogenic
shock. The catheter was used for several days for intensive
monitoring to keep MAP >60, CVP >10, and PAWP >20. The Swan was
d/c'd on [**1-3**]. During her hospital course, several EKG's were
performed in the setting of the transient tachypnea, but no
changes were noted from baseline. Her cardiac enzymes were
cycled during this admission and she did not have a rise in her
troponin. At the time of discharge the patient continued to be
on a statin, ASA, B-blocker, and ACE for BP control. She may
require a cath to revaluate her cardiac function after discharge
from rehab. This decision will be differed to her PCP. [**Name10 (NameIs) **] the
time of discharge the pt still had evidence of fluid overload as
part of her CHF exacerbation and was benefiting from continued
diuresis with Lasix.
3. ARF: Shortly after admission to ICU, patient's creatine
peaked at 3. She was oliguric for several days, but slowly
recovered her renal fuction and urine output improved with down
trending creatine. At the time of discharge her creatine was 1.2
near her baseline. Renal was consulted during the [**Hospital 228**]
hospital stay for concern for AIN in setting of Ceftaz
administration but results from urine sediment were more
consistent with ATN (muddy brown casts seen in urine and patient
had relatively quick recovery). Patient was started on steroids
on admission in the setting of sepsis and continued for
suspected AIN, will be discharged on a slow oral taper of
prednisone.
4. Subclavian artery puncture during central line placement:
Occurred during night of admission. Hct remained stable. No
hemothorax developed. No further issues.
5. Anemia of Chronic Dz: On admission to ICU, patient had iron
studies which were abnormal but non-diagnostic in the setting
sepsis. The patient did require transfusions during her hospital
stay. She was transfused to keep HCT > 28 based on significant
cardiac history. Hemolysis work-up was performed during hospital
stay which was negative. Transfused a total of 4 units during
her hospital stay.
6. C Diff infxn: Patient was noted to be c diff antigen + at the
OSH. She completed a 14 day course of Flagyl while at [**Hospital1 18**] and
surveillence c diff after therapy was negative.
7. Coagulopathy: On transfer, patient had an elevated INR as she
was on coumadin previously s/p CVA. She was reversed and
coumadin was held during her admission here. Her PCP should
decided if this should be restarted.
8. Septic Arthritis of right hip: Aspirate done on [**12-28**] at
[**Location (un) 620**] showed rare growth of coag neg staph that was
pan-sensitive. After initial removal of hardware on [**12-5**] the
patient was started On vanco and levo and was planned to
continue these antibiotics until [**2121-1-19**] for supposed GNR and
definite GPC on gram stain in OR [**12-5**]. After transfer to [**Hospital1 18**],
ortho was consulted and a x-ray film of the patient's right hip
was obtained showing joint space widening and potential areas of
continued infection. She was taken to the OR on [**1-2**] for
debridement of right hip joint space where they found necrotic
hip/bone as well as some purulent material. Gram stain results
revealed 3+ polys, no organisms, no fungus, and the culture had
no growth. The patient also had a JP drain which remained in
place until the day of discharge and was placed in traction
transiently per ortho. She is to remain NWTB on the RLE and
follow-up with ortho 7 to 10 days after discharge from the
hospital for removal of staples. She was continued on both Vanc
and Levo for most of her hospital stay but Levo was d/c'd on
[**1-10**] after no evidence could be found supporting the GNR
cultured from the right hip aspirate. Patient will complete a
full 6 week course of the Vancomycin IV until [**2121-2-13**].
She will be given 1g IV daily, which is adjusted for her renal
function, but may require monitoring of levels if her renal
function worsens.
9. Rash: On admission to [**Hospital1 18**] patient had a diffuse, puritic
maculopapular rash thought to be related to Ceftaz
administration at the OSH. Her rash became less erythematous and
less puritic during the admission. After I&D by ortho on [**1-2**]
the patient received a one time dose of Zosyn and the rash
flared up again. Dermatology was consulted to evaluate the rash
when desquamation was noted on the patient's neck, back and
torso. They agreed with drug-reaction etiology and stated no
treatment was necessary, it would resolve over time and Vanc
should be continued to treat the Right hip infxn.
10. FEN: cardiac diet, low sodium diet.
Medications on Admission:
meds on transfer:
vancomycin by level
ceftazidime (stopped [**12-28**])
flagyl 500mg IV tid
dopamine 5mch
RISS
aspirin
lopressor (held)
lipitor 80mg po daily
captopril (held)
folate
Celexa 20mg po daily
multivitamin
Synthroid 0.125mg daily
levofloxacin 500mg po every other day
lansoprazole
iron sulfate 325mg po daily
albuterol, atrovent nebs
Discharge Medications:
1. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed.
13. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q4H (every 4 hours).
15. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
Inhalation Q4H (every 4 hours).
16. prednisone taper
20mg po daily x 2days, then 10mg po daily x 2days, then 5mg po
daily x2 days, then off
17. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at
bedtime) as needed.
18. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
20. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) gram
Intravenous once a day for 30 days: until [**2-13**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Primary:
1. right hip septic arthritis
2. congestive heart failure
3. chronic obstructive pulmonary disease
4. rash, resolving, thought to be due to ceftazidime or Zosyn
allergy
5. acute renal failure, resolved
6. Clostridium dificile positive (last stool culture [**12-31**]
negative)
Secondary:
1. hypertension
2. peripheral vascular disease status post abdominal aortic
aneurysm repair
3. hypothyroidism
4. anemia
5. gout
6. history of breast cancer status post mastectomy in [**2110**]
7. coronary artery disease status post coronary artery bypass
graft in [**2113**]
Discharge Condition:
stable, tolerating po, non-weight bearing on right lower
extremity
stable, tolerating po, not able to ambulate
Discharge Instructions:
Please call your primary care doctor with increasing shortness
of breath, chest pain, pain in the right hip, fevers, or any
other symptom that is concerning to you.
Followup Instructions:
Please follow up with your primary care doctor within the next
1-2 weeks. Please call [**Telephone/Fax (1) 59466**] to make an appointment.
|
[
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icd9cm
|
[
[
[]
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] |
[
"00.17",
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"96.6",
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] |
icd9pcs
|
[
[
[]
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] |
14275, 14420
|
5435, 12127
|
321, 362
|
15049, 15161
|
3437, 5412
|
15375, 15519
|
2400, 2418
|
12521, 14252
|
14441, 15028
|
12153, 12153
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15185, 15352
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2433, 3418
|
241, 283
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390, 1716
|
1738, 2307
|
2323, 2384
|
12171, 12498
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,178
| 138,402
|
52944
|
Discharge summary
|
report
|
Admission Date: [**2143-6-25**] Discharge Date: [**2143-7-3**]
Date of Birth: [**2088-4-5**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Bactrim
Attending:[**First Name3 (LF) 7141**]
Chief Complaint:
pelvic mass
Major Surgical or Invasive Procedure:
[**2143-6-25**] Radical hysterectomy, BSO, lower anterior resection of
rectum with anastomosis, infracolic omentectomy, collection of
ascites, and pelvic and paraaortic lymphadenectomy for presumed
ovarian CA
History of Present Illness:
55-year-old G2P0 with bilateral ovarian masses noted on CT
measuring 6-7 cm with densities within the anterior mesentery
and omentum (~2 cm). Pt reports mild symptoms of pelvic
pressure, pain and bloating for several months.
Past Medical History:
MEDICAL HISTORY: Mitral valve prolapse, reentry
supraventricular tachycardia (very infrequent epidsodes).
Stress echo two weeks ago was good per patient report.
SURGICAL HISTORY: Tonsillectomy, pilonidal cyst excision,
breast
biopsy which was benign.
GYN HISTORY: Normal Paps, normal mammograms. Last menstrual
period one week ago, normal. Benign breast lump.
OB HISTORY: SAB times two.
Social History:
Recently married, works as a social worker, does not smoke,
drinks one glass of wine each day.
Family History:
Father died at 68 years of age with pancreatic cancer.
Physical Exam:
GENERAL: Well nourished, well developed, in no acute distress.
HEENT: Anicteric sclerae.
NECK: No thyromegaly.
LYMPH NODES: Complete lymph node exam negative.
CARDIOVASCULAR: Regular rate and rhythm.
RESPIRATORY: Clear to auscultation.
BREASTS: No skin or soft tissue abnormalities noted.
ABDOMEN: Soft with tenderness in the lower abdomen. No rebound
or guarding.
EXTREMITIES: No edema.
GENITOURINARY: Complete rectovaginal exam significant for
adnexal masses appreciated by Dr. [**First Name (STitle) 1022**].
Pertinent Results:
preliminary pathology: Stage IIIC ovarian CA involving bilateral
ovaries, uterus, rectum, lymphnodes (peri-aortic & pelvic), and
omentum. Predominantly papillary serous with clear cell and
carcinosarcoma components.
[**2143-7-3**] 08:50AM BLOOD WBC-4.5 RBC-3.45* Hgb-10.7* Hct-31.3*
MCV-91 MCH-31.0 MCHC-34.1 RDW-12.5 Plt Ct-397
[**2143-6-26**] 03:22AM BLOOD CA125-251*
Brief Hospital Course:
Pt was admitted for debulking surgery for presumed ovarian CA -
please see op note for full details.
Her postoperative course was as follows by system.
1. SICU admission: pt was observed in the ICU on POD#0 to POD#1.
She was initially hypotensive with a MAP of approximately 60.
Hct was stable and there were no other signs of postoperative
bleeding. The hypotension was most likely secondary to
epidural. This resolved by POD#1.
2. GI: Given rectal anastomosis, pt was NPO until flatus. Her
diet was advanced slowly starting on POD#5. She was tolerating
pos well without nausea/vomiting at the time of discharge.
3. PAIN: Postoperative pain was initially controlled with
epidural/PCA as per acute pain service recommendation given
extensive surgery. She was transitioned to oral pain medication
when tolerating adequate pos.
4. ONC: ovarian CA. Pt was counseled on prognosis and aggresive
histology. She was presented at tumor board prior to discharge
and recommendations were discussed with her (see prior OMR note
for summary of recommendations). Pt was referred to Dr.
[**Last Name (STitle) **] (MedOnc) for chemotherapy.
Medications on Admission:
calcium
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Stage IIIC Ovarian CA
Discharge Condition:
stable, tolerating pos, ambulating, voiding, and good pain
control
Discharge Instructions:
Call your doctor [**First Name (Titles) **] [**Last Name (Titles) **] > 100.5, inability to keep down food,
severe nausea/vomiting, draining from your incision or anything
that concerns you. Do not drive for the next 2 wks, while
taking prescription pain meds or while having significant pain.
No exercise, intercourse or heavy lifting (>10 lbs) for 6 wks.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] B. GYN ONC PPS (SB) Where: GYN ONC PPS (SB)
Date/Time:[**2143-7-25**] 3:15
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] B. [**Telephone/Fax (1) 5777**] Call to schedule
appointment for staple removal for approximately 2 wks from date
of surgery.
Provider: [**Name10 (NameIs) **], [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 32192**] (MEDICAL ONCOLOGY). Call
to schedule appointment.
|
[
"997.4",
"197.5",
"196.5",
"427.89",
"198.89",
"198.82",
"276.5",
"183.0",
"196.6",
"197.6",
"196.2",
"458.29",
"560.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"68.6",
"40.3",
"48.63",
"65.61",
"83.21",
"54.25",
"54.4"
] |
icd9pcs
|
[
[
[]
]
] |
3788, 3794
|
2316, 3459
|
291, 501
|
3862, 3930
|
1919, 2293
|
4336, 4803
|
1304, 1360
|
3517, 3765
|
3815, 3841
|
3485, 3494
|
3954, 4313
|
1375, 1900
|
240, 253
|
529, 756
|
778, 1176
|
1192, 1288
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,676
| 169,586
|
49264
|
Discharge summary
|
report
|
Admission Date: [**2161-11-4**] Discharge Date: [**2161-11-16**]
Date of Birth: [**2087-12-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Nsaids / Lipitor / Codeine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
DOE/exertional angina
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x 3
History of Present Illness:
73 yo M with h/o CAD s/p LAD stenting now with worseing of
angina and DOE. Cath showed LM and 2 VD.
Past Medical History:
HLipid, HTN, CAD s/p stent '[**59**], Obstructive sleep apnea,
Rosacea, Septoplasty, R Knee Surgery, tonsills
Social History:
law professor [**First Name (Titles) **] [**Last Name (Titles) **]
denies etoh, tobacco
Family History:
2 sisters, 2 brothers and both parents with CAD, all > 55 yo.
Physical Exam:
Admission:
WDWN M in NAD HR 80 RR 18 BP 132/78
Lungs CTAB
Heart RRR, No M/R/G
Abdomen benign
Extrem warm, no edema
No varicosities
Discharge
VS 96.6 73SR 124/62 20 97% RA
Gen: NAD
Pulm: scattered rhonchi
CV: RRR, sternum stable, incision CDI
Abdm: soft, NT/+BS
Ext: Warm,trace edema bilat
Pertinent Results:
[**2161-11-4**] 03:10PM GLUCOSE-90 NA+-138 K+-4.0
[**2161-11-4**] 02:52PM UREA N-15 CREAT-0.9 CHLORIDE-109* TOTAL
CO2-25
[**2161-11-4**] 02:52PM WBC-10.5 RBC-3.45* HGB-10.0* HCT-28.4* MCV-82
MCH-28.9 MCHC-35.2* RDW-14.2
[**2161-11-4**] 02:52PM PLT COUNT-236
[**2161-11-4**] 02:52PM PT-14.4* PTT-34.5 INR(PT)-1.3*
[**2161-11-13**] 06:10AM BLOOD WBC-8.9 RBC-3.72* Hgb-10.4* Hct-31.5*
MCV-85 MCH-27.9 MCHC-32.9 RDW-14.4 Plt Ct-605*
[**2161-11-13**] 06:10AM BLOOD Plt Ct-605*
[**2161-11-13**] 06:10AM BLOOD PT-15.1* INR(PT)-1.3*
[**2161-11-13**] 06:10AM BLOOD Glucose-101 UreaN-25* Creat-1.0 Na-141
K-4.4 Cl-108 HCO3-20* AnGap-17
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Normal interatrial
septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Moderate symmetric LVH. Moderately dilated LV
cavity. Mild-moderate regional LV systolic dysfunction. Low
normal LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Mildly
dilated descending aorta. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. No AS. Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. 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.
REGIONAL LEFT VENTRICULAR WALL MOTION: PRE-BYPASS:
1. The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler.
2. There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity is moderately dilated. There is mild to
moderate regional left ventricular systolic dysfunction of the
inferior septal wall from the mid-papillary to apical area..
Overall left ventricular systolic function is low normal (LVEF
50-55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. The descending thoracic aorta is mildly dilated. There are
simple atheroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is no aortic valve
stenosis. There is mild (1+)Aoritc Regurgitation
6. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
POST-BYPASS:
1.Preserved biventricular function. LVEF 50-55%.
2. Mitral regurgitatioin is now mild to moderate without
structural defect of the valve
3. Aortic Regrugitation remains mild
4. Aortic contours remain intact
5. Remaining exam is unchanged
6. All findings discussed with surgeons at the time of the exam.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Brief Hospital Course:
He was taken to the operating room on [**11-4**] where he underwent a
CABG x 3. He was transferred to the ICU in critical but stable
condition. He was kept intubated overnight due to a difficult
intubation and was extubated on POD #1. He was transferred to
the floor on POD #2. His pacing wires were removed, he was
started on diuresis, and progressed slowly from a PT standpoint
due to depression & anxiety. He had some tachypnea w/wheezes
and sputum production. He was empirically started on
ceftriaxone for presumed pneumonia. His x-ray revealed right
upper lobe opacity, but despite 3 attempts, it was not posiblt
to abtain an appropriate sputum specimen for culture. He
improved clinically on the Ceftriaxone, so he will be discharged
on PO Bactrim for another week of treatment for presumed
pneumonia. On [**11-11**], the patient was seen by the psychiatry
service at the request of the pateint's wife. They recommended
Zoloft, with low dose Ativan prn. A TSH was sent and was 1.1.
He has remained hemodynamically stable, and is ready for
discharge home with visiting nurses on POD12.
Medications on Admission:
Coreg 6.25', ASA 325', Plavix 75', Diovan 320', Zocor 10', NTG
PRN, Flomax 0.4mg
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
5. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: Two (2)
puffs Inhalation Q4H (every 4 hours) as needed for wheezes.
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed.
Disp:*50 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO BID (2
times a day).
Disp:*150 Tablet(s)* Refills:*2*
8. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*0*
9. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a
day for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home with Service
Facility:
tba
Discharge Diagnosis:
Hyperlipidemia
Hypertension
CAD s/p LAD stent (DES) [**2159**]
Obstructive Sleep Apnea on CPAP
GERD
Rosacea
Septoplasty
R knee surgery
Tonsilectomy
Discharge Condition:
good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain. Please contact surgeon at ([**Telephone/Fax (1) 4044**] with any wound issues.
2) Report any fever greater then 100.5
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) No lifting greater then 10 pounds for 10 weeks from the date
of surgery.
5) No driving for 1 month or while taking narcotics.
6) CPAP at night
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 8645**]
Date/Time:[**2162-1-19**] 4:40
Dr. [**Last Name (STitle) 131**] 2 weeks
Dr. [**Known lastname **] 2 weeks
Completed by:[**2161-11-16**]
|
[
"413.9",
"327.23",
"300.4",
"401.9",
"V45.82",
"486",
"272.4",
"530.81",
"425.4",
"414.01",
"695.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.12",
"88.72",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
6707, 6741
|
4365, 5464
|
317, 352
|
6933, 6940
|
1130, 3029
|
7420, 7683
|
736, 800
|
5595, 6684
|
6762, 6912
|
5490, 5572
|
6964, 7397
|
3069, 4342
|
815, 1111
|
256, 279
|
380, 481
|
503, 614
|
630, 720
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,488
| 153,750
|
13022
|
Discharge summary
|
report
|
Admission Date: [**2105-11-22**] Discharge Date: [**2105-11-25**]
Service: CCU
CHIEF COMPLAINT: Inferior ST-elevation myocardial
infarction.
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
male with no prior cardiac history who described atypical
neck and arm pain over the preceding two to three months
prior to admission while playing golf.
He had been told by his orthopaedic surgeon that he had
arthritis; however, the character of the pain changed over
the past two weeks to include substernal pressure and pain
with exertion which was relieved with rest. He presented to
[**Hospital3 **] twice over the past two weeks. He had
electrocardiograms done, enzymes, and chest x-rays and told
that his pain was likely not cardiac. His primary care
physician thought that his pain was musculoskeletal and
prescribed ibuprofen.
On the night prior to admission, at around 11 p.m., the
patient experienced sudden [**9-1**] to [**10-1**] substernal chest
pain radiating to the arms and neck. Not associated with any
nausea, vomiting, or diaphoresis. He went to [**Hospital3 38285**] where electrocardiogram showed initially 1-mm ST
elevations in II, II, and aVF and ST depressions in V1
through V3. He was given sublingual nitroglycerin times
three, morphine, and given 10 units of Retavase times two (30
minutes apart). Subsequent electrocardiograms showed
worsening ST elevations up to 2 mm to 3 mm inferiorly with
reciprocal 3-mm to 4-mm ST depressions in V1 through V4. The
patient was started in a heparin drip and was pain free at
the time of transfer to [**Hospital1 69**].
PAST MEDICAL HISTORY:
1. Hypertension.
2. Anxiety/panic attacks.
3. Hiatal hernia.
4. Irritable bowel syndrome.
5. Gastroesophageal reflux disease.
6. Glaucoma.
ALLERGIES: TETRACYCLINE (causes swelling of the tongue) and
TIMOPTIC and other BETA BLOCKER MEDICATIONS (which have led
to respiratory difficulty).
MEDICATIONS ON ADMISSION:
1. Ibuprofen p.o. as needed.
2. Bentyl.
3. Librium 10 mg p.o. q.d. as needed.
4. Rescula eyedrops one drop both eyes b.i.d.
5. Cardizem-CD 240 mg p.o. q.d.
6. Zantac 150 mg p.o. b.i.d.
7. Aspirin 81 mg p.o. q.d.
8. Glucosamine chondroitin.
9. Multivitamin.
MEDICATIONS ON TRANSFER: Additional medications at the time
of transfer included nitroglycerin drip and a heparin drip.
SOCIAL HISTORY: The patient has about a 30-pack-year smoking
history, though he quit in [**2062**]. Currently, he smokes
approximately two cigars per day (which he quit this Winter).
he drinks alcohol only occasionally. He used to work as a
motion picture projectionist. He is now retired and works at
a golf course.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed he was a very pleasant, in no acute
distress. He had no jugular venous distention. His lung
was clear to auscultation bilaterally. His heart examination
had a normal first heart sound and second heart sound without
murmurs, gallops, or rubs. He had no peripheral edema and 2+
dorsalis pedis pulses.
RADIOLOGY/IMAGING: Electrocardiogram on admission to the
Coronary Care Unit showed a sinus rhythm at 90 beats per
minute with a leftward axis. Normal intervals and upward
cove ST segments inferiorly with resolution of the ST
elevations and only slight residual ST depressions in V3 and
V4.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
admission were remarkable for a creatine kinase of 2768 with
a MB fraction of 158. Laboratories from the outside hospital
showed a MB of 7.9 and a troponin of 5.1. Complete blood
count and Chemistry-10 were all within normal limits.
Coagulations revealed PTT was 100.8.
HOSPITAL COURSE:
1. CARDIOVASCULAR SYSTEM: (a) Coronary artery disease: As
the patient was pain free on admission to the Coronary Care
Unit, there was no indication for emergent catheterization.
He was continued on aspirin, heparin drip, and a
nitroglycerin drip.
Because of the patient's adverse reaction in the past to beta
blockers, there was concern in initiating this medication.
The patient was initially given a test dose of esmolol at 50
mcg/kg per minute to control his heart rate which was
elevated in the 90s. The patient tolerated the esmolol very
well, and the following morning was changed to oral Lopressor
at 12.5 mg b.i.d.
On the morning of admission, the patient was also loaded on
Plavix at 300 mg with the dose then changed to 75 mg p.o.
q.d. thereafter. He was also started on Integrilin that
evening in preparation for a catheterization the next day.
His creatine kinases were cycled and showed that his peak
creatine kinase was 2768; the value on admission.
On [**2105-11-23**], the patient was taken to the cardiac
catheterization laboratory. Coronary angiography revealed a
right-dominant system. There was a 90% proximal left
circumflex stenosis, 70% medial left circumflex stenosis, and
70% first obtuse marginal stenosis. There was also a long
80% medial right coronary artery lesion. The proximal
circumflex lesion was stented times two; the second stent
being placed distally because of dissection. The distal
circumflex stent was stented as well as was the medial right
coronary artery stenosis.
The patient tolerated the procedure well, and after the
catheterization laboratory went to the general medicine
floor. His beta blocker had been titrated up to a dose as
high as 50 mg p.o. b.i.d., at which time the patient began to
develop some respiratory complaints including shortness of
breath, the feeling of tightness in his chest, and a cough.
His Lopressor was held initially, and the beta blocking
effects were reversed with an albuterol inhaler; to which the
patient responded to very well; however, his cough persisted.
Due to the possibility that his cough could have been induced
by captopril which the patient had been started on, captopril
was stopped, and he was changed to an angiotensin receptor
blocker (Cozaar) on which he was to be discharged.
(b) Pump: The patient was started initially on captopril
and titrated as his blood pressure allowed. Because his
blood pressures remained in the 80s to 90s systolic, he was
continued on only 6.25 mg p.o. t.i.d.
As stated above, because of the cough, the patient's
captopril was stopped and he was changed to Cozaar on the day
of discharge.
(c) Rhythm: As the patient did not tolerate a beta blocker,
it was discontinued. The patient was to be restarted on his
outpatient dose of Cardizem 240 mg p.o. q.d. He was in
sinus rhythm throughout his admission.
2. PULMONARY SYSTEM: On hospital day three, the patient
developed respiratory complaints thought to be due to his
beta blocker medications (as stated above). The beta blocker
was reversed with an albuterol inhaler, to which he responded
to very well, and his symptoms resolved short of a mild dry
cough; felt likely to be due to the captopril.
3. ANXIETY: The patient was treated with librium as needed.
DISCHARGE STATUS: The patient was discharged to home.
Following a Physical Therapy evaluation, he was deemed safe
to return home.
MEDICATIONS ON DISCHARGE:
1. Cozaar 25 mg p.o. q.d.
2. Aspirin 325 mg p.o. q.d.
3. Plavix 75 mg p.o. q.d.
4. Cardizem-CD 240 mg p.o. q.d.
5. Rescula eyedrops one drop both eyes b.i.d.
6. Zantac 150 mg p.o. b.i.d.
7. Librium 10 mg p.o. q.d. as needed (for anxiety).
8. Ibuprofen p.o. as needed.
9. Bentyl p.o. as needed
10. Glucosamine chondroitin (as taken prior to admission).
DISCHARGE DIAGNOSES: Acute myocardial infarction.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow
up with his primary care physician (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) in one
to two weeks following discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**]
Dictated By:[**Name8 (MD) 3491**]
MEDQUIST36
D: [**2105-11-25**] 12:06
T: [**2105-11-27**] 10:02
JOB#: [**Job Number 39874**]
|
[
"401.9",
"530.81",
"553.3",
"414.01",
"300.00",
"410.41",
"365.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"99.20",
"36.06",
"37.22",
"36.05"
] |
icd9pcs
|
[
[
[]
]
] |
7520, 7550
|
7127, 7498
|
1952, 2219
|
3698, 7100
|
7584, 8021
|
107, 153
|
182, 1608
|
2245, 2341
|
1630, 1926
|
2358, 3680
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,952
| 187,920
|
27998
|
Discharge summary
|
report
|
Admission Date: [**2147-9-11**] Discharge Date: [**2147-9-22**]
Date of Birth: [**2081-1-14**] Sex: F
Service: UROLOGY
Allergies:
Compazine / Penicillins
Attending:[**First Name3 (LF) 6440**]
Chief Complaint:
Bladder cancer.
Major Surgical or Invasive Procedure:
Anterior pelvic exenteration and right simple nephrectomy (1.
Cystectomy. 2. Ileal conduit. 3. Right nephrectomy.)
History of Present Illness:
The patient is a 66-year-old
female with known bladder cancer post chemotherapy who
presents today for cystectomy and ileal loop urinary
diversion. In addition, she has a known atrophic right
kidney, which she has elected to have removed rather then to
have the nonfunctional kidney plugged into the urinary
diversion. After all questions were answered preoperatively
and appropriate consent was obtained, the patient was
transferred to the operating suite.
Past Medical History:
muscular invasice 5transitional cell cancer of bladder, s/p CTX
carboplatium and [**Company **] last cycle [**2147-6-14**]
leukopenawith associated thrombocytopenia secondary to CTX
anxiety/depression
former smoker, d/c [**2138**], former [**3-17**] ppd
coronary artery disease s/p angioplasty w stenting
drug allergy : compazine: hives
biliary dyskensia by HIDA scan [**6-17**]
Social History:
widowed
lives alone in [**Hospital3 4634**]
former smoker d/c [**2138**] [**3-17**] ppd
denies ETOH use
Family History:
+ diabetes
Pertinent Results:
[**2147-9-22**] 04:47AM BLOOD WBC-6.9 RBC-3.28* Hgb-9.9* Hct-29.8*
MCV-91 MCH-30.2 MCHC-33.2 RDW-15.0 Plt Ct-184
[**2147-9-21**] 05:47AM BLOOD WBC-7.3 RBC-3.58* Hgb-10.6* Hct-31.7*
MCV-89 MCH-29.6 MCHC-33.3 RDW-15.3 Plt Ct-224
[**2147-9-13**] 03:42AM BLOOD Neuts-84.4* Lymphs-8.7* Monos-6.2 Eos-0.6
Baso-0.1
[**2147-9-22**] 04:47AM BLOOD Plt Ct-184
[**2147-9-22**] 04:47AM BLOOD Glucose-91 UreaN-9 Creat-1.0 Na-137 K-4.0
Cl-104 HCO3-26 AnGap-11
[**2147-9-20**] 04:10AM BLOOD ALT-15 AST-20 AlkPhos-135* TotBili-1.6*
[**2147-9-19**] 11:59AM BLOOD ALT-14 AST-18 LD(LDH)-210 AlkPhos-130*
Amylase-57 TotBili-1.5
[**2147-9-19**] 11:59AM BLOOD Lipase-82*
[**2147-9-12**] 02:04PM BLOOD CK-MB-11* MB Indx-2.1 cTropnT-<0.01
[**2147-9-20**] 04:10AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.7
[**2147-9-17**] 01:07PM BLOOD Triglyc-267*
[**2147-9-12**] 12:39AM BLOOD Type-ART pO2-179* pCO2-37 pH-7.37
calTCO2-22 Base XS--3
[**2147-9-12**] 12:39AM BLOOD Lactate-3.4*
[**2147-9-12**] 12:39AM BLOOD O2 Sat-98
[**2147-9-12**] 12:39AM BLOOD freeCa-1.33*
[**2147-9-12**] 01:54AM URINE Color-LtAmb Appear-SlHazy Sp [**Last Name (un) **]-1.015
[**2147-9-12**] 01:54AM URINE Blood-LGE Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2147-9-12**] 01:54AM URINE RBC-726* WBC-3 Bacteri-NONE Yeast-NONE
Epi-<1
.
.
[**2147-9-18**] 6:04 am STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2147-9-18**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2147-9-18**]):
REPORTED BY PHONE TO L. CALL [**2147-9-18**] @13:03.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
.
.
[**2147-9-12**] 1:54 am BLOOD CULTURE 2 OF 2.
**FINAL REPORT [**2147-9-18**]**
AEROBIC BOTTLE (Final [**2147-9-18**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2147-9-18**]): NO GROWTH.
.
.
[**2147-9-12**] 1:54 am URINE Site: CATHETER
**FINAL REPORT [**2147-9-13**]**
URINE CULTURE (Final [**2147-9-13**]): NO GROWTH.
.
.
Brief Hospital Course:
Ms [**Known lastname 18252**] was admitted under the Urology service for her
procedure. She was prepared and consented as per standard.
.
She was taken to the OR. During the surgery, there were some
episodes of hypotension. She received neosynephrine
intermittently during the case. Midway during the case, during
the vaginal ressection, she was noted to have 1.2 L blood loss.
She received 3 units of PRBCs. Immediately post transfusion her
hct was noted to be 43. She had no cardiovascular events or
other significant events. In the recovery room, her blood
pressure was slightly low and this was addressed. She was
transfered to the ICU soon after. In the ICU, the Pt had a hard
to measure and read BP; a-line attempted in radial, brachial,
and femoral positions. On transfer to the [**Hospital Unit Name 153**], her noninvasive
BP readings were 170-190 mmhg, which was confired after
placement of an a-line by the surgical service. She was on an
epidural dilaudid infusion during the OR, and this was stopped
post op given her labile BP. She was give 2 L LR on transfer to
the [**Hospital Unit Name 153**]. For pain control, she was given a totoal of 125 mcg
fentanyl over 1.5 hrs while she was being settled.
.
Initally in the [**Hospital Unit Name 153**] she was hypertensive, with the working
diagnosis related to pain and anxiety. In addition, she was on
lopressor and clonidine outpt and there was some thought she
might be having a tachyphylaxisis response. She had a few beats
on NSVT, one run on [**10-22**] beats with BP in the 80's. She denied
any chest pain or pressure at that time. LR 250 cc given with
improvment in her BP. K was normal but Mg noted to be 1.4, which
was repleted. IV lopressor 2.5 mg given for periop protection
and for the NSVT. Her EKG was unchanged from her preop. Cardiac
enzymes were sent.
.
A CVL was placed in the left subclavian. Initially, the line was
too deep; this was pulled back and another CXR confirmed the
position.
.
Repeat Hcts showed 40 and then 35.3. With transient low BP's to
the mid 70's and high 80's there was concern for bleeding. CVP
was measured at 0. Pt given IVF, another hct was sent. Surgery
notified for concern of bleeding. Two unit of PRBCs were given
for hct 32 and BP in the low 80's.
.
Ms [**Known lastname 18252**] continued to improve in the ICU and was closely
monitored. The following morning, she was given another 2 units
of packed red blood cells. Her hematocrit then went up to 33.5.
From this point on, she was stablized and her vitals continued
to improve. However, there were some blood pressure
difficulties, as she was initially hypotensive, but soon after,
became hypertensive.
.
In the following few days, Ms [**Known lastname 18252**] made a gradual recovery.
She was able to be sent to the floor, where she was put back on
her home medications. Despite her antihypertensive home
medications, her overnight blood pressure was not
well-controlled. She was given IV hydralazine for a systolic BP
greater than 160 overnight.
.
On the floor, Ms [**Known lastname 18252**] was able to pass gas and hence advance
her diet. However, she had a great deal of nausea, vomiting and
was generally not feeling well. Her vomit did not contain any
blood. Her abdomen was slightly distended, and hence, it was
decided to obtain a C. Diff stool culture. This came back as
positive, and hence, Ms [**Known lastname 18252**] was started on a 14-day course of
Flagyl, which she will continue at home for another 9 days after
discharge. Initially, her bowel movements remained loose, and
frequent (4-5 times per day) and her nausea and vomiting
persisted. It was suspected that she was vomiting the
antibiotic, but before switching to an oral antibiotic, she
slowly began to tolerate her oral medication. SHe then slowly
began to increase her oral food intake, starting with soup and
eventually progressing to toast and then a full dinner.
.
Ms [**Known lastname 18252**] was discharged with her staples removed and in a
stable condition.
Medications on Admission:
isosorbide mononitrate 30 mg qd, lopressor 100 mg [**Hospital1 **], protonix
40 mg qd, avapro 300 mg qHS, catapres TTS 0.1 qweek, senna qHS,
tylenol, percocet prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain, headache, fever.
Disp:*100 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*20 Capsule(s)* Refills:*2*
3. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 9 days.
Disp:*27 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
6. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
7. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSUN (every Sunday).
8. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
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. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1)
Intravenous Q8H (every 8 hours) as needed.
11. Metoclopramide 5 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours) as needed for nausea.
12. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours) as needed for SBP > 160.
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Bladder cancer.
Discharge Condition:
Stable.
Discharge Instructions:
You are being prescribed a narcotic pain medication. DO NOT
DRIVE OR OPERATE HEAVY MACHINERY WHILE TAKING THIS MEDICATION.
IT [**Month (only) **] MAKE YOU DROWSY.
Contact a physician for fever >100.5, bleeding or increasing
redness from incisions, difficulty swallowing or breathing,
headache, nausea or vomiting, double or blurry vision, or any
other concerns.
Please continue all home medications and those given to you by
your surgeon. Please also visit your primary care physician in
order to follow up on your blood pressure levels - in hospital,
you were given all of your home medications, but your BP
overnight was elevated and hence, we reccomend for you to visit
your primary doctor in regards to this.
Please complete your ENTIRE course of antibiotic (remaining 9
days of a 14 day course). You have been given the exact number
of tablets left in order to complete this course.
Followup Instructions:
Please follow-up with your surgeon, Dr. [**Last Name (STitle) 365**] by calling to
arrange a follow-up appointment: ([**Telephone/Fax (1) 6441**].
Completed by:[**2147-9-22**]
|
[
"753.0",
"427.1",
"008.45",
"413.9",
"585.9",
"414.01",
"E878.6",
"V45.82",
"998.11",
"188.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.51",
"99.04",
"68.8",
"38.93",
"56.51"
] |
icd9pcs
|
[
[
[]
]
] |
9368, 9451
|
3771, 7782
|
299, 418
|
9510, 9519
|
1478, 3748
|
10458, 10551
|
1447, 1459
|
7995, 9345
|
9472, 9489
|
7808, 7972
|
9543, 10435
|
244, 261
|
10574, 10635
|
446, 906
|
928, 1309
|
1325, 1431
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,415
| 150,871
|
50482
|
Discharge summary
|
report
|
Admission Date: [**2176-11-19**] Discharge Date: [**2176-12-3**]
Date of Birth: [**2121-12-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
palpitations, cough
Major Surgical or Invasive Procedure:
[**2176-11-25**] MVR ( 33mm St. [**Male First Name (un) 923**] porcine)/ Maze/ligation LAA
History of Present Illness:
This 54 year old white male is status post instrumentation of a
urethral stricture in [**2176-7-18**] when he underwent
cystoscopy and urethral dilatation for hematuria. Since that
time he has had some increased lethargy and generalized
weakness, weight loss, night sweats. He is also complaining of
more recent onset of a cough productive of clear, brown sputum
and chills for the last 1 week. These symptoms have also been
associated with chest congestion. He denies sick contacts,
recent travel, sore throat, myalgias, or rhinorrhea. As part of
the workup, he had elevated ESR and CRP, and blood cultures
drawn, which today resulted in positive results in both aerobic
bottle and anaerobic bottle for enterococcus, no sensitivities
yet available. He was referred to the ED for admission and
further workup of suspected endocarditis. He denies any history
of heart disease including valvular abnormalities.
.
In the ED a central line was placed and Levophed was started due
to systolic BP's around 90. He was noted to be febrile to 101.1
which came down to 98.8 without intervention. Bedside echo did
not show pericardial effusion and valves were not well
visualized.
Past Medical History:
Sleep apnea
Urethral stricture
benign prostatic hyperplasia
IMPINGEMENT SYNDROME - SHOULDER, rt
ATRIAL FIBRILLATION
ARTHRALGIA - KNEE, rt
SEIZURE DISORDER
Mitral regurgitation
Social History:
Lives with:wife
Contact:[**Name (NI) **] (wife) Phone #[**Telephone/Fax (1) 105157**]
Occupation:
Cigarettes: Smoked no [x] yes []
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**12-24**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
Hypertension: MGM. NB father died of esophageal cancer, mother
of leukemia
Premature coronary artery disease- non contributory
Physical Exam:
Vitals: T:99.1 BP: 100/85 P: 100 R: 18 O2: 100%, nonrebreather
100%
patient wt is 174lbs and height is 6ft 2in
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL , no
cervical adenopathy
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, 4th intercostal
murmur [**1-21**],nonradiating ,no rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, insp.
rales at the bases and mid lung fields b/l,no ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Rubbery subcentimeter lymph node in the left groin area,
movable, nontender
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Skin- no rashes or nail lesions
Pertinent Results:
[**2176-9-1**]
URINE CULTURE: Enterococcus faecalis >100,000 cfu/mL
Antibiotic
Atrius Blood cx grew enterococcus
ECHO [**2175-11-21**]: Mild prolapse of the posterior leaflet with
valvular vegetation and moderate-severe mitral regurgitation. No
abscess visualized. Hyperdynamic left ventricular systolic
function. .
EKG: AF/flutter 104 (old), upsloping sub-mm [****]
TEE [**2176-11-25**]:
PRE-BYPASS:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage.
No spontaneous echo contrast is seen in the body of the right
atrium.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is mildly depressed (LVEF= 45 %).
The diameters of aorta at the sinus, ascending, arch, and
descending levels are normal.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. There is
an echodensity on the noncoronary cusp seen in both short & long
axes is most consistent with the appearance of a fibroelastoma
although an endocarditic related mass can not be ruled out.
The mitral valve leaflets are myxomatous. There is bileaflet
flail versus destruction from endocarditis. The anterior leaflet
may be torn. Torn mitral chordae/masses are present at both
leaflet tips. An eccentric, jet of Severe (4+) mitral
regurgitation is seen (Coanda effect).
There is a left pleural effusion
There is no pericardial effusion.
POSTBYPASS:
The patient is inituially AV paced and then atrially paced and
is on a norepinephrine infusion. There is a well seated
bioprosthetic valve in the mitral position. The leaflets appear
to be moving normally. There is trace valvular MR and can not
completely rule out a jet of trace perivalvular MR. The maximum
gradient through the valve is 12mmHg with a mean of 4 mmHg at a
cardiac output in the 7.5 liter/minute range. The remaining
valves are unchanged. The RV function is unchanged. The LV
function is improved with an estimated EF of 55%. The septum is
dyssynchronous consistent with bundle branch block seen on ECG.
The aorta remains intact after decannulation.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2176-11-25**] 14:43
[**2176-11-25**] 10:00 am TISSUE POSTERIOR LEAFLET.
**FINAL REPORT [**2176-11-30**]**
GRAM STAIN (Final [**2176-11-25**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2176-11-30**]):
ENTEROCOCCUS SP.. RARE GROWTH.
Reported to and read back by DR.[**Last Name (STitle) **],P [**2176-11-28**] AT
1300.
SENSITIVITIES PERFORMED ON CULTURE # 338-2732L [**2176-11-19**].
ENTEROCOCCUS SP..
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS. SECOND MORPHOLOGY.
SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 105158**],
[**2176-11-25**].
ANAEROBIC CULTURE (Final [**2176-11-29**]): NO ANAEROBES ISOLATE
[**2176-12-2**] 05:56AM BLOOD WBC-8.9 RBC-3.24* Hgb-9.9* Hct-29.8*
MCV-92 MCH-30.5 MCHC-33.3 RDW-13.9 Plt Ct-422
[**2176-11-19**] 02:45PM BLOOD WBC-16.4* RBC-3.57* Hgb-11.0* Hct-32.9*
MCV-92 MCH-30.7 MCHC-33.3 RDW-13.5 Plt Ct-366
[**2176-12-3**] 05:17AM BLOOD PT-15.1* INR(PT)-1.4*
[**2176-12-2**] 05:56AM BLOOD PT-13.3* INR(PT)-1.2*
[**2176-12-1**] 08:10PM BLOOD PT-12.3 INR(PT)-1.1
[**2176-11-30**] 05:51AM BLOOD PT-12.4 INR(PT)-1.1
[**2176-11-29**] 03:23AM BLOOD PT-11.8 PTT-26.3 INR(PT)-1.1
[**2176-12-2**] 05:56AM BLOOD UreaN-13 Creat-0.9 Na-136 K-4.5 Cl-99
[**2176-11-19**] 02:45PM BLOOD Glucose-98 UreaN-14 Creat-1.1 Na-134
K-4.6 Cl-99 HCO3-24 AnGap-16
Brief Hospital Course:
He was referred to Cardiac Surgery and on [**11-25**]. He weaned from
bypass on Levophed and Propofol and was transferred to the CVICU
in stable condition. He was extubated later that day, but
remained pressor dependent for several days. He was transferred
to the floor on POD# 4 after weaning from pressor support.
His activity level was increased and he was gently diuresed
toward his preop weight. OR tissue cultures grew enterococcus as
preop and Infectious disease recommended a 6 week course of IV
gentamicin and ampicillin. Beta blockade and coumadin wre begun.
A PICC line was placed. Chest tubes and pacing wires removed
per protocol.
He continued to make good progress and was cleared for discharge
to [**Hospital 105159**] rehab in [**Hospital1 **] on [**2176-12-3**].
Arrangements were made for ID followup after discharge as welll
as with surgery and his cardiologist.
Medications on Admission:
Atenolol 25 mg Oral Tablet [**11-18**] tab daily
Lamotrigine (LAMICTAL) 100 mg Oral Tablet TAKE 1 TABLET TWICE A
DAY
Aspirin 81 mg Oral Tablet 1 tab daily
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
5. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
7. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
8. ampicillin sodium 2 gram Recon Soln Sig: Two (2) gms
Intravenous every four (4) hours for 6 weeks: 6 week course
through [**1-6**].
9. gentamicin sulfate (PF) 100 mg/10 mL Solution Sig: One
[**Age over 90 **]y (120) mg Intravenous every twelve (12) hours for
6 weeks: 6 week course through [**1-6**]; .
10. 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.
11. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
12. warfarin 2.5 mg Tablet Sig: as directed Tablet PO once a
day: goal INR 2-2.5.
13. Outpatient Lab Work
[**Month/Year (2) **] (beginning [**12-9**]) CBC,CMP,gentamicin peak/trough levels.
Fax results to ID at [**Telephone/Fax (1) **]
Discharge Disposition:
Extended Care
Facility:
tbd
Discharge Diagnosis:
mitral endocarditis
mitral regurgitation
s/p mitral valve replacement,Maze and ligation of left atrial
appendage
Sleep apnea
Urethral stricture
benign prostatic hyperplasia
Impingement syndrome - right shoulder
Atrial fibrillation
Seizure disorder
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema: none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) on [**2176-12-30**] at 1:15PM , [**Hospital Ward Name **]
2A
Cardiologist: Dr. [**Last Name (STitle) 19**] (her office will call you with appt)
ID followup:
Opat attending visit: [**Last Name (LF) **],[**First Name3 (LF) **], [**2176-12-10**] 10:00a
Fellow visit: [**2176-12-25**] 11:00a ID,[**Doctor Last Name 8021**],[**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] gentamicin peak and trough levels, CMP,CBC,and FAX
results to [**Telephone/Fax (1) **]
Please call to schedule appointments with your:
Primary Care: Dr.[**Last Name (STitle) **] in [**2-20**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication atrial fibrillation
Goal INR 2-2.5
First draw day after discharge to rehab
*** please arrange for coumadin f/u prior to discharge from
rehab
Completed by:[**2176-12-3**]
|
[
"600.01",
"599.0",
"428.31",
"726.2",
"427.31",
"327.23",
"428.0",
"424.0",
"998.59",
"598.8",
"995.92",
"427.32",
"518.4",
"345.90",
"041.04",
"E878.8",
"458.29",
"783.21",
"785.52",
"038.0",
"421.0",
"715.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.23",
"39.61",
"37.22",
"37.36",
"38.93",
"88.56",
"37.33",
"88.72",
"37.27"
] |
icd9pcs
|
[
[
[]
]
] |
9641, 9671
|
7056, 7947
|
331, 424
|
9963, 10141
|
3203, 7033
|
10982, 12072
|
2116, 2245
|
8153, 9618
|
9692, 9942
|
7973, 8130
|
10165, 10959
|
2260, 3184
|
272, 293
|
452, 1628
|
1650, 1828
|
1844, 2099
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,342
| 104,863
|
31879
|
Discharge summary
|
report
|
Admission Date: [**2148-9-19**] Discharge Date: [**2148-9-25**]
Date of Birth: [**2089-3-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
angina
Major Surgical or Invasive Procedure:
[**2148-9-19**] Coronary Artery Bypass graft x1 off pump (left internal
mammary artery > left anterior descending)
History of Present Illness:
59 year old male with exertional angina for 1 year. Angina
continued to increase and occurring at rest occassionally.
Underwent cardiac work up that revealed coronary artery disease.
Past Medical History:
Coronary artery disease
Hypertension
Left ventricular hypertrophy
Elevated cholesterol
Social History:
Works as housekeeper
Lives with wife
[**Name (NI) 1139**] quit 17 years ago
ETOH social
Family History:
no premature cardiovascular disease
Physical Exam:
General WDWM in NAD
Skin, HEENT unremarkable
Neck full rom, supple
Chest CTA bilat
Heart RRR
Abd soft, NT, ND +BS
Ext warm well perfused no edema, pulses palpable
Neuro grossly intact
Pertinent Results:
[**2148-9-23**] 07:20AM BLOOD WBC-7.9 RBC-3.46* Hgb-11.2* Hct-33.2*
MCV-96 MCH-32.4* MCHC-33.8 RDW-12.2 Plt Ct-302
[**2148-9-19**] 09:48AM BLOOD WBC-8.4 RBC-3.50* Hgb-11.5*# Hct-33.1*
MCV-94 MCH-32.8* MCHC-34.8 RDW-12.1 Plt Ct-193
[**2148-9-24**] 06:40AM BLOOD PT-12.4 INR(PT)-1.1
[**2148-9-23**] 07:20AM BLOOD Plt Ct-302
[**2148-9-19**] 09:48AM BLOOD Plt Ct-193
[**2148-9-19**] 09:48AM BLOOD PT-15.7* PTT-33.8 INR(PT)-1.4*
[**2148-9-19**] 09:48AM BLOOD Fibrino-251
[**2148-9-23**] 07:20AM BLOOD Glucose-118* UreaN-14 Creat-0.9 Na-141
K-3.6 Cl-103 HCO3-27 AnGap-15
[**2148-9-19**] 10:39AM BLOOD UreaN-16 Creat-0.7 Cl-109* HCO3-24
[**2148-9-23**] 07:20AM BLOOD Amylase-93
[**2148-9-23**] 07:20AM BLOOD Lipase-44
[**2148-9-23**] 07:20AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.3
RADIOLOGY Final Report
CHEST (PA & LAT) [**2148-9-22**] 7:58 AM
CHEST (PA & LAT)
Reason: interval change
[**Hospital 93**] MEDICAL CONDITION:
59 year old man with s/p POD 3 OP CABG
REASON FOR THIS EXAMINATION:
interval change
EXAMINATION: PA and lateral chest.
INDICATION: Status post CABG.
Single AP view of the chest is obtained on [**2148-9-22**] at 0830 hours
and compared with the prior radiograph of [**2148-9-20**].
The patient is status post CABG. Again is seen increased
retrocardiac density on the left side consistent with airspace
disease/atelectasis at the left base. Linear atelectasis is seen
in the right base. There appears to be a small left pleural
effusion. Allowing for technical differences, there has not
being any marked change since the prior examination.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Approved: SUN [**2148-9-22**] 10:53 AM
Cardiology Report ECG Study Date of [**2148-9-19**] 12:25:42 PM
Sinus bradycardia. Possible inferoposterior myocardial
infarction. Compared
to previous tracing of [**2148-9-17**] no definite change.
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
52 192 98 468/454 21 -8 43
Cardiology Report ECHO Study Date of [**2148-9-19**]
PATIENT/TEST INFORMATION:
Indication: Intraoperative TEE for CABG procedure
Height: (in) 69
Weight (lb): 194
BSA (m2): 2.04 m2
BP (mm Hg): 123/67
HR (bpm): 72
Status: Inpatient
Date/Time: [**2148-9-19**] at 09:47
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW2-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 55% (nl >=55%)
Aorta - Ascending: *3.9 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.4 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 7 mm Hg
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.4 m/sec
Mitral Valve - E/A Ratio: 1.75
INTERPRETATION:
Findings:
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA
and extending into the RV. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal regional LV systolic function. Overall
normal LVEF
(>55%). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated ascending aorta. Normal descending aorta
diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
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.
Conclusions:
1. No atrial septal defect is seen by 2D or color Doppler.
2.Regional left ventricular wall motion is normal. Overall left
ventricular
systolic function is normal (LVEF>55%).
3.Right ventricular chamber size and free wall motion are
normal.
4.The ascending aorta is mildly dilated. There are simple
atheroma in the
descending thoracic aorta.
5.The aortic valve leaflets (3) appear structurally normal with
good leaflet
excursion and no aortic regurgitation.
6.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
7. Post revascularization biventricular systolic function is
unchanged.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD on [**2148-9-19**] 14:38.
[**Location (un) **] PHYSICIAN
Brief Hospital Course:
Admitted [**9-19**] and underwent OPCABG x1 with Dr. [**Last Name (STitle) **].
Transferred to the CSRU in stable condition on a propofol drip.
Extubated that afternoon and transferred to the floor on POD #1
to begin increasing his activity level. Chest tubes and pacing
wires removed without incident. Went into Afib and was treated
with amiodarone and coumadin. Made excellent progress and was
cleared for discharge to home with VNA services on POD #6. First
blood draw is scheduled for Friday [**9-27**]. Pt. to make all appts.
as per discharge instructions.
Medications on Admission:
plavix
zocor
diovan/hctz
toprol xl
ASA
NTG
Discharge Medications:
1. Outpatient Lab Work
Lab: PT/INR mon/wed/fri for coumadin dosing - goal INR 2-2.5 for
atrial fibrillation
results to Dr [**Last Name (STitle) 14522**] office # [**Telephone/Fax (1) 14525**] fax # [**Telephone/Fax (1) 66753**]
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. 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. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 5 days: 400 mg [**Hospital1 **] until [**9-30**], then 400 mg daily for
7 days, then 200 mg daily ongoing until stopped by cardiologist.
Disp:*50 Tablet(s)* Refills:*1*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO ONCE (Once) for
1 doses: 3 mg today and tomorrow, then daily dosing per Dr.
[**Last Name (STitle) 14522**].
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Location (un) 86**]
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
Post op atrial fibrillation
Hypertension
Left ventricular hypertrophy
elevated cholesterol
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**Last Name (STitle) 14522**] in [**1-9**] week ([**Telephone/Fax (1) 14525**]) please call for
appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3633**])-
Lab: PT/INR mon/wed/fri for coumadin dosing - goal INR 2-2.5 for
atrial fibrillation
results to Dr [**Last Name (STitle) 14522**] office # [**Telephone/Fax (1) 14525**] fax # [**Telephone/Fax (1) 66753**]
Completed by:[**2148-9-25**]
|
[
"272.0",
"997.1",
"427.31",
"401.9",
"414.01",
"429.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7904, 7964
|
5804, 6367
|
328, 445
|
8132, 8139
|
1148, 2032
|
8651, 9208
|
892, 929
|
6460, 7881
|
2069, 2108
|
7985, 8111
|
6393, 6437
|
8163, 8628
|
3281, 5781
|
944, 1129
|
282, 290
|
2137, 3255
|
473, 659
|
681, 770
|
786, 876
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,373
| 170,789
|
49994
|
Discharge summary
|
report
|
Admission Date: [**2199-1-5**] Discharge Date: [**2199-1-12**]
Service: MEDICINE
Allergies:
Tetanus Antitoxin / Penicillins / Ethambutol
Attending:[**First Name3 (LF) 4028**]
Chief Complaint:
Hypoxia and Altered Mental Status
Major Surgical or Invasive Procedure:
intubation/extubation
central line placement
History of Present Illness:
This is a [**Age over 90 **] yof with hx of COPD on home 02, Bronchiectasis,
Diastolic CHF, Aortic Stenosis, HTN, DM diet controlled Found
obstunded at home in resp failure- put on bipap- then intubated
on arrival. Was given steroids. Sputum sample- MRSA- started on
vanco. Patient was suicidal. She wanted to be DNR/DNI- psych was
consulted; suicidality not endorsed to psych. Didn't recommend
1:1 sitter. She is on 2L nasal cannula. Not on home O2. needs
picc for MRSA PNA. Also UTI- on cipro. Was obtunded/respiratory
status was [**2-11**] OD of ambien and ativan. Also- resp failure may
have been PNA than COPD.
Patient caretaker pulled lifeline and pt was found by EMS in
respiratory distress and placed on BiPAP , she was given 6 NTG
and Lasix 40mg IV by EMS prior to arrival. In the ED she was
still in respiratory distress. She was intubated and given
solumedrol, levaquin, and nebulizers for possible COPD
exacerbation. Labs showed a UTI on U/A so she was also given
ceftriaxone. She was tranfered to CCU [**1-5**] for COPD
exacerbation in setting of UTI. There is also a question of her
accidentally, or purposefully taking extra ambien and thereby
depressing respirations and precipitating resp distress. Pt
extubated [**1-6**]. She continues on steroids and nebs. PT has been
hypertensive with hx of diastolic dysfunction and AS. Home
cardiac regimen not yet restarted. She has foley. She began
eating [**1-7**] and needs pureed food as she does not have dentures
here, and does not wear them at home as they are too painful.
Post extubation she expressed the desire to die. Seen by psych
[**1-7**] for suicidal ideation who felt she was not suicidal or a
danger to herself. She is full code. She is MRSA positive by
routine nasal swab. + LLL PNA. OOB to chair today w/ one person
assist.
Past Medical History:
--COPD: Last spirometry [**9-16**]: FVR 78% pred, FEV1 74% pred,
FEV1/FVC 95%.
--Bronchiectasis: history of atypical mycobacteria on sputum
culture in [**2191**]- followed by Dr. [**Last Name (STitle) 21848**].
-Aortic stenosis: Last ECHO on [**1-/2197**] shows moderate to severe
aortic valve stenosis (area 0.8-1.19cm2) Mild to moderate ([**1-11**]+)
aortic regurgitation is seen.
--Diastolic CHF: on home lasix
-Cholelithiasis/cholangitis
--Diabetes Mellitus: Diet-controlled
Pertinent Results:
[**2199-1-5**] 04:50AM GLUCOSE-190* UREA N-31* CREAT-1.2* SODIUM-137
POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-27 ANION GAP-11
[**2199-1-5**] 05:18AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2199-1-5**] 05:18AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.009
[**2199-1-5**] 08:00AM NEUTS-89.1* LYMPHS-8.4* MONOS-2.0 EOS-0.3
BASOS-0.2
[**2199-1-5**] 08:00AM WBC-14.3* RBC-3.50* HGB-11.4* HCT-32.8*
MCV-94 MCH-32.4* MCHC-34.6 RDW-13.6
[**2199-1-5**] 08:46AM TYPE-ART TEMP-36.1 PO2-200* PCO2-43 PH-7.40
TOTAL CO2-28 BASE XS-1 INTUBATED-INTUBATED
[**2199-1-5**] 04:07PM CK-MB-NotDone cTropnT-0.01
[**2199-1-5**] 10:52PM CK-MB-NotDone cTropnT-<0.01
INDICATION: [**Age over 90 **]-year-old with shortness of breath. Evaluate for
ET tube
placement and pneumonia.
COMPARISON: [**2198-9-18**].
SINGLE AP SUPINE VIEW OF THE CHEST: ET tube terminates 3.3 cm
above the
carina. An NG tube descends below the diaphragm, with tip not
visualized.
Superimposed on the patients long-standing interstitial
abnormality,
there are increased interstitial markings, Kerley B lines, and
mild increase
in the cardiac silhouette, consistent with mild interstitial
pulmonary edema.
No effusion. No focal consolidation to suggest pneumonia. Heart
size is top
normal and the aorta remains tortuous.
IMPRESSION:
1. ET tube in satisfactory position.
2. Mild pulmonary edema superimposed on chronic interstitial
abnormality.
INDICATION: [**Age over 90 **]-year-old with altered mental status. Evaluate for
stroke
complaints.
No prior examinations.
NON-CONTRAST HEAD CT: There is no acute intracranial hemorrhage
or major
vascular territorial infarct. [**Doctor Last Name **]-white matter differentiation
is preserved.
Extensive periventricular hypoattenuation is consistent with
chronic
microvascular ischemic disease. Encephalomalacia in the right
occipital lobe,
related to prior infarct. There is an 8-mm calcification along
the right
parietotemporal dura, which may represent a calcified
meningioma. There is
extensive calcification within the carotid siphons and vertebral
arteries.
There is extensive pneumatization of the petrous apices. The
visualized
paranasal sinuses and mastoid air cells are clear. No skull
fracture or soft
tissue abnormalities identified.
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Encephalomalacia related to prior right occipital lobe
infarct.
3. Extensive small vessel ischemic disease.
4. Calcified dural-based lesion in the right parieto-occipital
lobe may
represent a meningioma.
PORTABLE CHEST [**2199-1-8**]
COMPARISON: [**2199-1-7**]
INDICATION: COPD exacerbation.
FINDINGS: Cardiac silhouette is normal in size. Previously
present
widespread interstitial pulmonary edema on [**2199-1-7**] has
resolved.
Small pleural effusions are present, right greater than left.
These may be
due to patchy atelectasis, aspiration or early pneumonia.
Followup
radiographs may be helpful in this regard.
[**2199-1-9**]
R knee films
Brief Hospital Course:
Patient is a [**Age over 90 **] year old female with COPD on home O2 of 2L and
severe aortic stenosis p/w MRSA bronchitis/pneumonia and urinary
tract infection. Patient was intially admitted to the MICU and
worsened respiratory depression secondary to medication and was
intubated for 24 hours. Patient was extubated and was found to
have MRSA pneumonia, treating as HAP with Vancomycin IV through
PICC line until [**2199-1-16**]. Patient was treated with Cipro for
pansensitive EColi urinary tract infection until [**2199-1-13**]. Patient
was called out of the unit on [**2199-1-8**] and on the floor was
noted to have acute renal failure secondary to overdiruesis and
dehydration. Resolved with gentle fluids. Patient was placed at
an extended care facility.
.
# COPD - Pt had an acute exacerbation secondary to MRSA
Pneumonia/bronchitis. Patient was sent to the MICU after being
intubated. There is an additional component of pulmonary edema
from the CHF which resolved with Lasix. Aspergillus was
determined to be a colonizer and not relevant clinically.
Patient was extubated and called out to the floor. Patient was
started on Vancomycin, PICC line was placed and patient to
recieve 8 day course for MRSA in sputum. Patient was placed on
prednisone taper starting at 60mg PO daily. Nebulizers were
continued. Patient quickly returned to baseline oxygen
requirement of 2L. Survillance cultures were negative.
.
# UTI - Urine cultures were done and positive for
E.Coli/Lactobaccilus. Patient will be treated with a one week
course of Cipro.
.
# dCHF - patient was gently diuresed. At the time of discharge
patitent was euvolumeic and severe aortic stenosis was stable.
.
# HTN - Pt's outpatient meds were resumed.
.
# ARF - This was likely secondary to overdiruesis, and
self-resolved once Lasix was stopped. Patient give gentle a NS
250cc bolus x 1 with urine output and ARF improving further.
Lasix was resumed at discharge.
.
# Physical therapy - patient seen by PT here and is to continue
PT as outpatient.
.
# FEN- regular
.
# PPX- Heparin SC, PPI
.
# CODE- Full
Medications on Admission:
Albuterol Inhaler PRN
Budesonide 2 puffs [**Hospital1 **]
Diazepam 2mg daily
Furosemide 10mg daily
Hydralazine 25mg [**Hospital1 **]
Isosorbide Dinitrate 10mg TID
Quinine Sulfate 325mg qHS
Metoprolol Tartrate 25mg [**Hospital1 **]
Nifedipine 30mg daily
Nitro SL
Omeprazole 40mg daily
Ranitidine 150mg [**Hospital1 **] PRN
Tiotropium once daily
Ambien 10mg qHS PRN
ASA 81mg daily
LacHydrin Lotion
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] of [**Location (un) 583**]
Discharge Diagnosis:
Primary Diagnosis: MRSA Pneumonia- community acquired
COPD exacerbation
Urinary Tract Infection
Acute Renal Failure
Discharge Condition:
stable on home 2L oxygen, afebrile, hemodynamically stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500 cc/day
You were admitted for difficulty breathing and mental status
changes when you were at home. You were initially intubated,
and noted to have a pneumonia which likely caused your symptoms
at home. You are being treated with antibiotics (VANCOMYCIN)
through your PICC line ending [**2199-1-14**]. You were also noted to
have a urinary tract infection at the time of your admission for
which you were started on CIPROFLOXACIN. You are to continue
this medicaiton through [**2199-1-13**]. Once you were extubated, you
were resumed on your home regimen of 2 liters of oxygen.
You were seen by physical therapy who felt that you would likely
benefit from continued PT in rehab.
Please take all medications as prescribed. Please keep all
scheduled [**Month/Day/Year 4314**]. You will need to complete an 8 day
course of vancomycin for your pneumonia, and a 7 day course of
ciprofloxacin for your urinary tract infection.
If you develop any of the following concerning symptoms, please
call your PCP or go to the ED: chest pains, shortness of breath,
fevers, chills, nausea, vomiting, diarrhea, or altered mental
status.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500 cc/day
You were admitted for difficulty breathing and mental status
changes when you were at home. You were initially intubated,
and noted to have a pneumonia which likely caused your symptoms
at home. You are being treated with antibiotics (VANCOMYCIN)
through your PICC line ending [**2199-1-14**]. You were also noted to
have a urinary tract infection at the time of your admission for
which you were started on CIPROFLOXACIN. You are to continue
this medicaiton through [**2199-1-13**]. Once you were extubated, you
were resumed on your home regimen of 2 liters of oxygen.
You were seen by physical therapy who felt that you would likely
benefit from PT in rehab.
Please take all medications as prescribed. Please keep all
scheduled [**Month/Day/Year 4314**]. You will need to complete an 8 day
course of vancomycin for your pneumonia, and a 7 day course of
ciprofloxacin for your urinary tract infection.
If you develop any of the following concerning symptoms, please
call your PCP or go to the ED: chest pains, shortness of breath,
fevers, chills, nausea, vomiting, diarrhea, or altered mental
status.
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 250**] to schedule a
followup appointment in the next 2 weeks.
Provider: [**Name10 (NameIs) 7158**] [**Last Name (NamePattern4) 7159**], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2199-4-10**] 10:30
Completed by:[**2199-1-11**]
|
[
"584.9",
"482.42",
"424.0",
"599.0",
"491.21",
"428.0",
"250.00",
"428.32",
"518.81",
"494.0",
"401.9",
"786.59",
"041.4",
"309.28"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8278, 8355
|
5758, 7831
|
285, 332
|
8515, 8576
|
2686, 4318
|
11120, 11461
|
8376, 8376
|
7857, 8255
|
8600, 11097
|
212, 247
|
360, 2164
|
4327, 5735
|
8395, 8494
|
2186, 2667
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,603
| 166,061
|
37823
|
Discharge summary
|
report
|
Admission Date: [**2164-8-1**] Discharge Date: [**2164-8-3**]
Date of Birth: [**2140-1-18**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Furosemide
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Fever and rash
Major Surgical or Invasive Procedure:
punch biopsy on [**2164-8-1**]
History of Present Illness:
Ms [**Known lastname **] is s/p aortic root, ascending aorta and
hemiarch replacement on [**7-20**] with Dr. [**Last Name (STitle) 914**]. Her dialated
aorta was due to large vessel aortitis. Her post op course was
uneventful and she was discharged home on POD 6. She presented
to the ED on [**7-31**] for fever up to 101, cough and chest/back pain.
She had a CTA and echocardiogram which were unremarkable and it
was thought that she needed to increase her pain medication and
concentrate on pulmonary toilet. Shortly after leaving the ED
she developed total body itching and rash which progressed to
peeling skin on her back and arms. She took benadryl at home
with no relief. She states her face feels swollen but denies
difficulty breathing or throat swelling. She states that she
feels better after the solumedrol/benadryl/pepcid. Her temp on
arrival to ED was 102. She is also c/o nausea and R sided pain
which she has had since surgery.
Past Medical History:
- s/p aortic root, ascending aorta and hemiarch replacement on
[**7-20**] with Dr. [**Last Name (STitle) 914**].
- Para 1 [**Last Name (un) **] 2(twins)
- s/p tubal ligation
Social History:
Pt is from [**Doctor First Name 35537**], but has been in MA for the past 2 yrs
staying with her mother who is being treated for breast cancer.
Denies tobacco
social EtOH and denies illicit substances and no IVDA.
Denies current sexual activity.
Family History:
mother has breast cancer, denies FH of SLE or other
rheumatologic disease
Physical Exam:
Pulse:87 Resp:16 O2 sat:98%
B/P Right:106/57 Left:
Height: Weight:
General:
Skin: diffuse macular papular rash w/areas of exfoliation on
arms
and back, painful to palpation
mouth w/areas of white plaques on tongue w/ulcers on L lateral
surface
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] +tender to palpation over
upper abdomen, no guarding, no rebound bowel sounds + [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact[x]
Sternal incision clean and dry with no drainage or erythema
Pertinent Results:
[**2164-7-31**] ECHO
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion. Trace aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. The tricuspid regurgitation jet is eccentric and
may be underestimated. The estimated pulmonary artery systolic
pressure is normal. There is a trivial/physiologic pericardial
effusion.
No vegetation seen (cannot definitively exclude).
Compared with the prior study (images reviewed) of [**2163-7-20**],
tricuspid regurgitation appears similar to slightly more
prominent.
[**2164-8-1**] 03:30AM GLUCOSE-82 UREA N-14 CREAT-0.7 SODIUM-135
POTASSIUM-4.6 CHLORIDE-96 TOTAL CO2-25 ANION GAP-19
[**2164-8-1**] 03:30AM ALT(SGPT)-17 AST(SGOT)-24 LD(LDH)-322* ALK
PHOS-104 AMYLASE-145* TOT BILI-0.6
[**2164-8-1**] 03:30AM WBC-20.2*# RBC-3.66* HGB-9.8* HCT-31.7*
MCV-87 MCH-26.7* MCHC-30.9* RDW-14.6
[**2164-7-31**] CTA
1. No evidence of aortic dissection.
2. Linearly arranged locules of gas at distal anastomotic site
have an
appearance somewhat reminiscent of packing material, or may
alternatively
represent non-resolved postoperative gas. Given the imaging
appearance
overlap, infection cannot be entirely excluded.
3. Additional expected postoperative findings including
periaortic fluid.
4. Small right pleural effusion.
[**2164-8-3**] 06:20AM BLOOD WBC-10.9 RBC-3.74* Hgb-9.8* Hct-32.4*
MCV-87 MCH-26.3* MCHC-30.3* RDW-14.2 Plt Ct-580*
[**2164-8-3**] 06:20AM BLOOD Neuts-81.4* Lymphs-13.9* Monos-3.1
Eos-1.1 Baso-0.4
[**2164-8-3**] 06:20AM BLOOD Plt Ct-580*
[**2164-8-3**] 06:20AM BLOOD ALT-15 AST-14 AlkPhos-83 TotBili-0.3
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2164-7-31**] for further
management of her rash and fever. The dermatology service was
consulted and a biopsy of her rash was obtained. Viral exanthem
versus a lasix induced drug eruption was suspected. Steroid
creams were applied. A CT scan was performed which ruled out an
aortic dissection. Her amylase and lipase were elevated and an
abdominal ultrasound was performed. Rheumatology saw her in
consultation, as did infectious disease. Rheumatology will see
her next week as an outpatient and will likely begin prednisone
treatment at that time. Infectious disease requested an ASO
titer and strep B screen, which they will follow as an
outpatient. Within days the rash began to resolve and her
fevers abated. Her punch biospy returned inconsistent with
[**First Name8 (NamePattern2) **] [**Location (un) **] syndrome. The pathology report suggested a
differential dignosis of drug induced dermatitis verses viral
exanthum. As her symptoms resolved she was discharged by Dr.
[**Last Name (STitle) 914**] to home with follow-up appointments with rheumatology
and dermatology.
Medications on Admission:
Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day)
Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day)
Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Dilaudid and Ultram d/c today
Percocet and Ibuprofen started
Discharge Medications:
1. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
3. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
5. Hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for itching.
Disp:*30 Tablet(s)* Refills:*0*
6. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
DAILY (Daily).
Disp:*1 tube* Refills:*2*
7. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) for 2 weeks: to skin affected by rash.
Disp:*1 tube* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Drug induced pancreatitis
Drug induced dermatitis v viral exanthum
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 914**] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) 29065**] in [**12-27**] weeks. [**Telephone/Fax (1) 29068**]
Scheduled apppointments:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4900**], MD (RHEUM) Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2164-8-6**] 10:00
ECHOCARDIOGRAM Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2164-8-24**] 11:00
[**Name6 (MD) **] [**Last Name (NamePattern4) 6559**], MD (CARDS) Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2164-8-24**] 1:20
[**Name6 (MD) **] [**Name8 (MD) **], MD (DERM) Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2164-8-3**] 2:00
Sutures to be removed on [**2164-8-15**]. [**Month (only) 116**] shower and get biopsy
site wet. [**Month (only) 116**] place vaseline or bacitracin to site.
Completed by:[**2164-8-3**]
|
[
"E947.8",
"577.0",
"693.0",
"057.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.11"
] |
icd9pcs
|
[
[
[]
]
] |
7247, 7322
|
4491, 5646
|
289, 322
|
7433, 7440
|
2496, 4468
|
8238, 9132
|
1782, 1858
|
6421, 7224
|
7343, 7412
|
5672, 6398
|
7464, 8215
|
1873, 2477
|
235, 251
|
350, 1305
|
1327, 1502
|
1518, 1766
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,469
| 147,691
|
25476
|
Discharge summary
|
report
|
Admission Date: [**2190-8-20**] Discharge Date: [**2190-10-1**]
Date of Birth: [**2117-9-23**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
72M w/ 3 day h/o abd. pain.
Major Surgical or Invasive Procedure:
Emergency thorocoabdominal aneurysm replacement (#32 Gelweave)
[**2190-8-20**]
History of Present Illness:
72WM w/ PMHx sig. smoking who had 3 days increasing of L sided
back and flank pain. He presented to an OSH and a CT revealed a
8.5 cm thorocoabdominal aneurysm. He was transferred to [**Hospital1 18**]
for surgery.
Past Medical History:
None
Social History:
Lives alone
Cigs: [**1-10**] ppd for 55 years
ETOH: none
Family History:
unremarkable
Physical Exam:
Gen: Elderly [**Male First Name (un) 4746**] c/o abd. pain
T: 98.9 HR: 78 BP: 177/119 RR:20 100% sat
HEENT: NC?AT, PERLA, EOMI, oropharynx benign
Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids
2+=bilat. without bruits.
Lungs: Clear to A+P
CV: RRR without R/G/M, nl. s1, s2
Abd: +BS, soft, diffuse tenderness, + palpable mass
Ext: without C/C/E, pulses palpable throughout
Neuro: nonfocal
Pertinent Results:
[**2190-9-27**] 02:43AM BLOOD WBC-10.5 RBC-3.40* Hgb-10.3* Hct-30.7*
MCV-90 MCH-30.2 MCHC-33.5 RDW-14.9 Plt Ct-278
[**2190-9-27**] 02:43AM BLOOD PT-14.0* PTT-54.0* INR(PT)-1.3
[**2190-9-27**] 02:43AM BLOOD Glucose-118* UreaN-15 Creat-0.5 Na-134
Cl-97 HCO3-27
[**2190-9-27**] 12:32PM BLOOD Type-ART pO2-105 pCO2-46* pH-7.39
calHCO3-29 Base XS-1
[**2190-9-24**] 5:32 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2190-9-26**]**
GRAM STAIN (Final [**2190-9-24**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2190-9-26**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. MODERATE GROWTH.
PENICILLIN SENSITIVITY AVAILABLE ON REQUEST.
Please contact the Microbiology Laboratory ([**7-/2491**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- 4 I
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- 0.5 S
RADIOLOGY Final Report
CHEST PORT. LINE PLACEMENT [**2190-9-24**] 2:08 PM
CHEST PORT. LINE PLACEMENT
Reason: check PICC placement
[**Hospital 93**] MEDICAL CONDITION:
72 year old man with AAA s/p thoracoabdominal aneurysm repair
now s/p percutaneous tracheostomy placement
REASON FOR THIS EXAMINATION:
check PICC placement
HISTORY: AAA repair. Assess line placement.
AP BEDSIDE CHEST. Bilateral effusions layering in semierect
position. There is considerable associated left lower lobe
atelectasis and possible consolidation. Lungs remain well
inflated, suggesting possible emphysema. Tip of left central
line just reaches the mid SVC. Satisfactorily positioned NG tube
below diaphragm and ET tube. Lower thoracic and upper lumbar
midline skin staples and large unusual a wire suture material
overlying left upper abdomen. Multiple tiny skin staples
overlying the mediastinum up to the level of the aortic arch
with no sternal wires sutures. No overt vascular congestion or
consolidations in the visualized mid and upper lungs. Little
change from similar exam one day previous. Heart normal size
with a poorly assessed dilated thoracic aorta.
IMPRESSION: No short interval change in bilateral effusions and
probable emphysema.
DR. [**First Name (STitle) **] M. [**Doctor Last Name **]
Approved: FRI [**2190-9-24**] 5:17 PM
Brief Hospital Course:
This 72WM was admitted on [**2190-8-20**] with 3 days of increaseing
abdominal pain. CTA revealed an 8.5 cm thorocoabdominal
aneurysm. He had an hypotensive episode shortly after admission
and was taken emergently to the OR. He had repalcement of the
descending thoracic aorta and abdominal aorta with
reimplantation of the visceral arteries. He tolerated the
procedure well and was transferred to the CSRU on Labetolol and
Propofol. The following morning he had a pulseless L foot and
had a femoral-femoral bypass grafting done. His foot improved
and he was in stable condition. He was unable to move his lower
extremities following his initial surgery, and had no sensation.
He was evaluated by neurology who felt he had a spinal cord
infarct with a poor prognosis for recovery.
He was unable to wean from the vent and required occasional
bronchoscopy for secretions. He had intermittent bouts of
atrial fibrillation and was treated with Amiodorone. on [**9-1**] he
had R arm swelling and had a DVT of the cephalic vein. He was
heparinized at that time. [**9-6**] he underwent tracheostomy. He
continued to progress and was having trach mask trials and short
periods of using the Passe-Muir valve. He was doing well until
he began desaturating during the week of [**2190-9-17**]. He was
eventually very hard to ventilate and had a bronchsocopy which
revealed granulomatous tissue growth which was blocking the
trach. This was debrided and very friable. Later that day he
had an arrest when and was difficult to ventilate. He had clots
removed and improved. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 295**] trach was placed and patient
tolerated it well. He had 2 bronchs since that tiem, for
secretions, and grew out MSSA on [**9-24**]. Since that time he has
progressed and he had an open G tube placed on [**9-24**]. He has
undergone routine bronchoscopies X 2. He was discharged to
acute rehab for vent wean and spinal cord rehab. He should
follow-up with Dr. [**Last Name (STitle) **] & [**Last Name (Prefixes) **] upon discharge from
rehab or in 1 month.
Medications on Admission:
None
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-10**]
Puffs Inhalation Q4H (every 4 hours).
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
8. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
9. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
14. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO once a day.
15. Oxacillin 2 gm IV Q4H
16. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
17. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day.
18. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime on
[**10-1**], then check INR and dose for target 2.0-2.5
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Thorocoabdominal aneurysm
Tracheostomy
Open G tube
Femoral-femoral bypass graft
Thorocoabdominal aneurysm
Paraplegia
Reespiratory Failure
PVD
Thorocoabdominal aneurysm
Paraplegia
Reespiratory Failure
PVD
Thorocoabdominal aneurysm
Paraplegia
Reespiratory Failure
PVD
Discharge Condition:
Good.
Discharge Instructions:
Wean vent as tolerated.
Call for any wound drainage.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) **] when able.
Make an appointment with Dr. [**Last Name (STitle) 1290**] when able.
Completed by:[**2190-10-1**]
|
[
"518.5",
"305.1",
"336.1",
"997.2",
"263.9",
"707.03",
"997.09",
"441.7",
"427.31",
"427.5",
"444.22",
"482.41",
"519.02",
"576.2",
"344.1",
"557.1",
"453.8",
"786.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"43.19",
"96.6",
"99.15",
"38.08",
"39.29",
"31.74",
"39.59",
"39.61",
"96.05",
"31.1",
"33.21",
"38.45",
"38.44"
] |
icd9pcs
|
[
[
[]
]
] |
7685, 7764
|
3951, 6053
|
342, 423
|
8077, 8085
|
1240, 2724
|
8186, 8353
|
786, 800
|
6108, 7662
|
2761, 2867
|
7785, 8056
|
6079, 6085
|
8109, 8163
|
815, 1221
|
275, 304
|
2896, 3928
|
451, 668
|
690, 696
|
712, 770
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,495
| 140,081
|
27214
|
Discharge summary
|
report
|
Admission Date: [**2159-6-5**] Discharge Date: [**2159-6-7**]
Date of Birth: [**2123-5-22**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Communicating hydrocephalus, status post traumatic brain injury
as well as right frontal hygroma.
Major Surgical or Invasive Procedure:
VP shunt
History of Present Illness:
the patient is a 35-year old male who had a traumatic
brain injury when he fell from a tree in [**7-26**]. The patient
underwent emergent surgery in New [**Country 6679**]. A bicoronal
craniectomy and insertion of right frontal extraventricular
catheter was performed for a complex right frontal fracture
extending through his frontal sinus and along the roof of his
orbits. There was extensive facial fracturing and massive
bilateral frontal contusions, worse on the right. The patient
has recovered from his surgery with significant impairment
secondary to his TBI. He follows up with us because sequential
imaging has revealed that he has dilated ventricles which seem
to
be out of proportion to the amount of injury that he sustained.
The question is whether the patient would benefit from
ventricular shunting as well as shunting from bifrontal
hygromas.
The patient is seen with his parents in the office. The patient
is in a wheelchair. He is able to communicate in limited
phrases. He remains oriented to himself and to his family, he is
not fully oriented to other qualities. He can follow commands.
He has the ability to move all four extremities. The patient
overall has extensive periods of keeping still. He also suffers
from seizure activities, increased during the months of [**Month (only) 404**]
and [**Month (only) 956**]. The patient is currently on anticonvulsants. He
was last imaged at [**Hospital1 18**] on [**2159-2-15**].
Overall, the patient has extensive areas of encephalomalacia in
a
bifrontal pattern suggestive of posttraumatic encephalopathy. He
has disproportionate ventriculomegaly with compressed
ventricles.
There are signs of communicating hydrocephalus as well as
anterior extradural CSF collection underlying the bifrontal
craniotomy. We have discussed the situation with the family at
large. The family has reviewed for me his overall course of
recovery and they feel that the patient has somewhat been
stagnant at his current level. It is unclear to all of us
whether the majority of his changes are secondary to tissue loss
frontally; however, this seems to be clearly a component of
increased pressure.
Past Medical History:
s/p TBI after fall from tree in [**7-26**]
seizures
Social History:
lives with parents
Family History:
NC
Physical Exam:
Able to say few pnrases; able to move all extremities; spends
most of time in wheelchair; able to recognize family but no
other orientation
Pertinent Results:
[**2159-6-7**] 05:15AM BLOOD WBC-7.7 RBC-4.74 Hgb-14.4 Hct-41.3 MCV-87
MCH-30.4 MCHC-34.9 RDW-13.2 Plt Ct-189
[**2159-6-6**] 02:46AM BLOOD WBC-9.6# RBC-4.74 Hgb-14.3 Hct-40.5
MCV-86 MCH-30.1 MCHC-35.2* RDW-13.4 Plt Ct-195
[**2159-6-7**] 05:15AM BLOOD Plt Ct-189
[**2159-6-7**] 05:15AM BLOOD PT-13.0 PTT-34.7 INR(PT)-1.1
[**2159-6-6**] 02:46AM BLOOD Plt Ct-195
[**2159-6-7**] 05:15AM BLOOD Glucose-84 UreaN-7 Creat-0.9 Na-136 K-4.7
Cl-98 HCO3-26 AnGap-17
[**2159-6-6**] 02:46AM BLOOD Glucose-94 UreaN-7 Creat-0.8 Na-132*
K-5.1 Cl-100 HCO3-27 AnGap-10
[**2159-6-7**] 05:15AM BLOOD Calcium-9.4 Phos-3.6 Mg-2.2
[**2159-6-6**] 02:46AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.9
Head CT [**6-5**]:
FINDINGS: There has been interval placement of a ventriculostomy
catheter via the right frontal approach, terminating in the left
frontal [**Doctor Last Name 534**] of lateral ventricles. No significant change in
moderate hydrocephalus and mild sulcal effacement. The
previously seen anterior extraaxial fluid collection is now
almost entirely replaced with air. There is displacement of the
calcified frontal dura. Low density within the left posterior
temporal/occipital region and inferior frontal lobes are
consistent with encephalomalacia due to prior trauma. Extensive
microplates and screws fixate known facial fractures, unchanged
in position compared to the prior exam. There is a tiny degree
of subcutaneous emphysema along the right frontal scalp from
recent surgery. No evidence of new hemorrhage or major vascular
territorial infarct.
IMPRESSION:
1. Interval placement of ventriculostomy catheter terminating in
the left lateral frontal [**Doctor Last Name 534**] with no change in hydrocephalus.
2. Status post drainage of frontal extraaxial fluid collection,
now mostly replaced with air.
3. No evidence of acute hemorrhage or major vascular territorial
infarct.
4. Extensive sequela of prior trauma as described above.
Brief Hospital Course:
Pt taken to the operating room for insertion of VP shunt by Dr.
[**Last Name (STitle) **] from Neurosurgery and Dr. [**Last Name (STitle) **] from General Surgery.
Procedure without complication and patient was transferred to
ICU overnoc for observation. With in first 24hrs postop pt with
2 generalized tonic clonic seizures each lasting approximately 2
minutes and breaking on their own without additional medication.
Dr. [**Name (NI) **] (pts neurologist) was contact[**Name (NI) **] and
recommendations were made. Following Dr.[**Name (NI) 66745**]
recommendations there were no medication changes made and pt
with no further seizures. Transferred to the floor on POD#1 and
was ready for discharge on POD#2.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed: Please take cautiously with percocet as
both products contain acetaminophen. Tablet(s)
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day): please take while taking narcotics.
Disp:*90 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Communicating Hydrocephalus; Hygromas
Discharge Condition:
good
Discharge Instructions:
Please call the office with any questions that you may have.
Please call the office or come to the emergency room for any
change in mental status, seizure or weakness.
Please call the office or come to the emergency room if incision
becomes reddened, has drainage or patient develops fever >101.5.
Please do not soak incision site in bathtub or pool. You may
hand was hair around incision site but keep incision dry.
Please continue your home presurgery medications
Followup Instructions:
Please call Dr. [**Last Name (STitle) 17511**] office to make a follow up appointment.
You will need an appointment in 4-6weeks with a CT scan at that
time. You also need to come to the office on [**2159-6-15**] to have
your sutures removed. Please call the office to schedule a time
for that appointment. The office number is ([**Telephone/Fax (1) 11314**].
You will also need an appointment to see Dr. [**Last Name (STitle) **] from general
surgery. Please call his office at [**Telephone/Fax (1) 600**] to make an
appointment with in 2 weeks
Completed by:[**2159-6-7**]
|
[
"345.90",
"784.5",
"331.3",
"905.0",
"432.1",
"294.9",
"781.3",
"729.89",
"E929.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.34",
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
6089, 6095
|
4858, 5575
|
416, 426
|
6177, 6184
|
2913, 4835
|
6699, 7278
|
2734, 2738
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5598, 6066
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6116, 6156
|
6208, 6676
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2753, 2894
|
278, 378
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454, 2607
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2629, 2682
|
2698, 2718
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,002
| 115,042
|
40752
|
Discharge summary
|
report
|
Admission Date: [**2125-7-19**] Discharge Date: [**2125-7-25**]
Date of Birth: [**2084-2-27**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
altered mental status
fever
acute renal failure
Major Surgical or Invasive Procedure:
mid-line IV
History of Present Illness:
41yo woman w/ PMH hypothyroidism, s/p laparoscopic
cholecystectomy and umbilical hernia repair [**2125-6-27**] at [**Hospital1 89097**] transferred to [**Hospital1 18**] with fever, acute renal failure
and mental status changes.
.
She was originally admitted [**6-26**] with recurrent biliary colic
and had a laparascopic cholecystectomy with concurrent repair of
an umbilical hernia. Intraoperatively she had a bile leak that
was controlled with small clips and a JP drain was left in
place. During that admission she apparently had malignant
hypertension thought to be due to self-induced hyperthyroidism
(?). She had ERCP showing peripheral bile leak, with
sphincterotomy and placement of a stent. She then improved and
was discharged home [**7-1**].
.
She was seen as an outpatient [**7-8**] when she was doing well,
except for pain at the JP site. [**7-12**] she was readmitted b/c of
persistent abdominal pain. Repeat ERCP and MRCP showed no leak,
though a HIDA scan showed pooling of small amounts of bile in
the peripheral of the liver. [**7-14**] and [**7-15**] she spiked fevers.
She was thought to have cellulitis around the JP site, and the
bile grew [**Last Name (LF) 8974**], [**First Name3 (LF) **] she was started on oxacillin with removal of
the JP drain. She subsequently developed a small biloma. She
began to develop acute kidney injury with rising creatinine.
[**7-18**], she had WBC 13.3, BUN 8, Cr 4.8, total bili 4.3. She also
had R UQ pain. CVL was placed. CT scan of the abd and pelvis
showed the small biloma and severe right sided colitis. No
biliary duct obstruction. The decision was made to transfer her
to the [**Hospital1 18**] SICU.
.
On arrival to the SICU, the surgery team did not feel that her
biloma was her primary issue and that she did not require
surgical intervention. They requested transfer to the medical
team. The patient is intermittently oriented to place and year.
She is confused and agitated and unable to provide further
history. It is unclear when her confusion began as it is not
mentioned in the OSH notes.
Past Medical History:
- anxiety
- hypothyroidism
- cesarean section x2
- alcohol abuse
Social History:
Unknown at this time.
- Tobacco:
- Alcohol: reports of EtOH abuse, unknown amount.
- Illicits:
Family History:
Unknown
Physical Exam:
At admission:
Vitals: T: 99.1 BP:157/85 P: 77 R: 18 O2: 100% 2L NC
General: Alert, but confused and agitated
HEENT: Sclera anicteric, dry mucous membranes with dried blood
in the oropharynx
Neck: supple, JVP not elevated, no LAD, R IJ clean and in place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, obese, right-sided tenderness with some guarding,
non-distended, bowel sounds present, no rebound tenderness, no
organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
At discharge:
Vitals: T:97.9 BP: 133/72 P: 80 R: 18 O2: 99 on RA
General: Alert and oriented, in NAD
HEENT: Sclera anicteric, MMM
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, obese, not TTP, BS+
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
At admission:
[**2125-7-19**] 02:45PM BLOOD WBC-7.5 RBC-2.92* Hgb-9.3* Hct-27.3*
MCV-94 MCH-31.8 MCHC-34.0 RDW-13.8 Plt Ct-321
[**2125-7-19**] 02:45PM BLOOD Neuts-85.2* Lymphs-10.1* Monos-3.2
Eos-1.3 Baso-0.2
[**2125-7-19**] 02:45PM BLOOD PT-13.9* PTT-30.7 INR(PT)-1.2*
[**2125-7-19**] 02:45PM BLOOD Glucose-135* UreaN-17 Creat-3.7* Na-142
K-3.6 Cl-107 HCO3-24 AnGap-15
[**2125-7-20**] 03:03AM BLOOD Lipase-93*
[**2125-7-19**] 02:45PM BLOOD Albumin-2.7* Calcium-8.5 Phos-4.3 Mg-2.2
[**2125-7-19**] 02:45PM BLOOD TSH-0.11*
[**2125-7-20**] 03:03AM BLOOD Free T4-0.81*
[**2125-7-20**] 07:45AM BLOOD Type-[**Last Name (un) **] pO2-38* pCO2-43 pH-7.39
calTCO2-27 Base XS-0
[**2125-7-20**] 07:45AM BLOOD Lactate-0.9
[**7-20**] Abd U/S
IMPRESSION:
1. Small collection in the gallbladder fossa, which has
decreased in size
compared to ultrasound [**2125-7-18**]. No free fluid within the
abdomen.
2. Moderate pleural effusions, right greater than left.
[**7-19**] CXR
IMPRESSION: Increased pulmonary vascular pattern most likely
representing
perioperative fluid overload.As no previous chest examination is
available for
comparison, consider followup examination within a few days.
[**2125-7-19**] Urine Cx: no growth
WOUND CULTURE - catheter tip (Final [**2125-7-22**]): No significant
growth.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST X3 (Final 06/25-28/11)
[**2125-7-20**]: blood cx: no growth
[**2125-7-23**] Stool culture: no O/P, no campylobacter
Discharge:
WBC 9.0 hgb 10.1* hct 29.8* Plt 557*
Chem 7 glucose 112 BUN 14 Cr 1.8* Na 137 K 3.3 Cl 100 HCO3 28
Brief Hospital Course:
41 yo female s/p lap CCY/bile leak transferred from OSH.
Hospitalization notable for fevers, transient cholestasis
(resolved), [**Month/Day/Year 8974**] recovery from biliary drainage, AMS, ARF
(attributed to AIN). Showed significant Right sided colitis on
recent abdominal CT. Pt's course was complicated by HAP.
AMS: Mental status changes were worked up for toxic, metabolic
and infectious etiologies. It was determined that her mental
status changes were due to accumulation of benzodiazepines and
narcotics in the setting of acute renal failure. When the
offending substances were removed and pt's renal function
improved, her mental status returned to baseline. Pt does have
history of alcohol abuse, but had not drank within past week
prior to admission and she never showed signs of EtOH
withdrawal.
Acute renal failure: Pt was admitted with creatinine of 3.7.
In outside hospital, injury was attributed to nafcillin AIN. On
admission, pt was found to be hypovolemic and was resuscitated
with fluids in the ICU. Her kidney function improved, but she
began putting out large volumes of urine when she arrived on the
floor. Based on urine lytes with FeUrea consistent with
intrinsic failure it was determined that she was experiencing
post ATN diuresis. During this time, she was found to be
hypokalemic from the copious diuresis. K was replaced, urine
output decreased and creatinine continued to improve by time of
discharge. She was discharged with Cr of 1.8, and pt had good
urine output. Baseline creatinine was unknown.
Hyperkalemia: In ICU pt was found to be hyperkalemic. EKG
showed no signs of hyperkalemia, was given kayexalate and K
trended down as kidney function improved.
Hospital acquired PNA: In SICU, pt was found to have right
lobar PNA, was febrile with leukocytosis and cough with SOB.
She could not produce sufficient sputum sample for culture and
all blood cultures were negative, so she was treated empirically
for HAP with cefepime and vancomycin for a 10 day course. She
was discharged with a midline IV to complete the final four days
of ABX therapy with VNA services.
Colitis: In ICU pt developed watery diarrhea. On admission she
had abdominal pain and outside CT showed pericolic stranding.
An infectious process associated with previous cholecystectomy
and JP tube was ruled out in the ICU with U/S and neg cultures
from JP site. Pt also had leukocytosis and was suspected to
have c. diff and started on empiric PO vancomycin and flagyl.
She had three negative c diff toxin assays and diarrhea and
abdominal pain resolved. Symptoms were likely caused by
intra-abdominal inflammation secondary to bile leak and small
biloma.
Hypertension: On floor, the pt was found to be consistently
hypertensive with systolic pressures in the 160s. She reported
that her PCP has diagnosed her with HTN but she has refused
medication. We treated her with amlodipine 10 mg qday and
pressures became normotensive. She was discharged on Amlodipine
10mg qday.
Hypothyroidism: Pt was found to have a low TSH (0.11) in ICU
indicating that her dose of synthroid might be too high. Pt's
renal failure could have contributed to accumulation of
synthroid and suppression of TSH. As condition improved, she
did not show any signs of hyperthyroidism and she was discharged
with home dose of synthroid.
Depression/anxiety: Pt's depression was stable on duloxetine
and she was discharged on home dose. On the floors, when pt's
renal function improved and mental status returned to baseline,
she was restarted on her home dose of xanax qHS.
There are no outstanding results that need to be followed up at
time of discharge. Pt will follow up with PCP after course of
abx. Midline IV will be removed by VNA after abx course.
Medications on Admission:
Medications (home):
- Synthroid 0.2mg daily
- Cymbalta 90 daily
- Xanax 2mg PO QHS
- Vicodin after surgery
.
Medications (on transfer from OSH):
- Tylenol 650mg PO PRN
- Xanax 1mg PO PRN
- Cefazolin 1gm IV Q8hrs
- Benadryl 25mg Q6hrs PRN pruritus
- Cymbalta 90mg PO daily
- lovenox 40mg SQ daily
- Vicodin 1 tab Q8hrs PRN
- Synthroid 200mcg PO daily
- Reglan 10mg IV Q6hrs PRN nausea
- Flagyl 500mg IV Q8hrs
- Morphine 1mg IV Q2hrs PRN
- Narcan 0.1mg IV PRN
- Protonix 40mg IV daily
Discharge Medications:
1. levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Three
(3) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Xanax 2 mg Tablet Sig: One (1) Tablet PO at bedtime as needed
for insomnia.
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain for 4 days.
Disp:*30 Tablet(s)* Refills:*0*
5. cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q24H (every 24 hours) for 3 days.
Disp:*3 Recon Soln(s)* Refills:*0*
6. vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
every other day for 3 days.
Disp:*1 1g* Refills:*0*
7. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush for 4 days.
8. Outpatient Lab Work
please check a potassium on friday [**2125-7-27**] and fax to primary
care doctor [**Month/Day/Year 89098**] at fax number [**2125**].
9. potassium citrate 10 mEq Tablet Extended Release Sig: One (1)
Tablet Extended Release PO once a day for 4 days.
Disp:*4 Tablet Extended Release(s)* Refills:*0*
10. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Home Solutions
Discharge Diagnosis:
1. Right sided colitis
2. hospital acquired pneumonia
3. acute mental status changes
4. Acute kidney injury from acute tubular necrosis
5. hypertension
6. hyperkalemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname **],
It was a pleasure taking care of you. You were admitted to
[**Hospital1 18**] because of suspicion of an abdominal infection secondary
to your previous gallbladder surgery. It was determined that
you did not have an infection from the surgery. Infectious
diarrheal disease was also ruled out. It was determined that
you had a colitis secondary to irritation from the bile leak
from your surgery. While you were in the hospital, you were
diagnosed with a kidney injury that was treated with IV fluids
and electrolyte replacement. You also experienced mental status
changes which resolved as your kidney function improved.
Finally, you were diagnosed with a pneumonia, which we have been
treating with IV antibiotics which will be continued at home for
three days. During your hospital stay, your blood pressures
were elevated and you were diagnosed with hypertension.
You will be going home with a mid-line IV and a visiting nurse
will come to administer medications and will remove the line.
When you leave the hospital, continue with your home medications
and add the following.
- START amlodipine 5mg by mouth every day
- START Vancomycin 1 gram intravenous every other day
- START cefepime 2g intravenous every 24 hours
Followup Instructions:
Please follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 89098**]
within one week.
Please follow up with your surgeon, Dr. [**Last Name (STitle) 89099**] at [**Hospital 487**]
hospital on your scheduled appointment date, [**7-31**].
|
[
"244.9",
"300.00",
"311",
"584.5",
"401.9",
"276.7",
"486",
"558.9",
"799.02",
"276.8",
"305.00",
"348.30",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10856, 10901
|
5349, 9119
|
351, 365
|
11113, 11113
|
3762, 5326
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12554, 12839
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3343, 3743
|
264, 313
|
393, 2459
|
11128, 11240
|
2481, 2548
|
2564, 2661
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,355
| 115,843
|
876
|
Discharge summary
|
report
|
Admission Date: [**2135-7-15**] Discharge Date: [**2135-7-25**]
Date of Birth: [**2096-2-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1070**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
[**2135-7-17**] IVC Filter Placed
History of Present Illness:
39 y/o M with PMHx of HTN, iritis, who presented to his PCP's
office with a 2 days of worsening SOB, and dizziness on standing
after going to the gym.
Patient said on tuesday he noticed left calf "knot" after
swimming, with no other symptoms. On weds/thurs. he noticed he
was sob, dizzy and diaphoretic with normal exertion (walked [**1-3**]
block). Finally, on friday, his left calf "knot" was not
resolved with vigorous massage, and his symptoms of SOB,
dizziness and diaphoresis were not improved so he saw his PCP.
[**Name10 (NameIs) **] arrived to his PCP's office who found him to be hypotensive
and tachycardic, and he was sent into the ED. Interestingly,
patient notes ~ 5 weeks ago he had some sob while boxing, and 3
weeks ago he also had sob after a long flight.
.
Brief hospital course: In the ED, VS: T98.1, HR116, BP96/80,
RR16 o2sat: 97% RA. His CT scan showed bilateral PEs and he was
given ASA 325 x1, & started on hep gtt. The patient was
admitted to the ICU, and for his saddle emboli he was continued
on heparin gtt, and had an IVC filter placed. He will start
coumadin. His ARF was treated with fluids, which led to
improvement. In the setting of PE/hypotension, his blood
pressure meds were held and he was aggressively hydrated
Past Medical History:
1)HTN
2)Iritis
Social History:
The patient grew up in a farm in [**Location (un) 3844**], currently works
for EScription Services for the past 3 years. There is a lot of
traveling around the country for up to a week at a time. He
works pretty hard but likes his job. He has no history of
alcohol, drug abuse, or smoking. He currently lives in the
[**Location (un) 4398**]. He lives alone. He has an occasional male partner
with whom he is sexually active. He does use condoms. He has
no history of sexually transmitted diseases.
Family History:
Mother has hypercholesterolemia and history of alcohol abuse;
diagnosed with breast cancer one year ago. His father has
nonmelanoma skin cancer. No other fam hx of blood clots or
malignancy.
Physical Exam:
On Admission to ICU...
Vitals: T 99 BP 106/63 HR 95 RR 22 O2: 98% on 2L
Gen: Well appearing male in NAD; able to talk in complete
sentences
HEENT: Anicteric sclera. O/P clear. MMM.
Neck: No elev JVP. No cervical or supraclavicular LAD.
Cardio: Regular, nml s1,s2. No murmurs
Resp: CTAB. No c/w/r.
Abd: Soft. NTND. No TTP. No inguinal LAD
Ext: 2+ pulses bilat, no edema. No erythema. (-) [**Last Name (un) 5813**] sign
Neuro: AAOx3
GU: No testicular masses palpated.
RECTAL: Guiaic (-) in ED per notes.
.
on floor:
Vitals: 98.4, 104/70, 96, 16, 95% RA
Gen: Well appearing male in NAD
HEENT: Anicteric sclera. O/P clear. MMM.
Neck: No JVD noted, no [**Doctor First Name **], no bruit noted
Cardio: Regular, nml s1,s2. No murmurs
Resp: CTAB. No c/w/r.
Abd: Soft. NTND. + BS
Ext: 2+ pulses bilat, no edema. No erythema. no calf tenderness.
IVC filter in right thigh
Neuro: AAOx3
RECTAL: Guiaic (-) in ED per notes.
Pertinent Results:
[**2135-7-15**] Chest CT: Massive bilateral pulmonary emboli involving
the bilateral distal, lobar and multiple proximal segmental
pulmonary arteries. Focal gound glass opacity in the left upper
lobe may represent focal infarction, although follow up films
are recommended to ensure resolution.
[**2135-7-15**] CXR: The heart size and mediastinal contours are
normal. There is no pleural effusion or pneumothorax. The
lungs are clear.
[**2135-7-16**] ECHO - Right ventricular cavity enlargement with free
wall hypokinesis and preserved apical function c/w acute RV
pressure overload/pulmonary embolism.
[**2135-7-16**] LE Doppler - Occlusive intraluminal thrombus is seen
within the right distal superficial femoral vein extending
inferiorly into the right popliteal and calf veins.
.
EKG on admission: Sinus tachycardia. Inferior Q of waves
doubtful significance. Since previous tracing, rate faster.
.
admission labs:
[**2135-7-15**] 11:10AM D-DIMER-4016*
[**2135-7-15**] 11:10AM WBC-12.2* RBC-5.80 HGB-16.1 HCT-46.8 MCV-81*
MCH-27.7 MCHC-34.4 RDW-13.3
[**2135-7-15**] 11:10AM CK-MB-6 cTropnT-0.11
[**2135-7-15**] 11:10AM CK(CPK)-684*
[**2135-7-15**] 11:10AM UREA N-21* CREAT-1.4* SODIUM-137
POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-27 ANION GAP-19
[**2135-7-15**] 11:10AM GLUCOSE-68*
[**2135-7-15**] 08:30PM D-DIMER-4256*
[**2135-7-15**] 08:30PM NEUTS-66.6 LYMPHS-22.4 MONOS-5.5 EOS-3.4
BASOS-2.1*
[**2135-7-15**] 08:30PM WBC-10.7 RBC-5.63 HGB-16.0 HCT-45.0 MCV-80*
MCH-28.3 MCHC-35.4* RDW-13.4
[**2135-7-15**] 08:30PM CK-MB-5
[**2135-7-15**] 08:30PM cTropnT-0.03*
[**2135-7-15**] 08:30PM GLUCOSE-95 UREA N-24* CREAT-1.5* SODIUM-135
POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-24 ANION GAP-18
Brief Hospital Course:
This is 39 y/o M with h/o HTN who presents with intermittant
SOB, and hypotension found to have massive bilateral saddle
emboli
.
1) Pulmonary embolism - The patient was admitted with extensive
bilateral pulmonary emboli. As this is a very serious condition
and the patient was unstable in the ED (but responding to
fluids) the patient was admitted to the ICU and started on
heparin. In the ICU, he was hemodynamically stable, so no lytic
therapy was started. After transfer, the patient remained
stable, and his course on the floor was without events. He
remained on heparin and coumadin and we waited until he became
therapeutic, by closely monitoring his PT, PTT and INR and
adjusting his coumadin dose. As an outpatient he will remain on
coumadin and should have a hypercoaguability workup, TTE, and a
repeat chest CT.
.
2) Deep vein thrombus: The patient was noted to have an
intraluminal thrombus within the right distal superficial
femoral vein extending inferiorly into the right popliteal and
calf veins. As above, the patient was treated with heparin and
coumadin, but due to this large clot that had potential to break
off, he was placed with an IVC filter. The patient responded
well to the IVC filter and anticoagulation, and should have this
IVC filter in for life for protection.
.
3) Right Ventricular strain: On admission, the patient was noted
to have elevated troponins, and this was attributed to the right
ventricular strain from the pulmonary embolism. The case was
discussed with cardiology, and since he was hemodynamically
stable and responding to anticoagulation they felt lytic therapy
was unnecessary. The right ventricle is resilient and should
recover, in time. The patient had no problems during his
course, and will have a repeat ECHO in 3 months to revalute.
.
4) Anemia: The patient was noted to have a mild anemia. He was
hemodynamically stable, and we felt this could be followed up
further as an outpatient.
.
5) Hypertension - The patient was hypotensive on admission, and
in the setting of a pulmonary embolism, his blood pressure
medications were held. He remained normotensive during his
course, and therefore we continued to hold his medications as
they can be restarted as an outpatient.
.
6) Acute renal failure: On admission the patient presented with
a creatinine of 1.4, increased from his baseline of 1.0. This
improved with hydration, although increased again during the
course to 1.3. The Fena was calculated to be ~ 1% and therefore
assumed to be pre-renal. Hydration was provided and the patient
improved, leading to the diagnosis of pre-renal failure.
Medications on Admission:
Lisinopril 20mg QD
Claritin
Discharge Medications:
1. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day: You
can retake your home claritin.
2. Outpatient Lab Work
Please check PT, PTT, INR
3. Warfarin 2 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime):
take 8 mg daily.
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Pulmonary embolism
2. Deep vein thrombosis
3. Anemia
4. Mulculoskeletal pain
Discharge Condition:
stable, tolerating medications, afebrile
Discharge Instructions:
1. Please attend all appointments
2. Please take all medications as prescribed, we are holding
your lisinopril because your blood pressure was low. This
should be readdressed with Dr. [**Last Name (STitle) **].
3. Please return for worsening shortness of breath, chest pain,
vomiting, high fever and inability
4. Please have your labs drawn in 2 days (bring lab slip
prescription), at Dr.[**Name (NI) 6001**] office.
Followup Instructions:
1. Would have a repeat chest CT in 3 months
2. You need a repeat ECHO in 3 months
3. You need a work-up for hypercoagulability, which Dr. [**Last Name (STitle) **]
will help you coordinate.
4. You have an appointment with Dr. [**Last Name (STitle) **] (# [**Telephone/Fax (1) 250**]) on
Friday [**7-29**] at 9:50 am.
|
[
"415.19",
"276.52",
"453.42",
"401.9",
"285.8",
"429.9",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
8087, 8093
|
5103, 7725
|
319, 354
|
8216, 8258
|
3363, 4159
|
8724, 9043
|
2216, 2411
|
7803, 8064
|
8114, 8195
|
7751, 7780
|
8282, 8701
|
2426, 3344
|
276, 281
|
382, 1159
|
4291, 5080
|
4173, 4274
|
1658, 1675
|
1691, 2200
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
434
| 141,168
|
17319
|
Discharge summary
|
report
|
Admission Date: [**2101-6-14**] Discharge Date: [**2101-6-30**]
Date of Birth: [**2024-8-2**] Sex: M
Service: Blue Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old
male who presented to the emergency room with worsening
abdominal pain, nausea, and vomiting x 4.
The patient had recently been undergoing an evaluation for
painless jaundice. In early [**Month (only) 116**] the patient had an abdominal
CT at an outside hospital which demonstrated intrahepatic
ductal dilatation. On [**2101-6-10**] the patient came to [**Hospital1 1444**] and underwent an ERCP by the
GI team which demonstrated a pancreatic duct stricture, which
was compatible with a mass, a biliary stricture, and a stent
placement in the biliary system. The patient tolerated this
procedure well and during the admission when told that the
most likely [**Hospital1 **] was cancer, signed out against medical
advice.
At home over the next several days the family reported the
patient developed worsening abdominal pain accompanied with
nausea and vomiting. When this continued to worsen the
family brought the patient to the emergency room for further
evaluation.
PAST MEDICAL HISTORY: 1. Hypertension. 2.
Hypercholesterolemia.
PAST SURGICAL HISTORY: None.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: Unknown.
PHYSICAL EXAMINATION: On admission the patient was
tachycardic with a blood pressure of 110/41. He was alert
but agitated. The chest was clear. Heart was regular but
tachycardic. He had diffuse abdominal tenderness with
guarding and rebound. The rectal examination was normal and
guaiac negative.
LABORATORY DATA: White count 13, hematocrit 46, INR 2.1, BUN
80, creatinine 4.9, bicarbonate 11, ALT 84, AST 91, alkaline
phosphatase 545, bilirubin 10.
Chest x-ray demonstrated the possibility of free air
overlying the epigastrium.
HOSPITAL COURSE: Due to the presentation of an acute abdomen
following an ERCP and the possibility of free air the patient
was emergently taken to the operating room where he underwent
an exploratory laparotomy. A duodenal perforation was
discovered and repaired with oversewing and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] patch.
At that time also a jejunostomy tube was placed. The biliary
stent was removed and a T tube was placed as well. A liver
biopsy was taken as well. The patient remained tenuous
during the perioperative period. In the operating room he
received two units of packed cells, three units of fresh
frozen plasma, 3,000 of crystalloid. He did continue to make
urine and was postoperatively taken to the surgical intensive
care unit for close hemodynamic monitoring.
During the early postoperative course the patient's
hemodynamics were maintained with Neo-Synephrine pressor
support. The patient demonstrated improvement over the
ensuing days and the pressor support was weaned. The
hematocrit remained stable. The patient's renal function
improved with a significant drop in the creatinine. As the
patient improved, the respiratory support was weaned as well
as tolerated.
During this time with the sedation weaned the patient would
follow commands and appeared to be neurologically intact. By
postoperative day three the patient was extubated. The
jejunostomy tube feeds were started and advanced to goal.
The patient was maintained on broad-spectrum antibiotics. On
postoperative day number six the patient was transferred to
the floor. On the floor the patient had a temperature spike
which prompted a work-up and a CAT scan was performed. The
patient demonstrated multilocular retroperitoneal fluid
collection. He underwent a CT-guided drainage and the
cultures demonstrated [**Female First Name (un) 564**] from this collection. The
patient was started on AmBisome IV. Infectious disease was
consulted and the patient was maintained on the
broad-spectrum antibiotics as before as well. The patient
defervesced and a follow-up CAT scan done prior to discharge
demonstrates that the fluid collections have decreased in
size. The patient will be discharged with drains in place.
The patient was evaluated by physical therapy, has been
ambulating with no assistance and will not require intensive
rehabilitation.
The patient's tube feeds have been cycled at night and the
patient has been allowed to advance to a house diet which he
has tolerated.
The patient prior to discharge underwent a T-tube
cholangiography to examine the placement of the T-tube and
the anatomy of the biliary tree. This was normal with good
contrast entering the duodenum and the T-tube was capped
prior to discharge, which he has tolerated. The patient's
family had multiple meetings with his doctors regarding the
[**Name5 (PTitle) **] of presumed cancer. The patient's family and the
patient understand that without definitive tissue [**Name5 (PTitle) **],
the prognosis is unclear. The patient also does not want any
further invasive therapy at this time. The family would
rather have the patient be discharged to home, recover from
his current illness, and reassess the situation at a later
time during a follow-up visit. Arrangements are being made
for a visiting nurse.
The patient will be discharged home with VNA and cycled tube
feedings at night.
DISCHARGE DIAGNOSES:
1. Biliary stricture which is presumably a carcinoma but with
no definitive tissue [**Name5 (PTitle) **].
2. Duodenal perforation and repair.
3. Malnutrition.
4. Abdominal fungal abscess.
5. Hypertension.
DISCHARGE MEDICATIONS:
1. Levofloxacin 500 mg p.o. q.d. to be continued for one week
after drains have been removed.
2. Flagyl 500 mg p.o. t.i.d. to be continued for one week
after drains have been removed.
3. Fluconazole 400 mg p.o. q.d. to be continued until the
drains have been removed.
4. Lansoprazole 30 mg p.o. q.d.
5. Flomax 0.4 mg p.o. q.d.
6. Albuterol inhaler 4 puffs q. 6 hours p.r.n.
7. Dilaudid 2 mg p.o. q. 4 hours p.r.n.
8. Colace 100 mg p.o. b.i.d.
9. The patient will continue on medications as before.
DISCHARGE INSTRUCTIONS:
1. Wet-to-dry dressing changes to the abdominal wound b.i.d.
2. Drainage catheters #1 and #2 to gravity with daily volume
recording.
3. Tube feedings from 7 PM to 7 AM which would be ProMod with
fiber 70 mL per hour.
4. Two cans of Boost per day.
5. Diet as tolerated.
6. Jejunostomy tube should remain clamped during the day.
7. T-tube should be capped and remain underneath the
dressing.
8. No showers, but sponge baths as tolerated.
9. Activity as tolerated.
10. Continue antibiotics and antifungals as directed.
FOLLOW UP: The patient will follow up with Dr. [**First Name (STitle) **] in
the clinic in one week.
CONDITION ON DISCHARGE: Stable.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**]
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2101-6-29**] 12:18
T: [**2101-6-29**] 12:44
JOB#: [**Job Number 48472**]
|
[
"263.9",
"576.1",
"486",
"996.59",
"512.1",
"576.8",
"998.59",
"584.5",
"157.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93",
"51.51",
"54.91",
"87.54",
"46.39",
"97.55",
"96.6",
"44.42",
"50.12",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
5339, 5545
|
5568, 6067
|
1356, 1366
|
1924, 5318
|
6091, 6608
|
1268, 1329
|
6620, 6711
|
1389, 1906
|
173, 1177
|
1200, 1244
|
6736, 7019
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,879
| 114,661
|
55076+59650+59651
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2125-7-31**] Discharge Date: [**2125-8-17**]
Date of Birth: [**2050-3-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Dilaudid / Heparin Agents
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Shortness of breath, s/p NSTEMI at [**Hospital1 **]
Major Surgical or Invasive Procedure:
[**2125-8-6**] AVR(tissue)/CABGx1(SVG->PDA)
[**2125-8-4**] dental extractions
History of Present Illness:
75 year old male with known aortic stenosis was admitted to
[**Hospital **] Hospital with shortness of breath. He was at home and
was he was feeling short of breath and his wife checked his
oxygen level, which was in the 90's on 2.5L
of oxygen and gave him 40mg of Predinsone. After a little bit he
seemed to be breathing more labored and she called EMT and he
was brought to [**Hospital1 **]. In the ED he was found to have elevated
troponins. He was admitted and cathed the next day. He was
transferred to [**Hospital1 18**] for surgical evaluation.
Past Medical History:
COPD
CAD s/p MI with 2 stents placed [**2116**]
Diabetes Mellitus
Hypertension
Depression
Asthma
Hyperlipidemia
CVA resulting in short-term memory impairment [**2120**]
Peripheral vascular disease
h/o lung mass in left upper lobe which is being followed by
serial CT scans
Paroxysmal Atrial Fibrillation-not on coumadin
Esophageal Carcinoma
BPH
Aortic Stenosis
Congestive Heart Failure
Pacemaker placed [**6-/2125**] (for sick sinus syndrome)
Iron deficiency anemia
Achilles rupture-not repaired
Anxiety
H/O GI bleed ischemic Colitis
Gout
EtOH abuse
fatty liver by US [**2123**]
Past Surgical History:
s/p Esophagectomy with gastric pull through in [**2108**] w/ pre-op
chemotherapy and radiation therapy (at [**Hospital1 112**])
Left shoulder surgery
Angioplasty to right femoral artery [**2122**]
Unsuccessful angioplasty of the right superficial femoral artery
[**2122**]
s/p pacer placement [**6-/2125**]
s/p bilat cataract surgery
s/p dialation of GE junction [**3-/2124**] for stricture
Past Cardiac Procedures:
Dual Chamber Pacemaker placed [**2125-6-25**] model:
LAD stent placed [**2116**] at [**Hospital1 1774**]
LAD stent placed [**2122**] at [**Hospital1 1774**]
s/p MI with 2 stents placed [**2122**]
Social History:
Race:caucasian
Last Dental Exam:
Lives with:wife
Contact:[**Name (NI) **] (wife) Phone #[**Telephone/Fax (1) 112394**]
Occupation:retired quality assurance worker
Cigarettes: Smoked no [] yes [x] Hx:quit 20 years ago, 90-100
pack year history(3PPD)
Other Tobacco use:
ETOH: < 1 drink/week [] [**2-6**] drinks/week [x] >8 drinks/week []1
beer per night-much less than previous
Illicit drug use-denies
Family History:
non-contributory
Physical Exam:
Pulse:67 AV paced Resp:14 O2 sat:96% on 3 L NC
B/P Right:137/86 Left:
Height:5'7" Weight:88 kgs
General:
Skin: Dry [x] intact [x]
HEENT: pupils unequal-L4-5mm reactive, R2-3mm reactive EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest:increased AP diameter, Lungs rales bilat R>L, decreased
at
bases[]
Heart: RRR [x] Irregular [] Murmur [] grade [**3-6**] harsh SEM
radiating to carotids______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x] brown discoloration to
anterior LE consistent with venous stasis Edema [] none_____
Varicosities: None [x]
Neuro: awake, alert, oriented to self, place, knows year but not
date, president, not why he's in the hospital. many
difficulties
with recall of both short and long term events; grip strength
equal upper and knee flextion/extension equal lower extremities
Pulses:
Femoral Right:1+ Left:1+
DP Right:doppLeft:dopp
PT [**Name (NI) 167**]:doppLeft:dopp
Radial Right:1+ Left:1+
Carotid Bruit Right:murmur radiating Left:
murmur radiating
Pertinent Results:
ECHO:[**2125-8-8**]
The left atrium is mildly dilated. The right atrium is
moderately 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. Right ventricular chamber size is
normal. An aortic valve prosthesis is present. The aortic valve
prosthesis appears well seated, with normal transvalvular
gradients. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
puomonary artery systolic pressure could not be quantified.
There is an anterior fat pad.
IMPRESSION: Very suboptimal image quality. Norrmally functioning
aortic valve bioprosthesis. Grossly normal left ventricular
cavity size and global systolic function.
.
[**2125-8-16**] 07:50AM BLOOD WBC-6.1 RBC-2.95* Hgb-9.8* Hct-30.8*
MCV-104* MCH-33.2* MCHC-31.8 RDW-18.9* Plt Ct-95*
[**2125-8-15**] 03:41AM BLOOD WBC-6.2 RBC-3.02* Hgb-10.1* Hct-31.0*
MCV-103* MCH-33.5* MCHC-32.5 RDW-18.5* Plt Ct-69*
[**2125-8-14**] 03:03AM BLOOD WBC-5.4 RBC-2.65* Hgb-9.0* Hct-27.3*
MCV-103* MCH-33.9* MCHC-33.0 RDW-18.6* Plt Ct-57*
[**2125-8-17**] 05:30AM BLOOD PT-24.4* INR(PT)-2.3*
[**2125-8-16**] 07:50AM BLOOD PT-34.0* INR(PT)-3.3*
[**2125-8-15**] 03:41AM BLOOD PT-32.8* PTT-37.2* INR(PT)-3.2*
[**2125-8-14**] 12:26PM BLOOD PT-35.1* INR(PT)-3.4*
[**2125-8-14**] 03:03AM BLOOD PT-31.3* PTT-36.2 INR(PT)-3.0*
[**2125-8-13**] 02:49AM BLOOD PT-18.2* PTT-31.9 INR(PT)-1.7*
[**2125-8-12**] 02:24AM BLOOD PT-17.7* PTT-32.6 INR(PT)-1.7*
[**2125-8-11**] 02:44AM BLOOD PT-23.3* PTT-46.0* INR(PT)-2.2*
[**2125-8-10**] 04:56PM BLOOD PT-33.9* PTT-66.0* INR(PT)-3.3*
[**2125-8-16**] 07:50AM BLOOD Glucose-91 UreaN-14 Creat-0.6 Na-135
K-4.7 Cl-99 HCO3-27 AnGap-14
[**2125-8-15**] 03:41AM BLOOD Glucose-104* UreaN-10 Creat-0.5 Na-133
K-3.9 Cl-97 HCO3-28 AnGap-12
[**2125-8-14**] 12:26PM BLOOD UreaN-12 Creat-0.6 Na-130* K-4.3 Cl-97
HCO3-26 AnGap-11
[**2125-8-14**] 03:03AM BLOOD Glucose-80 UreaN-14 Creat-0.6 Na-132*
K-4.1 Cl-97 HCO3-32 AnGap-7*
Brief Hospital Course:
Mr. [**Known lastname 33668**] was admitted to [**Hospital1 18**] from [**Hospital **] Hospital where he
was diagnosed with an NSTEMI. He underwent a plavix load for a
cardiac cath showing single vessel disease and aortic stenosis
and was transferred to [**Hospital1 18**] for evaluation of surgical
revascularization. He underwent a thorough pre-op work up. He
was found to have several teeth requiring extraction prior to
surgery and on HD#3 he was taken to the operating room for
dental extractions of teeth #22, 23, 24, 25, 26, 27. He was
also found to have significant left ICA stenosis and a vascular
surgery consul was obtained from Dr. [**Last Name (STitle) 1391**]. Mr. [**Known lastname 33668**] will
require a carotid endarterectomy one month after cardiac
surgery. On HD# 5 he was taken to the operating room again
where he underwent Coronary artery bypass grafting x1 with the
saphenous vein graft to the posterior descending artery, Aortic
valve replacement with a [**Street Address(2) 6158**]. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 4041**] tissue valve,
serial #[**Serial Number 112395**], reference number [**Serial Number 112396**].
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. He was
hemodynamically labile in the immediate post-operative period
requiring pressor and inotropic support. Over the ensuing
post-operative days he was weaned from intropes and pressors and
was extubated. Post extubation he had lot to secretions and
tenious respiratory status. He received aggressive pulmoanry
toileting and avoided reintubation. He was also aggressively
diuresed. His BUN/creat remained stable. His CT's were removed
wihtout difficulty. He was very confused and at times combative,
he was started on seroquel but became too sedate and was
eventually restarted on all his preopertaive psych meds. He
remains pleasantly confused but nonfocal. He was
thrombocytopenic and was HIT negative x2. He was started on
coumadin low dose for pre-op and post-op afib.
Beta blocker was initiated and the patient was diuresed towards
his preoperative weight. The patient was transferred to the
telemetry floor on POD# 8 for further recovery. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD 11 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
to Ledgewood in [**Hospital1 **] in good condition with appropriate
follow up instructions.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from
PatientAtrius.
1. Albuterol-Ipratropium [**1-1**] PUFF IH Q4H
2. Aspirin 325 mg PO DAILY
3. BuPROPion 200 mg PO DAILY
4. Citalopram 40 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Digoxin 0.125 mg PO DAILY
7. Diltiazem Extended-Release 180 mg PO DAILY
8. Furosemide 20 mg IV BID
9. Heparin 5000 UNIT SC TID
10. NPH 10 Units Breakfast
NPH 10 Units Bedtime
11. MethylPREDNISolone Sodium Succ 40 mg IV Q 12H
12. Metoprolol Tartrate 25 mg PO BID
13. Pravastatin 40 mg PO DAILY
14. Pantoprazole 40 mg PO Q24H
15. Mucinex *NF* (guaiFENesin) 600 mg Oral [**Hospital1 **]
Discharge Medications:
1. Albuterol-Ipratropium 2 PUFF IH Q6H
2. Aspirin EC 81 mg PO DAILY
if extubated
3. BuPROPion (Sustained Release) 200 mg PO QAM
4. Citalopram 40 mg PO DAILY
5. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
6. Metoprolol Tartrate 25 mg PO BID
7. Mucinex *NF* (guaiFENesin) 600 mg Oral [**Hospital1 **] Reason for
Ordering: Wish to maintain preadmission medication while
hospitalized, as there is no acceptable substitute drug product
available on formulary.
8. Pantoprazole 40 mg PO Q24H
9. Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38.0
10. Bisacodyl 10 mg PR HS:PRN constipation
11. Captopril 12.5 mg PO TID
12. Clonazepam 0.5 mg PO QHS
13. Docusate Sodium 100 mg PO BID
14. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
15. FoLIC Acid 1 mg PO DAILY
16. Lactulose 30 mL PO TID
17. Potassium Chloride 20 mEq PO BID
Hold for K >4.5
18. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
19. Thiamine 100 mg PO DAILY
20. Warfarin MD to order daily dose PO DAILY
21. Furosemide 40 mg PO DAILY Duration: 10 Days
22. Pravastatin 80 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5682**] Rehabilitation and Skilled Nursing Center - [**Hospital1 **]
Discharge Diagnosis:
COPD
CAD s/p MI with 2 stents placed [**2116**]
Diabetes Mellitus
Hypertension
Depression
Asthma
Hyperlipidemia
CVA resulting in short-term memory impairment [**2120**]
Peripheral vascular disease
h/o lung mass in left upper lobe which is being followed by
serial CT scans
Paroxysmal Atrial Fibrillation-not on coumadin
Esophageal Carcinoma
BPH
Aortic Stenosis
Congestive Heart Failure
Pacemaker placed [**6-/2125**] (for sick sinus syndrome)
Iron deficiency anemia
Achilles rupture-not repaired
Anxiety
H/O GI bleed ischemic Colitis
Gout
EtOH abuse
fatty liver by US [**2123**]
Past Surgical History:
s/p Esophagectomy with gastric pull through in [**2108**] w/ pre-op
chemotherapy and radiation therapy (at [**Hospital1 112**])
Left shoulder surgery
Angioplasty to right femoral artery [**2122**]
Unsuccessful angioplasty of the right superficial femoral artery
[**2122**]
s/p pacer placement [**6-/2125**]
s/p bilat cataract surgery
s/p dialation of GE junction [**3-/2124**] for stricture
Past Cardiac Procedures:
Dual Chamber Pacemaker placed [**2125-6-25**] model:
LAD stent placed [**2116**] at [**Hospital1 1774**]
LAD stent placed [**2122**] at [**Hospital1 1774**]
s/p MI with 2 stents placed [**2122**]
Discharge Condition:
Alert and oriented x2 nonfocal
Ambulating with 4 person assist
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right - healing well, no erythema or drainage. 1+ lower ext
Edema. Multiple ecchymotic areas
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] MD Phone: [**Telephone/Fax (1) 170**] Date/Time:[**2125-9-13**] 1:15
Cardiologist: Dr [**Last Name (STitle) 28181**] [**Name (STitle) 81956**] [**2125-9-5**] @ 3:00pm
Vascular surgeon: Dr. [**Last Name (STitle) 1391**] [**Telephone/Fax (1) 1393**] -needs carotid
endarterectomy
[**9-12**] at 10:45 Am [**Last Name (NamePattern1) **] [**Hospital Unit Name 17173**]
Please call to schedule appointments with your
Primary Care Dr. ,[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 79695**] in [**4-5**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? afib/stroke
Goal INR [**2-2**]
First draw [**2125-8-18**]
Coumadin follow up to be arranged upon discharge from rehab
Completed by:[**2125-8-17**] Name: [**Known lastname 18448**],[**Known firstname 126**] J Unit No: [**Numeric Identifier 18449**]
Admission Date: [**2125-7-31**] Discharge Date: [**2125-8-17**]
Date of Birth: [**2050-3-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Dilaudid / Heparin Agents
Attending:[**First Name3 (LF) 135**]
Addendum:
Klonopin stopped prior to discharge. Patient not aggitated,
oriented x 2. Slept night prior to discharge with no Klonopin.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 13725**] Rehabilitation and Skilled Nursing Center - [**Hospital1 1263**]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**]
Completed by:[**2125-8-17**] Name: [**Known lastname 18448**],[**Known firstname 126**] J Unit No: [**Numeric Identifier 18449**]
Admission Date: [**2125-7-31**] Discharge Date: [**2125-8-17**]
Date of Birth: [**2050-3-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Dilaudid / Heparin Agents
Attending:[**First Name3 (LF) 135**]
Addendum:
Past Medical History:
COPD
CAD s/p MI with 2 stents placed [**2116**]
Diabetes Mellitus
Hypertension
Depression
Asthma
Hyperlipidemia
CVA resulting in short-term memory impairment [**2120**]
Peripheral vascular disease
h/o lung mass in left upper lobe which is being followed by
serial CT scans
Paroxysmal Atrial Fibrillation-not on coumadin
Esophageal Carcinoma
BPH
Aortic Stenosis
Chronic Diastolic Congestive Heart Failure
Pacemaker placed [**6-/2125**] (for sick sinus syndrome)
Iron deficiency anemia
Achilles rupture-not repaired
Anxiety
H/O GI bleed ischemic Colitis
Gout
EtOH abuse
fatty liver by US [**2123**]
Past Surgical History:
s/p Esophagectomy with gastric pull through in [**2108**] w/ pre-op
chemotherapy and radiation therapy (at [**Hospital1 10986**])
Left shoulder surgery
Angioplasty to right femoral artery [**2122**]
Unsuccessful angioplasty of the right superficial femoral artery
[**2122**]
s/p pacer placement [**6-/2125**]
s/p bilat cataract surgery
s/p dialation of GE junction [**3-/2124**] for stricture
Past Cardiac Procedures:
Dual Chamber Pacemaker placed [**2125-6-25**] model:
LAD stent placed [**2116**] at [**Hospital1 **]
LAD stent placed [**2122**] at [**Hospital1 **]
s/p MI with 2 stents placed [**2122**]
Brief Hospital Course:
The patient was extubated within 24 hours of surgery and did not
develop post-op respiratory failure.
He did require inotropic and vasopressor support
post-operatively, which is not unexpected. He did not have
post-op shock.
He has a history of chronic diastolic heart failure.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 13725**] Rehabilitation and Skilled Nursing Center - [**Hospital1 1263**]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**]
Completed by:[**2125-9-4**]
|
[
"V45.01",
"458.29",
"401.9",
"496",
"412",
"410.71",
"V15.3",
"780.93",
"287.5",
"443.9",
"600.00",
"438.0",
"599.0",
"427.31",
"433.10",
"V10.03",
"293.0",
"396.0",
"276.3",
"272.4",
"521.09",
"041.04",
"428.32",
"998.2",
"285.1",
"428.0",
"V45.82",
"414.01",
"V15.82",
"997.99",
"274.9",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"53.84",
"35.21",
"39.61",
"23.19",
"38.97",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
16834, 17102
|
16531, 16811
|
345, 425
|
12009, 12259
|
3832, 6032
|
13100, 14601
|
2681, 2700
|
9432, 10621
|
10772, 11351
|
8730, 9409
|
12283, 13077
|
15900, 16508
|
2715, 3813
|
253, 307
|
453, 1007
|
15280, 15877
|
2261, 2665
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,475
| 154,113
|
26281
|
Discharge summary
|
report
|
Admission Date: [**2159-6-15**] [**Month/Day/Year **] Date: [**2159-6-22**]
Date of Birth: [**2088-11-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Transferred from OSH s/p variceal bleed and banding of varices
for TIPS evaluation
Major Surgical or Invasive Procedure:
Esophageal banding prior to admission at [**Hospital1 18**]
TIPS during this admission
History of Present Illness:
Mr. [**Known lastname 931**] is a 70 yo M with history of NASH/alcoholic
hepatitis complicated by variceal bleeding admitted to an
outside hospital ([**Hospital 8641**] Hospital) for upper GI bleeding on
[**Last Name (LF) 766**], [**2159-6-11**] with a hematocrit of 24.7. He was admitted
to the outside hospital with complaints of dizziness and black
liquid stools x 2 days in addition to a small amount of bright
red blood per recutm on the day of admission. He complained of
nausea without emesis, "heartburn" and vague abdominal
discomfort. Patient was initially hypotensive but never required
pressors and was fluid responsive. He was taken for EGD where he
was found to have grade 3 varices which were banded. He was
started on octreotide drip, IV protonix and received 9 units of
packed red blood cells total. On [**2159-6-13**], patient was
taken for repeat EGD which showed gastric varices as well. RUQ
ultrasound was performed and showed no flow through a shunt that
was supposedly placed at [**Hospital1 18**] in [**2157-12-25**]; however, it was
later found that no TIPS had been placed during that visit. He
has not required any transfusions in the the last 48 hours prior
to admission.
.
Mr. [**Known lastname 931**] was transferred to [**Hospital1 18**] originally for a TIPS
revision, but later was found out not to have ever received
TIPS. On admission to [**Hospital1 18**], his hematocrit was 33.6. Patient
was also started on nadolol. Of note, the patient was started on
Zosyn for a few days but that was stopped as there was no
obvious infection going on (afebrile with negative blood
cultures).
.
His last admission in [**2158-12-25**] for upper GI bleed required 4
units of packed red blood cells. EGD at the time revealed grade
1 varices that were banded x 2.
Past Medical History:
1. alcoholic/non alcoholic steatohepatitis cirrhosis
2. history of portal hypertension
3. recurrent upper GI bleeding
4. history of thrombocytopenia
5. CAD
6. questionable hx of inflammatory bowel disease
7. history of diverticulosis
8. shortness of breath
9. gastroesophageal reflex
10. admission in [**12-31**] for bleeding varices
Social History:
Quit smoking in [**2120**]. Now drinks 1 quart/month. Used to have
max of five drinks/night in [**2131**] on Sat and Sun nights.
Family History:
No FH CAD, DM, CA.
Physical Exam:
VS: 99.1, 66, 147/68, 16, 98% RA
GEN: elderly obese male in no acute distress
HEENT: no scleral icterus, PERRL, MMM, JVP difficult to assess
LUNGS: mild basilar crackles
HEART: RRR, No M/R/G
ABD: distended, non tender, + bowel sounds, no hepatomegaly
noted. No caput visible.
EXT: No edema, warm, well perfused. +DP pulses bilaterally. No
asterixis.
Pertinent Results:
[**2159-6-16**] 12:16AM BLOOD WBC-6.2# RBC-3.80* Hgb-11.3* Hct-32.2*
MCV-85 MCH-29.6 MCHC-35.0 RDW-17.5* Plt Ct-89*
[**2159-6-16**] 05:50AM BLOOD Neuts-55.8 Lymphs-36.0 Monos-3.5 Eos-4.4*
Baso-0.3
[**2159-6-16**] 12:16AM BLOOD PT-14.3* PTT-28.8 INR(PT)-1.3*
[**2159-6-16**] 12:16AM BLOOD Glucose-100 UreaN-7 Creat-0.8 Na-140
K-4.1 Cl-112* HCO3-21* AnGap-11
[**2159-6-16**] 12:16AM BLOOD ALT-14 AST-24 LD(LDH)-148 AlkPhos-73
Amylase-37 TotBili-1.0
[**2159-6-16**] 12:16AM BLOOD Lipase-46
[**2159-6-16**] 05:50AM BLOOD Lipase-41
[**2159-6-16**] 12:16AM BLOOD Albumin-3.1* Calcium-7.9* Phos-2.3*
Mg-2.0
[**2159-6-20**] 03:39PM BLOOD Hct-34.9*
[**2159-6-21**] 10:30AM BLOOD Hct-31.7*
[**2159-6-22**] 06:05AM BLOOD WBC-5.2 RBC-3.64* Hgb-10.5* Hct-31.8*
MCV-87 MCH-28.9 MCHC-33.0 RDW-17.5* Plt Ct-98*
CHEST (PORTABLE AP) [**2159-6-16**] 3:19 AM
.
COMPARISON: [**2157-12-23**].
.
INDICATION: Upper GI bleed.
.
Cardiac silhouette is enlarged, and pulmonary vascularity
appears engorged and indistinct. Hazy opacities are present in
the perihilar and basilar regions accompanied by scattered
septal lines on the right, consistent with pulmonary edema from
either fluid overload or CHF.
.
RADIOLOGY
US ABD LIMIT, SINGLE ORGAN [**2159-6-16**] 10:38 AM
An addendum is issued in light of the patient's subsequent CT
and a more detailed history revealing that the patient does not
have a TIPS in situ. It is unclear as to the nature of the
apparent intrahepatic thrombosed vascular structure that was
visualized on the current examination, but there is a linear
hyperechoic tubular structure with contained echogenic debris.
It is that this represents a thrombus within a branch of the
portal vein. Given that the subsequent CT did not reveal
intrahepatic portal vein thrombosis, it is possible that the
findings represent a thrombus that is subsequently dislodged in
a hepatofugal fashion secondary to the patient's portal
hypertension.
.
CT ABD W&W/O C; CT PELVIS W/CONTRAST [**2159-6-17**] 4:45 PM
IMPRESSION:
1. TIPS not present.
2. Cirrhosis with associated splenomegaly, ascites and varices.
3. Non-occlusive thrombus in SMV extending into main portal
vein, which is widely patent.
.
US ABD LIMIT, SINGLE ORGAN [**2159-6-19**] 9:34 AM
IMPRESSION: Small amount of ascites, too small to [**Month/Day/Year **] safely
for paracentesis.
.
TIPS [**2159-6-20**] 7:51 AM
IMPRESSION:
1. Technically successful placement of a transjugular
intrahepatic portosystemic shunt (TIPS) using a 10 x 6.8 mm wall
stent.
2. Technically successful ablation and embolization of large
gastric varices using alcohol and microcoils.
.
US ABD LIMIT, SINGLE ORGAN [**2159-6-21**] 11:00 AM
IMPRESSION: 1) Patent TIPS.
US ABD LIMIT, SINGLE ORGAN [**2159-6-22**]
IMPRESSION: 1) Patent TIPS.
Brief Hospital Course:
1. Alcoholic/NASH cirrhosis: During hospitalization, the
patient complained of increasing abdominal girth. An U/S was
performed that showed very little ascites, so paracentesis was
not attempted. The patient's liver function tests and bilirubin
remained within normal limits throughout his admission. He was
continued on his regimen of nadolol, spironolactone, furosemide,
and ciprofloxacin x 7 days for SBP prophylaxis. There was some
confusion as to whether a TIPS had been placed at [**Hospital1 18**] in the
past. A CT of the abdomen showed that there was no TIPS, so
patient underwent the procedure on [**2159-6-20**], only with
complications from post-general anesthesia. He was started on
lactulose after TIPS placement. His post-TIPS abdominal
ultrasound showed patent TIPS. He had no complications.
.
2. Upper GI bleeding due to varices s/p banding at outside
hospital: Patient's hematocrit remained steady at 31-32. An EGD
on [**2159-6-18**] showed portal gastropathy and gastric varices.
He was given Protonix for prophylaxis. The outside hospital
started octreotide prior to this admission, and he completed the
remaining doses of a 5 day course at [**Hospital1 18**].
.
3. Chest Pain: Pt stated that he could not lose weight because
of "burning" chest pain with exertion. He did not have chest
pain during this admission. Protonix and calcium carbonate were
used for GERD. He is to follow up with outpatient cardiology
for this reported chest pain.
Medications on Admission:
Inderal LA 60 mg daily
Omeprazole 20 mg daily
Ferrous gluconate TID
[**Hospital1 **] Medications:
1. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*32 Tablet(s)* Refills:*2*
2. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*64 Tablet(s)* Refills:*2*
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*32 Tablet(s)* Refills:*2*
4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
Disp:*64 doses* Refills:*0*
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day) as needed.
[**Hospital1 **] Disposition:
Home
[**Hospital1 **] Diagnosis:
Primary diagnoses:
1. Alcoholic/NASH cirrhosis s/p TIPS
2. Upper GI bleeding
Secondary diagnoses:
1. Gastroesophageal reflux
2. Chest Pain
[**Hospital1 **] Condition:
Stable
[**Hospital1 **] Instructions:
You had an upper gastrointestinal bleed due to esophageal
varices that was controlled by banding. You also had a TIPS
procedure completed to help with your cirrhosis.
If you have a fever>100.4, bloody vomit, bright red blood per
rectum, dizziness and lightheadedness, chest pain or shortness
of breath that cannot be relieved, you should call your primary
care physician or report to the nearest ER.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 10285**] (hepatology) [**Telephone/Fax (1) 2422**] on
[**2159-7-24**] @ 12pm.
.
You have an abdominal ultrasound scheduled for [**2159-7-24**] @
10 am, on the [**Hospital Ward Name 517**], [**Location (un) 470**]. Do no drink or eat
anything the morning before the ultrasound.
.
You need to schedule a cardiology outpatient appointment for
your reported chest pain at ([**Telephone/Fax (1) 2037**].
.
Please call your PCP: [**Name10 (NameIs) **],[**First Name3 (LF) 251**] [**Telephone/Fax (1) 39243**] to schedule a
follow-up appointment.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2159-6-23**]
|
[
"303.90",
"456.8",
"530.81",
"572.3",
"456.20",
"578.9",
"287.5",
"571.2",
"571.8",
"070.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.79",
"39.1",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
6031, 7507
|
411, 500
|
3245, 6008
|
8837, 9579
|
2839, 2859
|
7533, 7603
|
2874, 3226
|
8301, 8380
|
289, 373
|
8168, 8174
|
7633, 8138
|
528, 2316
|
8202, 8280
|
2338, 2674
|
2690, 2823
|
8411, 8814
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,375
| 192,276
|
10505+56134
|
Discharge summary
|
report+addendum
|
Admission Date: [**2171-9-18**] Discharge Date: [**2171-10-1**]
Date of Birth: [**2109-9-5**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 51 year old man
who was recently discharged on [**9-13**] to [**Hospital 38**]
[**Hospital **] Hospital with the discharge diagnosis of
coronary artery disease, status post coronary artery bypass
grafting times four with left internal mammary artery to the
left anterior descending coronary artery, saphenous vein
graft to the diagonal, saphenous vein graft to obtuse
marginal #1, and saphenous vein graft to obtuse marginal #2,
hypertension, hypercholesterolemia, benign prostatic
hypertrophy, atrial fibrillation, status post tracheostomy
and asthma. The patient returned on [**9-18**], with
complications of operative procedure/scleral dehiscence
requiring exploration requiring Robicsek weave on [**9-5**].
The patient was discharged to [**Hospital 34638**] rehabilitation.
The patient was seen in the office on [**9-18**] and found to
have sternal drainage with unstable lower sternum. The
patient also was status post emergent tracheostomy placement
after difficulty with intubation with the patient prior to
coronary artery bypass graft.
REVIEW OF SYSTEMS: The patient's review of systems on
admission was without fevers, chills, bleeding, shortness of
breath with change in appearance, positive for increased
drainage.
PAST MEDICAL HISTORY: Past medical history includes coronary
artery disease, hypertension, hypercholesterolemia, atrial
fibrillation, benign prostatic hypertrophy and asthma and
incentive tracheostomy.
MEDICATIONS ON ADMISSION: Lasix 20 q.d., Kayciel 20 q.d.,
Amiodarone 200 q.d., Lopressor 75 t.i.d., Aspirin 81 q.d.,
Ranitidine 150 q.d., Terazosin 5 q.d., Pravastatin 20 q.d.,
Flovent 2 puffs b.i.d., Albuterol 2 puffs q. 4 prn,
Salmeterol 2 puffs b.i.d., Singulair 10, Percocet 5/325 one
to two tablets q. 6 prn, Vancomycin 1 gm b.i.d., Levaquin 500
q.d., Coumadin on hold.
PHYSICAL EXAMINATION: The patient was afebrile with stable
vital signs on admission and generally in no acute distress.
Head, eyes, ears, nose and throat examination was supple with
moist mucous membranes without erythema, without
lymphadenopathy and without bruit. #6 Shiley tracheostomy was
placed. Pupils equal, round and reactive to light with
extraocular movements intact, anicteric. Respiratory was
clear to auscultation on the left with decreased breathsounds
on the right, upper one-third. Cardiac examination was
regular rate and rhythm, S1 and S2, without murmur, rubs or
gallops. Sternum with click, lower one-third positive
serosanguinous drainage with erythema. Abdomen was soft,
nontender, positive bowel sounds. Extremities were warm and
well perfused.
HOSPITAL COURSE/LABORATORY DATA: The patient was continued
on Vancomycin and Levofloxacin, and placed on cardiac diet
and transfused 2 units of packed red blood cells for a
hematocrit of 26.9. The patient's other laboratory values
included a white count of 7.9, platelets 487, INR 2.2, sodium
139, potassium 4.1, chloride 102, bicarbonate 24, BUN 10.4,
creatinine 1.0 and glucose of 94 with random Vancomycin level
of 2.1. Plastic Surgery saw the patient on the date of
admission and noted unstable lower extremity drainage and
recommended proceeding to the Operating Room for exploration
and closure [**9-19**]. The patient was taken to the
Operating Room on [**9-19**] and continued on cardiac
medications of Lopressor 75 t.i.d., Amiodarone 200 q.d. and
Lasix. Postoperatively the patient did well, however,
required two units of blood immediately postoperatively.
Pulmonary Medicine consulted on postoperative day #1,
increased Flovent and recommended to discontinue Metoprolol.
The patient remained intubated on postoperative day #1
through 2 and the patient was extubated on [**2171-9-20**].
The patient continued to do well throughout the hospital
course with some low-grade temperature. The patient's rectus
flap was in place and the wound was clean, dry and intact
postoperatively throughout the hospital course. The
patient's asthma continued to be managed by pulmonary consult
team and Plastic Surgery continued to follow the patient's
rectus flap wound closure. Physical therapy continued
evaluating the patient through day of admission and
throughout peri and postoperative period. On postoperative
day #6 moderate drainage was still noted from the sternal
wound site, however, it was decreasing. Tracheostomy was
changed to cuffless #4 Shiley buttoned, and the patient had
good vocalization. On [**9-26**], the patient was continued
on antibiotics of Levofloxacin, Flagyl and Vancomycin, and
Lopressor was discontinued on [**9-25**]. Diltiazem was
started on [**2128-9-26**] q.i.d. with continuing of Lasix and
Amiodarone 200 q.d. The patient complained of some
tremulousness of bilateral lower extremities times one day on
[**9-27**] and Neurology was consulted and recommended
watching clinically and checking panel of laboratory data
including liver function tests and TSH which were normal.
The patient was discharged on postoperative day #12,
[**2171-10-1**], in good condition to [**Hospital 38**]
Rehabilitation with the following diagnoses.
DISCHARGE DIAGNOSIS:
1. Wound dehiscence, status post rectus flap closure,
coronary artery disease status post coronary artery bypass
grafting times four.
2. Hypertension
3. Hypercholesterolemia
4. Benign prostatic hypertrophy
5. Atrial fibrillation
6. Status post tracheostomy
7. Asthma
DISCHARGE DISPOSITION: The patient is to be discharged to
rehabilitation at [**Hospital 38**] [**Hospital **] Hospital. He has
follow up with Dr. [**Last Name (STitle) 70**] and follow up with his primary
care physician as well.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern4) 10197**]
MEDQUIST36
D: [**2171-9-30**] 15:48
T: [**2171-9-30**] 16:43
JOB#: [**Job Number 34639**]
Name: [**Known lastname **], [**Known firstname 126**] Unit No: [**Numeric Identifier 6040**]
Admission Date: [**2171-9-18**] Discharge Date:
Date of Birth: [**2109-9-5**] Sex: M
Service:
ADDENDUM TO PRIOR DISCHARGE:
MEDICATIONS ON DISCHARGE:
1. Aspirin 81 mg po q.d.
2. Amiodarone 200 mg 1 po q.d.
3. Diltiazem 60 mg, 1 po q.i.d.
4. Protonix 40 mg, 1 po q.d.
5. Multivitamin.
6. Ascorbic acid 500 mg, 1 po b.i.d.
7. Levofloxacin 500 mg, 1 po q.d.
8. Solu-medrol >..........<50 mcg disc, 1 disc po b.i.d.,
9. Inhalations b.i.d.
10. Montelukast sodium 10 mg tablet, 1 po q.d.
11. Fluticasone propionate 110 mcg aerosol with adapter, 8
puffs inhalation b.i.d.
12. Quifenadine 600 mg by mL syrup, [**6-8**] mL po q. 6.
13. Zinc sulfate 220 mg, 1 po q.d.
14. Percocet #5, 325 mg tablet, 1-2 tablets po q. 4 hours as
needed for one week.
15. Terazosin 5 mg capsule, 1 capsule po q.h.s. at bedtime.
16. Vancomycin 500 mg, 6 mL solution, 8 mL po twice a day for
33 days to give 1 gram of vancomycin b.i.d. times 33 days.
DISCHARGE STATUS: Patient is to be discharged to [**Hospital 6041**]
Rehabilitation Center in [**Location (un) **], [**State 1145**].
Patient also had tracheostomy removed and dry sterile
dressing should be placed over tracheostomy site with wound
care.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 2728**]
Dictated By:[**First Name3 (LF) 4140**]
MEDQUIST36
D: [**2171-10-1**] 03:32
T: [**2171-10-1**] 15:40
JOB#: [**Job Number 6042**]
cc:[**Hospital 6043**]
|
[
"998.32",
"272.0",
"493.90",
"E878.2",
"V55.0",
"600.0",
"427.31",
"401.9",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.82",
"77.61",
"97.23",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5585, 6356
|
5286, 5561
|
6382, 7743
|
1663, 2013
|
2036, 5265
|
1268, 1432
|
183, 1248
|
1455, 1636
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,841
| 113,354
|
29202
|
Discharge summary
|
report
|
Admission Date: [**2144-3-16**] Discharge Date: [**2144-3-17**]
Date of Birth: [**2097-12-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
none
History of Present Illness:
46 yo f with hx of EtOH abuse, who presented at ER after being
found down at a McDonald's appearing intoxicated. Pt was
unresponsive in [**Last Name (un) 8491**] and brought to ER. She had a bottle of
trazadone that was Rx early in [**Month (only) 404**] with the appropriate
amount of tabs remaining. Pt smelled of etoh. She does not
remember what happen today, but states she usually drinks about
a pint of vodka a day. She denies other drug use. She does
report a recent productive cough, but is unclear about the
details. She c/o chronic LBP. She denies CP, SOB, and GI sx.
.
On arrival to the ER pt VS were reported 96.7 90 89/63 12 94;
however [**Name8 (MD) **] MD pt was not hypotensive and BP was in 110s. Pt had
a CXR concerning for a RML infiltrate and was given levo 750mg,
and flagyl. Also given thiamine, folate, and MV. Pt started to
awake and was responsive to verbal stimuli. 3 liters of NS was
given including banana bag. Initially pt was low 90s% sats on
[**Last Name (LF) **], [**First Name3 (LF) **] a nasal trumpet was placed and pt was 100% on 4 liters.
Pt was admitted to MICU for observation and concern for
continued AMS. VS at transfer were 98.1 89 103/65 20 100% on 4
liters.
.
On the floor, pt is more awake but confused and a poor
historian.
Past Medical History:
-etoh use
-low back pain, s/p surgery
Social History:
Pt is homeless, lives at a shelter. Is single, reports a 12 yo
child, but unclear where the child is. Reports drinking a pint
of vodka a day. +tobacco use, but unclear on amount. Denies drug
use.
Family History:
NC
Physical Exam:
Vitals: 98.2 98 102/66 15 90% on RA
General: Alert, not oriented except to person and season
HEENT: Sclera anicteric, MMM, oropharynx with secretions
Neck: supple, no LAD
Lungs: diffuse rhonchi, + wheezes, bronchial breath sounds
CV: Regular rate and rhythm, no M, 2+ pulses
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley removed
Ext: warm, no edema, no clubbing
at time of leaving AMA, pt was orientated and had capacity
Pertinent Results:
[**2144-3-17**] 01:43AM BLOOD WBC-5.0 RBC-3.70* Hgb-12.0 Hct-37.7
MCV-102* MCH-32.5* MCHC-31.9 RDW-14.9 Plt Ct-460*
[**2144-3-16**] 07:50PM BLOOD WBC-6.7# RBC-3.82* Hgb-12.7 Hct-38.7
MCV-101* MCH-33.2* MCHC-32.8 RDW-14.7 Plt Ct-495*
[**2144-3-17**] 01:43AM BLOOD Neuts-56.1 Lymphs-39.3 Monos-3.8 Eos-0.4
Baso-0.3
[**2144-3-16**] 07:50PM BLOOD Neuts-52 Bands-2 Lymphs-36 Monos-7 Eos-0
Baso-0 Atyps-3* Metas-0 Myelos-0
[**2144-3-16**] 07:50PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-OCCASIONAL Schisto-OCCASIONAL
Burr-OCCASIONAL
[**2144-3-17**] 01:43AM BLOOD Glucose-75 UreaN-6 Creat-0.5 Na-146*
K-3.8 Cl-115* HCO3-22 AnGap-13
[**2144-3-16**] 07:50PM BLOOD Glucose-97 UreaN-6 Creat-0.6 Na-143 K-4.0
Cl-110* HCO3-23 AnGap-14
[**2144-3-17**] 01:43AM BLOOD ALT-95* AST-172* LD(LDH)-236 AlkPhos-74
TotBili-0.2
[**2144-3-16**] 07:50PM BLOOD ALT-105* AST-172* AlkPhos-80 TotBili-0.2
[**2144-3-17**] 01:43AM BLOOD Calcium-6.9* Phos-3.1 Mg-1.6
[**2144-3-16**] 07:50PM BLOOD ASA-NEG Ethanol-568* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2144-3-16**] 07:56PM BLOOD Glucose-94 Lactate-2.2*
[**2144-3-16**] 08:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2144-3-16**] 08:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2144-3-16**] 08:00PM URINE Hours-RANDOM
[**2144-3-16**] 08:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2144-3-17**] 1:43 am SPUTUM Site: EXPECTORATED
**FINAL REPORT [**2144-3-17**]**
GRAM STAIN (Final [**2144-3-17**]):
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2144-3-17**]):
TEST CANCELLED, PATIENT CREDITED.
cxr
AP UPRIGHT BEDSIDE RADIOGRAPH OF THE CHEST: There is a hazy
opacity with a
central more dense consolidation in the right lower lobe. Linear
left lower lobe opacity is also present, the configuration of
the latter however favors atelectasis. There is no pleural
effusion or pneumothorax. There is no pulmonary edema. Heart
size is upper limits of normal. Hilar contours are unremarkable.
IMPRESSION: Right lower lobe opacity, could reflect pneumonia or
perhaps
aspiration. Differential considerations include atelectasis and
clinical
correlation is advised.
The study and the report were reviewed by the staff radiologist.
CT head
FINDINGS: There is no intra- or extra-axial hemorrhage, mass
effect, or shift of normally midline structures. The ventricles
and sulci are normal in size and configuration and the [**Doctor Last Name 352**] and
white matter differentiation is well preserved. There is no
acute major vascular territorial infarct. The basilar cisterns
appear preserved. There is no herniation. There is mucosal
thickening in bilateral ethmoid air cells and in the right
maxillary sinus. No acute fracture is seen.
IMPRESSION: No acute intracranial process.
Brief Hospital Course:
46 yo f with hx of etoh abuse, presented to ER after being found
unresponsive at a McDonald's, with suspected etoh intoxication.
# Etoh intoxication: pt has known hx of etoh use, on admission
alcohol level was 568. This is likely the cause of the pt's AMS,
since it improved after staying in the ICU overnight. Serum and
urine tox were only positive for etoh. Pt was given a banana bag
and 2 liters NS in ER. During the night pt became combative and
required a code purple while still intoxicated. She briefly was
in 4 point restraints since she still had an AMS. She was given
Ativan and improved. In the morning, pt did not want to go to a
detox center and once her MS had cleared she requested to leave
AMA. Pt was able to understand the risks and benefits of leaving
10:30AM.
# Aspiration PNA: on exam had diffuse rhonchi and some wheezing.
Pt was producing thick white sputum. CXR was concerning for
aspiration, which pt is at risk for due to intoxication. She
was given levo and Flagyl while admitted. She refused to stay
for further tx. She stated she would go to her homeless clinic
today. At time of leaving the sputum cx was contaminated and the
blood cx were pending. She remained afebrile and no longer was
hypoxic.
# Transaminitis: Mild elevation, likely [**3-10**] to etoh
# Bandemia: 2% bands, concerning for infection. Pt likely has a
PNA. UA was negative. This may also explain mild elevation of
lactate. However, pt also had some atypical cells initially.
However on repeat labs and bands and atypical cells were not
seen.
Attending and fellow were notified that pt left.
Medications on Admission:
trazadone
tramadol (currently off)
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
left AMA
Discharge Condition:
left AMA
Discharge Instructions:
left AMA
Followup Instructions:
left AMA
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2144-3-17**]
|
[
"338.29",
"507.0",
"305.01",
"724.5",
"790.4",
"288.66"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7330, 7336
|
5618, 7216
|
327, 333
|
7388, 7398
|
2466, 5595
|
7455, 7630
|
1925, 1929
|
7301, 7307
|
7357, 7367
|
7242, 7278
|
7422, 7432
|
1944, 2447
|
284, 289
|
361, 1634
|
1656, 1696
|
1712, 1909
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,401
| 115,480
|
3607
|
Discharge summary
|
report
|
Admission Date: [**2120-6-10**] Discharge Date: [**2120-6-12**]
Date of Birth: [**2052-10-18**] Sex: F
Service: MEDICINE
Allergies:
Poison [**Female First Name (un) **] / Metallic Poisoning, Agents To Treat / Naprosyn /
Silvadene / Adhesive / nickel metal
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Referred for repeat flutter/pulmonary vein isolation
Major Surgical or Invasive Procedure:
Pulmonary Vein Isolation
History of Present Illness:
67 yo F with hx of bacterial endocarditis s/p porcine MVR in
[**2112**] and MP/MR, Afib/flutter s/p cardioversions, and pulmonary
vein isolation in [**9-/2119**] who intially presented for repeat
flutter/pulmonary vein isolation and subsequently became
hypotensive requiring pressor support in the cath [**Year (4 digits) **] after
sedation.
.
Of note, patient was recently admitted from [**5-29**] to [**2120-5-31**] to
[**Hospital1 18**] c/o rapid palpitations due to atrial tachycardia with HR
15-150. During her admission quinidine was d/c and metoprolol
was initiated for rate control. She was discharged on metoprolol
150 mg daily.
.
In the cath [**Last Name (LF) **], [**First Name3 (LF) **] anesthesia report the pt was intubated and
given fentanyl, propofol and midazolam. Her BPs remained stable
for fisrt 3 hours of the case and then subsequently became
hypotensive with SBPs in the 90s. She was started on
phenylephrine for pressure support. She was given 3L of NS and
then 20 mg IV lasix with 1L of UOP.
.
Currently, her only complaint is generalized itching. She denies
any CP, SOB, palpitations, lightheadedness.
.
On review of systems, she denies any prior history of stroke,
TIA, pulmonary embolism, bleeding at the time of surgery, cough,
hemoptysis. 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 chest pain,
DOE, PND, orthopnea, LE edema, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, -HTN
2. CARDIAC HISTORY:
Atrial Fibrillation s/p 7 cardioversions
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
-History of bacterial endocarditis [**2108**]
-Porcine mitral valve replacement [**2112**]
-Hypothyroidism
-Rheumatoid arthritis
-History of bleeding ulcer
-Low back pain
-Status post foot surgery with titanium implant
-Laminectomy
-Appendectomy
-Endometriosis
-Right oophorectomy
Social History:
-Tobacco history: denies
-ETOH: denies
-Illicit drugs: denies
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Physical Exam
GENERAL: NAD. Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, MMM
NECK: Supple with no JVD
CARDIAC: RR, normal S1, S2. systolic murmur at RLSB
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: + bowel sounds. Soft, NTND.
EXTREMITIES: No c/c/e. No evidence of hematoma at L. groin.
SKIN: dry
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
.
Discharge Physical Exam
vitals: BP 80s-90s/50s
Gen: NAD
HEENT: NCAT, MMM
NECK: no JVD
CV: RRR, normal s1/s2
Resp: CTAB
ABD: soft, NT/ND
Ext: no peripheral edema bilaterally
Skin: warm, dry
Pertinent Results:
Admission Labs:
[**2120-6-10**]
WBC-4.0 RBC-4.75 Hgb-11.5* Hct-35.7* MCV-75* MCH-24.2* MCHC-32.2
RDW-18.7* Plt Ct-324
PT-22.9* INR(PT)-2.1*
Glucose-96 UreaN-22* Creat-1.2* Na-139 K-3.8 Cl-103 HCO3-26
AnGap-14
.
Discharge Labs:
[**2120-6-12**]
WBC-4.9 RBC-3.60* Hgb-8.5* Hct-26.6* MCV-74* MCH-23.6* MCHC-31.9
RDW-18.5* Plt Ct-210
PT-37.3* INR(PT)-3.8*
Glucose-80 UreaN-20 Creat-1.1 Na-137 K-4.1 Cl-106 HCO3-24
AnGap-11
.
Other Results:
ECG ([**6-12**]): "Slow" atrial flutter or atrial tachycardia with 2:1
response. ST-T wave changes are non-specific. Since the previous
tracing of [**2120-6-10**] the rhythm as [**Date Range 4030**] has replaced atrial
fibrillation.
.
ECG ([**6-10**]): Atrial fibrillation with rapid ventricular response.
Modest ST-T wave changes are non-specific.
Brief Hospital Course:
67 yo F with atrial flutter s/p multiple cardioversions and
pulmonary vein isolation in [**9-/2119**] who presented for repeat
pulmonary vein isolation. Pt's post-procedure course was
complicated by hypotension and return to atrial
flutter/fibrillation.
.
#Hypotension: Patient became hypotensive to the 90s systolic
during pulmonary vein isolation procedure and initially required
pressor support in the cath [**Year (4 digits) **]. This hypotension was most
likely due to the fact that a) this patient's baseline SBP is in
the low 100s and b) the anesthetics used during the procedure
(she received fentanyl, propofol, and midazolam) contributed
significantly to a drop in pressures. In the cath [**Year (4 digits) **], she was
started on phenylephrine for pressure support and she was given
3L of NS and then 20 mg IV lasix with 1L of urine output. In the
CCU, the pt was mentating well, her hematocrit was stable, she
had no signs of infection, and she maintained good urine output
so pressors were weaned the same evening. On transfer to the
floor on [**6-11**], her blood pressures were recorded to be in the
mid 70s systolic though pt was asymptomatic at the time and
again showed no signs of infection or acute blood loss. She
received a 500cc bolus of fluid and her calcium channel blocker
was held. Her pressures gradually improved to the 90s systolic
where she remained until discharge.
.
#Atrial flutter/fibrillation - Pt is s/p multiple cardioversions
and a previous pulmonary vein isolation and she presented for
repeat pulmonary vein isolation. Immediately following the
procedure, the patient was in sinus rhythm but the evening of
[**6-11**] the patient complained of some palpitations and she was
noted to be tachycardic to the 100s, up from 50s previously. ECG
at the time showed atrial flutter with 2:1 conduction. Her blood
pressures remained stable and the patient was otherwise
asymptomatic. She received 5mg IV Lopressor, 50mg PO Lopressor
and 40mg PO verapamil with some improvement of her rate but no
conversion of her rhythm. Per electrophysiology, she was started
on verapamil 40 mg po TID and quinidine 648 po q8. She converted
back into sinus rhythm for a few hours on [**6-11**] but in the late
evening, she was found to be in atrial fibrillation with rates
in the 90s. She continued to alternate between sinus and atrial
arrhythmias throughout the night though she remained
asymptomatic and hemodynamically stable throughout. Patient was
discharged on quinidine; her beta-blocker and CCB were held in
the setting of her low blood pressures (again though this is
likely pt's baseline) and she was given [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor
and was instructed to follow-up with EP.
.
Chronic Diagnoses
.
#MR s/p porcine valve replacement - Stable. Continued
anticoagulation with coumadin.
.
#Hyperlipidemia - Stable. Continued simvastatin.
.
#GERD - Stable. Continued protonix.
.
#Hypothyroidism - Stable. Continued synthroid.
.
#Insomnia - Stable. Continued ambien.
.
Transitional Issues
.
Patient will follow-up with EP this week regarding her
medication adjustments and her [**Doctor Last Name **] of Hearts event recorder
results.
Medications on Admission:
levothyroxine 88 mcg po qd
protonix 40 mg po qam
verapamil ER 120 mg po qd
metoprolol succinate 150 mg po qday
warfarin 5 mg po qd
ASA - 81 mg po qhs
amoxicillin - 500 mg tablet - 4 tabs po 1 hr before dental
procedure
estradiol - 10 mcg po q Tuesday and Friday
ranitidine 300 mg po qhs
ambien 10 mg po qhs prn
diazepam 10 mg po qhs for insomnia
simvastatin 40 mg po qhs
artifical tears
vitamin D
colace
MVI
Discharge Medications:
1. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: Do
not take until Friday [**2120-6-14**] after INR drawn and after talking
to Dr. [**First Name (STitle) 679**].
2. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
7. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: Two (2)
Tablet PO at bedtime.
8. multivitamin Tablet Sig: One (1) Tablet PO at bedtime.
9. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
10. diazepam 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
11. estradiol 10 mcg Tablet Sig: One (1) tablet Vaginal every
Tuesday and Friday.
12. Artificial Tears Drops Sig: Three (3) drops Ophthalmic
twice a day.
13. ranitidine HCl 300 mg Capsule Sig: One (1) Capsule PO at
bedtime.
14. quinidine gluconate 324 mg Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q8H (every 8 hours).
Disp:*240 Tablet Extended Release(s)* Refills:*2*
15. Outpatient [**First Name (STitle) **] Work
Please check CBC, INR on Friday [**6-14**] with results to Dr. [**First Name (STitle) 679**]
at [**Telephone/Fax (1) 250**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Atrial fibrillation/flutter
Secondary Diagnosis:
Dyslipidemia
Hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a pumonary vein isolation procedure to try to eliminate
your atrial fibrillation. During the procedure you had some low
blood pressure and needed to be on a medicine intravenously to
keep your blood pressure up. Your blood pressure has been better
but still somewhat low since the procedure. You are now in a
normal sinus rhythm. We have adjusted your medicines to try to
keep you in a regular sinus rhythm. Please keep the follow up
appts below, Dr.[**Name (NI) 12467**] office is working on an earlier
appt for you. Please call his office if you notice any
palpitations, pain at the groin sites, dizziness or
lightheadedness. We made the following changes to your
medicines:
1. Stop taking Verapamil and metoprolol
2. Start taking quinidine again and increase the dose to 2
tablets every 8 hours.
3. Do not take coumadin today or tomorrow, please check your INR
on Friday with results to Dr. [**First Name (STitle) 679**] and he will tell you how much
coumadin to take from then on.
3. Continue your other medicines as before
.
[**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) 16403**] can be reached at ([**Telephone/Fax (1) 16404**] Office Location:
W/[**Location (un) **] 407 to discuss further use of the Lifewatch monitoring
system. For now you will need to use the [**Doctor Last Name **] of Hearts Loop
recorder and send daily transmissions to the holter [**Doctor Last Name **].
Followup Instructions:
Department: MEDICAL SPECIALTIES
When: MONDAY [**2120-7-1**] at 9:30 AM
With: [**First Name11 (Name Pattern1) 3972**] [**Last Name (NamePattern4) 3973**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: TUESDAY [**2120-7-30**] at 11:20 AM
With: [**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: THURSDAY [**2120-9-5**] at 7:30 AM
With: RADIOLOGY [**Telephone/Fax (1) 327**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INTERNAL MEDICINE
When: WEDNESDAY [**2120-6-26**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 143**], MD [**Telephone/Fax (1) 142**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
NOTE: Please call the office if you have any issues before
then.
|
[
"780.52",
"E879.8",
"272.4",
"427.31",
"530.81",
"427.32",
"V42.2",
"V12.71",
"714.0",
"244.9",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.27",
"37.34",
"37.26"
] |
icd9pcs
|
[
[
[]
]
] |
9465, 9471
|
4281, 7492
|
437, 464
|
9608, 9608
|
3472, 3472
|
11197, 12454
|
2641, 2756
|
7950, 9442
|
9492, 9492
|
7518, 7927
|
9759, 11174
|
3699, 4258
|
2771, 3453
|
2118, 2232
|
345, 399
|
492, 2020
|
9560, 9587
|
3488, 3683
|
9511, 9539
|
9623, 9735
|
2263, 2545
|
2042, 2098
|
2561, 2625
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,262
| 146,381
|
48314
|
Discharge summary
|
report
|
Admission Date: [**2189-7-9**] Discharge Date: [**2189-7-31**]
Date of Birth: [**2134-8-19**] Sex: M
Service: MEDICINE
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
hyperkalemia found on routine labs
Major Surgical or Invasive Procedure:
Bone Marrow Biopsy
Kidney Biopsy
Skin Biopsy
History of Present Illness:
54 y/o M s/p OLT [**10-2**] and CRT [**11-1**] secondary to Hep C,
post-transplant cryoglobulinemia, h/o endocarditis, anemia, and
CHF who presents w/hyper K (6.7) found on routine lab draws and
elevated Cr (3.2 up from 2.3). Recurrent hepatitis and MPGN
([**4-2**]) on the liver and kidney biopsy respectively. S/p
plasmapheresis, prednisone, and rituximab on admission in [**Month (only) **].
He was recently started on a regimen of lisinopril and diovan.
.
Was admitted to transplant surgery, where he received Calcium
gluconate, Kayaxelate, and Insulin/D50. He got serial EKGs and K
checks.
.
Past Medical History:
ESLD from Hepatitis C
h/o ETOH abuse
ESRD from Hepatitis C and Membranous Proliferative
Glomerulonephritis
Nephrolithiasis
CHF
h/o Endocarditis/Sepsis
Anemia
h/o Herpes Zoster
OLT [**2188-10-21**]
CRT [**2188-10-21**]
L AVF x3
Social History:
Married. H/o of alcohol abuse in past; quit alcohol use 3y ago.
Quit tobacco 3y ago after 80 pack-year history. H/o IVDU [**2153**]'s.
Family History:
Mother with CAD. Father with [**Name2 (NI) **] CA
Physical Exam:
VS T98.7 BP134-148/69-81 HR72-85 RR20 02sat:96-99%3L
Is/Os 180/2500cc in 18 hrs. Wt 77.4 kg
GEN: Middle aged male, lying in bed, NAD
HEENT: PERRL, EOMI, anicteric, nl conjunctiva, MM dry, OP clear
CVS: Reg, nml s1,s2. no gallops or rubs
LUNGS: CTAB, decreased breath sounds at bases bilaterally, no
w/c/r
ABDOMEN: +BS, soft, obese, NT/ND
EXT: 1+ LE edema, 1+ DP and 1+ radial pulses
NEURO: 5/5 strength UE and LE,
Skin - no erythema or rash, well healed bx site left leg,
stitches in place
Pertinent Results:
sinus CT([**7-12**]): Minimal sinus disease involving left maxillary
sinus.
.
CXR [**7-13**]: Chronic right pleural effusion and pleural
thickening.
.
CXR-P [**7-16**]: New left lower lobe patchy opacity concerning for
possible pneumonia. Increased mild pulmonary edema. Chronic
right pleural effusion and pleural thickening.
.
CXR pa/lat [**7-16**]: Increasing patchy peripheral opacities in the
left mid and lower lung zones, which may be due to a developing
pneumonia in this patient with fever. Increasing small left
pleural effusion.
Chronic right pleural thickening.
.
CXR pa/lat [**7-18**]: Congestive failure. Bilateral air space
disease may be on the basis of edema or bilateral infection,
left more than right.
.
Neck US [**7-19**]: In the right neck, there is an echogenic lesion
measuring 1.4 x 4.2 cm. No focal fluid collection or mass is
identified on either side of the neck. There is no evidence of
edematous changes within the skin. Lesion in the right neck may
represent an enlarged lymph node or a small lipoma.
Brief Hospital Course:
- 54 y/o M s/p OLT [**10-2**] and CRT [**11-1**] secondary to Hep C,
post-transplant cryoglobulinemia, recurrent hepatitis C, MPGN,
h/o endocarditis, anemia, and CHF who was admitted to Transplant
Surgery on [**7-9**] w/hyper K (6.7) and acute on chronic renal
failure(3.2 up from 2.3). His hyperkalemia was managed medically
(insulin, kayexelate, calcium gluconate) and, given concern that
recently initiated lisinopril/diovan was contributing to his
renal failure, these were discontinued. In addition, cyclosporin
was discontinued and he was started on rapamycin.
.
On [**2189-7-19**] he developed new neck swelling which progressed over
the next several days. [**7-20**] neck MRI showed diffuse, symmetric
bilateral soft tissue edema from the parotid glands to the
clavicles. Rapamycin was discontinued (given possible drug
reaction) and, given new fevers and concern for infection,
Unasyn was started. ENT was consulted [**7-20**]; fiberoptic scope
showed airway edema, and he was transferred to the MICU for
continuous O2 monitoring/airway protection.
.
In the MICU, his neck swelling was felt to most likely represent
med reaction (nifedipine vs rapamycin). He was continued on IV
dexamethasone with gradual improvement of neck edema ([**7-21**]
ifiberoptic scope showed near clomplete resolution of airway
edema). Initially, he was continued on Unasyn for concern about
new submental soft tissue infection + levo for possible LLL PNA.
His neck soft tissue infection, however Unasyn was discontinued
[**7-22**] given low suspicion of neck soft tissue infection. MICU
course was remarkable for (+) HSV swab, for which he was
initially on acyclovir, subsequently changed to valacyclovir. He
also developed progressive pancytopenia, attributed to
azothiaprine (which was started 8/16 per Dr. [**Last Name (STitle) 497**].
Azathioprine was discontinued and he was started on neupogen
[**7-22**]. He underwent biopsy of renal transplant [**7-23**].
Pt was weaned off of high dose steroids that were started out of
concern for swelling around his airway. Tacrolimus was initiated
to replace rapamycin as an immunopsuppressant. His levels were
followed daily with a goal of >5. Shortly after start of this
medication, the patient developed a macular erythematous rash on
the posterior/lateral aspect of both lower extremities spairng
the heel/soles and much of the dorsum of the foot. Derm was
consulted who biopsied the rash and results supported
leokocytoclastic vasclulitis possibly from cryoglubinemia. This
rash resolved over the next several days with initiation of
plasma [**Month/Year (2) **]. The patient's renal biopsy results showed
evidence of ongoing MPGN c/w with ongoing cryoglobulinemia.
However, the patient's LFT's and HCV viral load have remained
normal and undetectable, respectively. Hem/Onc was consulted
early in his course to r/o a lymphoproliferative disorder to
account for his ongoing cryoglubinemia. A bone marrow biopsy did
not show evidence of this. A port was placed in the OR on [**7-29**]
and plasma [**Month/Day (4) **] was initaited afterwards to address ongoing
cryoglubinemia. Pt has 3 sessions of plasma [**Month/Day (4) **] and was
discharged on [**7-31**] with plans for ongoing outpatient plamsa
[**Month/Day (2) **].
Pt was ruled out for HIT with antibotdy serologies 2 X during
his hospital stay. His thrombocytopenia was thought to be due to
recent azathioprine and hypersplenism.
Pt complained of wrist pain on the day of discharge thought to
be due to a gout flare (? cryglobulinea) and was given stress
dose prednisone 40mg PO QD X 5days.
Pt was discharged in good condition, without pain, feeling well,
to follow up with plasmapheresis 3x/week.
Medications on Admission:
1. OsCal 500"
2. Cyclosporine 100"
3. Prednisone 7.5'
4. Bactrim ss'
5. Protonix 40"
6. Fenofibrate 40'
7. Valsartan 80"
8. Baking soda 1tsp'
9. Metoprolol 150"'
10. Neurontin 300'
11. Epogen 60k wed
12. Ribavirin 200'
13. Lisinopril 40'
14. Hydralazine 30""
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
2. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution Sig:
Thirty (30) ML PO DAILY (Daily).
Disp:*900 ML(s)* Refills:*0*
3. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for
4 days.
Disp:*8 Tablet(s)* Refills:*0*
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
once a day.
Disp:*90 Tablet(s)* Refills:*0*
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO QHS (once a day (at bedtime)).
Disp:*60 Tablet, Chewable(s)* Refills:*0*
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet* Refills:*0*
7. Epoetin Alfa 20,000 unit/mL Solution Sig: One (1) Injection
Injection QMOWEFR (Monday -Wednesday-Friday): or 60,000 units
per week as previously prescribed.
Disp:*QS Injection* Refills:*0*
8. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*0*
9. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
Disp:*12 Tablet(s)* Refills:*0*
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
11. Valsartan 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
12. Nifedipine 90 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
13. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
14. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day:
Please begin on [**8-5**] after 4 days of prednisone 40mg dose.
Continue on prednisone 10mg indefinitely until otherwise
specified.
Disp:*30 Tablet(s)* Refills:*1*
15. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO twice a
day.
Disp:*224 Capsule(s)* Refills:*0*
16. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
17. Outpatient Lab Work
Please check CBC with plasmapheresis on Tuesday, [**8-4**]. Please
fax results to Dr.[**Name (NI) 948**] office at ([**Telephone/Fax (1) 3618**].
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Renal Failure
Hyperkalemia
neck swelling
pneumonia
anemia requiring transfusion
thrombocytopenia
leukocytoclastic vasculitis
gout
cryoglubinemia
Discharge Condition:
Afebrile. hemodynamically stable, tolerating full diet,
ambulating without difficulty
Discharge Instructions:
1. Please call Dr. [**Last Name (STitle) 497**] for any questions or concerns. Please
return to the nearest ER if you experience bleeding, fever,
chest pain, or any other worrisome symptoms.
.
2. Please take all medications as directed.
.
3. Follow up with Dr. [**Last Name (STitle) 497**] as scheduled below.
.
4. Please follow up for plasmapheresis as scheduled below.
Followup Instructions:
Please follow-up with the Renal [**Hospital 1326**] clinic with Dr.
[**Last Name (STitle) **] within 1-2 weeks ([**Telephone/Fax (1) **])
Provider: [**Name10 (NameIs) 1248**],BED ONE [**Name10 (NameIs) 1248**] ROOMS Where: [**Name10 (NameIs) 1248**] ROOMS
Date/Time:[**2189-8-4**] 9:15
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 5628**]
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2189-8-5**] 3:40
Provider: [**Name10 (NameIs) 1248**],ISOLATION ROOM [**Name10 (NameIs) 1248**] ROOMS Where: [**Name10 (NameIs) 1248**]
ROOMS Date/Time:[**2189-8-6**] 10:15
Completed by:[**2189-8-8**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,735
| 160,282
|
29950
|
Discharge summary
|
report
|
Admission Date: [**2120-11-25**] Discharge Date: [**2120-12-8**]
Date of Birth: [**2074-4-6**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 14037**]
Chief Complaint:
Fever, lethargy
Major Surgical or Invasive Procedure:
Gastric tube placement [**2120-12-4**].
History of Present Illness:
HPI: Patient is a 46 yo female with history of poorly controlled
HIV/AIDS, not on HAART, with last CD4 9, VL 329,000 who
presents for fever, lethargy, and latered mental status. The
patient was seen in the E.D. by covering attending, Dr.
[**Last Name (STitle) 71526**] prior to transfer to floor.
The patient is reported to have poor mental status at baseline,
following some commands, but without significant interaction.
The patient has been noted over the last 2 -3 days to have
increasing lethargy, ? increasing secretions from her mouth, and
now feves to 102 today at nursinf facility where she lives. The
patient is transferred to [**Hospital1 18**] for further eval of these
symptoms.
.
In the ED the patient had WBC of 7.4 with left shit, 5% bands,
lactate 2.6. A CXR was negative for acute process but UA was +
with leuks. A CT Head was performed, initially interpeted as
negative, although second eval by ED raised question of a ring
enhancing lesion. Given this lesion, decision was made not to
perform LP at this time but treat empirically with CTX/Vanc at
meningeal dosing. Blood and urine cultures were obtained and the
patient is now transferred to the floor for further eval.
Attempts were made to obtain an MRI in the ED but patient's
brother/HCP were not successful.
.
The patient was seen previously at [**Hospital1 2177**] in [**Month (only) **] [**Numeric Identifier **] for
altered mental status although at that time was without fever or
white count. The patient refused MRI and LP with a non-reactive
RPR. Patient seen by psych and assessed to be without capacity.
The patient's son [**Name (NI) 653**] and gave consent. MRI at that time
revealed significant atrophy and periventricular white matter
densities likely related to HIV, and no other acute process. The
patient's delta MS at that time was thought likely [**12-27**] seizure
disorder and or HIV dementia and patient was D/C back to
facilty.
.
.
Labs/Data:
UA:+
WBC: 7.4 ( N:77 Band:5 L:6 M:12 E:0 Bas:0 Nrbc: 1) <- 1.3 on
[**2120-10-22**]
Hct: 32.3
Plt: 77
Lactate: 2.6
CK: 3078 MB 3 Trop: < .01
Blood/Urine cxs pending
.
[**2120-11-24**]:
WBC 4.0
Hct: 27.4
Plt: 67
.
ECG: ST, 136, nml axis, nml intervals. No acute ST or TW changes
.
Imaging:
.
[**2120-11-25**]: CT Head
There is no intra- or extra-axial hemorrhage, mass effect, or
shift
of normally midline structures. There is no major vascular
territorial infarction. Diffuse low attenuation in the
periventricular white matter is consistent with chronic
microvascular infarction. Moderately large air-fluid levels are
seen in bilateral maxillary sinuses. A small amount of fluid is
seen within the sphenoid air cells bilaterally, and scattered
ethmoid air cells. No fracture is identified.
.
[**2120-11-25**]: Portable Chest
1. No acute pulmonary process.
2. Speckled calcifications in the abdomen adjacent to the L2 and
L3 vertebral bodies consistent with pancreatic calcifictions
from prior episodes of pancreatitis.
.
.
A/P: Patient is a 46 year old female with med history
significant for poorly controlled HIV/AIDS, seizure disorder,
history of FTT/AIDS dementia who now presents with altered
mental status, fevers with left shift concerning for underlying
infectious process
.
#. Fever/Delta MS - Patient with altered MS in setting of likely
infection. Patient with +UA but prudent to treat for meningitis
until this can be ruled out. Given ? for ring enhacing lesion in
ED, LP not performed until MRI could be performed, however no
shift or edema noted. Plan to continue empiric treatment
otherwise as per attending on admission
- patient received CTX, Vanc in [**Last Name (LF) **], [**First Name3 (LF) **] continue this. Given
HIV/AIDS status however would add Ampicillin for Listeria
coverage at this time until Bacterial meningitis ruled out
- patient with MRI in late Novemeber without ring enhancing
lesion, not clear one is present now given CT read by rads. If
present, less likely malignancy such as lymphoma but could be
infectious such as toxo/crypto, although patient reportedly on
toxo ppx, also seems like this would be rapid development of
lesion as well
- continue attempts to reach family for MRI consent
- ID curbsided overnight who agrees with plan for empiric
coverage, MRI in a.m. LP will definitely be needed with CSF sent
[**Male First Name (un) 2326**] virus to eval for PML, Crypto, toxo, TB, etc. LP unable to be
performed overnight but not clear that MRI necessary first given
no evidence of elevated ICP on CT. Will check coags in the a.m.
in anticipation of LP
- toxo IgG in a.m., crypto serologies
- follow up blood/urine cultures
- significance of sinus air-fluid levels not clear, however
sinusitis would be covered with above coverage
- if symptoms persist EEG in a.m. for ? seizure activity
- continue outpatient anti-epileptics as possible
- as per outpatient notes as well, discussions regarding Code
Status prudent, full code currently
.
#. HIV/AIDS - patient with poorly controlled HIV, not on HAART
- repeat CD4/VL in a.m., unclear when last values from
- would not start HAART in acute setting given concern for
potential infection, particularly concern would be for
meningitis and immune reconstitution syndrome
.
#. Seizure disorder - patient's oral secretions may have been
[**12-27**] seizure, although still copious.
- continue Keppra per outpatient dosing, will attempt to place
NGT tonight given likely inability to take POs reliably
- consider EEG if symptoms persist
.
#. Pancytopenia - likely from underlying HIV, levels at baseline
currently
- monitor daily
.
#. FEN - NPO for now given delta MS
.
#. Access: PIV
.
#. PPx: SQ heparin, seizure ppx, PPI
.
#. Code: Full for now, need to discuss with family members
.
#. Dispo: Pending eval/improvement
.
#. Communication: [**Name (NI) **] [**Name (NI) 731**] -
Brother: [**Name (NI) **] [**Name (NI) 71527**] [**Telephone/Fax (1) 71528**]
Son: [**Telephone/Fax (1) 71529**]
Past Medical History:
HIV/AIDS: CD4 < 4, VL 329,000 not on HAART
- ? AIDS dementia/FTT
- PPD negative [**2120-11-3**]
- Pneumovax [**2120-10-24**]
Seizure Disorder
S/p Right MCA CVA [**2116**]
Pancytopenia
GERD
Bladder Incontinence
Social History:
The patient is a resident at [**Hospital **] [**Hospital 731**] nursing home. She is
reported to follow commands but have altered communication at
baseline
Tobacco: Previous use, unknown
ETOH: Previous abuse, amount unknown
Illicits: None reported
Family History:
NC
Physical Exam:
Vitals: T - 99.4 BP: 112/81 HR: 108 RR: 18 O2: 96% on 2L
General: Patient is a chornically ill appearing African-American
female. Patient is awake and looks around but does not interact.
Patient closes eyes to command but follows no other simple
commands. Patient resists mouth opening.
HEENT: NCAT, EOMI grossly. OP: Exam not performed, patient does
not open mouth, resists passive opening
Neck: Supple, no JVD
Chest: Relatively CTA anterior and laterally.
Cor: RRR, normal S1/S2. No M/R/G
Abdomen: Soft, NT, ND. +BS
Extremity: no C/C/E. DP 2+ bilaterally
Skin: No obvious rashes
Neuro: Patient awakre, orientation?. Closes eyes to command but
follows no other commands, non-verbal but cries out
intermittently during exam
CN II-XII without obvious defect, limited by cooperation
Motor/Sensation: Difficult to test
Pertinent Results:
Admission Labs:
142 106 41
------------<178
4.9 22 1.0
estGFR: 60/72 (click for details)
CK: 3078 MB: 3
.
11.5
7.4>---<77
32.3
N:77 Band:5 L:6 M:12 E:0 Bas:0 Nrbc: 1
Comments: Plt-Ct: Verified By Smear
Plt-Est: Very Low
.
Urine Cx: STAPHYLOCOCCUS, COAGULASE NEGATIVE
LP showed: WBC..RBC....Polys..lymphs..monos
tube#1.....[**Telephone/Fax (1) 71530**]...94.....3.......3
tube#4.....941..[**Numeric Identifier 42617**]..90.....4.......6
CSF gram stain negative
CSF culture negative
CSF cryptococcal negative
CSF viral ngtd
Serum showed:
serum toxoplasma negative
serum cryptococcal negative
EBV-PCR negative
HERPES 6 PCR negative
HERPES SIMPLEX VIRUS PCR negative
[**Male First Name (un) 2326**] VIRUS (JCV) DNA PCR negative
TOXOPLASMA GONDII PCR negative
.
CXR showed: Confluent opacity left base.
.
ECG: ST, 136, nml axis, nml intervals. No acute ST or TW changes
.
CT head w/o contrast [**2120-11-25**]:
FINDINGS: There is no intra- or extra-axial hemorrhage, mass
effect, or shift of normally midline structures. There is no
major vascular territorial infarction. Diffuse low attenuation
in the periventricular white matter is consistent with chronic
microvascular infarction. Moderately large air-fluid levels are
seen in bilateral maxillary sinuses. A small amount of fluid is
seen within the sphenoid air cells bilaterally, and scattered
ethmoid air cells. No fracture is identified.
NOTE ADDED AT ATTENDING REVIEW: There are no prior exams for
comparison.
The patient is considered to young for the amount large amounts
of
periventricular white matter hypodensity, which is greater on
the right. In addition, there is hypodensity of the right
caudate head. An underlying lesion cannot be excluded and an
MRI with gadolinium is needed for further evaluation.
.
Portable CXR [**2120-11-26**]:
A nasogastric tube has been inserted. Its tip overlies the
antrum of the stomach. The cardiac and mediastinal contours are
normal. The may be a small amount of retrocardiac left lower
lobe opacity. There is mild persistent elevation of the left
hemidiaphragm. No pleural effusion or pneumothorax is seen.
The osseous structures appear unremarkable.
IMPRESSION:
1. Nasogastric tube tip overlying the antrum of the stomach.
2. Possible left lower lobe opacity. Correlation with a
lateral view
recommended.
Brief Hospital Course:
A/P: 46 F w/ AIDS (CD4=9, VL=>300,000, not on HAART), prior
stroke, seizure disorder, and baseline dementia who presented on
[**2119-11-26**] with fever and altered mental status, diagnosed w/ ?
meningitis though determined to be unlikely per ID, ? pneumonia
(improved on CXR [**12-1**]), UTI, and angiodema s/p intubation for
airway protection improving on dexamethasone taper but unable to
swallow so s/p G tube placement.
.
1. Angioedema: Most likely reaction to B-lactam antibiotic in
context of PCN allergy. Pt did not receive asa, nsaids, acei,
although lack of pruritis and urticaria, as well as, location in
oral area suggestive of kinin-mediated agioedema. Improved after
dexamthasone, diphenhydramine and famotidine, taper dex starting
[**12-2**]. C4 normal, pointing away from C1 inhibitor, CH 50 NL,
parvovirus B19 pending neg, C1 inhibitor NL, other studies
pending. Edema improved and she is discharged on a steroid
taper.
.
2. CNS lesions: CSF difficult to interpret, but likely does not
represent meningitis. Spoke with pt's PCP, [**Name10 (NameIs) 1023**] agreed with
minimizing invasive tests such as reepat LP. Currently unable to
get MRI as she can not tolerate lying flat/managing her
secretions. No further CSF to send for flow cytometry. Otherwise
all studies negative to date, cultures no [**Last Name (un) 4904**] to date, monitor
mental/neurologic status.
.
3. UTI: positive for coag negative staph, s/p vanc x3 days,
surveillance UA with yeast, otherwise not looking infected,
foley d/c'd, no further treatment.
.
4. Seizure: No seizure activity noted, EEG suggesting
encephalitic picture, f/u neuro recs, continue Keppra IV, when
GI access will change to PO.
.
5. Mental status: Reportedly poor at baseline, likely below
where she previously was but stable, could represent clinical
impact of CNS lesions. Multiple causes for change in mental
status - infection, stroke, worsening HIV dementia.
.
6. GI access: Not able to swallow speech and swallow assessed
her and she needed PEG tube for alimentation which was placed by
IR [**2120-12-4**], with 2 packs platelets, but despite this and nl
coags (plt count increased appropriately) she continued to ooze
(hemodynamicly stable, hct stable). IR injected with thrombin
[**2120-12-6**] and placed prothrombotic dressing with improved but
minimally continuing oozing can attempted to feed via g tube
successfully. Of note had repeat speech and swallow [**2120-12-6**] and
found to be aspirating so recomended to remain NPO. Started on
hyoscyamine for copious oral secretions.
.
7. HIV/AIDS: (CD4=9, VL=>300,000, not on HAART), ID following
here, on azithromycin q week and SS bactrim daily for PPx.
.
8. Pancytopenia: Noted this hospital course, dropping wbc and
hct (unclear etiology), chronically low platelets (stable).
Could be that initial wbc represented stress response, and is
now back to baseline for pt with end-stage AIDS. Alternate would
be drug effect. Noted to have guaiac + stool [**2120-12-2**] but on
pantoprazole, hct stable. Pt recieved 2 uPRBC's [**2120-11-30**] with
appropriate improvement in hct that has been relatively stable,
will continue to monitor, guaiac all stools (+ [**2120-12-2**]). Pt also
received 2 packs of platelets prior to G tube placement.
.
9. Hyperglycemia: no known DM, likely [**12-27**] dexamethasone used to
treat angioedema, covered with SSHI, QID accu checks, will need
to continue this until blood glucose improved.
.
10. Inability to swallow: After angioedema pt noted not to be
able to swallow, had formal speech and swallow eval which she
failed, so she had G tube placed by IR. 24 hours after tube
placed she started tube feeds per nutrition recs, and tolerated
those. She was noted to have some blood oozing at the site 24
hours later. She will need to have the cotton-ball like anchors
(held by wires) removed on [**2120-12-8**] following discharge.
.
11. CODE: DNR/DNI-MICU team verified with son.
.
12. Communication: [**Name (NI) **] (son) [**Telephone/Fax (1) 71529**], [**Female First Name (un) 71531**]
[**Telephone/Fax (1) 71532**]
Medications on Admission:
Ferrous Sulfate 325 tid
Omeprazole 20mg daily
Batrim SS daily
Thiamine 100 daily
Folic Acid 1mg daily
MVI daily
Keppra 500mg [**Hospital1 **]
Azithromax 1200mg q Tuesday
Flonase daily
Nystatin S+S
Ensure
Discharge Medications:
1. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO every
thursday: via gtube.
2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily): via gtube.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Insulin Lispro (Human) 100 unit/mL Solution Sig: 2-8 units
Subcutaneous ASDIR (AS DIRECTED): Per sliding scale: 150-199 2
units,
200-249 4 units,
250-299 6 units,
300-349 8 units .
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
via gtube.
6. Keppra 100 mg/mL Solution Sig: Five Hundred (500) mg PO twice
a day: via gtube.
7. Prevacid 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO once a day: via gtube.
8. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours): as needed for pain, not to exceed 4
gm in 24 hours.
9. Hyoscyamine 0.15 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed for copious oral secretions.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] [**Location (un) 731**]
Discharge Diagnosis:
HIV with AIDS dementia, angioedema.
.
Seizure disorder, right MCA CVA in [**2116**], pancytopenia, urinary
incintinence
Discharge Condition:
Stable.
Discharge Instructions:
Please keep all follow-up appointments, please take all
medications as prescribed. Please notify your primary care
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5762**] ([**Telephone/Fax (1) 8417**] or return to the
Emergency department if you experience any chest pain,
difficulty breathing, bleeding, nausea, vomiting, diarrhea,
constipation, fevers, chills, cough, worsening of tongue or lip
swelling, change in mentation or any symptoms that concern you.
Followup Instructions:
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5762**] after discharge.
|
[
"995.1",
"284.1",
"E930.9",
"998.11",
"042",
"294.10",
"345.90",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"44.32",
"03.31",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15316, 15387
|
10015, 11707
|
289, 331
|
15551, 15561
|
7661, 7661
|
16128, 16244
|
6805, 6809
|
14344, 15293
|
15408, 15530
|
14115, 14321
|
15585, 16105
|
6824, 7642
|
234, 251
|
359, 6289
|
7677, 9992
|
11722, 14089
|
6311, 6523
|
6539, 6789
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,608
| 145,982
|
31933
|
Discharge summary
|
report
|
Admission Date: [**2104-9-7**] Discharge Date: [**2104-9-12**]
Date of Birth: [**2052-4-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
52 M w/ PMH of MVP presented to [**Hospital3 **] after collapsing
at a football field and was found to be unresponsive w/o a
pulse. Off-duty nurse [**First Name (Titles) **] [**Last Name (Titles) **]. ECHO at OSH w/ severe AS.
.
He states that he has been under a great deal of stress late
recently and had not been eating well. As he was walking down a
grass incline, he began to feel lightheaded. He sat down and
next awoke w/ bystanders around him. He believes that he was
unconscious for approximately 30 seconds. He thinks [**Last Name (Titles) **] was
briefly performed on him and that a "plastic airway" was placed.
He has not had an episode like this before except for possibly
when the wind was knocked out of him when playing ball at a
young age.
.
On arrival to the floor, he feels well without complaints.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
Past Medical History:
? SVT/afib (admitted to [**Hospital6 33**] 10 yrs ago)
R Rotator cuff repair
R Knee [**Doctor First Name **]
L Clavicle fx
nasal fx
Social History:
Social history is significant + tob, 1ppd X 14 yrs. There is no
history of alcohol abuse although he drinks 1-2 drinks
frequently. He is going through a divorce.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother passed away from [**Name (NI) 8751**]. Father has
arthritis and some form of cancer of the bone.
Physical Exam:
VS - 97.9, 120/81, 56, 18, 95% on RA
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with flat neck veins.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. IV/VI systolic murmur heard in RUSB; IV/VI
Systolic murmur heard at LLSB w/ radiation to axilla. No
thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. 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. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
[**2104-9-7**] 05:15PM BLOOD WBC-7.9 RBC-4.75 Hgb-15.1 Hct-43.6 MCV-92
MCH-31.8 MCHC-34.7 RDW-13.7 Plt Ct-214
[**2104-9-7**] 05:15PM BLOOD Neuts-56.1 Lymphs-33.3 Monos-6.9 Eos-2.7
Baso-1.0
[**2104-9-7**] 05:15PM BLOOD PT-11.6 PTT-31.3 INR(PT)-1.0
[**2104-9-7**] 05:15PM BLOOD Glucose-77 UreaN-14 Creat-0.9 Na-139
K-4.3 Cl-103 HCO3-27 AnGap-13
[**2104-9-7**] 05:15PM BLOOD CK(CPK)-48
[**2104-9-7**] 05:15PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2104-9-7**] 05:15PM BLOOD Calcium-9.4 Phos-4.7* Mg-2.4
[**2104-9-7**] 05:15PM BLOOD TSH-1.9
.
2D-ECHOCARDIOGRAM performed on [**2104-9-7**] demonstrated: EF 70%,
LVH, severe AS (valve area 0.9 cm2)
.
OSH:
Trop I 0.04 -> 0.12 -> 0.07
CK 90 -> 85 -> 56
.
Brief Hospital Course:
ASSESSMENT AND PLAN, AS REVIEWED AND DISCUSSED IN
MULTIDISCIPLINARY ROUNDS
Patient is a 52 M w/ pmh of SVT and MVP who presents s/p syncope
after exertion.
Syncope: OSH w/ ECHO showing severe AS w/ valve area of 0.9. He
also was found to have LVH so this could also be consistent w/
outflow-tract obstruction from HOCM. Also could have been [**1-18**]
VT. Currently hemodynamically stable without further symptoms.
If found to have HOCM, could be a candidate for alcohol septal
ablation vs surgical myomectomy. Would also potentially need an
ICD. If found to have critical AS as the cause, would likely
need AVR.
- tele
- ECHO
- low-dose metoprolol to inc filling time
CAD: no history. Had trop leak in the setting of [**Month/Day (2) **] so would
not consider this ACS.
- fasting lipids
Taken to the OR on [**9-9**], underwent AVR (tissue), please see
operative report for details of surgical procedure. He was
weaned from mechanical ventilation, and extubated the day of
surgery. His chest tubes were removed on POD # 1, and he was
transferred from the ICU to the telemetry unit. He has remained
hemodynamically stable, and is ready to be discharged home. Due
to relatively low BP (asymptomatic), he is being discharged with
no beta blockers per Dr. [**Last Name (STitle) 914**].
Medications on Admission:
None
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 5 days.
Disp:*10 Capsule, Sustained Release(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
AS
HTN
Discharge Condition:
good
Discharge Instructions:
no driving for 1 month
may shower, no bathing or swimming for 1 month
no lifting > 10# for 10 weeks
no lotions, creams or powders to any incisions
Followup Instructions:
[**Last Name (STitle) 17290**] in [**1-19**] weeks
with Dr. [**Last Name (STitle) 4469**] in [**1-19**] weeks
with Dr. [**Last Name (STitle) 914**] in 4 weeks
Please call for appointments
Completed by:[**2104-9-12**]
|
[
"401.9",
"458.29",
"285.9",
"424.1",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21",
"37.23",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
6078, 6097
|
3920, 5212
|
327, 352
|
6148, 6155
|
3199, 3897
|
6350, 6569
|
2092, 2280
|
5267, 6055
|
6118, 6127
|
5238, 5244
|
6179, 6327
|
2295, 3180
|
280, 289
|
380, 1739
|
1761, 1895
|
1911, 2076
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,142
| 136,148
|
23470+23471+57356
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2162-2-25**] Discharge Date: [**2162-4-5**]
Date of Birth: [**2101-4-3**] Sex: F
Service: NSU
REASON FOR CONSULTATION: Subarachnoid hemorrhage.
HISTORY OF PRESENT ILLNESS: This is a sixty year old female
who was transferred from [**Hospital3 1280**] Hospital for management
of a subarachnoid hemorrhage. She presented to that hospital
with a headache and a seizure, and then had a second
witnessed seizure. CT scan done noted hemorrhage in the pre
pontine cisterns extending through the ventricles, without
herniation. The patient was intubated after the second
seizure, and transferred to the [**Hospital1 188**] emergency department. She was loaded with Dilantin
prior to transport.
PAST MEDICAL HISTORY: None.
MEDICATIONS ON ADMISSION: None.
ALLERGIES: Tylenol and codeine.
FAMILY HISTORY: Unable to obtain.
SOCIAL HISTORY: Unable to obtain.
PHYSICAL EXAMINATION: Blood pressure was 152/90, heart rate
80. She was ventilated. Head, eyes, ears, nose and throat:
Normocephalic, atraumatic. Heart showed regular rate and
rhythm, no murmurs. Abdomen was soft and nontender. Lungs
were clear to auscultation bilaterally. Extremities showed
no cyanosis, clubbing or edema. On neurologic examination,
she moved to noxious stimuli bilaterally. Otherwise she was
sedated. Pupils were three to two bilaterally. She had
positive corneal reflexes. She did withdraw in the upper
extremities, right more so than left, and the same in the
lower extremities.
LABS AT TIME OF ADMISSION: White count 7.5, hematocrit 40.3,
platelets 225. Sodium 136, potassium 4.0, chloride 102,
bicarbonate 23, BUN 4, creatinine .6, glucose 161. PT 26.7,
INR 1.05. She underwent a CTA which did show a left A1
aneurysm. She had a ventricular drain placed on the left and
was then transferred to the angiogram suite, where Dr. [**Last Name (STitle) 1132**]
performed an angiogram and coiled her anterior communicating
aneurysm. Post-procedure, she was transferred to the
intensive care unit for close monitoring. She did sustain an
acute drop in her systolic blood pressure from the 130's to
the 80's, accompanied by bradycardia. EKG done did show some
flipped T waves in the precordial leads. Cardiology felt
that this was unlikely an acute coronary event, but rather
secondary to her intracranial pathology. However, they did
recommend obtaining an echocardiogram. Her troponins were
also elevated, but they were followed and they did trend
downward. She was on amlodipine to prevent vasospasm in the
cerebral arteries. Her goal blood pressure was less than
140. She received medications for this. She was covered on
cefazolin while her ventricular drain was in place. She did
have Keppra started for seizure prophylaxis. She was
extubated on [**2162-2-27**]. Her activity was increased to
out of bed. She was also followed with CT scans of her head,
which showed no new hemorrhage. Her hematocrit was followed
and was low on the 28th, and she was transfused with packed
red blood cells. She also had a chest x-ray that was
consistent with pulmonary edema, and she was diuresed. She
continued to be managed in the intensive care unit. Titrated
intravenous fluid to increase her cerebral perfusion, but not
overload her cardiac status. Her exam showed that she was
awake and alert. She did follow some commands, and her motor
strength did appear full. Echocardiogram did show a septal
defect. On [**3-4**], she did receive three units of fresh
frozen plasma for an elevated INR of 2.0. CT done on
[**3-4**] showed no evidence of spasm. Her vent drain was
increased in height. She was started on tube feedings for
nutrition.
Dictation ends.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2162-4-5**] 12:01:03
T: [**2162-4-5**] 12:21:40
Job#: [**Job Number 60139**]
Admission Date: [**2162-2-25**] Discharge Date: [**2162-4-5**]
Date of Birth: [**2101-4-3**] Sex: F
Service: NSU
ADDENDUM: This is the continuation of a Discharge Summary
that was started earlier.
HOSPITAL COURSE CONTINUED: On [**2162-3-12**] she
underwent both tracheostomy and placement of a PEG tube. She
ended up being evaluated by Neurology for her mental status
examination that was decreased in ability when compared to
her pre hospital stay. Recommendations included an EEG to
rule out ongoing seizure and correction of thyroid
abnormalities which could cause a fluctuation of mental
status. She was started on Synthroid, and TSH and free T4
were followed. She ended up having her Synthroid increased.
EEG results did show the patient had findings that may
indicate an increased risk for seizure activity but clear
epileptiform discharges were not seen.
On [**3-17**] her ventricular drain was removed and a
lumbar drain was inserted at its place with the goal of 10 to
15 cc of drainage per hour. On [**3-18**] the patient ended
up having a Passy-Muir valve placed. Her mental status exam
waxed and waned. She was sometimes following commands and
other times not. She did move extremities spontaneously.
She was seen by a Wound Care nurse [**First Name (Titles) **] [**Last Name (Titles) 60140**] on her
buttocks. On [**3-23**] the lumbar drain output was
decreased to 5 cc per hour. On [**2162-3-24**] she ended
up spiking a temperature to 102.4 rectally and was pan-
cultured. A chest x-ray did show right interstitial
opacities and a small right pleural effusion.
She was seen by Infectious Disease who recommended Zosyn for
her pneumonia. They also recommended to change her Foley.
She did have a urinalysis culture that was not consistent
with colonization, and therefore not felt to be a UTI. A
sputum culture did end up growing Pseudomonas and Infectious
Disease recommended double coverage with ciprofloxacin as
well as the Zosyn. As part of her pneumonia workup she had a
CT of the chest that did show a right upper lobe lesion and
recommended a repeat CT which was done one week later without
any change in appearance. After consultation with Pulmonary
it was recommended that this could be infection related and
she should continue on her full course of antibiotics. After
that time she could be re-imaged, and if the appearance is
unchanged she may need a needle biopsy at that point as it
was in a location that did not lend itself to bronchoscopy.
On [**2162-3-31**] the patient was brought to the Operating
Room where under general anesthesia she underwent placement
of a right frontal ventriculoperitoneal shunt.
Postoperatively, she was monitored in the Post Anesthesia
Care Unit for an appropriate amount of time and then was
returned to the floor. She was seen by Physical Therapy and
Occupational Therapy throughout this time. She was also seen
by Orthopedics on [**3-31**] for a question of hardware that was
palpable on the right distal femur. X-rays did confirm that
the plate was shifted and there was evidence of a broken
screw. However, it was recommended that if there was no skin
[**Month (only) 60140**] there was no further treatment recommended at this
time.
Endocrine was also consulted in regards to an enlarged
thyroid that was seen on the previously mentioned chest CT.
An ultrasound was recommended; however, due to her
tracheostomy this was unable to be performed. Endocrine felt
that she most likely had a benign goiter but did recommend an
ultrasound of the thyroid after the tracheostomy was out.
They also recommended following the TSH with the goal being
0.5. If the thyroid ultrasound showed any abnormalities she
would at that time need to follow up with Endocrinology.
DISCHARGE DIAGNOSES:
1. Subarachnoid hemorrhage.
2. Hydrocephalus.
3. Aspiration pneumonia.
4. Hypothyroidism.
5. Seizures.
6. Status post hardware placement in right femur.
7. Anemia.
MEDICATIONS ON DISCHARGE:
1. Clindamycin 4.5 grams IV q.8h. (which should be
discontinued on [**4-11**] after a total of 14 days).
2. Morphine 1 mg to 2 mg IV q.4.h. as needed (for pain).
3. Heparin 5000 units subcutaneously twice per day.
4. Metoprolol 12.5 mg p.o. twice daily (hold for a systolic
of less than 110 or heart rate less than 55).
5. Levothyroxine 50 mcg via NG daily.
6. Keppra 1000 mg p.o. twice daily.
7. Ascorbic acid 504 mg p.o. twice daily.
8. Zinc sulfate 220 mg p.o. once daily.
9. Famotidine 20 mg p.o. twice daily.
10. Miconazole powder 2 percent 1 application three
times daily as needed.
11. Ipratropium bromide nebulizer q.4-6h. as needed.
12. Albuterol nebulizer solution q.4-6h. as needed.
13 Aspirin 81 mg p.o. once daily.
1. Docusate sodium 100 mg p.o. twice daily.
2. Bisacodyl 10 mg per rectum at bedtime as needed.
DISCHARGE DISPOSITION: The patient will be transferred to a
rehabilitation hospital once a bed is available.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2162-4-5**] 13:23:21
T: [**2162-4-5**] 16:40:00
Job#: [**Job Number 60141**]
Name: [**Known lastname 11012**],[**Known firstname 4176**] Unit No: [**Numeric Identifier 11013**]
Admission Date: [**2162-2-25**] Discharge Date: [**2162-4-12**]
Date of Birth: [**2102-1-30**] Sex: F
Service: NEUROSURGERY
Allergies:
Codeine / Acetaminophen
Attending:[**First Name3 (LF) 10598**]
Addendum:
patient has remained neurologically unchanged. She was having
some bleeding from her trach. General surgery did a bronchoscopy
on her which did not show anything, since then she continues to
have some pink tinged sputum, but no frank blood as before. Her
condition as otherwise remained stable. she will followup with
[**First Name8 (NamePattern2) **] [**Name8 (MD) 365**] MD in one month.
Chief Complaint:
Subarachnoid hermorrhage
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2876**] - [**Location (un) 3542**]
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 10600**]
Completed by:[**2162-4-12**]
|
[
"482.1",
"518.81",
"428.0",
"780.39",
"507.0",
"430",
"305.1",
"707.8",
"599.0",
"584.9",
"276.0",
"786.3",
"240.9",
"285.9",
"996.4",
"331.4",
"745.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"38.91",
"33.21",
"03.31",
"96.72",
"99.07",
"02.39",
"39.72",
"38.93",
"96.6",
"02.34",
"99.04",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
9976, 10187
|
848, 867
|
7753, 7919
|
7945, 8795
|
790, 831
|
926, 7732
|
9927, 9953
|
215, 733
|
756, 763
|
884, 903
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,963
| 109,433
|
781
|
Discharge summary
|
report
|
Admission Date: [**2191-5-9**] Discharge Date: [**2191-5-13**]
Date of Birth: [**2120-12-22**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5606**]
Chief Complaint:
Chief Complaint: LLE pain and SOB
Reason for MICU transfer: close hemodynamic monitoring
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 70 yo M with a hx of PE/DVT [**8-23**] whose
anticoagulation was recently stopped [**3-30**] after a neg CTA and
negative doppler study, who now presents with recurrent DVT/PE.
He reports experiencing left sided lower extremity edema that
has been present since his initial DVT presentation [**8-23**]. This
became significantly work for the past 2 days, along with left
foot pain. He presented to [**Hospital3 **], where he was
found to have an extensive DVT in the LLE and was given a dose
of lovenox 100 mg at 0220 and coumadin 10 mg at 0200. He also
reportedly endorsed some discomfort and a CTA revealed a saddle
PE. He was subsequently transferred to [**Hospital1 18**] for further
management. Pt reports he is only minimally ambulatory due to
"pinched nerves in the spine" that have been active for the past
2.5 years. He has been even less active more recently, given
that he experiences LLE radicular pain and SOB with any
ambulation after about one minute. He does feel his SOB was
particularly worse this past friday and believes his blood clots
are related to his lack of ambulation.
In the ED, initial VS were: 97.6 57 188/77 16 99% 2L Nasal
Cannula. Reportedly a bedside u/s showed no right heart strain.
ECG showed did not show RHS, but did show old inferior and
possible anterior infacts. Labs were notable for a proBNP of 565
and a negative trop.
On arrival to the MICU, the patient states he feels
uncomfortable, but this is due to his chronic radicular pain.
He denies feeling chest discomfort, SOB, palpitations or
dizziness.
Review of systems:
Per HPI, also reports recent bout of diarrhea about 1 month ago,
resolved with stopping PO Mg, metformin and starting immodium.
Denies fever, chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies coughor wheezing. Denies chest pain, chest pressure,
palpitations. Denies constipation, abdominal pain, dark or
bloody stools. He does report recent bleeding hemorrhoids that
occurred in setting of [**Last Name (un) **] prep last week. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
-CAD s/p CABG x3 in [**2171**]
-Diabetes mellitus
-Hx DVT/PE [**8-23**]
-Hx nephrolithiasis
-Gout
-Hx MI [**2170**]
-Hypercholesterolemia
-Morbid obesity
-HTN
-Hx of chronic radicular pain x 2.5 years, radiating from left
knee to hip. Has received several epidural steroid injections,
most recently 2-3 weeks ago.
-umbilical hernia
-Hx bladder Ca 4-6 years ago - dx with hematuria, cystoscopy
showed a lesion that was resected. This was localized, no known
recurrence.
-Hx prostate Ca 5 years ago s/p resection and xrt, localized,
followed with PSAs.
-Hx tonsillectomy
-Rotator cuff injury [**2-21**], currently undergoing PT
-Hx colonic polyps - last colonoscopy [**4-23**], 1 polyp removed
Social History:
Married, lives with wife. [**Name (NI) **] grown children who live in the
area. Retired, used to work as a technical writer. Denies
tobacco, Etoh, illicit drugs.
Family History:
Father, brother and several uncles with [**Name2 (NI) 499**] cancer. Mother
with breast cancer. Sister died of a stroke about 1 month ago.
No known history of blood clots or miscarriages.
Physical Exam:
Admission Physical Exam:
Vitals: HR 59, BP 151/77, RR 16, 100% on RA
General: Alert, oriented, no acute distress. Obese middle aged
male.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not appreciably elevated, although difficult
to assess given body habitus
CV: Distant heart sounds, 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
tenderness to palpation
Ext: Warm, well perfused, 1+ pulses pulses b/l. [**12-13**]+ pitting
edema in LE b/l, L > R
Neuro: CNII-XII intact
Pertinent Results:
ADMISSION LABS:
[**2191-5-9**] 07:00AM BLOOD WBC-5.8# RBC-3.98* Hgb-12.7* Hct-38.2*
MCV-96 MCH-31.8 MCHC-33.2 RDW-13.9 Plt Ct-221
[**2191-5-9**] 07:00AM BLOOD Neuts-67.5 Lymphs-20.9 Monos-6.9 Eos-4.1*
Baso-0.6
[**2191-5-9**] 07:00AM BLOOD PT-12.1 PTT-65.5* INR(PT)-1.1
[**2191-5-9**] 07:00AM BLOOD Glucose-136* UreaN-18 Creat-1.2 Na-136
K-4.5 Cl-98 HCO3-28 AnGap-15
[**2191-5-9**] 07:00AM BLOOD cTropnT-<0.01
[**2191-5-9**] 07:00AM BLOOD proBNP-565*
.
OSH US: + DVT in LLE
.
OSH CTPA:
saddle pulmonary emboli extending bilaterally subsegmental and
segmental without acute CT heart strain or consolidations.
2. Active small airway disease int he bases.
3. Cholelithiasis without cholecystitis or pancreatitis.
.
[**2191-5-11**] ECHO:
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and 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 root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is high normal. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Moderate mitral regurgitation.
Brief Hospital Course:
Patient is a 70 yo M with Hx of DVT/PE who recently completed a
course of anticoagulation and now presents with extensive LE DVT
and saddle PE.
.
ACTIVE ISSUES:
.
# PE/DVT - The patient has a history of PE/DVT which was treated
for approximately 7 months and had discontinued treatment in
[**Month (only) 547**]. The patient is up to date on cancer screening with a
recent colonoscopy (with a reported polyp seen -path pending),
normal PSA. He does have a hx of prostate and bladder cancer.
He is relatively immobile. There is no family history of blood
clots or other bleeding disorders. He was transferred from
[**Hospital3 2783**] to the ICU at [**Hospital1 18**] for close hemodynamic
monitoring. The patient did not have any SOB at rest but did
endorse some DOE that was worse recently. He was treated with a
heparin gtt and bridged to coumadin. Hematology was consulted
regarding the need for further hypocoagulable work up and a
question of the need for an IVC filter. They did not feel
either was necessary but recommended that he have a bridge to
coumadin for 48 hrs and that he remain on coumadin life long.
The pt was not bridged with lovenox given his weight was> 100kg.
A TTE was obtained which did not show evidence of RV strain.
it was a limited study due to his obesity but showed no major
structural abnormalities with only mild LVH. The patient never
required oxygen. He was able to ambulate the hallways without
significant difficulty prior to discharge. His foot pain that
he had at admission resolved.
.
#HTN - his antihypertensives were held at admission. Metoprolol
and HCTZ were restarted and during his hospitalization and as he
remained hypertensives to the 140-170s, Avapro was restarted at
discharge as well.
.
# DM - Byetta and glimepramide were held during his
hospitalization and restarted on discharge. He was continued on
Lantus qhs and a humalog SS.
.
# CAD s/p CABG - continued ASA, pravastatin, BB.
.
# HL - continued pravastatin
.
# Radicular pain - chronic, continued on quinine.
.
TRANSITIONS OF CARE:
Mr. [**Known lastname 5607**] will follow up at the [**Hospital 2436**] [**Hospital **]. He has historically required low doses of coumadin
approximately 11.25 mg/week.
Medications on Admission:
Medications: confirmed with wife
aspirin 81 mg daily
Avapro 300 mg daily (irbesartan)
hydrochlorothiazide 25 mg daily
metoprolol tartrate 50 mg 1 in morning, [**12-13**] in evening
pravastatin 40 mg daily
glimepiride 4 mg daily
Byetta 10 mcg/0.04 mL per dose Sub-Q [**Hospital1 **] before meals
Levemir 100 unit/mL Sub-Q 20 units at bedtime
Qualaquin 324 mg Cap Oral 1 qhs
potassium 99 mg Tab daily
omeprazole 20 mg daily
immodium [**12-13**] tab Daily - takes prn
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. quinine sulfate 324 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO QAM
(once a day (in the morning)).
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO QPM
(once a day (in the evening)).
7. Coumadin 2.5 mg Tablet Sig: half tablet (1.25 mg) Tablet PO
once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Avapro 300 mg Tablet Sig: One (1) Tablet PO once a day.
9. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
10. glimepiride 4 mg Tablet Sig: One (1) Tablet PO once a day.
11. Byetta 10 mcg/0.04 mL Pen Injector Sig: One (1)
Subcutaneous with meals.
12. Levemir 100 unit/mL Solution Sig: One (1) 20 units
Subcutaneous at bedtime.
13. Imodium A-D 2 mg Tablet Sig: [**12-13**] tab Tablet PO once a day as
needed for diarrhea, loose stools.
14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. potassium 99 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
PE
DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for leg pain and found to have a recurrent DVT
and pulmonary embolus. You were started on a heparin drip and
transitioned to coumadin with a 48 hour overlap. Given the size
of the blood clot, you were evaluated by hematology who
recommended that you continue on coumadin life long.
New meds: coumadin
Followup Instructions:
Follow up in the coumadin clinic on [**Last Name (LF) 766**], [**5-16**], at 11AM.
Follow up with your PCP as scheduled. Their clinic will call
you with an earlier appointment if they are able to see you
sooner.
|
[
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"278.01",
"V45.81",
"401.9",
"V16.0",
"250.00",
"412",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10129, 10135
|
6117, 6263
|
397, 404
|
10186, 10186
|
4422, 4422
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10683, 10899
|
3542, 3731
|
8861, 10106
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10156, 10165
|
8369, 8838
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10337, 10660
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3771, 4403
|
2024, 2625
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283, 359
|
6278, 8151
|
432, 2005
|
4438, 6094
|
10201, 10313
|
8172, 8343
|
2647, 3343
|
3359, 3526
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,239
| 155,197
|
22157
|
Discharge summary
|
report
|
Admission Date: [**2130-7-8**] Discharge Date: [**2130-7-24**]
Date of Birth: [**2065-8-23**] Sex: M
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old
male who was transferred from an outside hospital with right
upper quadrant pain and increased LFTs. An ultrasound done
at the outside hospital reportedly showed a 1 cm gallstone
with no evidence of cholecystitis and a 7 mm common hepatic
duct. The patient did not complain of fever, chills, or
shortness of breath. He did complain of nausea and vomiting.
He has an expressive aphasia, Parkinson's, and dementia, so
the patient was not a reliable historian. Difficult to
obtain.
PAST MEDICAL HISTORY:
1. Dementia.
2. Parkinson's disease.
3. Expressive aphasia.
4. History of a stroke.
5. Mood disorder.
6. Seizure disorder.
7. Hypertension.
8. History of alcohol abuse.
PAST SURGICAL HISTORY: No history of surgeries.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS:
1. Multivitamin with minerals.
2. Folic acid 1 mg q.d.
3. Lisinopril 50 mg q.d.
4. Lopressor 75 mg q.d.
5. Tylenol 325 mg b.i.d.
6. Buspar 20 mg t.i.d.
7. Depakote 750 mg t.i.d.
8. Remeron 15 mg p.o. q.h.s.
9. Lipitor 10 mg p.o. q.h.s.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient came from a rehabilitation
center. He has two sisters who are intimately aware of his
condition. He is currently a nonsmoker/nondrinker.
PHYSICAL EXAMINATION: Vital signs on admission: Temperature
99.5, heart rate 110, blood pressure 233/119, respirations
18, oxygen saturation 93 percent on room air. General: The
patient was awake, alert, in no apparent distress. He has a
slight tremor. Pulmonary: Breathing easily. The lungs were
clear to auscultation bilaterally. Cardiovascular:
Tachycardiac but regular. Abdomen: Distended, diffusely
painful, more in the upper right quadrant. No masses; no
guarding. Extremities: The extremities were warm with no
edema.
LABORATORY DATA: On admission, white count 8.8, hematocrit
40.9, platelets 226,000. Sodium 144, potassium 3.9, chloride
105, bicarbonate 25, BUN 25, creatinine 1.0, platelets
146,000. Lactate 1.3, ALT 381, AST 433, amylase 208,
alkaline phosphatase 463, total bilirubin 6.3, lipase 1,030.
HOSPITAL COURSE: The patient was admitted to the Platinum
Surgery Service on [**2130-7-8**]. He received fluid
resuscitation and was started on Unasyn. On hospital day
number two, the patient underwent an ERCP which showed
ampullary edema and inflammation. A mild diffuse dilation
was seen at the common bile duct with the common bile duct
measuring 9 mm. A single 8 mm round stone that was causing
partial obstruction was seen at the lower third of the common
bile duct. A sphincterotomy was performed in the 12 o'clock
position using a sphincterotome over an existing guide-wire.
Following sphincterotomy, frank pus drained from the common
bile duct. The stone was extracted successfully using a 12
mm balloon.
On hospital day number two, the patient developed a rash
diffusely over his entire body. It was thought that it might
be related to either his IV Unasyn or Enalaprilat.
Therefore, the Unasyn was discontinued and changed to
Meropenum and the Enalaprilat was discontinued.
On hospital day number four, a Dermatology consult was called
regarding his rash and they recommended started a clobetasol
cream, Sarna lotion, and Adenex four times a day. Throughout
his hospital course, the rash seemed to improve with the use
of these medications.
On hospital day number seven, the patient underwent an open
cholecystectomy and a central line was placed. On
postoperative day number one, the patient was started on TPN.
On postoperative day number three, the patient experienced a
hypertensive episode with a blood pressure of 180/100. He
was otherwise asymptomatic. He was treated with IV
hydralazine and his IV Lopressor dose was increased. The
combination of these medications decreased his blood pressure
and the patient remained stable.
On postoperative day number four, the patient was tolerating
clears and underwent a swallow evaluation which demonstrated
that he could tolerate an oral diet of regular liquids and
moist, soft solids. He was, therefore, started on this diet.
On postoperative day number five, the patient experienced a
temperature spike to 103.3 as well as tachycardia to 130 and
hypertension of 171/99. His central line was discontinued
and sent for culture and a central line was placed in the
opposite internal jugular vein. Blood cultures, a
urinalysis, and a chest x-ray were obtained and the patient
was transferred to the ICU for close monitoring. An
ultrasound and CT of his abdomen were obtained which showed
no abnormalities. The blood cultures and central line
culture were all negative for growth. The Clostridium
difficile toxin was sent on his stool which was negative.
On postoperative day number six, a Neurology consult was
called for an episode of seizures. The patient has an
unspecified seizure disorder but the family did not know
anything about it. Therefore, Neurology recommended changing
his Meropenem to an alternative antibiotic since this has
been known to decrease seizure threshold and to ensure that
the patient received his prehospital level of Depakote.
The biliopancreatic Surgery Service was consulted to evaluate
for potential biliopancreatic source of sepsis but since the
patient was improving clinically, they recommended the ultrasound
and CT which were obtained and continued to follow the patient
with this throughout his hospital course. Also, on postoperative
day number six, an Infectious Disease consult was obtained and
they recommended replacing the Meropenem with vancomycin,
Flagyl, and Levaquin. The patient continued to improve with
IV antibiotics and was tolerating clears by postoperative day
number seven.
On postoperative day number eight, the patient was stable
enough to be transferred back to the floor. By postoperative
day number ten, the patient was improving clinically. He was
tolerating a p.o. diet. He was afebrile with stable vital
signs. All IV antibiotics were discontinued and he was
continued on p.o. Flagyl. His staples were removed and
replaced with Steri-Strips and his central line was
discontinued. Plans were made for him to return to the [**Doctor First Name 57858**] House in [**Location (un) 38**], [**State 350**].
The laboratories on the day of discharge revealed a sodium of
141, potassium 3.9, chloride 107, bicarbonate 26, BUN 11,
creatinine 0.9, glucose 119, calcium 8.5, magnesium 1.9,
phosphorus 3.9. White blood cell count 11.1, hematocrit
29.9, platelets 500,000. ALT 28, AST 16, alkaline
phosphatase 123, amylase 68, total bilirubin 0.8, albumin
2.3.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Extended care facility.
DISCHARGE DIAGNOSES: Gallstone pancreatitis.
Biliary obstruction.
Seizure disorder.
Hypertension.
Status post ERCP.
Status post open cholecystectomy.
Anemia requiring blood transfusion.
DISCHARGE MEDICATIONS:
1. Clobetasol propionate 0.05 percent cream one application
topically b.i.d. as needed for drug rash.
2. Camphor menthol 0.5-0.5 percent lotion one application
topically p.r.n. as needed for rash.
3. Hydroxyzine hydrochloride 25 mg tablet one tablet p.o.
every six hours as needed for itching.
4. Metoprolol 75 mg p.o. q.d.
5. Miconazole 2 percent powder one application topically four
times a day as needed.
6. Flagyl 500 mg tablet, one tablet p.o. every eight hours
for nine days.
7. Multivitamin with minerals one capsule p.o. q.d.
8. Folic acid 1 mg tablet, one tablet p.o. q.d.
9. Lisinopril 5 mg tablet, three tablets p.o. q.d.
10. Tylenol 325 mg tablet, one tablet p.o. b.i.d.
11. Buspar 20 mg t.i.d.
12. Depakote 750 mg p.o. three times a day.
13. Lipitor 10 mg tablet, one tablet p.o. q.h.s.
14. Remeron 15 mg tablet, one tablet p.o. q.h.s.
FOLLOW UP: The patient is to follow-up with Dr. [**Last Name (STitle) **] in
two weeks. The patient is to call for an appointment. The
telephone number is [**Telephone/Fax (1) 3201**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 13137**]
Dictated By:[**Last Name (NamePattern1) 11988**]
MEDQUIST36
D: [**2130-7-24**] 12:48:50
T: [**2130-7-24**] 13:39:43
Job#: [**Job Number 57859**]
|
[
"332.0",
"577.0",
"693.0",
"780.39",
"285.9",
"V64.41",
"574.81",
"576.1",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"99.04",
"99.15",
"38.93",
"51.22"
] |
icd9pcs
|
[
[
[]
]
] |
1260, 1278
|
6892, 7064
|
7087, 7979
|
2298, 6792
|
912, 1243
|
7991, 8441
|
1470, 1482
|
182, 695
|
1497, 2280
|
717, 888
|
1295, 1447
|
6817, 6870
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,285
| 152,404
|
44220
|
Discharge summary
|
report
|
Admission Date: [**2156-3-23**] Discharge Date: [**2156-3-29**]
Date of Birth: [**2072-5-20**] Sex: M
Service: MEDICINE
Allergies:
Ticlid / Lipitor
Attending:[**First Name3 (LF) 2972**]
Chief Complaint:
Weakness, hypotension
Major Surgical or Invasive Procedure:
Cardioversion
History of Present Illness:
Mr. [**Known lastname 1726**] is an 83M with hx parosysmal Afib not on coumadin,
CAD s/p CABG in [**2135**] with LIMA to LAD which is totally occluded
after D1, SVG-D1 (stent in graft), SVG-OM (chronically
occluded), with most recent PCI in [**5-26**] with stenting Lcx, s/p
hip replacement, with hx chronic c.diff infection x 5 years. Pt
was in USOH until the night prior to admission when he noted
that he was unable to get up out of bed secondary to weakness,
which he noted was worse in his legs than in his arms. He
struggled to get OOB for a while, eventually becoming SOB, with
subsequent mid sternal sharp non radiating chest pain
experienced, similar to his anginal episodes. The pain was not
associated with diaphoresis or nausea, p.o intake, there was no
positional or pleuritic component. He took SLNTG x1 and the CP
resolved. He continued to experience this weakness on the day of
admission, called life line, with EMS sent to his home. On
arrival he was noted to have ? NSVT on monitor. Of note, he has
experienced several days of diarrhea with 10 or more loose
stools a day. Increased from baseline.
.
In the ER, initial VS were T97.1, HR 150, BP 73/54 -> 86/59, RR
36, O2 100% NRB. EKG showed wide complex tachycardia afib with
aberancy. Having CP. Labs notable for WBC 26, Cr 1.9 from
baseline 1.3. Underwent cardioversion for A. Fib with
hypotension and subsequently converted to sinus rhythm with
resolution of his chest pain. CXR negative for PNA. Overall
impression was for sepsis [**2-24**] C. diff and patient given
metronidazole for his diarrhea and 2L of IVF. Prior to transfer
had been making urine >800cc.
.
Vitals prior to transfer HR72 113/70 17 100%2L.
.
ROS is notable for chronic fatigue. He denies recent URIs,
cough, hemoptysis, fever, chills, rigors, diaphoresis, abdominal
pain, sick contacts, travel, prior history of stroke, TIA, deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, cough, black stools or red
stools. He denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
On arrival to the CCU he was seen to be in slow A.fib on EKG,
and hypotensive to the high 80s. IVF boluses were initiated with
subsequent improvement in pressure. He was found to have GNR on
blood culture and was started on IV vanc/flagyll. He was started
on amniodorone drip .
Past Medical History:
-CAD with stable angina, s/p CABG '[**35**], multiple stents (last
cath report [**5-26**]: Two vessel CAD. Patent LIMA-LAD. Patent
SVG-D1. SVG-OM is known to be chronically occluded. The LCx had
70% in-stent stenosis in the proximal stent. There was a 70%
lesion just distal to the stent. Successful PTCA of the LCX.)
-Moderate systolic CHF - LVEF of 35%-40% on echo in [**5-30**]
-Moderate pulmonary artery systolic hypertension - TR gradient
of 49 mmHg on echo in [**5-30**]
-A-fib (paroxysmal)previously on coumadin but not currently
taking
-hemoperitoneum around the liver and in the pelvis along with
two splenic artery pseudoaneurysms s/p IR embolization of both
in [**11/2155**]
-NSTEMI in the setting of acute blood loss anemia during
hospitalization in [**11/2155**]
- H/o C Diff - found in [**2152**], on chronic PO vanco at home; when
taken off vanco, has frequent diarrhea and dehydration
-HTN
-Hyperlipidemia
-Anemia
-Prostate CA s/p XRT (over 10 years ago), s/p TURP [**1-11**]
-s/p discectomy [**9-25**]
-Left hip arthroplasty [**12-26**]
-Severe osteoarthritis
.
Cardiac Risk Factors: Dyslipidemia, Hypertension
.
Cardiac History: CABG, in [**2135**] anatomy as follows:
-LIMA to LAD, SVG-D1 (stent in graft), SVG-OM (chronically
occluded)
Social History:
Denies tobacco and ETOH use.
Family History:
Noncontributory
Physical Exam:
VS - T: HR: 80 BP: 93/55 (64) RR: 13 SPO2: 99%
Gen: Notable pallor. Poor cap refill. Poor skin turgor.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 7 cm.
CV:mostly regular rymth. PMI located in 5th intercostal space,
midclavicular line. RR, normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. 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. No femoral bruits. Cool lower extremities. [**5-26**]
muscle strength BUE, BLE.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
DP/PT: dopperable bilaterally.
Pertinent Results:
[**2156-3-23**] 10:56PM HCT-30.0*
[**2156-3-23**] 07:56PM LACTATE-2.6*
[**2156-3-23**] 07:45PM GLUCOSE-250* UREA N-37* CREAT-1.9* SODIUM-139
POTASSIUM-4.7 CHLORIDE-109* TOTAL CO2-18* ANION GAP-17
[**2156-3-23**] 07:45PM CK(CPK)-597*
[**2156-3-23**] 07:45PM cTropnT-2.85*
[**2156-3-23**] 07:45PM CK-MB-58* MB INDX-9.7*
[**2156-3-23**] 02:00PM GLUCOSE-281* UREA N-37* CREAT-1.9* SODIUM-139
POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-14* ANION GAP-25*
[**2156-3-23**] 02:00PM CK(CPK)-39*
[**2156-3-23**] 02:00PM cTropnT-0.05*
[**2156-3-23**] 02:00PM CALCIUM-9.1 PHOSPHATE-4.1 MAGNESIUM-2.0
[**2156-3-23**] 02:00PM WBC-26.4*# RBC-3.40* HGB-10.2* HCT-31.2*
MCV-92# MCH-30.0 MCHC-32.7 RDW-15.8*
[**2156-3-23**] 02:00PM NEUTS-93.8* LYMPHS-4.5* MONOS-1.3* EOS-0.2
BASOS-0.2
[**2156-3-23**] 02:00PM PLT COUNT-292#
[**2156-3-23**] 02:00PM PT-13.8* PTT-22.9 INR(PT)-1.2*
.
CXR [**2156-3-23**]
FINDINGS: Overlying EKG leads slightly obscures film. There is
moderate
cardiomegaly, unchanged. There is a tortuous aorta. Patient is
status post
CABG. Sternotomy wires are intact. There is no focal
consolidation, pleural
effusion or pneumothorax.
IMPRESSION: No focal consolidation.
[**2156-3-27**] 05:58AM BLOOD WBC-12.5* RBC-3.14* Hgb-9.4* Hct-28.9*
MCV-92 MCH-30.0 MCHC-32.6 RDW-15.9* Plt Ct-169
[**2156-3-28**] 05:04AM BLOOD WBC-10.5 RBC-3.20* Hgb-9.3* Hct-28.2*
MCV-88 MCH-29.0 MCHC-32.8 RDW-16.4* Plt Ct-167
[**2156-3-29**] 06:54AM BLOOD WBC-13.2* RBC-2.91* Hgb-8.6* Hct-25.8*
MCV-89 MCH-29.4 MCHC-33.2 RDW-16.9* Plt Ct-155
[**2156-3-24**] 04:54AM BLOOD PT-15.0* PTT-26.5 INR(PT)-1.3*
[**2156-3-25**] 04:29AM BLOOD PT-15.0* PTT-28.3 INR(PT)-1.3*
[**2156-3-25**] 03:44PM BLOOD Glucose-110* UreaN-42* Creat-1.5* Na-138
K-3.6 Cl-111* HCO3-17* AnGap-14
[**2156-3-26**] 06:15AM BLOOD Glucose-133* UreaN-43* Creat-1.4* Na-140
K-3.8 Cl-112* HCO3-15* AnGap-17
[**2156-3-27**] 05:58AM BLOOD Glucose-110* UreaN-39* Creat-1.2 Na-140
K-3.6 Cl-112* HCO3-17* AnGap-15
[**2156-3-28**] 05:04AM BLOOD Glucose-111* UreaN-36* Creat-1.0 Na-141
K-3.5 Cl-114* HCO3-18* AnGap-13
[**2156-3-29**] 06:54AM BLOOD Glucose-120* UreaN-31* Creat-1.1 Na-139
K-3.5 Cl-112* HCO3-16* AnGap-15
[**2156-3-23**] 07:45PM BLOOD CK(CPK)-597*
[**2156-3-24**] 04:54AM BLOOD ALT-194* AST-345* LD(LDH)-459*
CK(CPK)-529* AlkPhos-128 Amylase-224* TotBili-0.4
[**2156-3-25**] 04:29AM BLOOD ALT-150* AST-167* LD(LDH)-388*
AlkPhos-111 TotBili-0.4
[**2156-3-28**] 05:04AM BLOOD CK(CPK)-32*
[**2156-3-24**] 02:39PM BLOOD Lipase-15
[**2156-3-23**] 02:00PM BLOOD cTropnT-0.05*
[**2156-3-23**] 07:45PM BLOOD CK-MB-58* MB Indx-9.7*
[**2156-3-23**] 07:45PM BLOOD cTropnT-2.85*
[**2156-3-24**] 04:54AM BLOOD CK-MB-50* MB Indx-9.5* cTropnT-4.12*
[**2156-3-28**] 05:04AM BLOOD CK-MB-NotDone cTropnT-2.48*
[**2156-3-23**] 02:00PM BLOOD Calcium-9.1 Phos-4.1 Mg-2.0
[**2156-3-29**] 06:54AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.1
[**2156-3-23**] 07:56PM BLOOD Lactate-2.6*
[**2156-3-24**] 05:16AM BLOOD Lactate-3.6*
[**2156-3-24**] 03:11PM BLOOD Lactate-1.5
Brief Hospital Course:
Patient is a 83 y/o M w PAF, CAD s/p CABG/PCI and chronic C.
diff infection who p/w hypotension, a. fib with RVR, and found
to have GNR bacteremia.
# Urosepsis- Patient was admitted to the ICU with hypotension.
He was volume resuscitated with adequately controlled blood
pressures not requiring additional fluids. He was initially
treated with IV flagyl, IV zosyn and PO vancomycin given concern
for C.diff (patient has chronic C.diff). Blood cultures grew
back GNR and urine cultures grew E.coli. Patient diagnosed with
urosepsis. He was switched to cefepime and flagyl. Once
stabilized in the unit, he was transferred to the floor. Blood
cultures remained negative since [**3-24**] and WBC trended down.
Patient remained afebrile with no systemic complaints. He was
continued on PO vanc (125mg PO BID) for his chronic C.diff. Of
note, C.diff was negative x 2 while here. Cultures grew
pansensitive E.coli so he was switched from cefepime to PO cipro
(and continued on PO vancomycin). He is to continue antibiotics
for 14 days (course started on [**2156-3-28**]).
# Atrial Fibrillation: Patient has paroxysmal atrial
fibrillation. He required cardioversion in ED. He went to slow
VT and then to A.fibrillation. He was admitted to the CCU for
further stabilization. While there, he was started on IV
amiodarone and then transitioned to PO on [**3-25**] (400mg TID x 1
week and then 200mg daily x 3 weeks). He remained in sinus
rhythm while on the floor. It was thought that the RVR was due
to sepsis. He is not anticoagulated with coumadin due to fall
risk and history of hemoperitoneum. Home beta-blocker was held
given slow HR (60-65 on day of discharge). Patient continued on
home dose of aspirin.
#. Coronary Artery Disease : CAD s/p CABG in [**2135**] with LIMA to
LAD which is totally occluded after D1, SVG-D1 (stent in graft),
SVG-OM (chronically occluded), with most recent PCI in [**5-26**]
with stenting Lcx, s/p hip replacement. EKG not consistent with
ACS, chest pain and elevated troponin presumed due to demand
ischemia (CK peaked [**3-24**]).
# Anemia: Chronic normocytic anemia (MCV 92).near or above
baseline, has a history of chronic anemia of unknown origin
requiring multiple transfusions, no active issues. He did not
require any transfusions while here.
#ARF: Patient admitted with Cr. of 1.5 (baseline 1.2). Cr
trended down to 1.1 after getting IV fluids and remained stable.
#Metabolic Acidosis- Improved; occured in setting of elevated
lactate from sepsis/bacteremia; Patient received IV fluids (NS)
while here.
# Diarrhea: Patient has a history of C. diff infection x 5
years. Pt did present with worsening diarrhea prior to
admission; initially received treatment dose of flagyl/vanc and,
after urine culture returned, he resumed suppressive doses of
vancomycin which he will continue indefinitely.
Medications on Admission:
aspirin 81 mg daily
nigtroglycerin SR 2.5 mg
metoprolol 25mg q24
sertraline 100mg [**Hospital1 **]
vanco 125 [**Hospital1 **]
folic acid 400mg
avicor 20mg [**Hospital1 **]
multivitamin
Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 12 days.
2. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for
indigestion.
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Sertraline 100 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Nitroglycerin 2.5 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day as needed for chest
pain.
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day): through [**2156-3-31**].
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day
for 1 months: Please start on [**2156-4-1**] and take until [**2156-5-2**].
11. Heparin (Porcine) 5,000 unit/mL Cartridge Sig: One (1)
injection Injection three times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 4103**] on the [**Doctor Last Name **]
Discharge Diagnosis:
Primary
Paroxysmal Atrial fibrillation
Urosepsis
Secondary
Clostridium difficile infection
Discharge Condition:
stable, good, baseline ambulatory status, baseline mental status
Discharge Instructions:
You were admitted to the hospital because you were having
weakness, diarrhea and chest pain. You were found to have atrial
fibrillation and an infection in your blood. You were treated
with antibiotics, and your heart rhythm was cardioverted. You
were started on a new medication for your heart rhythm,
amiodarone. You infection improved, and upon discharge, you
were afebrile and hemodynamically stable.
The following changes were made to your medications:
1. Please START taking ciprofloxacin 500mg by mouth every 12
hours for 14 days (day 1- [**2156-3-28**])
2. Please continue taking your vancomycin by mouth twice a day
for your chronic C.diff infection
3. Please STOP taking your metoprolol until you follow-up with
Dr. [**Last Name (STitle) **]
4. Please continue taking amiodarone 400mg by mouth three times
per day until [**2156-3-31**]. On [**2156-4-1**], please take 200mg by mouth
daily for one month (until [**2156-5-2**])
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] on [**2156-4-26**] at 1PM. You can
contact him at [**0-0-**].
Completed by:[**2156-3-29**]
|
[
"V10.46",
"414.04",
"276.2",
"V43.64",
"790.7",
"599.0",
"414.01",
"416.8",
"584.9",
"401.9",
"715.90",
"285.9",
"V45.82",
"414.02",
"041.85",
"272.4",
"412",
"041.4",
"427.31",
"008.45"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
12294, 12372
|
8146, 11003
|
299, 315
|
12508, 12576
|
5118, 8123
|
13569, 13715
|
4245, 4262
|
11238, 12271
|
12393, 12487
|
11029, 11215
|
12600, 13546
|
4277, 5099
|
238, 261
|
343, 2900
|
2922, 4182
|
4198, 4229
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,483
| 173,397
|
52593
|
Discharge summary
|
report
|
Admission Date: [**2133-4-2**] Discharge Date: [**2133-4-7**]
Date of Birth: [**2088-9-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
Overdose.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
44 yo F h/o depression, SA in '[**30**] p/w OD/SA. Pt last spoken to
by her mother last night at around 8:30 pm. Pt gave no
indication that she was planning to kill or hurt herself.
However, her mother does note that she has been recently
depressed, particularly in regards to her job. This morning her
sister was unable to reach her by phone and called EMS. When EMS
arrived pt's VSS, though, by report, pt was minimally
responsive. A suicide note was found at the pt's home as well as
a list of the pt's medications. Pt transported to [**Hospital1 **].
.
In the ED, vitals: 98.6, hr 104, bp 127/80, rr 18, 98% ra. Pt
was somnolent, opening eyes to voice. wbc 13.8. lytes wnl. CEs
negative. U/S tox negative. U/A negative. EKG: ST@107 bpm, qtc
422. Pt given 1 L NS and 1 amp of bicarb. Pt was given seen by
tox who recommended 2 amps of bicarb and repeat EKG. Repeat EKG
essentially unchanged. Pt given benadryl 25 mg, ativan 2 mg for
CT head which was negative. Pt transferred to MICU for further
management.
Past Medical History:
Admission to [**Hospital1 **] '[**30**] for overdose
s/p meningioma resection
PCOS and adrenal incidentaloma
Migraine and tension headaches
Chronic cholecystitis, s/p lap cholecystectomy
Social History:
Per pt's mother: no etoh, tob, or illicits. Lives alone with
cat. Has no friends. Sister [**Name (NI) **] ([**Telephone/Fax (1) 108584**] lives in
[**Location **]. mother lived in [**Name (NI) 108**], [**Telephone/Fax (1) 108585**]
Family History:
mother and sister with depression
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Temp 97.7
BP 125/76
Pulse 104
Resp 26
O2 sat 100% ra
Gen - somnolent, not opening eyes to name
HEENT - pupils sluggish 4 to 3 mm, mucous membranes dry
Neck - no JVD, no cervical lymphadenopathy
Chest - Clear to auscultation bilaterally
CV - tachy regular, no murmurs
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally
Neuro - moving all four extremities, withdraws to pain, no
response to commands
Skin - No rash
PHYSICAL EXAM UPON TRANSFER:
============================
Vitals - T 99.3, BP 122/85, HR 84, RR 20, O2 95% RA
Gen - awake, tearful, A+O x 2 (able to tell me her name and [**Hospital **] hospital), difficulty w/ word finding
HEENT - PERRL, MMM
Neck - no JVD, no cervical lymphadenopathy
Chest - Clear to auscultation bilaterally
CV - regular, no murmurs
Abd - Soft, nontender, nondistended
Extr - no c/c/e
Neuro - FROM x 4 ext, as above A+O x 2, difficulty w/ word
finding, but otherwise appropriate
Skin - No rash
Pertinent Results:
ADMISSION LABS:
=================
12.9
13.88 >------< 299
37.7
MCV 88 Neuts 92.9 Bands 0 Lymphs 5.7 Monos 1.2 Eos 0 Basos
0.2
PT 11.8 PTT 24.0 INR 1.0
140 108 23
-----|-----|-----< 136
3.7 24 1.0
ALT 17 AST 16 Alk Phos 75 Bili 0.2
CK 19 Trop <0.01
Serum Tox: negative
Urine Tox: negative
[**2133-4-2**] 06:18PM TYPE-ART PO2-90 PCO2-46* PH-7.39 TOTAL CO2-29
BASE XS-1
[**2133-4-2**] 06:18PM LACTATE-1.3
PERTINENT LABS DURING HOSPITALIZATION:
=======================================
WBC Trend: 13.88 - 8.7 - 12.3 - 9.2 - 11 - 8.9
BNP 452
STUDIES:
========
CHEST (PORTABLE AP) [**2133-4-2**]
FINDINGS: A single view shows the cardiac silhouette to be
within normal limits. There is an area of increased
opacification at the left base medially. This could represent
atelectatic change or possibly aspiration. The right lung is
essentially clear.
CT HEAD W/O CONTRAST [**2133-4-2**]
FINDINGS: The study is limited by patient motion. There is no
evidence of hemorrhage, edema, mass effect, hydrocephalus, or
acute vascular territorial infarct. The ventricular and sulcal
prominence may be slightly more than expected for age. There has
been a left frontal craniotomy. The visualized paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
Soft tissues are unremarkable.
IMPRESSION: Limited study due to motion. No evidence of
hemorrhage or mass effect. Please note for the detection of
acute brain ischemia, MRI with diffusion weighting is more
sensitive than CT.
CHEST (PORTABLE AP) [**2133-4-4**]
New areas of confluent opacification have developed in the
perihilar and basilar regions, and may be due to the provided
history of acute aspiration, but a component of pulmonary edema
from fluid overload is likely, and there are also bilateral
scattered septal lines in the lung periphery. Heart is upper
limits of normal in size. Small pleural effusions have developed
bilaterally.
EKG [**2133-4-2**]
Sinus tachycardia. Baseline artifact makes interpretation
difficult.
RSR' pattern in lead V1 is non-specific. Compared to the
previous tracing
of [**2130-5-15**] sinus tachycardia, RSR' pattern and artifact are all
new.
TRACING #1
Brief Hospital Course:
Ms. [**Known lastname **] is a 44 y.o. F with a history of depression, two
prior suicide attempts, admitted for medication overdose s/p
suicide attempt.
# Medication overdose: Initially, it was unclear what
medications the patient had taken and quantity. On arrival, her
vital signs were stable, but she was unresponsive. Head CT was
negative. She was never intubated. She received bicarbonate x
2 in the ED per Toxicology, who was consulted. She was admitted
to the MICU for altered mental status. As the patient was on
Ditropan, this was concerning for anticholinergic toxicity, and
she was given physostigmine, which did not change her mental
status. Urine tox and serum tox were negative. Serial EKGs
were followed for conduction disorders, which remained
unremarkable during her hospitalization. Her mental status
improved, and she was called out to the medical floor. While on
the medical floor, her mental status returned to baseline per
the patient's sister. Ms. [**Known lastname **] was able to recall the
events surrounding her suicide attempt and recalled that she
took both Klonopin and Lamictal.
# Depression: On admission to the MICU, the patient's
psychiatric medications were all held and continued to be held
on the medical service per psychiatry. Psychiatry followed the
patient during her hospitalization and recommended that all her
outpatient psychiatric medications continue to be held. She had
a 1:1 sitter during her hospitalization. Of note, on [**2133-4-7**],
the patient was noted to have more pressured speech and was
slightly manic. Per Psych, clonazepam 0.5 mg TID prn agitation
and haldol prn were given.
# Leukocytosis: Initially, noted in the MICU. UA negative. CXR
with ? RLL opacity with atelectasis vs. aspiration vs. fluid.
The patient remained afebrile and without respiratory symptoms.
Her leukocytosis resolved without any antibiotics.
# Hct Drop: Noted to have Hct drop of 37 --> 31. Repeat Hct was
37.
# Headache: Fioricet and Tylenol prn
# FEN: regular diet, monitor and replete lytes PRN
# PPX: heparin SQ, bowel regimen
# FULL CODE
# Dispo: Transfer to inpatient psychiatric facility.
Medications on Admission:
MEDICATIONS ON ADMISSION(per EMS; list unavailable):
clonazepam
lamictal
topamax
ditropan
spironolactone
cymbalta
MEDICATIONS ON TRANSFER:
Ondansetron 4 mg IV Q8H:PRN nausea
Heparin 5000 UNIT SC TID
Lorazepam 1-2 mg IV Q2H:PRN agitation
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Location (un) 10059**]
Discharge Diagnosis:
Primary Diagnosis:
1. Medication Overdose
2. Depression
Secondary Diagnosis:
1. Headache
Discharge Condition:
Stable. Afebrile.
Discharge Instructions:
You were admitted after a medication overdose. You were
originally in the medical intensive care unit as your mental
status was altered. You were then sent to the medicine floor
after you mental status cleared. The toxicologists and
psychiatrists followed you during your hospitalization.
Please keep all your medical appointments. Please take all your
medications as prescribed. Your psychiatric medications were
held during your hospitalization. You were restarted on
Klonopin as needed.
You will be transferred to an inpatient psychiatric facility for
further psychiatric management.
If you have any of the following symptoms, please call your
doctor or go to the nearest ER: fever>101, chest pain, shortness
of breath, abdominal pain, increased thoughts of suicide or
homidcide, or any other concerning symptoms.
Followup Instructions:
Inpatient Psychiatric Facility
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
Completed by:[**2133-4-7**]
|
[
"E950.4",
"276.8",
"507.0",
"E950.3",
"784.0",
"296.23",
"293.0",
"969.4",
"966.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7658, 7737
|
5209, 7369
|
323, 330
|
7871, 7892
|
2978, 2978
|
8765, 8955
|
1847, 1882
|
7758, 7758
|
7395, 7510
|
7916, 8742
|
1922, 2959
|
274, 285
|
358, 1371
|
7836, 7850
|
2994, 5186
|
7777, 7815
|
7535, 7635
|
1393, 1582
|
1598, 1831
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,376
| 160,949
|
24930
|
Discharge summary
|
report
|
Admission Date: [**2181-5-25**] Discharge Date: [**2181-6-9**]
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5667**]
Chief Complaint:
parotid tumor
Major Surgical or Invasive Procedure:
ENT
1. right parotidectomy with facial nerve excision
2. subtotal auriculectomy
3. modified radical neck dissection on right
PLASTICS
1. Anterolateral thigh free flap to right facial and temple
region.
2. Multiple facial nerve cable grafts for reconstruction of
facial nerve.
3. Harvest of sural nerve for facial nerve grafts.
4. Fascial sling for lower lip.
5. Tarsorrhaphy of right eye.
History of Present Illness:
86-year-old gentleman with a
history of malignancy of the parotid. He has had a prior
parotidectomy several months ago, however this has been
enlarging
in the last several months rapidly and he has had radiotherapy
that finished last week.
Past Medical History:
Parotid tumor as above
Congestive heart failure with an EF of
40%, moderate pulmonary hypertension, coronary artery disease,
BPH. 2 weeks postoperatively, Mr. [**Known lastname **] noted left lower
extremity swelling and was found to have a left lower extremity
DVT. He was admitted to the hospital for anticoagulation with
transition to Coumadin therapy.
PAST SURGICAL HISTORY: Status post appendectomy, status post
TURP.
Social History:
He lives at home with his wife. [**Name (NI) **] has four
children, one of which is deceased from cervical cancer. He has
five grandchildren. He walks with a cane. He has a remote
history of tobacco use - he smoked three packs per day for 15 to
20 years approximately 45 years ago. He drinks a rare glass of
wine. Prior to his clot in his legs, he used to frequently golf
nine holes. He is independent with his ADLs.
Family History:
Noncontributory.
Physical Exam:
AT discharge:
AVSS
HEENT: large free flap to right face, doppler signals intact,
good cap refill, warm. Pale in color in comparison to skin on
face. Right sided facial droop, significant.
RRR
CTA b/l
Right leg: STSG on thigh wound, healing well, no hematoma
Left leg: donor site healing well, dry
Brief Hospital Course:
Patient underwent a combined procedure with ENT and Plastics:
right parotidectomy with facial nerve exicision, subtotal
auriculectomy, right modified neck dissection by ENT and by
Plastics:
1.Anterolateral thigh free flap to right facial and temple
region.
2. Multiple facial nerve cable grafts for reconstruction of
facial nerve.
3. Harvest of sural nerve for facial nerve grafts.
4. Fascial sling for lower lip.
5. Tarsorrhaphy of right eye.
The case was approx 16 hours in length and the patient went to
the PACU post-op. His flap was checked every hour initially.
Initially he remained intubated, his BP dropped into the 80s for
a short period of time, his Hct was 26, so he received 2 units
PRBC. He was extubated on POD 1 successfully. He was very
agitated post-op and stayed in the unit for a few days secondary
to this. he required haldol, ativan, and narcotics to settle
him out. It was necessary that he wasnt agitated as to not
damage his new free flap.
GI: Once he became less agitated the meds were weaned. A
dobhoff was placed to start tube feeds but he pulled that out
shortly thereafter. He was started on PPN as a NG or dobhoff
type tube would unlikely remain in place. We had IR place a
Gtube under flouro prior to him leaving the hospital. Tube
feeds were started and advanced to a goal of 80cc/hr. This was
all done because he failed a swallow evaluation and was high
risk for aspiration. Prior to discharge he had a repeat video
swallow which showed he could tolerate thickened liquids and
purees. He was allowed to begin this for pleasure, but his main
nutrition would be PEG tube feeds for now.
CV: He was maintained on a betabblocker. While on the floor he
did have some episodes of Vtach for no longer than 10 beats.
Cards was consulted. We restarted all his home meds, we got an
ECHO, which showed EF 35% and hypokinesis of the inferior LV
wall with mild systolic function depression. This was
consistent with his baseline. He was also started on lasix. No
further Vtach occurred during his hospital stay.
Heme: Heme/Onc was consulted as they had followed him regarding
his Oncology preop. His WBC cont to trend down, as low as 1000.
They recommended switching his ancef to clindamycin as ancef
was the likely culprit. This was done and his wbc stopped
falling. His wbc never really came back above 2500. He was
cont on his lovenox until his coumadin was therapeutic. He is
on 60mg SC bid of lovenox, and 2mg PO QHS of coumadin. This
should cont until his INR is therapeutic. He also had b/l
LENI's to check on his DVT from [**Month (only) **] and make sure there was
no progression. He had no DVTs on these LENIs.
Medications on Admission:
Lovenox 100", Ramipril 5", Keflex 250 QID,
Discharge Medications:
1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-24**]
Drops Ophthalmic PRN (as needed) as needed for right eye
dryness.
2. Morphine 20 mg/5 mL Solution Sig: [**2-27**] ml PO every 4-6 hours.
3. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours).
4. Warfarin 2 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
5. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily).
6. Ramipril 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic QHS (once a day (at bedtime)).
10. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
11. Ondansetron 4 mg IV Q8H:PRN nausea/vomiting
12. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
13. Pantoprazole 40 mg IV Q24H
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
parotid tumor: spindle cell myoepithelial carcinoma
Discharge Condition:
stable
Discharge Instructions:
DIET: can have puree food and honey thickened liquids for
comfort. Primary source of nutrition will be Probalance tube
feeds with a goal of 80cc per hour. The residuals should be
checked every 4 hours and flushed with 50cc NS as well. The
patient will need to be reevaluated in the future by speech and
swallow to see if he will be able to tolerate regular food and
liquid so that he may have his PEG tube removed.
.
ACTIVITY: Full weight bearing on both extremities, enourage
walking. No strenuous activitiy or heavy lifting at this time.
.
WOUNDS:
Face:the flap should be monitored for signs of ischemia or
congestion. If it becomes cold, more pale, purple then plastic
surgery should be notified.
Right thigh: daily dressing changes with xeroform, gauze and
kerlix. Monitor the skin graft for signs of breakdown or
hematoma collection
Left thigh: xeroform remains on until it falls off, DO NOT
CHANGE THIS ONE, leave open to air.
.
MEDS: cont the lovenox until coumadin therapeutic, this should
be followed closely and arrangements should be made with PCP to
follow this in the future. Cont the rest of his meds as
prescribed. They should all be given down his Gtube.
.
Followup Instructions:
please call to schedule a follow up appt with both Dr. [**First Name (STitle) **] and
Dr. [**Last Name (STitle) 1837**]
|
[
"142.0",
"427.89",
"428.0",
"414.01",
"292.81",
"V12.51",
"427.1",
"V15.3",
"787.22",
"E935.8",
"416.0",
"E938.4",
"V15.82",
"428.22",
"288.50",
"600.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"04.07",
"26.32",
"18.39",
"43.11",
"99.04",
"96.6",
"40.41",
"93.59",
"27.59",
"08.52",
"86.69",
"04.5",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
6121, 6198
|
2213, 4897
|
274, 673
|
6294, 6303
|
7534, 7657
|
1852, 1871
|
4991, 6098
|
6219, 6273
|
4923, 4968
|
6327, 7511
|
1348, 1394
|
1886, 1886
|
1901, 2190
|
221, 236
|
701, 944
|
966, 1324
|
1410, 1836
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,015
| 189,382
|
53144
|
Discharge summary
|
report
|
Admission Date: [**2109-3-30**] Discharge Date: [**2109-4-9**]
Date of Birth: [**2062-3-6**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Compazine / Codeine / Morphine
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
body pain and diarrhea
Major Surgical or Invasive Procedure:
Flexible sigmoidoscopy
History of Present Illness:
This is a 47yo F admitted 1m ago for LE cellulitis, treated with
Vancomycin IV then Bactrim PO, presents with total body pain,
nausea, and diarrhea of one day duration. Pain includes chest,
abdomen, and legs, unable to localize further. Nausea has
included infrequent emesis, non-bilious. Diarrhea has been
copious for last 24 hours, non-bloody. In ED, BP drifting to
90s, received total of 4L of IVF thus far and begun Levophed.
Given broad-spectrum Abx empirically (Vanco IV, Levaquin, and
Flagyl IV). CVL and Foley placed. CT Torso obtained to
identify
source finding edema of rectum and sigmoid colon and
gallbladder,
prompting surgical consultation for ? colitis or cholecystitis.
ROS: no prior episodes. no fever or chills. no CP, mild dyspnea.
last Abx dose was ~[**3-13**]. no HA or dizziness. still having
diffuse
body pain, partially relieved with prn IV pain meds in ED. no
current nausea.
Past Medical History:
Cardiac History:
Percutaneous coronary intervention: Pt reports previous C. cath
done in [**State 33977**] which was done in '[**96**] which was negative for
blockages. There is a note in OMR re: a history of 2VD, however
pt denies this.
.
Other Past History:
1) Fibromyalgia
2) Neuropathy - self reported.
3) Gastroesophageal Reflux Disease.
4) Hypertension
5) Osteoarthritis - right knee with severe disease
6) Migraine HAs
7) Hyperkeratosis of the skin on LE bilat with ulcerations
8) Previous Hx of Obesity.
9) Previous h/o impaired glucose tolerance vs. DMII, resolved
entirely s/p weight normalization. Last HbA1c 5.5.
10) H/O anemia - improved with Fe, Vit 12 and folate.
.
PSurgH:
1) Gastric bypass surgery in [**2081**]
.
Social History:
Moved to [**Location (un) 86**] [**8-/2107**] from [**State 33977**] and is living with
sister in [**Location (un) 686**]. Worked in accounting, but has been on
disability due to her fibromyalgia for past [**5-20**] yrs. Current
smoker. Smokes [**2-16**] ppd x 25yrs, denies EtOH or IVDU/illicit drug
use.
Family History:
All 5 siblings with DM. Pt reports one sister died of MI & CHF
at age 44. Reports a nephew had an MI in his 30s.
There is no history of sudden death.
Physical Exam:
On admission:
97.6 125 92/58 12 100 on RA
Levophed 0.04
4000 IVF || 360 UO since foley placement ~2h ago
A&Ox3, NAD although uncomfortable appearing
CTAB, no rales
tachycardic, regular rhythm
soft, mildly distended, diffusely tender to light palpation,
poorly localizing but greater in lower abdomen, + rebound.
well-healed upper-midline scar without hernia
rectal declined by patient
WWP, DP 2+ BL. 1+ edema BL LE between knees and ankles, no
erythema. dry flaking skin BL soles. no open lesions.
At discharge:
98.1 79 99/71 18 100%RA
A&Ox3, NAD
CTAB, no rales
RRR, no murmurs
soft, nondistended, mild RUQ discomfort but no
rebound/peritonitis.
well-healed upper-midline scar without hernia
rectal declined by patient
WWP, DP 2+ BL. 1+ edema BL LE between knees and ankles, no
erythema. dry flaking skin BL soles. no open lesions.
Pertinent Results:
2am:
6.1 > 28.3 < 112
N:58 Band:28 L:7 M:5 E:0 Bas:0 Metas: 2
PT: 20.1 PTT: 35.6 INR: 1.9
Fibrinogen: 232
137 98 12 27
2.8 19 1.3
estGFR: 44/53
CK: 29 MB: Notdone Trop-T: <0.01
ALT: 29 AP: 96 Tbili: 1.6 Alb:
AST: 73 LDH: 182 Dbili: TProt:
[**Doctor First Name **]: Lip: 6
Lactate 8.1
6am:
4.1 > 22.2 < 79
N:48 Band:28 L:17 M:4 E:0 Bas:0 Metas: 3
PT: 23.7 PTT: 39.8 INR: 2.3
135 105 11 115
2.7 16 1.1
Lactate 7.9
.
Imaging
CXR 1am: no infiltrate or effusion. 7mm LLL granuloma
CXR 4am: R IJ CVL tip in RA, no PTX
CT Torso [**2109-3-30**] 5am (IV contrast, no PO contrast): significant
wall thickening of rectum and sigmoid/descending colon, fair
sparing of transverse colon, and additional edema of ascending
colon. no pneumoperitoneum, no pneumatosis. distended
gallbladder with trace wall edema, no pericholecystic fluid, CBD
not well visualized. bypass anastamoses appear patent and in
proper position/alignment (although limited by lack of PO
contrast). [**Female First Name (un) 899**], SMA, and celiac all patent.
CXR 5:30am: R IJ CVL tip in SVC/RA juntion
XR BL ankles 5:30am: no fx, no subcutaneous gas. soft tissue
swelling and degenerative joint disease.
[**2109-3-30**] CT chest no PE
[**2109-3-31**] RUQ U/S fatty liver, no gallstones; no biliary
dilatation
[**2109-4-4**] MRCP: l. Gallbladder distention with no discrete calculi
within the gallbladder. Possibility of cholecystitis cannot be
excluded given the degree of gallbladder distension. 2. No
obvious peribiliary hyperemia, no overt ductal calculi.
[**2109-4-7**] HIDA: Tracer uptake in the gallbladder following
Morphine injection, consistent with a patent cystic duct and no
evidence of cholecystitis.
.
Micro
[**2109-4-1**] BCx pending at discharge
[**2109-3-30**] BCx group A beta strep, E. coli
[**2109-3-30**] cdiff negative
[**2109-3-30**] UCx negative
[**2109-3-30**] BCx NO GROWTH
[**2109-3-30**] VRE screen negative
[**2109-3-30**] stool cx negative
[**2109-3-30**] cdiff negative
[**2109-3-30**] cdiff negative
Blood Culture, Routine (Final [**2109-4-1**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
BETA STREPTOCOCCUS GROUP A.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 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---- =>16 R
Flexible sigmoidoscopy [**2109-4-9**]
Findings:
Very mild blunting of vascularity was noted in the sigmoid
colon. Two cold forceps biopsies were performed for histology at
the sigmoid colon. Two cold forceps biopsies were performed for
histology at the distal sigmoid colon. Very mild erythema of
mucosa was noted in the rectum consistent with mild
inflammation. Cold forceps biopsies were performed for histology
at the rectum.
Impression: Normal vascularity of the colon (biopsy, biopsy)
Abnormal mucosa in the colon (biopsy)
Otherwise normal sigmoidoscopy to distal sigmoid colon
Recommendations: Return patient to floor
Await biopsy reports and viral culture results
Brief Hospital Course:
The patient was admitted to the west3 general surgery service on
[**2109-3-30**] for proctocolitis and septic shock; she was found to
have blood cultures positive for E. Coli and Group A Strep. She
was initially admitted to the SICU due to hypotension.
Neuro: The patient had difficulty with pain control during her
hospitalization, likely as a result of chronic opiate use at
home and significant cross-tolerance. She was treated with
dilaudid PCA with prn dilaudid while NPO. When tolerating oral
intake, the patient was transitioned to oral pain medications
with moderate effect. She was also initially placed on a Valium
CIWA scaled, but this was weaned in the ICU. She was given a
banana bag and started on thiamine, folic acid.
CV: On the first day of admission the patient was transiently on
IV pressor support, but this was weaned as she was resuscitated
with IV fluids. For the remainder of her hospitalization, she
was kept on telemetry and vital signs were routinely monitored.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI: The patient was admitted for proctocolitis. Given her
history of recent antibiotic use for cellulitis (2 weeks prior
to admission), she was initially treated for presumed cdiff
colitis. However, after C. diff was negative x 3, this treatemtn
was stopped on HD#6. Her abdinal exam improved, and was soft and
fairly nontender at discahrge. Additionally, stool cultures were
negative. Due to elevated LFTs on admission, a hepatitis panel
was sent which was negative. The pt does need a hep B vaccine.
She had a RUQ U/S on [**2109-3-31**] which fatty liver, no gallstones;
no biliary dilatation. She underwent an MRCP to rule out
cholangitis, which showed no biliary duct dilatation,
non-specific GB dilatation and wall edema. HIDA scan likewise
showed no cholecystitis. GI evaluated the patient and thought
her elevated LFTs were c/w cholestasis of sepsis. GI also
performed flexible sigmoidoscopy on the patient, which showed
Normal vascularity of the colon and abnormal mucosa in the
colon. Biopsies and viral cultures were sent.
Nutrition: In regards to nutritional status, the patient was
aggressively resuscitated with IV fluids and albumin after
admission and was kept NPO initially; however, with clinical
improvement her diet was advanced, which was tolerated well.
GU: Foley was removed on HD#5. Although the patient was
initially in mild acute renal failure with a creatinine of 1.3,
it came down to 0.7 with resuscitation. Intake and output were
closely monitored. She was placed on Famotidine for ulcer ppx.
ID: She was treated initially with broad spectrum IV antibiotics
including Vancomycin (PO&IV), IV Cefepime, IV Flagyl, and IV
Levaquin in consultation with ID. Her antibiotic regimen
narrowed to Ceftriaxone alone after C. diff was negative x 3 and
she had negative stool cultures. She additionally had blood
cultures positive for group A beta strep and E. coli from the
day of admission. ID recommended a 14 day course of IV
ceftriaxone. A PICC line was placed to continue this course (day
1 = [**4-2**], last day = [**4-16**]).
Endocrine: The patient had several episodes of hypoglycemia
(CBGs in 40s) in the SICU when off of dextrose infusion. This
resolved as her clinical situation improved. CPeptide and
insulin level were sent, which were pending at time of
discharge.
Hematology: While admitted, the pt became coagulopathic with
elevated INR (1.8). This was stable during her hospitalization.
She also became thrombocytopenic with platelets reaching a nadir
of 25. All heparin products were discontinued, HIT antibodies
were sent which were negative. These abnormalites were likely
due to sepsis coagulopathy, and improved as the pt's clinical
situation improved. At discharge, T bili = 1.2, INR = 1.7 and
Plt = 90.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible. Although this was stopped when she developed low
platelets, it was subsequently restarted when PLT count
recovered. She was treated with famotidine [**Hospital1 **].
Wounds: The patient has bilateral lower ext chronic venous
stasis wounds. Wound care was consulted to make recommendations
regarding these.
At the time of discharge on HD#9, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating with assistance, voiding without assistance, and pain
was fairly well controlled.
Medications on Admission:
ASA 81', amitriptyline 75', omeprazole 20', ca 500'', vit B12
100', [**Doctor First Name 130**] 60''prn itching, hydroxyzine 25q6prn, eucerin prn,
lac-hydrin 12% '
Discharge Medications:
1. Ammonium Lactate 12 % Lotion Sig: One (1) Appl Topical ASDIR
(AS DIRECTED).
2. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
3. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain for 10 days.
9. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig:
One (1) piggyback Intravenous Q24H (every 24 hours) for 8 days:
Last day [**4-16**] for 14 day course.
10. Amitriptyline 75 mg Tablet Sig: One (1) Tablet PO once a
day.
11. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO
twice a day.
12. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for itching.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
Primary: 1. proctocolitis, 2. bacteremia, 3. sepsis, 4. venous
stasis cellulitis, 5. fibromyalgia
Secondary: 1. HTN, 2. GERD
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
*You were admitted to [**Hospital1 18**] to the general surgery service for
proctocolitis inflammation of the bowel. You were also found to
have bacteria in your blood. Initially you were admitted to the
ICU because your blood pressure was very low. You were treated
with IV fluids, IV antibiotics and IV pressors (medications to
raise the blood pressure). Your symptoms improved with these
treatments. You were also seen by the gastroenterologist (GI)
doctors.
*You will need to take 14 days of IV antibiotics for the
infection in your blood. A midline IV line was placed for this.
* You were evaluated by Gastroenterology and underwent a
flexible sigmoidoscopy, which showed abnormal mucosa but normal
vascularity of the distal colon. You will need to follow up
with [**Hospital **] clinic to get the results of cultures and tissue
specimens sent.
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, chest pain, shortness of breath,
worsening abdominal pain, or anything else that is troubling
you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] with general surgery in [**3-20**]
weeks. Call [**Telephone/Fax (1) 1864**] for an appointment.
Please also follow up with gastroenterology clinic with Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) 10314**] in 2 weeks. Please call ([**Telephone/Fax (1) 2233**] for an
appointment. You will need a colonoscopy, as directed by Dr.
[**Last Name (STitle) **].
Please call your regular doctor and let them know about this
hospitalization. You should follow up with them in [**2-16**] weeks to
discuss it.
|
[
"556.2",
"459.81",
"V43.65",
"038.9",
"682.6",
"V45.86",
"287.5",
"785.52",
"401.9",
"707.19",
"530.81",
"995.92",
"286.9",
"285.9",
"276.8",
"729.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"48.24",
"99.07",
"99.04",
"45.25",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
12685, 12755
|
6837, 11351
|
324, 349
|
12925, 12925
|
3414, 6814
|
14703, 15269
|
2380, 2532
|
11565, 12662
|
12776, 12904
|
11377, 11542
|
13070, 14680
|
2547, 2547
|
3064, 3395
|
262, 286
|
377, 1286
|
2561, 3050
|
12939, 13046
|
1308, 2040
|
2056, 2364
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,821
| 146,804
|
34572+57929
|
Discharge summary
|
report+addendum
|
Admission Date: [**2141-9-29**] Discharge Date: [**2141-10-4**]
Date of Birth: [**2108-4-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pressure
Major Surgical or Invasive Procedure:
[**2141-10-1**] IVC filter
History of Present Illness:
This 33 year old white male is well known to our service as he
presented with Type A aortic dissection approximately 2 weeks
ago. Post-op course complicated
by stroke with residual LUE weakness and RUE motor loss which
began to return prior to discharge. He was discharged to rehab
on POD 10. He returns today complaining of chest pressure that
came on at rest. It is present across the chest without
radiation. It is unlike his presenting pre-op pain, and not the
incisional pain he experienced post-operatively. Pain improves
with ativan. Pain is associated with SOB and anxiety. CXR is
unremarkable, initial
ED ultrasound reportedly does not reveal pericardial effusion.
EKG reveals normal sinus rhythm without evidence of ischemia.
The patient is not anticoagulated, and symptoms are concerning
for PE. Additionally, he is found to be in renal failure with a
rise in creatinine from 0.7 on discharge, to 2.4 today.
Past Medical History:
Past Medical History:
type A aortic dissection
s/p aortic valve resuspension, graft ascending aorta/hemiarch,
reimplantation of innominate artery [**2141-9-15**]
multiple sclerosis
glaucoma
depression
Past Surgical History
[**2141-9-15**]
1. Emergency repair of type A aortic dissection with ascending
aorta and total arch replacement with a size #28 Medusa Gelweave
graft.
2. Aortic valve resuspension.
Social History:
Mr. [**Known lastname 79362**] is married and lives at home with his wife. [**Name (NI) **] is
currently unemployed. He has a history of
smoking/alcohol/substance abuse: Smokes [**12-3**] PPD, has requested
more percocet recently, occasional alcohol.
Family History:
unremarkable
Physical Exam:
Pulse: 79 Resp: 15 O2 sat: 100%2L
B/P Right: 103/55
Height: 71" Weight: 124kg
General: anxious
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft[x] non-distended[x] non-tender[x] bowel sounds+
[x]
Extremities: Warm [x], well-perfused [x] Edema-trace
Varicosities: None [x]-bilateral calf tenderness
Neuro: Grossly intact -RUE range of motion has improved since
d/c
4 days ago
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Pertinent Results:
Admission:
[**2141-9-29**] 10:20AM PT-13.9* PTT-24.9 INR(PT)-1.2*
[**2141-9-29**] 10:20AM PLT COUNT-416
[**2141-9-29**] 10:20AM WBC-15.0* RBC-3.59* HGB-10.7* HCT-31.8*
MCV-89 MCH-29.9 MCHC-33.8 RDW-13.4
[**2141-9-29**] 10:20AM CALCIUM-8.5 PHOSPHATE-5.7*# MAGNESIUM-2.0
[**2141-9-29**] 10:20AM cTropnT-0.05*
[**2141-9-29**] 10:20AM LIPASE-78*
[**2141-9-29**] 10:20AM ALT(SGPT)-84* AST(SGOT)-34 ALK PHOS-86 TOT
BILI-1.0
[**2141-9-29**] 10:20AM GLUCOSE-96 UREA N-34* CREAT-2.4*# SODIUM-136
POTASSIUM-5.1 CHLORIDE-100 TOTAL CO2-26 ANION GAP-15
[**2141-9-29**] 10:30AM LACTATE-1.1 K+-4.9
[**2141-9-29**] 10:50AM URINE RBC-[**2-3**]* WBC-[**10-21**]* BACTERIA-MOD
YEAST-NONE EPI-0-2
[**2141-9-29**] 10:50AM URINE BLOOD-LG NITRITE-POS PROTEIN-150
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-6.5 LEUK-SM
Discharge:
[**2141-10-3**] 05:13AM BLOOD WBC-6.3 RBC-3.03* Hgb-9.1* Hct-26.1*
MCV-86 MCH-30.2 MCHC-35.1* RDW-13.2 Plt Ct-230
[**2141-10-3**] 05:13AM BLOOD Plt Ct-230
[**2141-10-3**] 05:13AM BLOOD PT-15.9* PTT-63.6* INR(PT)-1.4*
[**2141-10-3**] 05:13AM BLOOD Glucose-92 UreaN-15 Creat-1.2 Na-140
K-4.4 Cl-100 HCO3-33* AnGap-11
[**2141-10-3**] 05:13AM BLOOD Mg-1.7
Radiology Report CTA CHEST W&W/O C&RECONS, Date [**2141-10-1**] 12:08
AM
Clip # [**Clip Number (Radiology) 79363**]
[**Hospital 93**] MEDICAL CONDITION: 33 year old man with recent Type A
dissection now c/o acute exacerbation of similar chest pain
Final Report
There is an intimal flap arising from the proximal extent of the
aortic arch, extending all the way inferiorly into the left
common iliac artery, consistent with aortic dissection. The left
subclavian and left common carotid arteries arise from what
appears to be the true lumen. The innominate artery has been
bypassed and arises from the lateral aspect of the aortic root,
proximal to the dissection flap (4, 24). The celiac trunk, SMA,
and bilateral renal arteries also arise from the true lumen. The
[**Female First Name (un) 899**] arises from the false lumen (4, 79). Patient is status post
type A dissection repair of the thoracic aorta and arch with
post-surgical changes. There are soft tissue densities
surrounding the aortic root without definite evidence of active
extravasation.
Curvilinear calcifications are seen at the aortic root. There is
bypass of
the innominate artery, which is normal in caliber and patent.
Within
limitation of current examination, there is no definite
extension of the
dissection into internal or external iliac arteries on the left.
The right
iliac artery arises from the true lumen.
CT CHEST: The thyroid demonstrates no focal lesion. A few mildly
enlarged
prevascular and precarinal lymph nodes are noted, likely
reactive. The heart is normal in size without significant
pericardial effusion. Moderate left and small right pleural
effusions are seen with associated compressive atelectasis.
Ill-defined peripheral areas of ground-glass opacities
predominating the left upper lobe and right lower lobe are
nonspecific, which could represent infectious, inflammatory, or
ischemic changes.
A nonocclusive pulmonary embolus is seen in the right main
pulmonary artery extending into the upper, middle, and lower
lobe subsegmental pulmonary arteries. No definite pulmonary
embolism is appreciated in the left lung, although evaluation is
limited since current study is not tailored for evaluation of
pulmonary embolism.
CT ABDOMEN: Within limitation of early contrast bolusing
limiting organ
evaluation, the liver, spleen, pancreas, and adrenal glands
appear within
normal limits. Gallbladder contains intermediate density
material in its
dependent portion, suggestive of sludge. Bilateral kidneys
demonstrate
symmetric enhancement without hydronephrosis or hydroureter. The
stomach,
small and large bowel loops are normal in caliber. There is no
mesenteric or retroperitoneal lymphadenopathy. There is no free
air or free fluid.
CT PELVIS: The bladder is collapsed, with a Foley catheter in
place. The
rectum and sigmoid colon appear unremarkable. There is no
inguinal or pelvic lymphadenopathy. There is no free fluid
within the pelvis. A 5.5 x 2.8 cm area of simple fluid is
present in the right groin, anterior to the distal aspect of the
right external iliac artery, with several adjacent small clips,
likely related to recent intervention.
BONE WINDOWS: No definite concerning focal lesion. A bone island
is seen in the right anterior acetabulum. Anterior median
sternotomy wires appear
aligned.
IMPRESSION:
1. Status post recent thoracic aorta and arch repair with soft
tissue
densities surrounding aortic root without definite evidence of
active
extravasation.
2. Aortic dissection with intimal flap arising from the proximal
aortic arch distal to the origin of innominate artery bypass,
extending the entire length of the descending aorta into
proximal left common iliac artery. All major branching vessels
arise from the true lumen with the exception of the inferior
mesenteric artery, which arises from the false lumen.
3. Pulmonary embolus within the main right pulmonary artery
extending into
subsegmental pulmonary arteries in the upper, middle, and lower
lobes.
4. Ground glass peripheral pulmonary opacities in the left upper
lobe and
right lower lobe are nonspecific, which could represent
infection,
inflammation, or ischemic sequelae. Moderate left and small
right pleural
effusions.
5. Probable gallbladder sludge.
DR. [**First Name8 (NamePattern2) 8083**] [**Name (STitle) 8084**]
Radiology Report RENAL U.S. PORT Study Date of [**2141-9-29**] 4:51 PM
Clip # [**Clip Number (Radiology) 79364**]
[**Hospital 93**] MEDICAL CONDITION: 33 year old man with s/p cardiac
surgery, acute renal failure
Final Report
HISTORY: Acute renal failure. Evaluate for acute process.
FINDINGS: The right kidney measures 12.2 cm and left kidney
measures 11.75
cm. No stones or hydronephrosis are present. There is a possible
1.7 x 1.4 x 1.6 cm hypoechoic lesion in the interpolar region of
the left kidney, which may be a cyst, but evaluation is
suboptimal on this examination, which was technically
challenging due to inability to reposition the patient.
IMPRESSION:
No stones, no hydronephrosis. Possible cyst within the
interpolar region of the left kidney, but this is suboptimally
visualized.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 13879**] [**Name (STitle) 13880**]
Radiology Report BILAT LOWER EXT VEINS Study Date of [**2141-9-29**]
12:53 PM
Clip # [**Clip Number (Radiology) 79365**] Reason: CALF PAIN, R/O DVT
[**Hospital 93**] MEDICAL CONDITION: 33 year old man with s/p cardiac
surgery, presents with chest pressure, concern for PE, bilateral
lower extremity calf tenderness
Final Report:
The right posterior tibial vein is noncompressible and does not
have any color Doppler flow within it. The bilateral peroneal
veins were not seen. There is normal grayscale appearance,
compressibility, color flow and
augmentation of the bilateral common femoral, superficial
femoral,and
popliteal veins. The left posterior tibial veins demonstrated
were
compressible and demonstrated color flow.
There is a 3.8 x 4.6 cm avacular collection in the right groin
with no doppler flow which may represent hematoma from recent
catheterization.
IMPRESSION:
1. Thrombus in the right posterior tibial vein in the right
calf. Bilateral peroneal veins were not visualized.
2. Likely right groin hematoma.
Addendum to the wet [**Location (un) 1131**] was communicated with Dr [**Last Name (STitle) 17157**],
on [**2141-9-29**] at 4:00pm.
DR. [**First Name8 (NamePattern2) 819**] [**Last Name (NamePattern1) **]
Brief Hospital Course:
M.r [**Known lastname 79362**] was seen in the emergency room and assessed for new
onset chest pain associated with anxiety and shortness of
breath. He was also noted to have elevated creatinine.
His cardiac enzymes, EKG and chest X-Ray were unrevealing. An
initial echo showed no pericardial effusion/tamponade or RV
strain.
He was admitted for hydration and started on heparin for
presumed pulmonary embolism. He was scheduled for renal
ultrasound, LENI's to assess for venous thrombosis and when the
LENI's were positive for thrombus a chest CT to assess for
pulmonary embolism.
The chest CT revealed: A nonocclusive pulmonary embolus is seen
in the right main pulmonary artery extending into the upper,
middle, and lower lobe subsegmental pulmonary arteries. No
definite pulmonary embolism is appreciated in the left lung.
Vascular surgery was consulted for IVC filter placement, this
was placed on [**2141-10-1**].
Renal US revealed no obstruction or hydronephrosis however his
UA was positive- URINE CULTURE (Final [**2141-10-1**]): PSEUDOMONAS
AERUGINOSA. 10,000-100,000 ORGANISMS/ML. He was treated with
Ciprofloxacin.
Following IVC filter placement his Heparin infusion resumed he
was started on warfarin and the remainder of his hospital course
was uneventful.
He was discharged to [**Hospital6 **] Center in
[**Location (un) 246**], MA on [**2141-10-3**].
Medications on Admission:
Medications at rehab:
amlodipine 10mg daily
asa 81mg daily
baclofen 40mg TID
celexa 40mg daily
colace 100mg [**Hospital1 **]
lasix 40mg [**Hospital1 **]
lactulose 30mL daily
lisinopril 10mg daily
lopressor 100mg TID
oxycodone 10mg at midnight
protonix 40mg daily
KCl 20mg [**Hospital1 **]
simvastatin 20mg daily
flomax 0.4mg daily
tizanidine (zanaflex) 4mg TID
MVI daily
ativan 0.5mg q4h prn
oxycodone 10mg q3h prn
trazodone 50mg hs prn insomnia
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. baclofen 10 mg Tablet Sig: Four (4) Tablet PO TID (3 times a
day).
4. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. oxycodone 10 mg Tablet Sig: Ten (10) mg PO at bedtime as
needed.
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
11. tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
14. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
15. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
16. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
17. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
18. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
19. warfarin 1 mg Tablet Sig: as directed Tablet PO Once Daily
at 4 PM: Target INR 2.5-3.0.
20. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: 2500 (2500) units Intravenous per hour.
21. warfarin 10 mg Tablet Sig: One (1) Tablet PO once for 1
days: 11/2 dose.
22. influenza vaccine tr-s 10 (PF) 45 mcg (15 mcg x 3)/0.5 mL
Syringe Sig: One (1) ML Intramuscular NOW X1 (Now Times One
Dose).
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. baclofen 10 mg Tablet Sig: Four (4) Tablet PO TID (3 times a
day).
4. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. oxycodone 10 mg Tablet Sig: Ten (10) mg PO at bedtime as
needed.
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
11. tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
14. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
15. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
16. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
17. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
18. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
19. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: 2500 (2500) units Intravenous per hour:
discontinue when INR 2.0.
20. influenza vaccine tr-s 10 (PF) 45 mcg (15 mcg x 3)/0.5 mL
Syringe Sig: One (1) ML Intramuscular NOW X1 (Now Times One
Dose).
21. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a
day: 10 mg [**10-3**], then per INR.
goal INR 2.5-3.
22. Flexeril 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for muscle spasm.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
s/p aortic arch replacement, resuspension of aortic valve
[**2141-9-15**] pulmonary embolism
deep vein thrombosis and acute renal failure
h/o Type A aortic dissection
hypertension
s/p cerebrovascular incident
multiple sclerosis
Chronic lower back pain
Glaucoma (left eye)
Depression
anxiety
Discharge Condition:
Alert and oriented x3 nonfocal
Activity: OOB-chair with assistance advance to ambulation as
tolerated
Incisional pain managed with Oxycodone and Ativan
Incisions:
Sternal- healing well, no erythema or drainage
Leg Edema-1+ bilaterally
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 170**]-Cardiac Surgeon:
Date/Time:[**2141-10-16**] 1:30
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8271**] ([**Telephone/Fax (1) 15916**]) in [**1-4**] weeks
Completed by:[**2141-10-3**] Name: [**Known lastname 12756**],[**Known firstname **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 875**] Unit No: [**Numeric Identifier 12757**]
Admission Date: [**2141-9-29**] Discharge Date: [**2141-10-4**]
Date of Birth: [**2108-4-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 741**]
Addendum:
The patient was discharged on [**2141-10-4**] due to issues surrounding
heparin procurement at rehab. He received 10mg of Coumadin on
[**10-3**] and will take 10mg on [**10-4**] as well. Heparin can be
disconinued when his INR is greater than 2.0.
DATE INR Coumadin dose
[**10-4**] 1.5 10mg
[**10-3**] 1.4 10mg
[**10-2**] 1.4 5mg
[**10-1**] 1.3 0mg
Chief Complaint:
see summary
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 3465**] - [**Location (un) 824**]
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2141-10-4**]
|
[
"453.40",
"300.4",
"415.19",
"340",
"998.12",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.51",
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
19048, 19244
|
10420, 11793
|
336, 365
|
16659, 16896
|
2743, 4046
|
17737, 18995
|
2037, 2051
|
12289, 16229
|
9352, 10397
|
16345, 16638
|
11819, 12266
|
16920, 17714
|
2066, 2724
|
19012, 19025
|
393, 1323
|
1367, 1751
|
1767, 2021
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,380
| 195,667
|
42706
|
Discharge summary
|
report
|
Admission Date: [**2105-11-7**] Discharge Date: [**2105-11-20**]
Date of Birth: [**2035-9-2**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7575**]
Chief Complaint:
Status Epilepticus
Major Surgical or Invasive Procedure:
Intubated
History of Present Illness:
Mr. [**Known lastname 7739**] is a 70 year-old man with PMH of afib (not on
anticoagulation) s/p pacemaker, HTN, COPD, CAD s/p CABG [**1-/2104**],
DM2 and adrenal insufficiency (on chronic steroids), EtOH w/d
seizures [**3-/2105**] who is transferred from an OSH for status
epilepticus.
Patient was admitted to the neurology service s/p five seizures
last [**Month (only) 958**]. He was intubated for airway protection/respiratory
support initially in ICU. Seizures did not recur clinically or
on
EEG. Etiology was thought to be secondary to EtOH withdrawal.
He was discharged with plan to take dilantin monotherapy for 4
weeks anthen discontinue it. (200mg at 8am/8pm and 150mg at
2pm).
Per wife, patient took dilantin for 4 weeks as instructed and
tolerated it well. He discontinued it as planned.
He was doing well until in [**Month (only) 216**] he had a fall at home after "a
few beers." He went to the hospital at that time, was told he
was "fine" and sent home. Since the fall, he had been bed
ridden
and unable to get up without maximal assistance secondary to
pain
in his right hip (which they later found out had multiple
fractures).
In [**Month (only) **], he was at home when he had an episode of flapping
of the right arm, talking "mumbo jumbo, eyes open. This lasted
10-15 minutes. No associated tongue biting/incontinence. After
the episode, he was unconscious and "slept for the next 6 days"
in the hospital. Per wife, his vitals were stable, etc. but he
was asleep. He did have left upper/lower extremity paralysis
per
wife. This was found because when his left arm/leg were lifted
up and released, they dropped, whereas on the right he was able
to keep them up for a little bit. After Mr. [**Known lastname 7739**] [**Last Name (Titles) **] up
gradually, his speech was slurred as well. These deficits
gradually improved and he was back at baseline on discharge home
after ~2 weeks in the hospital. During that admission, he was
started on Keppra 500mg [**Hospital1 **].
Since that admission, he has been home but unable to walk around
without assistance. Thus, wife is sure he has not consumed EtOH
for 8 weeks as he is unable to stand up and get it himself and
she has not given him any. Today, he was "jittery" and restless
all day. He ate dinner at 8pm. Later, he was in bed. His
sister
in law asked him a question and he did not respond. When she
went over to him, his head was turned to the left, his left eye
was up and out, right eye looking straight ahead. He was
unresponsive, said "I'm crazy," and then became unresponsive
again. He had twitching of his abdomen, no tonic/clonic
activity
in upper or lower extremities. No tongue biting, no urinary
incont. EMS was called. He continued to be in this episode and
was nonpresponsive to noxious stimuli. In the ED at OSH, he
"was
observed to have shaking movements of his face, with
disconjugate
pupils and nystagmus." He was given 2 mg ativan, followed by
bolus of 1000 mg Keppra (takes keppra 500 mg [**Hospital1 **] as above).
He
was continuing to have "subtle seizure activity" despite these
interventions, so he was intubated, started on propofol drip.
Notably, had leukocytosis with WBC 15 as well as chest x-ray
consistent with pneumonia. He was started on ceftriaxone and
azithromycin, and vancomycin given recent hospitalization. He
was transferred to [**Hospital1 18**] as it was not possible to place patient
on EEG monitoring at OSH.
Per wife, he did not have any fevers/chills, cough, diarrhea,
dysuria prior to this episode. No recent falls, no EtOH abuse.
ROS: unable to obtain as patient is sedated and intubated
Past Medical History:
- afib not on anticoagulation
- s/p pacemaker
- HTN
- COPD
- CAD s/p cardiac bypass [**2104-1-19**]
- DM2
- hx of GIB
- LBB
- adrenal insuffiency
Social History:
smoked 20 yrs 1ppd, quit 25 years ago, drinks 5-6 beers per day
but not drinking recently. lives with wife, [**Name (NI) **] children.
retired
from being a truck driver
Family History:
unknown
Physical Exam:
Vitals: 35.6 80 110/78 16 100% (intubated)
General: intubated, sedated
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated.
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: unresponsive to voice or sternal rub, did not
follow commands,no eye opening.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2.5->1mm, briskly reactive. Unable to visualize
fundi.
Pt does not have corneal reflexes bilaterally
III, IV, VI: Unable to test [**Name (NI) 3899**], pt unable to follow commands
V: Unable to test
VII: No facial droop (although ETT in place, therefore difficult
to assess), facial musculature appears symmetric.
VIII: Unable to test
IX, X: unable to test
[**Doctor First Name 81**]: Unable to test
XII: Unable to test
-Motor: Normal bulk, tone throughout. No asterixis noted. Does
not withdraw to noxious stimuli in UE to nail bed pressure or
ABG
needle. Flexes/extends feet and toes to noxious stimuli, mild
movement to noxious stimuli in LEs, but not brisk.
-Sensory: Withdraws to noxious stim as above
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 1 1 0 0
R 1 1 1 0 0
Plantar response was up on the left, equivocal on the right.
-Coordination/Gait: Unable to test
Pertinent Results:
[**2105-11-7**] 06:05PM GLUCOSE-161* UREA N-16 CREAT-0.8 SODIUM-144
POTASSIUM-3.3 CHLORIDE-112* TOTAL CO2-22 ANION GAP-13
[**2105-11-7**] 06:05PM CALCIUM-8.8 PHOSPHATE-3.7 MAGNESIUM-1.8
[**2105-11-7**] 06:05PM WBC-8.5 RBC-2.66* HGB-9.1* HCT-28.8* MCV-108*
MCH-34.0* MCHC-31.4 RDW-14.6
[**2105-11-7**] 06:05PM PLT COUNT-196
[**2105-11-7**] 05:58PM CEREBROSPINAL FLUID (CSF) PROTEIN-43
GLUCOSE-112
[**2105-11-7**] 05:58PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-3*
POLYS-16 BANDS-5 LYMPHS-49 MONOS-27 METAS-3
[**2105-11-7**] 03:47AM TYPE-[**Last Name (un) **] PO2-119* PCO2-43 PH-7.33* TOTAL
CO2-24 BASE XS--3 COMMENTS-GREEN TOP
[**2105-11-7**] 03:47AM LACTATE-1.0
[**2105-11-7**] 03:30AM GLUCOSE-194* UREA N-20 CREAT-0.9 SODIUM-140
POTASSIUM-3.6 CHLORIDE-107 TOTAL CO2-21* ANION GAP-16
[**2105-11-7**] 03:30AM estGFR-Using this
[**2105-11-7**] 03:30AM ALT(SGPT)-17 AST(SGOT)-43* ALK PHOS-86 TOT
BILI-0.2
[**2105-11-7**] 03:30AM ALBUMIN-3.4* CALCIUM-8.4 PHOSPHATE-4.1#
MAGNESIUM-1.5*
[**2105-11-7**] 03:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2105-11-7**] 03:30AM URINE HOURS-RANDOM
[**2105-11-7**] 03:30AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2105-11-7**] 03:30AM WBC-9.5# RBC-2.65* HGB-9.1* HCT-28.5*
MCV-107*# MCH-34.3* MCHC-31.9 RDW-14.4
[**2105-11-7**] 03:30AM NEUTS-77.2* LYMPHS-16.4* MONOS-5.6 EOS-0.5
BASOS-0.2
[**2105-11-7**] 03:30AM PLT COUNT-200
[**2105-11-7**] 03:30AM PT-11.4 PTT-27.2 INR(PT)-1.1
[**2105-11-7**] 03:30AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2105-11-7**] 03:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR
[**2105-11-7**] 03:30AM URINE RBC-<1 WBC-5 BACTERIA-NONE YEAST-NONE
EPI-0
[**2105-11-7**] 03:20AM PO2-432* PCO2-41 PH-7.32* TOTAL CO2-22 BASE
XS--4
Brief Hospital Course:
Mr. [**Known lastname 7739**] is a 70 year-old man with PMH of afib (not on
anticoagulation) s/p pacemaker, HTN, COPD, CAD s/p CABG [**1-/2104**],
DM2 and adrenal insufficiency (on chronic steroids), EtOH w/d
seizures in [**3-/2105**] who is transferred from an OSH for status
epilepticus.
Neuro: The patient was monitored on continuous EEG while in the
ICU. He had contiuous PLEDS over the Right frontotemporal area.
This raised our concern for HSV encephalitis so he was started
empirically on acyclovir and an LP was done. The LP showed only
2 WBCs and 3 RBCs, 5 bands, protein 43 and glucose 112. PCR is
pending at this time but given benign CSF the acyclovir was
stopped after 1 day. The PLEDs may be arising from a recent
infarct but given the fact that the patient had a pacer an MRI
could not be obtained. He was initially started on Keppra and
this was titrated up to 2000mg [**Hospital1 **]. Once the patient was off of
propofol he had two electrographic seizures so Dilantin was
added with a 1 gram load. Overnight he became agitated and tore
off his EEG leads. On [**11-10**] the dilantin was discontinued due to
a concern for poor bone healing (right acetabular fracture). He
was started on Trileptal 300 [**Hospital1 **] instead, but patient had
another seizure on the floor so patient was loaded with
fosphenytoin and dilantin was restarted and trileptal stopped.
During the remainder of his stay, the patient was monitored
clinically and on EEG. His EEG initially showed intermittent
R-sided PLEDs. He was periodically agitated and belligerent,
requring temporary restraints. Because of this agitation, keppra
was weaned to off and lacosamide was started and titrated up.
His EEG improved and showed fewer and less severe discharges
than before.
On [**11-17**], the patient was insisting on signing out against
medical advice. He got up from a chair without calling for
assistance and was seen to fall down slowly in the hallway while
leaning on a walker. This may have been a seizure, as the
patient was sleepy afterwards. A head CT showed no acute injury,
wrist and hip x-rays showed no fractures. He had a superficial
abrasion on his R wrist. The patient recovered and was
instructed to always call for assistance when getting out of bed
or chair.
Per the patient's PCP, [**Name10 (NameIs) **] seizures have been thought to be
related to ETOH withdrawal which is why he was admitted on a low
dose of Keppra. It is unclear at this time what the etiology is
of his seizure now. The most recent one by history sounds rather
atypical but considering the EEG evidence it is likely that
there is an underlying seizure disorder beyond ETOH with drawal.
The patient has a history of atrial fibrillation and was not
anticoagulated. Per the patient's PCP this is because of his
ETOH abuse and poor compliance.
ID: The patient was initially put on acyclovir as above but was
stopped after a benign CSF was obtained. The HSV PCR was
negative, as was the CSF culture. He also had a chest xray that
was concerning for pneumonia so he was started on cefepime and
vancomycin. This was stopped after 2 days because the patient's
chest xray improved after diuresis and he had no further white
count or fever.
RESP: Patient was intubated for status. He was successfuly
extubated on [**11-9**] after getting extra lasix and diuresing the
day prior. His respiratory status remained stable on room air
for the remainder of his hospitalization.
ENDO: Patient has a history of adrenal insufficiency. He was
continued on his home dose of fludrocortisone and
hydrocortisone. His blood pressure and electrolytes were stable
and he did not require stress dose steroids.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Fludrocortisone Acetate 0.1 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. HumaLOG Mix 75-25 *NF* (insulin lispro protam & lispro) 14/6
u Subcutaneous [**Hospital1 **]
14units in the AM, 6 units QHS
5. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using REG Insulin
6. Hydrocortisone 15 mg PO BID
15mg in AM, 5mf in PM
7. LeVETiracetam 500 mg PO BID
8. Levothyroxine Sodium 150 mcg PO DAILY
9. Lisinopril 10 mg PO DAILY
10. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
11. Paroxetine 40 mg PO DAILY
12. Potassium Chloride 40 mEq PO BID Duration: 24 Hours
13. Senna 1 TAB PO BID:PRN constipation
14. Atenolol 25 mg PO DAILY
15. Omeprazole 40 mg PO DAILY
16. Thiamine 100 mg PO DAILY
17. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Fludrocortisone Acetate 0.1 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Furosemide 40 mg PO DAILY
6. Hydrocortisone 15 mg PO BID
15mg in AM, 5mg in PM
7. Levothyroxine Sodium 150 mcg PO DAILY
8. Lisinopril 10 mg PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Paroxetine 40 mg PO DAILY
11. Senna 1 TAB PO BID:PRN constipation
12. Phenytoin Sodium Extended 100 mg PO TID seizures
RX *phenytoin sodium extended [Dilantin Extended] 100 mg 1
capsule(s) by mouth three times a day Disp #*90 Capsule
Refills:*3
13. HumaLOG Mix 75-25 *NF* (insulin lispro protam & lispro) 14/6
u Subcutaneous [**Hospital1 **]
14units in the AM, 6 units QHS
14. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
15. Thiamine 100 mg PO DAILY
16. Lacosamide 200 mg PO BID
Discharge Disposition:
Home With Service
Facility:
Community Nurse [**First Name (Titles) **] [**Last Name (Titles) **] Care
Discharge Diagnosis:
Seizures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
No focal neurologic weakness, has weakness from prior R hip
surgery.
Discharge Instructions:
You were admitted for a seizure that would not stop. You were
intubated and transfered to our hospital for continuous EEG
monitoring. You have been started on antiepileptic medications
to prevent future seizures. You had several seizures while in
the hospital. Your EEG showed abnormal brain activity indicating
a high likelihood of further seizures. The cause of your
seizures is possibly an underlying brain injury or abnormality.
You were placed on phenytoin and levetiracetam for seizure
control. Your levetiracetam dose was raised to the maximum for
better seizure control, but had to be lowered and then stopped
because of worsening irritability. Another seizure medicine,
Lacosamide, was added and the dose titrated up.
You attempted to walk unassisted and had a fall, possibly due to
a seizure. You did not have any serious injuries but you should
always have assistance when you walk.
Followup Instructions:
Please call [**Telephone/Fax (1) 3506**] to schedule a neurology follow-up
appointment with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 2442**] in 1 month.
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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|
7704, 11374
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324, 335
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13218, 13218
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5781, 7681
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4808, 5762
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266, 286
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363, 4003
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13233, 13439
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4189, 4360
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,858
| 191,758
|
49912
|
Discharge summary
|
report
|
Admission Date: [**2133-4-7**] Discharge Date: [**2133-4-16**]
Date of Birth: [**2063-3-16**] Sex: F
Service: CARDIOTHOR
AGE: 70.
CHIEF COMPLAINT: Chest pain, coronary artery disease.
HISTORY OF THE PRESENT ILLNESS: The patient is a 70 female
with significant coronary artery disease, status post
catheterization with RCA stent times two on [**2133-1-19**],
complicated by dissection and stent migration. Acute
persistent thrombosis on [**2133-1-28**] with an acute
inferoposterior myocardial infarction, managed by
successfully RCA, PTCA.
The patient presented to an outside hospital on [**2133-4-6**]
with recurrent chest pain escalating over two weeks. The EKG
done there showed T-wave inversion in 3 and AVF with ST
depression in V3 to V6. She was started on Heparin infusion
and nitroglycerine infusion and transferred to the [**Hospital1 1444**], where she was admitted under
the medical service.
PAST MEDICAL HISTORY:
1. Coronary artery disease as above.
2. Hypertension.
3. Hypercholesterolemia.
4. Mitral valve prolapse.
ALLERGIES: The patient is allergic to CODEINE AND BENADRYL.
MEDICATIONS ON TRANSFER:
1. Heparin infusion.
2. Nitroglycerin infusion.
3. Integrilin infusion.
4. Aspirin 325 mg q.d.
5. Plavix 75 mg q.d.
6. Lopressor 50 mg b.i.d.
7. Lipitor, query 80 mg q.d.
8. Serax p.r.n.
9. Colace.
10. Captopril 625 mg t.i.d.
11. Protonix 40 mg q.d.
HOSPITAL COURSE: The patient was admitted under the medical
service and cardiac enzymes were sent. On [**2133-4-8**] she had
had an episode of nose bleeds for which a consultation was
obtained. The bleeding had stopped at that point.
Recommendations were made for humidified air or oxygen by
shovel mask. The patient underwent catheterization on
[**2133-4-8**], which showed moderate stenosis of 60% to 70% in the
LAD with 90% ostial stenosis, 40% to 50% ostial lesion in the
LCX with 99% ostial in-stent restenosis of the RCA. Post
catheterization, she continued to have chest pain and EKG
changes. Cardiac surgery was consulted at this point and
plan was made for the operating the following morning. That
night, she developed further chest pain and sinus
tachycardia, which was treated with beta blockers and
Diltiazem. This was then converted to atrial fibrillation.
She was cardioverted at the bedside. She converted to sinus
rhythm after the second attempt. She was admitted then to
the Coronary Care Unit for monitoring.
On [**2133-4-10**] she underwent CABG times two. She was extubated
without incident. She continued to be stable. She was
transferred to the regular floor on postoperative day #1. The
next couple of days were uneventful. On postoperative day
#3, the patient complained of feeling short of breath. Chest
x-ray was performed, which showed left lower lobe and
lingular consolidation with a small pleural effusion. She
improved symptomatically with chest PT. Wires were
discontinued on postoperative day #4. She continued to make
steady progress on postoperative day #5, although she
complained of some left scapular pain. On postoperative day
#6, it was decided to obtain thoracocentesis to drain the
pleural effusion. She underwent thoracocentesis at the
bedside on [**2133-4-16**] and 450 cc of blood-stained fluid was
obtained. She was symptomatically better now, and she is
ready for discharge to a rehabilitation facility.
MEDICATIONS ON DISCHARGE:
1. Lopressor 25 mg b.i.d.
2. Colace 100 mg b.i.d.
3. Zantac 150 mg b.i.d.
4. Aspirin coated 325 mg q.d.
5. Lasix 20 mg q.d. for one week.
6. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] mEq q.d. for one week.
7. Amiodarone 200 mg b.i.d. for one week, followed by 200 mg
q.d. for three weeks, then off.
8. Percocet one to two tablets q.4h. to 6h.p.r.n.
9. Lipitor 80 mg q.d.
FO[**Last Name (STitle) **]P CARE: The patient will followup with her primary
care physician in two weeks and with Dr. [**Last Name (Prefixes) **] in four
weeks.
CONDITION ON DISCHARGE: Stable. The patient is being
discharged to a rehabilitation facility.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2133-4-16**] 10:52
T: [**2133-4-16**] 10:56
JOB#: [**Job Number 46952**]
|
[
"411.1",
"272.0",
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"401.9",
"424.0",
"511.9",
"414.01",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.62",
"88.56",
"37.22",
"88.53",
"34.91",
"36.11",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
3414, 3995
|
1431, 3388
|
171, 934
|
1153, 1413
|
956, 1128
|
4020, 4356
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,793
| 138,649
|
33807
|
Discharge summary
|
report
|
Admission Date: [**2168-12-30**] Discharge Date: [**2169-1-4**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2972**]
Chief Complaint:
Nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is an 88 yo female with hitory of adult onset diabetes
mellitus, chronic renal failure (baseline Cr 3.5), and CHF who
was admitted to an OSH with 3-4 days of abdominal pain, nausea,
vomiting and poor PO. At that time she had a Cr 4.3, K 6.7, and
third degree heart block. Pt was then transferred to [**Hospital1 18**] for
further care.
Pt had similar hospitalization 2 weeks ago (potassium at that
time was 6.2, Cr 5.3, BUN 98), which was medically managed. Pt
was evaulated by cardiology in the ED and it was felt that there
was no need for pacemaker at that time. Of note, Pt was opposed
to the idea of begining dialysis during that hospitalization,
should it have been indicated.
Past Medical History:
CHF (EF 70% in [**2166**])
PVD
CRF (Cr 3.5 in [**9-29**])
Nephrolithiasis
DM2 w/ nephropathy and retinopathy
CVA, left face/upper extremity weakness, no residual deficits.
Diverticulitis
Junctional rhythm
HTN
Multinodular thyroid
s/p hysterectomy for fibroids
s/p CCY
s/p right ear/mastoid? surgery [**Hospital **] ~[**2162**]
R eye blindness
s/p left knee surgery
Social History:
Social History: Widowed x 3 years. Lives with son and daughter.
[**Name (NI) **] smoking, occasional alcohol, no drug use. Former nurses aide
at [**Hospital 4199**] hospital. BL walks with walker except at home.
Family History:
Family History: non-contributory
Physical Exam:
VS: Temp: 99.7 BP: 148/58 HR:73 RR: 16 O2sat 98% RA
GEN: Pt resting comfortably, NAD, Skin warm/moist
HEENT: 2cm x 2cm ecchymotic nodule with scab on R forehead.
Slight left sided facial droop. Sclera clear, OP clear.
NECK: No cervical LAD, No JVD, Prominent carotid
pulsations/upstrokes.
RESP: Bibasilar crackles that did not clear with cough present
to midway up the lung fields b/l.
CV: Regular rate, Normal S1/S2. Brisk, [**2-26**] crescendo/decrescendo
holosystolic murmur appreciated a the URSB with radiation to the
carotids and subclavians. [**2-26**] holosystolic murmur at along the
LSB with radiation to the apex.
ABD: Soft non-tender, non-distended, no masses.
EXT: Warm and well perfused. 1+ lower extremity edema, DP/PT 1+
bilaterally. Non-pitting upper extremity edema present
bilaterally. Radial pulses symmetric with brisk upstrokes.
SKIN: No rashes, multiple upper extremity (~ 1cm centimeter)
raised, scaled, brown plaques. Right forehead 2cm x 2cm purple
nodule with overlying black scab.
NEURO: Speech slurred, but content appropriate. CN II-XII
intact. No focal motor or sensory deficits with the exception of
minimal RUE weakness (4+/5 in the flexors and extensors).
Reflexes [**1-23**] at achilles/patellas b/l. Plantar reflexes
downgoing b/l.
Pertinent Results:
ECHO [**12-30**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 70%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. There are focal
calcifications in the aortic arch. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
renal U/S:
IMPRESSION: No hydronephrosis, mass, or stone.
.
CXR: [**12-29**]
PORTABLE UPRIGHT AP CHEST RADIOGRAPH: The heart is top normal in
size. Mediastinal and hilar contours are unremarkable. There is
no effusion. There is no pneumonia or evidence of CHF.
.
[**2168-12-29**] 11:35PM BLOOD WBC-6.9 RBC-3.42* Hgb-10.4* Hct-33.8*
MCV-99* MCH-30.3 MCHC-30.7* RDW-14.2 Plt Ct-198
[**2168-12-30**] 03:09PM BLOOD WBC-5.6 RBC-3.00* Hgb-9.0* Hct-29.7*
MCV-99* MCH-30.1 MCHC-30.4* RDW-14.3 Plt Ct-199
[**2168-12-31**] 03:52AM BLOOD WBC-5.5 RBC-3.04* Hgb-9.2* Hct-30.1*
MCV-99* MCH-30.3 MCHC-30.6* RDW-14.1 Plt Ct-188
[**2169-1-1**] 06:55AM BLOOD WBC-5.7 RBC-3.06* Hgb-9.1* Hct-30.5*
MCV-100* MCH-29.6 MCHC-29.7* RDW-13.9 Plt Ct-184
[**2169-1-2**] 07:00AM BLOOD WBC-5.1 RBC-2.94* Hgb-9.3* Hct-29.6*
MCV-101* MCH-31.7 MCHC-31.5 RDW-14.6 Plt Ct-178
[**2169-1-3**] 06:50AM BLOOD WBC-5.8 RBC-2.90* Hgb-9.1* Hct-28.5*
MCV-98 MCH-31.4 MCHC-32.0 RDW-14.6 Plt Ct-175
[**2169-1-4**] 07:05AM BLOOD WBC-6.8 RBC-2.85* Hgb-8.4* Hct-27.9*
MCV-98 MCH-29.7 MCHC-30.3* RDW-14.1 Plt Ct-170
[**2168-12-29**] 11:35PM BLOOD Glucose-163* UreaN-77* Creat-4.3* Na-139
K-6.3* Cl-106 HCO3-26 AnGap-13
[**2168-12-30**] 01:40AM BLOOD Glucose-103 UreaN-72* Creat-3.9* Na-143
K-5.6* Cl-107 HCO3-27 AnGap-15
[**2168-12-31**] 03:52AM BLOOD Glucose-98 UreaN-66* Creat-3.7* Na-144
K-4.7 Cl-108 HCO3-29 AnGap-12
[**2169-1-1**] 06:55AM BLOOD Glucose-84 UreaN-62* Creat-3.6* Na-145
K-4.6 Cl-106 HCO3-28 AnGap-16
[**2169-1-2**] 07:00AM BLOOD Glucose-82 UreaN-67* Creat-3.9* Na-144
K-4.4 Cl-105 HCO3-31 AnGap-12
[**2169-1-3**] 06:50AM BLOOD Glucose-92 UreaN-68* Creat-3.8* Na-143
K-4.5 Cl-103 HCO3-30 AnGap-15
[**2169-1-4**] 07:05AM BLOOD Glucose-38* UreaN-73* Creat-4.0* Na-142
K-4.5 Cl-102 HCO3-31 AnGap-14
[**2168-12-31**] 09:27PM BLOOD proBNP-9886*
[**2168-12-29**] 11:35PM BLOOD Calcium-7.8* Phos-6.0* Mg-5.6*
[**2168-12-31**] 09:27PM BLOOD Mg-4.1*
[**2169-1-1**] 06:55AM BLOOD Calcium-7.7* Phos-6.9* Mg-3.9*
[**2169-1-2**] 07:00AM BLOOD Calcium-7.9* Phos-6.4* Mg-3.5*
[**2169-1-3**] 06:50AM BLOOD Calcium-8.2* Phos-5.3* Mg-3.1*
[**2169-1-4**] 07:05AM BLOOD Calcium-8.2* Phos-4.9* Mg-3.0*
[**2168-12-30**] 01:40AM BLOOD VitB12-447 Folate-9.6
[**2168-12-30**] 01:40AM BLOOD %HbA1c-5.7
[**2168-12-30**] 03:32AM BLOOD Type-ART pO2-128* pCO2-49* pH-7.37
calTCO2-29 Base XS-2
Brief Hospital Course:
88 yo female with DM, HTN, and CRF admitted for bradycardia with
a junctional rhythm, hyperkalemia and acute creatinine elevation
likely representing acute on chronic renal failure in the
setting of nausea/vomiting. In [**Name (NI) **], Pt was bradycardic to 30s,
and she received D50, insulin, calcium, kayexalate, bicarbonate.
She was also given ciprofloxacin for positive U/A (E. Coli,
sensitivities pending). She had her [**Last Name (un) **] and lasix held on
secondary to ARF and hyperkalemia as well as amlodipine
secondary to bradycardia. Her K has stabilized and she has been
in 1st degree a-v block with a rate in 50s-60s, with good urine
output. Pt was evaluated in the ED for bradycardia by
electrophysiology and they did not think she needed emergent
pacemaker.
.
# Bradycardia: Pt was initially bradycardic with a junctional
rhythm on EKG in the setting of a magnesium of 5.6 on amlodipine
therapy. Pt was seen by EP in the emergency departement and they
felt comfortable with medical management at that point with no
need for temporarary pacemaker. Pt's amlodipine, lasix, and [**Last Name (un) **]
were subsequently held and she became hypertensive with 1st
degree heart block. Initial junctional rhythm/bradycardia was
felt to be attributable to amoldipine plus hypermagnesemia. With
resolution of electrolyte abnormalities and ARF these
medications were added back; initially lasix followed by [**Last Name (un) **] and
amlodipine. A repeat EKG showed stable 1st degree heart block.
.
# Acute renal failure: Complicated by hyperkalemia initially,
but resolved following glucose/insulin/CaCO/kayexelate and fluid
resuscitation. The 3-4 days of preceding malaise, n/v, and
FeUREA of <35% suggested a pre-renal etiology and the [**Last Name (NamePattern4) **] UTI
(UA on [**12-30**]) versus possible gastroenteritis was thought to be
the underlying etiology of the pre-renal state. Pt initially
presented with hyperkalemia (K 6.3), hypermagnesemia (Mg 5.6)
and hyperphosphatemia (6.0). These abnormalities were likely
secondary to decreased renal function in the setting of acute on
chronic renal failure. The potassium was corrected with
glucose/insulin/CaCO/kayexelate, and the magnesium trended down
with improved renal function. The phosphate was addressed with
Sevelamer and calcium acetate. Pt continued to be opposed to the
idea of dialysis during this admission. These electrolyte
abnormalities are concerning in the setting of transient 3rd
degree heart block as hyperMg can certainly potentiate this
condition. Hopefully, with adequate treatment of the UTI,
constipation, and sufficient PO intake Pt will be able to avoid
future episodes of pre-renal azotemia exacerbating her
underlying renal failure.
.
#. Nausea/Vomiting/Fever: U/A from [**12-30**] showed pan-sensitive E.
coli UTI and Pt was begun on ciprofloxacin on [**12-30**] and completed
a 5 day course while in the hospital. Symptoms of nausea and
vomiting continued with vomiting occuring shortly after eating.
With scant stool output Pt underwent aggressive laxative/stool
softener/enema therapy as constipation was thought to by
contributing to the ongoing nausea. She subsequently had large
stool output and subjectively began to feel much better.
.
# CHF: Per OSH records pt had a TTE in [**2166**] significant for EF
70%. Pt has minimal crackles on exam. CXR showed no pulmonary
edema and there was no diastolioc CHF on ECHO ([**12-30**]). However, Pt
received fluid resuscitation for acute renal failure and
subsequently manifested signs of CHF with increased extremity
edema and crackles/rales on chest auscultation. CHF was managed
with gentle lasix diuresis with prompt clinical resolution of
symptoms.
.
# HTN: Following fluid resuscitation and holding of
[**Last Name (un) **]/amlodipine Pt became hypertensive (sbp's in the 160s). Her
hydralazine was increased to 75mg QID and her isosorbide was
increased to 80mg. With persistent hypertension the amlodipine
was added back on [**1-3**]. Her SBP was subsequently in the 130-160
range and EKG showed stable first degree heart block.
.
# DM: Continued SC insulin while in the hospital.
.
# Anemia: Likely anemia of chronic disease/CKD.
.
# Skin lesions: Pt with multiple lesions consistent with
seborrheic keratosis. The right forehead lesion was more
concerning for recent trauma vs. possible basal cell or
melanoma. Pt was advised to see a dermatologist in the near
future as an outpatient and was provided with the number for the
[**Hospital1 18**] dermatology clinic to make an appointment at her earliest
convenience.
Medications on Admission:
Medications (home):
Hydral 50 mg tid
amlodipine 10 mg daily
lasix 80 mg daily
diovan 160 daily
isordil 40 mg [**Hospital1 **]
renagel 800 mg tid
meclizine 12.5 tid prn
insulin 70/30 10 U qam and 10 U qpm
Procrit
Phoslo 667 tid
Discharge Medications:
1. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for vertigo.
7. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO QID (4
times a day).
Disp:*336 Tablet(s)* Refills:*2*
8. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Isosorbide Dinitrate 40 mg Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO Q12H (every 12 hours).
Disp:*120 Tablet Sustained Release(s)* Refills:*2*
10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet
Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
Disp:*30 Powder in Packet(s)* Refills:*2*
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Primary:
1. Hyperkalemia
2. Acute Renal Failure
3. Congestive Heart Failure
4. Transient 3rd degree heart block
5. Urinary tract infection
6. Constipation
Secondary
1. Diabetes Mellitus
2. Chronic renal failure
3. Hypertension
4. Peripheral vascular disease
5. Cerebrovascualar accident
6. Diverticulosis
Discharge Condition:
Stable, alert and oriented, afebrile, stable creatinine, no
clinical signs of heart failure.
Discharge Instructions:
You were admitted to the hospital with nausea, vomiting and
abdominal pain that were likely due to chronic constipation
combined with a urinary tract infection. The constipation was
treated with laxatives and enemas while the UTI was treated with
5 days of antibiotics. Upon admission you were quite dehydrated
from the nausea and vomiting this lead to worsening kidney
function that resolved with fluid resusciation. You were also
found to have new changes on your EKG likely secondary to the
combined effects of electrolyte abnormalites and one of your
blood pressure medications (amlodipine) and milk of magnesia.
The amlodipine was held until your electrolyte abnormalities
were corrected.
.
Please take all medications as instructed and follow up at the
appointments outlined below. Please attempt to maintain good
oral hydration as becoming dehydrated will put you at risk for
worsening kidney failure and electrolyte abnormalities. Please
avoid Milk of Magnesia.
.
Should you experience fevers/chills/night sweats, nausea,
vomiting, lightheadedness, chest pain, palpitations, shortness
of breath, increased extremity swelling, decreased urine output,
or any other concerning symptoms please do not hesitate to call
your PCP or return to the hospital for evaluation.
Followup Instructions:
1. Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Hospital1 **] staff at the [**Hospital 21242**]
Hospital on Friday [**1-6**] at 10:00am.
.
3. You may arrange a follow up with the [**Hospital1 18**] dermatology clinic
to assess the chronic forehead nodule at a time convenient to
you and your family. [**Hospital 2652**] Clinic: ([**Telephone/Fax (1) 8132**]
Completed by:[**2169-1-4**]
|
[
"362.01",
"427.89",
"584.9",
"428.0",
"276.7",
"275.2",
"599.0",
"585.5",
"403.91",
"275.3",
"702.19",
"285.21",
"250.40",
"443.9",
"426.0",
"041.4",
"250.50",
"564.00",
"583.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12281, 12356
|
6089, 10663
|
295, 301
|
12705, 12800
|
2992, 6066
|
14122, 14528
|
1669, 1688
|
10940, 12258
|
12377, 12684
|
10689, 10917
|
12824, 14099
|
1703, 2973
|
223, 257
|
329, 1018
|
1040, 1407
|
1439, 1637
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,688
| 139,054
|
13084
|
Discharge summary
|
report
|
Admission Date: [**2149-9-20**] Discharge Date: [**2149-9-26**]
Date of Birth: [**2094-7-2**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 4765**]
Chief Complaint:
CP
Diaphoresis
Major Surgical or Invasive Procedure:
Cardiac catheterization
Suprapubic catheter placement
History of Present Illness:
55yo man with h/o CAD s/p PTCA, HTN, DM, hyperlipidemia, morbid
obesity and tobacco habit who p/t OSH on [**9-18**] w/CP and
diaphoresis. Pt thought was GERD since "burning" in neck
extending down throat to and across chest. No chest pressure,
n/v, or radiations.
At OSH, pt r/o for MI by serial CE, with peak CK 220, MB 4.2,
TropI 1.18. He was sent for stress test, though these results
are not in the record. Because of recurrent episodes of CP with
inferolateral ST depressions and HTN (and presumably the results
of the stress test), he was was transferred to [**Hospital1 18**] for cath.
Of note, pt was started on IV steroids for presumed COPD flare
prior to ETT and levaquin for bronchitis; however, pt denies
cough, f/c, wheezing in recent past.
Pt's EKG at OSH: NSR@86, nl axis, nl intervals, 1-2mm ST
depressions in V5-V6; no Q waves
Cath [**9-20**]: 70% mid LAD, subtotally occluded Lcx w/ slow flow,
distal 80-90% RCA stenoses; per V-gram EF 50%, no MR
Pt was then transferred to CCU with IABP in place until he can
have CABG.
Past Medical History:
CAD w/ PTCA [**58**] yr ago, HTN, DM2 (diet controlled),
hyperlipidemia (not on meds), morbid obesity, OSA, GERD, hiatal
hernia, arthritis (knees, s/p L TKA) on vicodin, depression/
anxiety
Social History:
retired roofer and carpenter; married with two sons
etoh - none
tob - 2-6ppd for 30+ years (60-180 pack years)
drugs - none
Family History:
GM - died from MI at 72yo; M with CRI on HD
Physical Exam:
Gen: obese man with wet washcloth on his forehead; not sweating;
NAD
Skin: warm and dry, no rash
HEENT: large round head, PERRL, EOMI, OP clear, MMM
CV: RRR, nl s1 s2 no M/G/R, JVP flat
Lungs: occassional wheezing at bases b/l
Abd: obese, nt nd + BS
Ext: 1+ pitting edema to knees b/l, no clubbing
Neuro/Psych: nonfocal, approp affect
Pertinent Results:
[**2149-9-20**] 04:26PM BLOOD Type-ART O2 Flow-2 pO2-73* pCO2-52*
pH-7.40 calHCO3-33* Base XS-5 Intubat-NOT INTUBA
[**2149-9-22**] 09:15PM BLOOD Type-ART pO2-76* pCO2-59* pH-7.37
calHCO3-35* Base XS-6
[**2149-9-21**] 05:26AM BLOOD Triglyc-85 HDL-54 CHOL/HD-4.1
LDLcalc-148*
[**2149-9-21**] 05:26AM BLOOD Calcium-8.6 Phos-5.1* Mg-2.4 Cholest-219*
[**2149-9-26**] 06:35AM BLOOD Calcium-8.3* Phos-3.6 Mg-2.2
[**2149-9-20**] 11:47PM BLOOD CK-MB-9 cTropnT-0.09*
[**2149-9-21**] 05:26AM BLOOD CK-MB-6 cTropnT-0.09*
[**2149-9-21**] 11:08PM BLOOD CK-MB-4 cTropnT-0.11*
[**2149-9-24**] 07:45AM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2149-9-25**] 06:30AM BLOOD CK-MB-3 cTropnT-0.06*
[**2149-9-21**] 11:08PM BLOOD Lipase-135*
[**2149-9-20**] 04:04PM BLOOD ALT-24 AST-18 CK(CPK)-213* AlkPhos-103
TotBili-0.4
[**2149-9-20**] 11:47PM BLOOD CK(CPK)-158
[**2149-9-21**] 05:26AM BLOOD CK(CPK)-136
[**2149-9-21**] 11:08PM BLOOD ALT-20 AST-20 LD(LDH)-213 AlkPhos-78
Amylase-172* TotBili-0.4
[**2149-9-23**] 01:35PM BLOOD CK(CPK)-59
[**2149-9-24**] 07:45AM BLOOD CK(CPK)-64
[**2149-9-25**] 06:30AM BLOOD CK(CPK)-118
[**2149-9-20**] 04:04PM BLOOD Glucose-195* UreaN-24* Creat-1.2 Na-136
K-4.7 Cl-97 HCO3-30* AnGap-14
[**2149-9-26**] 06:35AM BLOOD Glucose-110* UreaN-24* Creat-1.2 Na-140
K-3.8 Cl-100 HCO3-29 AnGap-15
[**2149-9-20**] 04:04PM BLOOD PT-17.4* PTT-35.8* INR(PT)-1.9
[**2149-9-20**] 04:04PM BLOOD Plt Ct-215
[**2149-9-26**] 06:35AM BLOOD PT-12.9 PTT-24.3 INR(PT)-1.1
[**2149-9-26**] 06:35AM BLOOD Plt Ct-171
[**2149-9-20**] 04:04PM BLOOD Neuts-87* Bands-4 Lymphs-5* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2149-9-20**] 04:04PM BLOOD WBC-12.3* RBC-4.61 Hgb-14.0 Hct-40.8
MCV-88 MCH-30.3 MCHC-34.3 RDW-13.4 Plt Ct-215
[**2149-9-21**] 02:06PM BLOOD WBC-14.4* RBC-4.34* Hgb-13.2* Hct-39.1*
MCV-90 MCH-30.4 MCHC-33.7 RDW-13.4 Plt Ct-190
[**2149-9-22**] 01:32AM BLOOD WBC-12.3* RBC-3.65* Hgb-11.0* Hct-32.6*
MCV-89 MCH-30.3 MCHC-33.9 RDW-13.6 Plt Ct-201
[**2149-9-23**] 06:46AM BLOOD WBC-15.5* RBC-3.05* Hgb-9.3* Hct-27.2*
MCV-89 MCH-30.6 MCHC-34.4 RDW-13.9 Plt Ct-155
[**2149-9-25**] 06:30AM BLOOD WBC-7.3 RBC-3.46* Hgb-10.7* Hct-30.9*
MCV-89 MCH-30.8 MCHC-34.5 RDW-13.4 Plt Ct-119*
[**2149-9-25**] 03:59PM BLOOD Hct-31.9*
[**2149-9-26**] 06:35AM BLOOD WBC-7.5 RBC-3.63* Hgb-11.2* Hct-32.7*
MCV-90 MCH-30.9 MCHC-34.3 RDW-13.3 Plt Ct-171
[**2149-9-21**] 07:20AM URINE RBC->50 WBC-[**3-7**] Bacteri-FEW Yeast-NONE
Epi-0
[**2149-9-23**] 02:30PM URINE RBC->50 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0
[**2149-9-23**] 02:30PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
Brief Hospital Course:
A/P: 54yo man with known CAD, DM2, HTN, hyperlipid, morbid
obesity, with burning CP likely representative of unstable
angina, cath showing 3VD.
1. Cardio
A. Coronaries: patient arrived in CCU CP free on IABP. The plan
initially was to cont the IABP and heparin until the patient
could have a CABG. However, CT [**Doctor First Name **] upon further eval felt that
the patient's obesity and DM made him a high risk surgical
candidate. Therefore, the patient went back to the cath lab on
[**9-23**] where he had his LCx and LAD stented, and is planned to
have his RCA stented after an interval of [**1-3**] weeks to avoid
dye-related ATN. In the meantime the pt was maintained on [**Date Range **],
BB, ACEI, statin, Plavix.
Of note, the patient had an episode of "burning" in his throat
after his stents were placed, an EKG showed V5-V6 1mm ST
elevations, CK 118, CK-MB 3, Trop .09. Pt was started on
Nitroglycerine drip and then PO Imdur with weaning off of drip.
He had no more CP or burning during the course of his admission.
B. Pump HTN: above mgmt
C. Rhythm: NSR
2. Pulm: COPD - suggested on OSH CXR; cont MDIs, tapered off the
steroids that the pt had been started on at the OSH; since there
was no evidence of bronchitis at admission, abx were held
3. Renal: Cr 1.2 on admit, 1.9 s/p cath, then back to 1.2 prior
to discharge; gave mucomyst and hydration for second cath
4. ID: no evid of bronchitis or other infection at this time;
will monitor
5. GI: bowel regimen; heart healthy, low fat, low salt diet
6. GU: in prep for possible CT surgery, a foley cath insertion
was attempted; after two nurses and a CCU doctor tried without
success [**2-3**] BPH, GU was called. After they failed to pass a
Foley, they inserted a suprapubic cath in the patient's midline
lower abd. The patient bleed from the site, possibly related to
his anticoagulated status given his CAD. The pt's hct dropped
during this time as well from 39 to 32 to 27. He was given 1
unit of PRBCs, bumped to only 28, and an abd CT was performed
that showed a large hematoma in the rectus muscle. The pt's hct
stablized however and evetually rose to 32.7 prior to his d/c.
Per GU, the pt was instructed to leave the SPT in and follow up
with Dr. [**Last Name (STitle) **] as an outpt in 2 weeks (after RCA stent placed)
to have it removed. They did not want to remove it in this
hospitalization given the risk for disrupting hemostasis that
had been acheived with it remaining in place. The patient was
able to void through his urethra through his hosp course.
7. Heme: see above
8. Endo DM: [**Doctor First Name **] diet, SSI; pt to be d/c'd with metformin 500mg
po qd
9. Psych: wellbutrin, celexa, ativan prn
10. Ortho: Arthritis: cont vicodin
11. PPx: heparin drip for IABP; zantac; colace
12. Communication: will speak with pt's wife
13. Code: FULL
14. Dispo: will go to CT [**Doctor First Name **] service for perioperative care
Medications on Admission:
On transder from [**Hospital3 **]: maxzide 25mg qd, zyban 150mg qd,
celexa 40mg qd, cardizem 180mg qd, aricept 10mg [**Last Name (LF) **], [**First Name3 (LF) **] 81mg qd,
prevacid 30mg qd, levaquin 500mg qd nicoderm patch, solumedrol
40mg IV q8h, vicodin, mylanta, NTG paste, plavix 75mg qd,
lovenox, metoprolol
At home: cardia XT 300mg [**Last Name (LF) **], [**First Name3 (LF) **] 81mg qd, aricept, wellbutrin,
celexa, dyazide, vicadin
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
3. 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:*2*
4. Donepezil Hydrochloride 5 mg Tablet Sig: Two (2) Tablet PO HS
(at bedtime).
Disp:*60 Tablet(s)* Refills:*2*
5. Citalopram Hydrobromide 20 mg Tablet Sig: Two (2) Tablet PO
QD (once a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for cough.
Disp:*1 mdi* Refills:*2*
8. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: 1-2 puffs
Inhalation once a day.
Disp:*1 mdi* Refills:*2*
9. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*2*
11. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
13. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
14. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Unstable angina from severe coronary artery disease
Discharge Condition:
Stable
Discharge Instructions:
Please take all medications and keep all appointments scheduled
for you. Also, if you have chest pain or burning sensations in
your throat or chest, please go to the nearest Emergency Room to
be evaluated.
Followup Instructions:
You will need:
1. An appointment in one week with your primary care doctor to
have your electrolytes checked now that you have started on new
medications. You have an appointment set up for you with Dr.
[**Last Name (STitle) 3314**] for this purpose on Thursday [**10-2**], at 11:15am.
Please call to confirm.
2. Another cardiac catheterization with Dr. [**First Name (STitle) **] in two weeks
to stent open your Right Coronary Artery. You will be contact[**Name (NI) **]
by phone in the days ahead to set this up.
3. An appointment with Dr. [**Last Name (STitle) **] of Urology to have your
suprapubic tube removed. You can reach him at ([**Telephone/Fax (1) 39998**], to schedule this appointment. He would like to see you
after you have your cardiac cath with Dr. [**First Name (STitle) **], [**First Name3 (LF) **] you can
call Dr.[**Name (NI) 39999**] office once you know the date of your cardiac
cath.
|
[
"414.01",
"250.00",
"411.1",
"496",
"998.12",
"401.9",
"593.9",
"278.01",
"600.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.07",
"88.56",
"99.04",
"37.61",
"57.17",
"37.22",
"88.55",
"88.53",
"36.06",
"99.20",
"36.05"
] |
icd9pcs
|
[
[
[]
]
] |
10229, 10284
|
4900, 7826
|
348, 404
|
10380, 10388
|
2264, 4877
|
10643, 11564
|
1849, 1894
|
8318, 10206
|
10305, 10359
|
7852, 8295
|
10412, 10620
|
1909, 2245
|
294, 310
|
432, 1477
|
1499, 1691
|
1707, 1833
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,902
| 144,279
|
43405
|
Discharge summary
|
report
|
Admission Date: [**2118-6-24**] Discharge Date: [**2118-7-4**]
Date of Birth: [**2067-2-17**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Small bowel obstruction
Major Surgical or Invasive Procedure:
Ex lap, lysis of adhesions [**6-28**]
History of Present Illness:
Mrs. [**Known lastname 93410**] is a lovely lady who presented to the ED on [**6-24**] with
abdominal pain for 1 day. CT scan of the abdomen showed partial
small bowel obstruction. She has had 2 episodes of this in the
past, which resolved with non-operative treatment. She did not
complain about nausea or vomiting on admission.
Past Medical History:
1. Small bowel obstruction
2. Asthma
3. Laparoscopic cholecystectomy
4. Appendectomy
5. Status post hysterectomy
6. Status post cervical rib removal
Social History:
The patient has a 5 pack year history of tobacco and quit 15-20
years ago. Denies alcohol and drugs.
Family History:
Non-contributory.
Physical Exam:
NAD, A&O x3
RRR, no murmur, B CTA
Abd soft, NT/ND, incision c/d/i, staples removed
B LE WWP, no edema
Pertinent Results:
[**2118-7-2**] 04:01AM BLOOD WBC-9.2 RBC-3.81* Hgb-10.8* Hct-33.8*
MCV-89 MCH-28.5 MCHC-32.0 RDW-14.2 Plt Ct-225
[**2118-7-3**] 05:30AM BLOOD Glucose-111* UreaN-12 Creat-0.6 Na-138
K-3.7 Cl-106 HCO3-25 AnGap-11
Cardiology Report ECHO Study Date of [**2118-7-1**]
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Aneurysmal
interatrial
septum.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
systolic
function (LVEF>55%). Normal regional LV systolic function.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. LV
inflow pattern c/w impaired relaxation.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PERICARDIUM: No pericardial effusion.
Conclusions:
1. The interatrial septum is aneurysmal.
2. There is mild symmetric left ventricular hypertrophy with
normal cavity
size and systolic function (LVEF>55%). Regional left ventricular
wall motion
is normal. The apex was not well seen.
Brief Hospital Course:
Mrs. [**Known lastname 93410**] was admitted and maintained NPO on iv fluids. Her
abdominal pain as well as bowel funciton did not improve over
the next days. She was taken to the operating room for
diagnostic laparoscopy and then exploratory laparotomy with
lysis of dense adhesions entrapping the small bowel. The
proximal bowel was markedly dilated. Postoperatively, she was
transferred to the surgical floor for further care. On POD 1 she
complained of chest pain. An EKG was obtained, which showed
st-elevation. Cardiology was consulted and recommended to
continue beta-blockers and start aspirin. The chest pain
resolved on nitroglycerin. Four sets of cardiac enzymes were
obtained and within normal limits. Otherwise, she had an
uncomplicated postop course. She developed bowel function in a
timely fashion and tolerated a regular diet at discharge. Her
pain was well controlled on oral pain medications. She was
mobile and walked the hallways without problems. [**Name (NI) **] incision
was clean, dry and intact. Her staples were removed just before
discharge. Leaving the hospital, she was in a good condition.
Medications on Admission:
reglan 10"", protonix 40", singulair ', albuterol", flovent "
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
6. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for
10 days.
Disp:*40 Capsule(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction.
Discharge Condition:
Good
Discharge Instructions:
Continue all preop medications.
Showers are fine.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 10 to 14d
F/u with PCP
Cardiac stress test per cardiology
Completed by:[**2118-7-4**]
|
[
"V64.41",
"786.59",
"560.81",
"493.90",
"998.2",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.73",
"54.59",
"38.93",
"99.77",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
4418, 4424
|
2371, 3493
|
337, 377
|
4493, 4499
|
1199, 2348
|
4597, 4717
|
1043, 1062
|
3605, 4395
|
4445, 4472
|
3519, 3582
|
4523, 4574
|
1077, 1180
|
274, 299
|
405, 736
|
758, 908
|
924, 1027
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,260
| 192,032
|
48813
|
Discharge summary
|
report
|
Admission Date: [**2128-7-29**] Discharge Date: [**2128-8-17**]
Date of Birth: [**2064-12-4**] Sex: M
Service: SURGERY
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Nonhealing ulcer of the left foot.
Ischemic rest pain of the right foot.
Major Surgical or Invasive Procedure:
[**7-29**] Aortobifemoral bypass with 14 x 7 Dacron graft and
thrombectomy of right fem-[**Doctor Last Name **] graft
[**8-3**] Exploratory laparotomy, left colectomy with proctectomy and
takedown splenic flexure.
History of Present Illness:
This 63-year-old gentleman with severe
peripheral vascular disease has rest pain of his right foot
and a nonhealing ulcer on the left. He has previously had a
left-to-right fem-fem bypass with a right femoral-popliteal
bypass with saphenous vein many years ago at another
institution. This graft was found to be failing and he has
undergone a combination of iliac angioplasty and stenting on
the left to improve inflow plus surgical revision of the fem-
fem bypass. He continues to have poor flow to his extremities
and we decided to convert his inflow to an aortobifemoral
graft.
Past Medical History:
PVD
DM2
HTN
hyperchol
CKD (Cr 1.4)
PSH: [**2127-6-26**] s/p Left 2nd toe amp, [**2127-5-22**] L [**Month/Day/Year 1793**] Angioplasty,
CABG '[**20**]. L. to R. fem-fem, R. fem-[**Doctor Last Name **], [**2126-12-10**] L iliac stent
Social History:
Denies tobacco. etoh rarely. Married, lives with his wife.
Worked as a computer programmer.
Family History:
Father - died of MI at 52
Mother - died of TB
no children/siblings
Physical Exam:
Upon discharge
Alert and oriented NAD
VSS
PERRL, moist mucus membranes, no JVD
RRR soft HS no m/r/g
CTAB, anteriorly
soft slightly distended
ostomy in place + green liquid output
incision slightly oozing, caudal portion with healthy
granulation tissues
R groin incision oozing serosanguious fluid
L groin incision c/d/i
No scrotal edema/erythema
R leg DP + DP, PT by doppler no edema
L heel ulcer black dry eschar, black eschar on L sole, L great
toe black eschar
Pertinent Results:
[**2128-8-17**] 05:11AM BLOOD WBC-15.4* RBC-2.75* Hgb-7.9* Hct-25.3*
MCV-92 MCH-28.9 MCHC-31.4 RDW-13.8 Plt Ct-804*
[**2128-7-29**] 03:15PM BLOOD WBC-9.9 RBC-3.22* Hgb-10.0* Hct-28.3*
MCV-88 MCH-30.9 MCHC-35.2* RDW-13.3 Plt Ct-218
[**2128-8-17**] 05:11AM BLOOD Plt Ct-804*
[**2128-7-29**] 03:15PM BLOOD Plt Ct-218
[**2128-8-17**] 05:11AM BLOOD Glucose-280* UreaN-41* Creat-1.1 Na-140
K-4.9 Cl-108 HCO3-26 AnGap-11
[**2128-7-29**] 03:15PM BLOOD Glucose-136* UreaN-53* Creat-1.4* Na-143
K-5.1 Cl-114* HCO3-22 AnGap-12
[**2128-8-11**] 02:58AM BLOOD ALT-40 AST-68* AlkPhos-189* Amylase-160*
TotBili-0.5
[**2128-7-30**] 11:38AM BLOOD ALT-31 AST-63* LD(LDH)-395* AlkPhos-44
TotBili-0.4
[**2128-8-11**] 02:58AM BLOOD Lipase-222*
[**2128-8-17**] 05:11AM BLOOD Calcium-7.6* Phos-2.6* Mg-2.5
[**2128-7-29**] 03:15PM BLOOD Calcium-8.4 Phos-4.2 Mg-1.8
Radiology Report CHEST (PORTABLE AP) Study Date of [**2128-8-15**] 9:55
AM
[**Last Name (LF) 1111**],[**First Name7 (NamePattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6889**] FA5 [**2128-8-15**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 102562**]
FINDINGS:
Compared to the prior study, there is increased prominence of
the left lower lobe density which has a more patchy appearance
and is concerning for evolving consolidation. This would be
consistent with pneumonia in the appropriate clinical setting.
The remainder of the lungs is unchanged. Mild increased
distension of the pulmonary vasculature suggests slight
worsening of fluid status.
IMPRESSION: Evolving left lower lobe consolidation, consistent
with pneumonia in the appropriate clinical setting. Slightly
worsened fluid status. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4347**]
Cardiology Report ECG Study Date of [**2128-8-12**] 4:21:56 AM
Technically difficult study
Sinus tachycardia ,Right bundle branch block
ST-T wave abnormalities , Since previous tracing of [**2128-8-3**],
heart rate faster, ST-T wave abnormalities more marked
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Radiology Report [**Numeric Identifier **] PICC W/O PORT Study Date of [**2128-8-11**] 2:37
PM
Final Report
PICC LINE PLACEMENT
TECHNIQUE: Using sterile technique and local anesthesia, the
left basilic
vein was punctured under direct ultrasound guidance using a
micropuncture set. Hard copies of ultrasound images were
obtained before and immediately after establishing intravenous
access. A peel-away sheath was then placed over a guide wire and
a double lumen [**Last Name (un) **] PICC line measuring 45 cm in length was
then placed through the peel-away sheath with its tip positioned
in the SVC under fluoroscopic guidance. Position of the catheter
was confirmed by a fluoroscopic spot film of the chest.
The peel-away sheath and guide wire were then removed. The
catheter was
secured to the skin, flushed, and a sterile dressing applied.
The patient tolerated the procedure well. There were no
immediate
complications.
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
double lumen [**Last Name (un) **] PICC line placement via the left basilic
venous approach. Final internal length is 45 cm, with the tip
positioned in SVC. The line is ready to use. The study and the
report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Doctor Last Name 3900**]
DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Brief Hospital Course:
63 y.o M patient who came in for a scheduled admission on
[**2128-7-29**] for Aortobifemoral bypass with 14 x 7 Dacron graft and
thrombectomy of right fem-[**Doctor Last Name **] graft. Patient tolerated procedure
well, in the PACU patient was noted to have abdominal
distention, bladder pressures monitored. Patient wa hypotensive,
started on Neosyniphrine IV drip, transfused with 1 unit PRBC's,
decision was made to keep patient intubated, transferred to
CVICU. Patient was fluid rescuscitated, Neo drip was able to be
weaned off.
POD1 [**2128-7-30**] T maxed 101.1 the rest of vitals stable, remains
sedated with Propofol and remains intubated, now acidotic.
Continued with fluid replacement. Monitored for colon ischemia,
abdomen remain distended and tender. Bladder pressures
monitored. Patient became hyperglycemic started with insulin
gtt.
POD2 [**2128-7-31**] T max 101, hypotensive at times- fluid replaced.
Patient failed vent wean, remains intubated with prn sedation.
Abdomen remains distended, and tympanic. Bladder pressures
rising 21->22->23. Hct and Plts down, HIT sent. Lactate stable
2.2->1.8->1.9. Started on Zosyn imperically for GNR in sputum.
Kept NPO. Remains on insulin gtt for glycemic control.
POD3 [**2128-8-1**] Remains febrile T max 101.3 HR and BP stable.
Patient remains intubated and slightly sedate, able to follow
commands. Reamins on Insulin gtt, started on Protonix IV.
Bladder pressure 17<-23. Hct 25<-26<-30, transfused with 1 unit
PRBC. HIT pending. C-diff sent.
POD4 [**2128-8-2**] T max 101.3, HR & BP stable. Remains intubated and
slightly sedate. Abdomen remain distended and firm, bladder
pressure 17, kept NPO, genral surgery consulted- recs KUB-showed
stomach air filled, abdominal CT with PO contrast-limited study
due to PO contrast. Remains on insulin gtt, Zosyn and added
Flagyl IV. PA RIJ converted to TLC CL. HIT pending.
POD5 [**2128-8-3**] Increasing melena stools with fever TM 102, general
surgery made decision to take to the OR. Patient underwent
Exploratory laparotomy, left colectomy/colostomy with
proctectomy and takedown splenic flexure. Patient tolerated
procedure well, returned to [**Location 42137**] for recovery and further
observation, J-Tube placement.
POD6/1 [**2128-8-4**] VSS, T M 97.7. No acute events. Remains intubated,
sedated with Versed and Fentanyl. Zosyn discontinued, started on
Vanco and Cipro, kept on Flagyl.
POD7/2 [**2128-8-5**] VSS, no acute events. Remains intubated and
sedate, weaning sedation, able to MAE and following commands.
Started on Lopressor IV for hypertension. HCT stable, HIT (-),
started on Hep SQ tid for DVT prophylaxis. Remains on Inulin gtt
and IV Protonix.
POD8/3 [**2128-8-6**] No acute events. Weaning sedation and from vent.
Reamins on Vanco, Cipro, Flagyl, insulin drip, Protonix IV,
Fenatnyl. Started to diurese with Lasix. UA (-).
POD9-10/4-5 [**Date range (1) 102563**] VSS. Diuresing with Lasix, remains on
Vanco, Cipro, Flagyl, insulin drip, Protonix IV, Fentanyl.
Remains intubated. C-diff (-). Remains intubated, Vent
weaning-extubated. Started tube feeds via J-tube (goal 100cc/h
of [**3-2**] strength). Converted Insulin gtt to RISS.
POD12/6 [**2128-8-9**] VSS, remains extubated. Endocrine consulted for
longterm glycemic control. Remains on Vanco,insulin drip,
Protonix IV, metoprolol IV,Cipro & Flagyl switched to PO. Tube
feeds advancing to goal.
POD13/7 [**2128-8-10**] VSS, doing well extubated. PICC line placed in
IR, CL d/c'd. Diuresing with Lasix, Lopressor IV. Remains on
Vanc/Cipro/Flagyl and Insulin gtt. Psyc was consulted for
delirium ? depressed. Out of bed to chair. Nasal swab came back
positive for Oxacillin RESISTANT Staphylococci, placed on
respective precaution.
POD13/8 [**2128-8-11**] VSS. Transferred to [**Hospital Ward Name 121**] 5 VICU. Physical
therapy consult. TF at goal, speech and swallow consult to
assess ability for PO intake-passed swallowing for soft solids.
Very depressed Psych following. Diamox for diuresis. Remains on
Vanc/Cipro/Flagyl and Insulin gtt.
POD14/9 [**2128-8-12**] VSS. Continue with out of bed with physical
therapy. Psych following-recs Haldol AM and PM. Continue
antibiotics. Tube feeds at goal, change to cycle at night,
encourage PO intake. Dispo [**Hospital **] Rehab screen.
POD15-17/10-11 8/15-16/08 VSS. Off Insulin gtt. Started clears
PO, continue to cycle tube feeds.
POD18/12 [**2128-8-16**] Fever spike- blood cultures sent. Continued to
work with PT for OOB activities. [**Hospital 25403**] rehab bed. Continue to
cycle tube feeds. PO's back to clears, patient became distended
and nauseous after soft solids. Started Reglan. Clamping G-tube.
Staples removed. Caudal portion of wound dressed with wet to
dry, DSD [**Hospital1 **]. R groin dressed with DSD. L foot ulcer - with
Accuzyme then DSD daily. Lydex to the rest of L LE then wrap
with kling.
POD19/13 [**2128-8-17**] VSS, discharged to extended facility in stable
condition.
Medications on Admission:
Carvedilol 25'', Lisinopril 40', Bumetanide 1.5', RISS, Lantus
34U qhs, MVI daily, Simvastatin 80', Aspirin 325', Plavix 75',
Garlic daily, Losartan 50mg daily, Lutein 6', Ranitidine 150'
Discharge Medications:
1. Fluocinonide 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours) as needed.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): [**Month (only) 116**] discontinue when patient is
fully ambulating.
4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day): Hold for diarrhea, excessively soft stool.
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): Ongoing for bowel necrosis.
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours: On going for bowel necrosis.
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-31**]
Drops Ophthalmic PRN (as needed).
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold for SBP < 110, HR < 60.
11. Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed.
15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
16. Haloperidol 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
17. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Powder in
Packet Sig: One (1) Powder in Packet PO TID (3 times a day) for
3 days: [**Month (only) 116**] discontinue pending Phosphate and Potassium levels.
18. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
19. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: One (1)
Tablet PO Q4H (every 4 hours) as needed: Maximum tylenol 4 g per
day.
20. Dextrose 50% in Water (D50W) Syringe Sig: One (1)
Intravenous PRN (as needed).
21. Insulin Glargine 100 unit/mL Solution Sig: One (1) 14 units
Subcutaneous once a day: 14 units glargine SQ q24h at 0600.
22. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1)
40 units Subcutaneous at bedtime: 40 units NPH SQ q24h at 2200.
.
23. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous four
times a day: Humalog slidingscale-adm per blood glucose
criteria:
5U humalog at starting at 161 mg/dl; increase insulin in
increments of 3 units for every 40 mg/dl change in blood glucose
eg. 161 - 200 5U
201-240 8U
241-280 11U
281-320 14U
320-360 17U
> 360 page MD
[**First Name (Titles) **] [**Last Name (Titles) **] scale as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Nonhealing ulcer of the left foot.
Ischemic rest pain of the right foot.
Malfunctioning femoral-femoral bypass.
Postoperative colonic ischemia
Postoperative delerium
Asplenia noted on [**8-3**] operation
Past Medical History:
CAD, Peripheral Vascular disease, Eczema, DM, Chol, HTN, CRI,
GERD, Anemia
Past Surgical History:
s/p RCA stent (bare metal [**6-6**]), Lt 2nd toe amp [**6-5**], CABG, Lt
to Rt Fem-fem bypass with Rt fem/[**Doctor Last Name **] bypass n past, revision
Left fem-fem [**11-5**], Lt iliac stent, Lt [**Name (NI) 1793**] PTA
Discharge Condition:
Weak but stable.
Discharge Instructions:
1. Keep G limb of GJ tube clamped with q4h residual checks; you
may need to return G limb to gravity if his abdomen becomes more
distended or he is uncomfortable.
2. Change caudal portion of abdominal wound with wet to dry
sterile gauze dressings [**Hospital1 **]; may dress R groin incision with dry
sterile dressing
3. Apply accuzyme ointment to ulcers on left foot, lidex and DSD
to calves b/l and change dressings on lower extremities once
daily
4. Check blood glucose ac and hs, administer [**Hospital1 **] scale as
needed; may need to adjust [**Hospital1 **] scale
5. Take medicines as prescribed. Pt will need to be on long
term cipro and flagyl for bowel ischemia.
6. The patient is in need of extensive rehab/PT.
7. Slowly taper down the Haldol at night over the course of [**12-31**]
weeks.
Followup Instructions:
1. Follow up with Dr [**Last Name (STitle) **] on [**2128-9-2**] at 2:00 pm. phone
[**Telephone/Fax (1) 1237**].
2. Follow up with Dr [**First Name (STitle) **] in [**12-31**] weeks Phone:[**Telephone/Fax (1) 63791**]
call to make an appointment
3. Follow up with your primary care physician, [**Name10 (NameIs) 7470**] for
your chronic renal disease, diabetes, htn, and heart disease
Completed by:[**2128-8-17**]
|
[
"403.90",
"E878.8",
"E849.8",
"518.0",
"593.9",
"V09.0",
"557.0",
"287.4",
"996.74",
"444.22",
"293.0",
"707.15",
"E934.2",
"785.52",
"995.92",
"250.70",
"440.23",
"038.9",
"585.9",
"E878.2",
"041.11",
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] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"44.39",
"39.25",
"45.75",
"39.49"
] |
icd9pcs
|
[
[
[]
]
] |
13637, 13709
|
5665, 10615
|
348, 565
|
14301, 14319
|
2130, 5642
|
15169, 15585
|
1560, 1628
|
10853, 13614
|
13730, 13935
|
10641, 10830
|
14343, 15146
|
14055, 14280
|
1643, 2111
|
235, 310
|
593, 1176
|
13957, 14032
|
1448, 1544
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,156
| 188,754
|
27377
|
Discharge summary
|
report
|
Admission Date: [**2126-10-5**] Discharge Date: [**2126-10-11**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Shortness of Breath, Chest Heaviness
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
88 y/o female with HTN, DM, CAD, CHF presents with shortness of
breath last night with development of chest tightness without
nausea, lightheadedness, palpitations, or diaphoresis. Patient
reports increasing dyspnea over the last month, with stable two
pillow orhtopnea until last night. Stable leg edema for years.
No fever, no cough. SL nitro given by EMS with improvement.
.
In the ED, VS: 97.0 88 172/69 21 2 sat 84% RA, 95% 4L. Lungs
with crackles at base, +LE edema to knee. CXR with mild
overload. Started on nitro gtt. Given 60 IV lasix with good UOP.
Given ASA and Azithromycin. First set CE negative,no EKG
changes. Mild elevated trop. BNP elevated. Sating mid 90's on
2L.
Past Medical History:
Diabetes
Dyslipidemia
Hypertension
CAD s/p PTCA [**2117**] x 2, CHF
Glaucoma
Hearing loss
h/o Hemorrhoids.
h/o decubitus ulcer
s/p partial thyroidectomy
Social History:
Lives in [**Location 67057**] Living Facility. Social history is significant
for the absence of current tobacco use. Former smoker stopped 30
years ago after smoking for 30 years. There is no history of
alcohol abuse.
Family History:
Family history is non contributory.
Physical Exam:
White female in no distress, wearing NRB mask, able to speak in
full sentances.
T 98.8 HR 92 BP 148/53 RR 20 Sat 98% on 5 L NC
HEENT:
NECK: JVP elevation of 8-10cm with hepatojugular reflex. No
bruits. No sustained carotid upstrokes.
CHEST: Crackles to mid lung fields. Decreased air movement and
breath sounds throughout. Faint Wheezing throughout.
HEART: Harsh 2/6 systolic murmur with audible S2 but no
radiation to carotids.
ABD: Soft, NT, ND, no masses, no bruits.
EXT: Pitting edema to the knee. Chronic edema of LE with chronic
venous stasis changes.
Pulses: No femoral bruits. 2+ radial bilaterally. 1+ DP with non
palpable PT bilaterally.
Pertinent Results:
[**2126-10-9**] 05:00PM BLOOD WBC-8.6 RBC-3.82* Hgb-11.6* Hct-34.1*
MCV-89 MCH-30.2 MCHC-33.9 RDW-13.6 Plt Ct-379
[**2126-10-5**] 07:50AM BLOOD WBC-16.3*# RBC-3.80* Hgb-11.2* Hct-34.2*
MCV-90 MCH-29.4 MCHC-32.7 RDW-13.6 Plt Ct-339
[**2126-10-5**] 07:50AM BLOOD Neuts-90.7* Bands-0 Lymphs-6.3* Monos-2.1
Eos-0.6 Baso-0.4
[**2126-10-7**] 05:30AM BLOOD PT-15.1* PTT-94.4* INR(PT)-1.4*
[**2126-10-8**] 06:06AM BLOOD PT-12.0 PTT-29.1 INR(PT)-1.0
[**2126-10-9**] 05:07AM BLOOD Glucose-151* UreaN-41* Creat-1.2* Na-146*
K-4.6 Cl-105 HCO3-36* AnGap-10
[**2126-10-5**] 07:50AM BLOOD Glucose-258* UreaN-46* Creat-1.3* Na-143
K-4.5 Cl-106 HCO3-27 AnGap-15
[**2126-10-8**] 06:06AM BLOOD CK(CPK)-44
[**2126-10-7**] 10:31PM BLOOD CK(CPK)-54
[**2126-10-7**] 05:30AM BLOOD CK(CPK)-81
[**2126-10-6**] 06:43PM BLOOD CK(CPK)-124
[**2126-10-6**] 04:00AM BLOOD ALT-23 AST-33 LD(LDH)-219 AlkPhos-71
TotBili-1.2
[**2126-10-5**] 11:05PM BLOOD CK(CPK)-187*
[**2126-10-5**] 03:00PM BLOOD CK(CPK)-211*
[**2126-10-5**] 07:50AM BLOOD CK-MB-NotDone proBNP-[**2064**]*
[**2126-10-5**] 07:50AM BLOOD cTropnT-0.02*
[**2126-10-5**] 03:00PM BLOOD CK-MB-38* MB Indx-18.0*
[**2126-10-5**] 03:00PM BLOOD cTropnT-0.24*
[**2126-10-5**] 11:05PM BLOOD CK-MB-25* MB Indx-13.4* cTropnT-0.45*
[**2126-10-6**] 06:43PM BLOOD CK-MB-9 cTropnT-0.47*
[**2126-10-7**] 05:30AM BLOOD CK-MB-NotDone cTropnT-0.61*
[**2126-10-8**] 06:06AM BLOOD CK-MB-NotDone cTropnT-0.67*
[**2126-10-6**] 04:00AM BLOOD Triglyc-63 HDL-77 CHOL/HD-2.4 LDLcalc-96
[**2126-10-6**] 11:40PM BLOOD Type-ART Temp-37.6 pO2-86 pCO2-41
pH-7.48* calTCO2-31* Base XS-6
.
EKG demonstrated NSR, PR >200 ms, LVH, ST dep V2-5, II with no
prior for comparison.
.
CXR
1. Mild cardiomegaly and very mild interstitial pulmonary edema.
2. Vague opacity within the right lower lung zone may be
secondary to edema although an early consolidation cannot be
completely excluded.
Brief Hospital Course:
CAD: Patient w/ hx of CAD w/ PCI w/ placement of BMS to RCA
and LCx in [**2117**] in NY, who presented w/ complaints of chest
pressure and elevation of cardiac enzymes. EKG showed diffuse
ST depressions w/ LVH, which at this time was believed to be due
heart strain in the setting of fluid overload with elevation of
troponint to 0.02 and CK to 80. Enzymes continued to rise, with
peak of CK to 211, and patient was started on
integrillin/heparin complicated by bleeding from hemmeroids.
Anticoagulation was continued, by ASA and plavix were continued.
Patient underwent RHC/LHC. Angiography revaeled a calcified
60% LMCA
disease and origin heavily calcified LAD 80% lesion. Cypher
was then deployed in the LMCA into LAD at 16 atms jailing the
LCX but not compromising flow. The procedure was without
complication.
.
Pump: Patient was with JVD to mandible and crackles to mid
lungs on exam. Patient underwent diursis with improvment of
dyspnea and above physcial exam findings. Unclear if heart
failure symptoms more secondary to valve abnormalities or acute
ischemia. Pre-procedure echo showed moderate aortic stenosis,
moderate mitral regurgitation, moderate symmetric left
ventricular hypertrophy with preserved regional and global
biventricular systolic function, and moderate to severe
pulmonary hypertension.
.
HTN: Patient's BP meds were adjusted over the course of the
hospitalization, due to elevation of sbp to 170s. Patient
discharged on HCTZ 25mg, Toprol XL 75mg, Ramipril 10mg, and
Norvasc 10mg. Pressures currently well controlled. Follow up
labs scheduled for week after dischare to evaluate after
starting HCTZ prior to discharge.
DM: Patient with history of DM. Continued home meds over
hospitalization. Discharged with continued plan of VNA services
as done prior to hospitalization.
Medications on Admission:
ASA 81 mg daily
Toprol XL 25 twice a day
Norvasc 10 mg HS
Ramapril 10 mg qAM
Lasix 40 po daily
Lantus 5 units at bedtime
Novolog 9 units breakfast, 10 units lunch, 9 units dinner
MVI
Ocean Nasal spray
Protonix 40 mg daily
Truspot 2% 1 Drop twice a day
Vit C 500 mg twice a day
Zinc 220 mg once a day
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic QAM (once
a day (in the morning)).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Ramipril 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily).
Capsule(s)
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Insulin Glargine 100 unit/mL Solution Sig: Five (5) units
Subcutaneous at bedtime.
12. Outpatient Lab Work
Please have complete blood count on [**Last Name (LF) 766**], [**10-13**] and have
the results sent to your primary care doctor Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
at [**Telephone/Fax (1) 719**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Primary Diagnosis: NSTEMI
Secondary Dx: HTN, CHF, Respiratory Distress, DM
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted with a heart attack. You received medicines
to help your heart recover and then you had a cardiac
catheterization done with a stent placed to keep the arteries in
your heart open.
1. Please take all medications as prescribed.
2. Please attend all follow-up appointments.
3. Return to the hospital if you have chest pain, shortness of
breath, fevers, or any other concerning symptom.
Resume your home insulin schedule as prescribed by your doctor.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2126-10-15**] 11:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 8754**] DERMATOLOGY GEN-[**Doctor First Name 8754**] (NHB)
Date/Time:[**2126-11-14**] 1:45
Cardiology follow up with Dr. [**Last Name (STitle) **] on [**10-29**] @ 9:40am [**Hospital 23**]
Clinic [**Hospital1 18**] [**Location 67058**] [**Location (un) **]
|
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24,687
| 175,749
|
95
|
Discharge summary
|
report
|
Admission Date: [**2146-1-14**] Discharge Date: [**2146-1-28**]
Date of Birth: [**2097-8-4**] Sex: M
Service: MEDICINE
Allergies:
Bactrim Ds / Indomethacin / Linezolid
Attending:[**First Name3 (LF) 1070**]
Chief Complaint:
seizures, mental status changes
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
The patient is a 48M w/ HIV/AIDS/HCV/IVDA sent from [**Hospital1 1099**] Rehab for evaluation of 2 witnessed tonic-clonic
seizures. Seizures occurred on evening [**2146-1-13**], lasted 30
seconds - 1 minute, resolved spontaneously. First seizure
occured while he was being cleaned up, second seizure occured
while family member (mother?) was in the room. His nurse
reported 'whole body shaking' L>R, not responsive to name or
sternal rub, dilated pupils, no LOC. Patient w/ foley, so not
able to assess loss of bladder function, no bowel movement
yesterday. Patient appeared 'sleepy' afterwards but then seemed
to return to his normal self between seizures. Hypertensive -
received nitropaste. Afebrile, T max 99.8, BP 116-120's/86-106,
HR 78-129, O2 sat96% on 2L. Also found to be hypokalemic with K
2.6, started on IVF @10cc/hrKcl 40 mEq [**Hospital1 **] x 6 doses.
.
No nausea/vomiting/diarrhea, no fevers/chills, no seizure
history.
Per brother, patient has had HIV encephalopathy x 1 month, not
completely oriented at baseline. His nurse describes his
baseline as oriented to self only, Spanish speaking with some
English, has sensation of pain to minimal stimulus.
.
ED Course: arrived [**1-13**] @9pm. Never oriented, drowsy --> very
agitated. VS 98.5, HR 97, PB 134/89, RR 16, 02 sat 100% on 2L.
Negative head CT. Midnight - noted to have tonic clonic seizure
activity lasting 1-2 minutes, post-ictal. O2 sat 100% on non
rebreather, weaned easily. Given Ceftriaxone 2gm, Vanc 1gm,
Ampicillin 2gm, Acyclovir 700mg. Sedated for LP (2mg Versed and
2mg Ativan). 200mg IV Diflucan for thrush. Morphine for pain,
received total of 12mg. Also received 2 gm IV magnesium, NS w/
40 mEq of K x 2L. Hypertensive in 140-150s and tachy up to 130's
throughout ED stay, Tmax 100.9 (not during seizure).
.
After arrival to the ICU, it was discovered that he had a urine
culture positive for acinetobacter at rehab and was started on
imipenem. BCx had reportedly been negative after 5 days.
.
Previous hospitalization ([**Date range (1) 1100**]) for change in MS after
being found down and minimally responsive; he was intubated for
airway protection; course complicated by R neck hematoma [**1-8**] to
line placement, alkalosis, hypernatremia, hypercacemia, improved
ARF, elevated lactate, transaminitis. Concern for toxic
metabolic encephalopathy, improved somewhat with fluids but did
not return to baseline. Also with rhabdomylosis - CK peaked at
3996, and improved to normal with IVFs, renal failure also
resolved. He was positive for c-diff, had MRSA positive sputum,
and sparse pseudomonas growth in sputum. When discharged he
needed 6 more days to finish 14 day course of vancomycin, 10
more days to complete 15 day course of meropenem and needed to
continue on flagyl for 14 days after all other ABX completed.
Past Medical History:
1. HIV/AIDS - last CD4 105, VL > 100,000 on [**11-13**], off HAART
because of suicidality and depression, on dapsone ppx for PCP [**Name Initial (PRE) **]
[**Name10 (NameIs) 1095**] noncompliant. Thought to have HIV encephalopathy.
2. Hepatitis C: treatment deferred because of
depression/suicidality. Last viral load [**8-14**] was 5,860,000.
3. Asthma
4. h/o Tuberculosis ([**2129**], now resolved)
5. h/o PCP x 2
6. h/o pericarditis ([**2139**])
7. h/o pneumococcal pneumonia with bacteremia ([**11-10**])
8. h/o LLL pneumonia ([**12-11**])
9. h/o MAC on BAL ([**5-11**])
10. h/o Neuropathy, thought [**1-8**] HIV
11. Disseminated herpes zoster [**2144**]
12. ? depression.
13. h/o pseudomonal pneumonia (+BAL- pan sensitive)
Social History:
Patient came to [**Hospital1 18**] from [**Hospital3 672**] Rehab. Smoker (less
than 1 ppd x 25 years), + h/o IVDA in past, occasional marijuana
use. No EtOh. Sexually active "occasionally" with one partner,
same partner for several years.
Family History:
NC
Physical Exam:
Admission Physical Exam:
VS: Temp: 98.1 BP: 142/100 HR: 112 RR: 20 O2sat 100% 2L
GEN: agitated, crying out, not oriented, cachectic
HEENT: PERRL, EOMI, anicteric, MM dry, thrush on tongue
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: tachy, RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, initially with voluntary guarding but
later without
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx0, unable to cooperate with neuro exam
At discharge, vitals were stable. The patient was afebrile.
The patient was more oriented. He was able to communicate his
needs in English. His neck was rotated the left and he had some
muscular spasm. His abdomen was benign. The remained of his
exam was unchanged.
Pertinent Results:
CXR ([**2146-1-23**]): Cardiomediastinal contours are normal. NG tube
tip is in the stomach. There is no pneumothorax or pleural
effusion. The lungs are grossly clear. Surgical clips projecting
over the left supraclavicular area are again noted. Left PICC
remains in place.
EKG: Sinus tachycardia, rate 115 beats per minute. Right atrial
abnormality. Possible old septal myocardial infarction. Possible
left ventricular hypertrophy. Tracing is compatible with
pulmonary disease. Compared to the previous tracing of [**2145-12-9**] QS
complexes in leads V1-V2 are less prominent and there is less
suggestion of possible left ventricular hypertrophy. Both
tracings are compatible with pulmonary disease.
CT Head ([**2146-1-13**]):
FINDINGS: Multiple acquisitions were performed due to patient
compliance. Despite this, there is motion artifact on the study
acquired limiting the evaluation.
There again noted is extensive confluent low attenuation
throughout the deep white matter of the brain. This is likely
related to underlying HIV encephalopathy. There is a advance
atrophy for age which is consistently seen in HIV encephalopathy
as well. There is no acute interval change or midline shift. No
intracranial hemorrhage is evident.
IMPRESSION: Stable head CT examination, although the current
examination is limited as above. Findings most consistent with
HIV encephalopathy with no superimposed acute process.
CT Neck: FINDINGS:
The patient is rotated to the left side, with the neck being
rotated to the left side. Hence, this study is limited in
acquiring the images in a proper manner, centered onto the
midline of the neck. In addition, lack of IV contrast,
significantly limits evaluation for any focal infection.
Within these limitations, there are no large masses noted on the
visualized images of the neck.
However, subtle areas of increased attenuation in the fat and
inflammation cannot be assessed.
There is moderate dilatation of the esophagus with small amount
of fluid/debris within the esophagus. This finding is new
compared to the CT chest on [**2145-12-16**], with interval removal of
the nasogastric tube.
Right-sided PICC line is incompletely included on the present
study.
There are a few surgical clips, noted lateral to the left side
of the thyroid, unchanged in position, compared to the prior CT
chest on [**2145-12-16**].
There is moderate dilatation of the ventricles on the visualized
images of the brain, which was noted on the prior MRI of the
head; however, the brain is incompletely included on the present
study.
There is a small 4-mm soft tissue density nodule in the upper
lobe of the left lung, unchanged.
There appears to be resolution of the previously noted
pneumothorax in the apices. However, the chest is not completely
evaluated on the present study.
There is moderate dilatation of the ventricles on the visualized
images of the brain, which was noted on the prior MRI of the
head; however, the brain is incompletely included on the present
study.
Brief Hospital Course:
# Seizures: The patient had two witnessed tonic-clonic seizures
before presenting to [**Hospital1 18**] ED and one seizure in the ED. The
most likely etiology for patient's seizures is imipenem which
was used to treat his urine culture positive for acinetobacter
and elavil which was given at high doses for neuropathy. Mr.
[**Known lastname 1071**] is thought to have HIV encephalopathy and this condition
combined with imipenem may have lowered his seizure threshold.
Patient's amitriptyline was also considered as possible cause of
patient's seizures.
Infectious etiology or mass effect were ruled out by [**Hospital 228**]
hospital course, benign appearance of CSF, and head CT;
however, initially the patient was given empiric IV acyclovir,
ceftriaxone, and vancomycin because of suspicion of viral or
bacterial central nervous system infection. Of note, patient has
had no seizures since admission and stopping of imipenem and
amitriptyline. The patient was started on 500 mg levetiracetam
(Keppra) [**Hospital1 **] as anti-seizure medication. Per the neurology
service, the patient should be on Keppra indefinitely.
# Mental status changes: The patient's mental status changes
are likely due to HIV encephalopathy. CT showed no CNS mass
effect and no acute CNS infectious etiology found. Patient's
mental status changes date back to [**11-13**] admission when patient
left hospital AMA, never having gone back to baseline mental
status s/p presumed fall. Patient's CMV viral loads were low
(2160) and treatment was deferred since there was no sign
end-organ disease. The patient was examined by Ophthomaology
who did not see any signs of CMV retinitis.
# Urine: The patient was found to have acinetobacter in his
urine sensitive to gentamicin. He was started on a three day
course of IV gentamicin on [**1-26**]. He will need his final dose
today at rehab ([**2146-1-28**]). Please recheck a UA and culture
tomorrow ([**2146-1-29**]) to confirm his urine has cleared
appropriately. The patient has also had urinary retention
during this hospitalization. He failed two voiding trials
during this stay. As he improves, he can be given another
voiding trial or can follow up with Urology if needed.
# Neck position: The patient had head turned to left and was
resistant to changing position and has point tenderness
bilaterally on sides of neck. Neck CT without contrast obtained
(could not use contrast as could not obtain peripheral IV access
necessary) but study was inconclusive due to patient positioning
and lack of contrast. Patient continuesd to keep head turned to
left with some improvement noted with use of clonazepam. Please
continue low dose clonazepam to help with muscular spasm. If
the patient continues to have neck pain, consider re-imaging the
neck.
# Allodynia: The patient had complaints of allodynia on last
admission and reports of neuropathic pain dating back to [**2142**].
This allodynia may be part of the spectrum of his neuropathy
which is thought to be secondary to HIV. According to OMR, the
patient has not had relief of his neuropathy with gabapentin in
the past. However, after patient left ICU for floor, opiates
were held because of worries of sedation affecting mental
status. His pain was treated with gabapentin and acetaminophen.
We did not restart his opiates during this hospitalization nor
his Remeron.
# Hypokalemia/hypomagnesmia: On admission, the patient was
hypokalemic (K of 3.0) and hypomagnesemic (1.1). Patient's poor
nutrition (albumin of 2.6) and no PO intake most likely cause.
As feeding via NG tube began, lytes were monitored [**Hospital1 **] in order
to assess refeeding syndrome. At the time of discharge, the
patient's PO intake was improving. He was able to eat his
entire breakfast with help from the nursing staff. Please
continue to monitor his electrolytes while he is on TPN at least
daily replete his electrolytes as needed and change TPN based on
electrolytes. Once he is able to increase his PO intake, please
consider discontinuing the TPN. Once discontinued, the patient
will not need his electrolytes monitored daily. Please
discontinue his PICC line once he no longer needs TPN.
# HIV: The patient is not on HAART (as he has declined it). ID
did not recommend HAART as HAART carries increased risk of
toxicity in setting of poor nutrition, and patient is vulnerable
to immune reconstitution syndrome with low CD4 count at start of
HAART and patient has known Hepatitis C. ID's recommendation
was that HAART not be initiated until Mr. [**Known lastname 1101**] nutritional
status improves and that Dr. [**Last Name (STitle) 1057**] (outpatient ID doctor for
patient) should make decisions about implementing HAART.
Patient has follow up appointment on [**3-2**] at 9:30 AM with
Dr. [**Last Name (STitle) 1057**]. Please continue his Dapsone for PCP [**Name Initial (PRE) 1102**].
# Fluid, electrolytes, nutrion: Patient was profoundly
cachectic, had not eaten in several days and failed a speech and
swallow evaluation. GI did not wish to place PEG because of
patient's low albumin (which would impede healing) and prominent
epigastric surgical scar. Patient received NG tube on [**2146-1-21**]
after neck was imaged with CT. NG tube feeds began at midnight
on night of [**2146-1-21**] at 10 ml/hr. Rate was increased by 10 ml/hr
every 12 hours with a goal rate of 50 ml/hour acheived at
midnight on Sunday [**2146-1-23**]. However, tube came out and patient
refused replacement. Patient did ask for tube to be replaced on
[**1-25**] but after primary medical team could not place tube,
patient refused IR placement of NG tube. Patient was begun on
TPN on [**2146-1-27**]. Patient's lytes were repleted PRN as mentioned
above. The patient is having improved PO intake and TPN can be
discontinued when patient is taking adequate oral intake. If
needed, the patient can be re-evaulated by Speech and swallow in
the future.
Despite numerous discussions with the family regarding poor
prognosis, the patient remained full code throughout his
hospital course.
Medications on Admission:
Medications at Rehab (per rehab notes):
Primaxin 500mg IV Q6 (started [**2146-1-11**])
Elavil 100mg PO QHS
Lactinex 1 Packet TID
Zantac PEG 150 mg Q12
Heparin subQ 5000u TID
Senokot [**Hospital1 **]
Atrovent Neb 2.5ml Q6 PRN
Albuterol 3ml Q6 PRN
Tylenol 500mg Q6 PRN
Discharge Medications:
1. Outpatient Lab Work
Please check chem-10 [**Hospital1 **] if possible, otherwise please check
daily electrolytes and replete lytes PRN as patient is
vulnerable to refeeding syndrome (hypokalemia, hypophosphatemia,
hypomagnesiema).
2. Nutrition TPN:
Non-Standard TPN For Date: [**2146-1-27**] Volume(ml/d)= 1000; Amino
Acid(g/d) = 0; Branched-chain AA(g/d) = 0; Dextrose(g/d)=
100; Fat(g/d) = 20.
Trace Elements will be added daily
Standard Adult Multivitamins
NaCL = 30; NaAc = 0; NaPO4 = 40; KCl = 10; KAc = 0; KPO4 = 0;
MgS04 = 15; CaGluc = 5.
Total volume of solution per 24 hours.
Rate of continous infusion determined by pharmacy-See Label
3. [**Month/Day/Year 1098**] 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
7. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
9. PICC line care
Heparin Flush PICC (100 units/ml) 2 mL IV DAILY:PRN
10 ml NS followed by 2 mL of 100 Units/mL heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
Order was filled by pharmacy with a dosage form of Syringe and a
strength of 100 U/ML
10. Gentamicin
Gentamicin 60 mg IV Q8H Duration: 3 Days
Order was filled by pharmacy with a dosage form of Piggyback and
a strength of 60MG/50ML. Pt has had 8 doses. He will need to
complete his additional 1 dose today.
11. Clonazepam 0.125 mg Tablet, Rapid Dissolve Sig: One (1)
Tablet, Rapid Dissolve PO twice a day: please hold for sedation.
12. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day:
please crush in purees.
13. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO three
times a day: please open capsule and give in purees.
14. Vitamin B-12 50 mcg Tablet Sig: Two (2) Tablet PO once a
day.
15. Outpatient Lab Work
Please check a urinanalysis and culture on [**2146-1-29**] to ensure the
patient has cleared his urinary infection.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Primary:
# Seizures thought due to Imipenem treatment
# Multi-drug resistent Acinetobacter UTI
# HIV/AIDS
# Urinary retention requiring foley catheter placement (failed
voiding trials x2)
# Cachexia requiring TPN
.
Secondary:
# HIV/AIDS
# HCV
# Asthma
# AIDS related neuropathy
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital with seizures. While you were
in the hospital we treated you with IV antibiotics for a
question of an infection in your spinal column. We also gave
you anti-seizure medication. Please continue taking this
anti-seizure medication.
Because you were having trouble swallowing, we put a tube from
your nose into your stomach and gave you nutrition through this
tube. This tube came out and you did not want it replaced. We
then gave you nutrition through the IV in your arm. We will
continue nutrition through your arm until you are able to keep
up with oral nutrition.
We also treated an infection in your urine with IV antibiotics.
Followup Instructions:
The following appointments have been made for you. Please
follow up at these appointments.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2146-2-3**] 2:40. Please call ahead of time to update
address, phone number, and insurance information.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1085**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2146-3-2**] 9:30
|
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icd9cm
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|
[
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14570, 16761
|
16860, 17140
|
14279, 14547
|
17194, 17867
|
4281, 5107
|
258, 291
|
375, 3205
|
3227, 3960
|
3976, 4221
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,091
| 126,085
|
47050
|
Discharge summary
|
report
|
Admission Date: [**2144-7-31**] Discharge Date: [**2144-8-10**]
Date of Birth: [**2090-5-20**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Bactrim / Prilosec / Heparin Agents
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
cold, painful right foot
Major Surgical or Invasive Procedure:
1. Insertion of Gunther-Tulip IVC filter, jugular approach.
2. Venous iliofemoral and femoral popliteal thrombectomy.
3. Right groin AV fistula.
History of Present Illness:
54F s/p right total knee replacement [**2144-7-16**]. Presented to
[**Hospital3 17031**] on [**2144-7-29**] with 3-4 day h/o shortness of
breath,
new RLE swelling, and right foot pain. CTA chest at that time
demonstrated PE. BLE US demonstrated DVT in right comomon
femoral vein, superficial femoral vein, and proximal greater
saphenous vein; popliteal vein was not assessed. Prior to
presentation, she was on Lovenox for DVT prophylaxis; platelet
count was 41,000 on presentation. Given suspicion of HIT, she
was started on an argatroban drip and coumadin for her DVT.
Since admission, her foot has become progressively more
cyanotic,
painful, and swollen. Report from transferring ICU physician
was
that right foot DP and PT pulses were dopplerable. She is
transferred here for further management.
Past Medical History:
OSA, fentanyl usage, mitral regurgitation/valve prolapse,
HTN, obesity, hyperlipidemia, asthma, h/o palpitations and
unifocal premature ventricular beats (followed by cardiology
here), GERD
Social History:
Denies EtOH and tobacco use. Former nurse [**First Name (Titles) **] [**Hospital3 **]Hospital. Currently disabled.
Family History:
family cardiovascular illness, o/w noncontributory
Physical Exam:
Vital: Tm99.2 Tc98.9 P80 BP102/60 RR98%RA
Gen: NAD, AAOx3
CV: RRR, +s1,s2
Lung: CTAB
Abd: +BS, Soft, NT/ND
Right foot: no drainage, less edematous, dressed with silvadine
ointment and gauze.
Palpable pulses on right LE
Pertinent Results:
[**2144-8-10**] 05:35AM BLOOD WBC-6.1 RBC-3.45* Hgb-9.4* Hct-28.9*
MCV-84 MCH-27.3 MCHC-32.6 RDW-15.2 Plt Ct-300
[**2144-8-9**] 05:33AM BLOOD WBC-5.3 RBC-3.39* Hgb-9.1* Hct-28.5*
MCV-84 MCH-27.0 MCHC-32.1 RDW-15.2 Plt Ct-234
[**2144-8-8**] 06:07AM BLOOD WBC-6.2 RBC-3.41* Hgb-9.2* Hct-28.2*
MCV-83 MCH-26.8* MCHC-32.5 RDW-15.0 Plt Ct-213
[**2144-8-7**] 04:00AM BLOOD WBC-8.2 RBC-3.55* Hgb-9.8* Hct-29.2*
MCV-82 MCH-27.5 MCHC-33.4 RDW-15.0 Plt Ct-194
[**2144-8-6**] 06:23AM BLOOD WBC-8.2 RBC-3.54* Hgb-9.5* Hct-29.3*
MCV-83 MCH-26.9* MCHC-32.5 RDW-15.5 Plt Ct-166
[**2144-8-5**] 03:24AM BLOOD WBC-10.2 RBC-3.56* Hgb-9.9* Hct-29.3*
MCV-82 MCH-27.9 MCHC-33.8 RDW-15.6* Plt Ct-128*
[**2144-8-4**] 01:54AM BLOOD WBC-8.8 RBC-3.46* Hgb-9.7* Hct-28.6*
MCV-83 MCH-28.1 MCHC-34.0 RDW-15.2 Plt Ct-112*
[**2144-8-3**] 06:02PM BLOOD WBC-9.8 RBC-3.60* Hgb-10.2* Hct-29.5*
MCV-82 MCH-28.3 MCHC-34.5 RDW-15.4 Plt Ct-109*
[**2144-8-3**] 02:15AM BLOOD WBC-7.5 RBC-3.67* Hgb-10.2* Hct-30.4*
MCV-83 MCH-27.8 MCHC-33.6 RDW-15.3 Plt Ct-89*
[**2144-8-2**] 04:57PM BLOOD WBC-6.6 RBC-3.85* Hgb-10.8* Hct-31.7*
MCV-82 MCH-27.9 MCHC-33.9 RDW-15.2 Plt Ct-101*
[**2144-8-2**] 02:10PM BLOOD WBC-4.7 RBC-3.81* Hgb-10.2* Hct-31.0*
MCV-81* MCH-26.7* MCHC-32.8 RDW-15.0 Plt Ct-119*
[**2144-8-2**] 09:27AM BLOOD Hct-30.6*
[**2144-8-2**] 03:07AM BLOOD WBC-5.5 RBC-3.27* Hgb-8.8* Hct-26.4*
MCV-81* MCH-27.0 MCHC-33.4 RDW-14.9 Plt Ct-120*
[**2144-8-2**] 01:11AM BLOOD Hct-28.2*
[**2144-8-1**] 10:19AM BLOOD Hct-26.6* Plt Ct-82*
[**2144-8-1**] 04:44AM BLOOD WBC-7.3 RBC-3.41* Hgb-9.1* Hct-26.8*
MCV-79* MCH-26.8* MCHC-34.0 RDW-15.2 Plt Ct-91*
[**2144-7-31**] 01:20PM BLOOD WBC-11.1* RBC-4.11* Hgb-10.7* Hct-33.6*
MCV-82 MCH-26.1* MCHC-31.9 RDW-15.3 Plt Ct-91*
[**2144-8-3**] 06:02PM BLOOD Neuts-87* Bands-0 Lymphs-6.0* Monos-5
Eos-2 Baso-0
[**2144-8-2**] 02:10PM BLOOD Neuts-67.5 Lymphs-18.8 Monos-7.0 Eos-6.4*
Baso-0.4
[**2144-7-31**] 01:20PM BLOOD Neuts-78* Bands-2 Lymphs-7* Monos-10
Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2144-7-31**] 01:20PM BLOOD Hypochr-NORMAL Anisocy-1+
Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-OCCASIONAL
Polychr-1+ Ovalocy-OCCASIONAL
[**2144-7-31**] 01:20PM BLOOD Hypochr-NORMAL Anisocy-1+
Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-OCCASIONAL
Polychr-1+ Ovalocy-OCCASIONAL
[**2144-8-10**] 05:35AM BLOOD Plt Ct-300
[**2144-8-10**] 05:35AM BLOOD PT-39.8* PTT-54.3* INR(PT)-4.3*
[**2144-8-9**] 05:33AM BLOOD Plt Ct-234
[**2144-8-9**] 05:33AM BLOOD PT-41.9* PTT-54.3* INR(PT)-4.6*
[**2144-8-8**] 12:15PM BLOOD PT-38.4* PTT-52.1* INR(PT)-4.1*
[**2144-8-8**] 06:07AM BLOOD Plt Ct-213
[**2144-8-8**] 06:07AM BLOOD PT-36.4* PTT-48.2* INR(PT)-3.9*
[**2144-8-8**] 02:58AM BLOOD PT-37.4* PTT-52.2* INR(PT)-4.0*
[**2144-8-7**] 04:45PM BLOOD PT-34.7* PTT-47.3* INR(PT)-3.7*
[**2144-8-7**] 12:47PM BLOOD PT-36.8* PTT-67.7* INR(PT)-3.9*
[**2144-8-7**] 09:50AM BLOOD PT-39.4* PTT-76.7* INR(PT)-4.3*
[**2144-8-7**] 04:00AM BLOOD Plt Ct-194
[**2144-8-7**] 04:00AM BLOOD PT-46.0* PTT-91.3* INR(PT)-5.2*
[**2144-8-6**] 11:45PM BLOOD PT-44.1* PTT-90.8* INR(PT)-4.9*
[**2144-8-6**] 04:55PM BLOOD PTT-85.9*
[**2144-8-6**] 06:23AM BLOOD Plt Ct-166
[**2144-8-5**] 05:48PM BLOOD PT-34.2* PTT-89.9* INR(PT)-3.6*
[**2144-8-5**] 03:24AM BLOOD Plt Ct-128*
[**2144-8-5**] 03:24AM BLOOD PT-34.1* PTT-99.6* INR(PT)-3.6*
[**2144-8-4**] 08:42AM BLOOD PT-32.8* PTT-77.1* INR(PT)-3.4*
[**2144-8-4**] 01:54AM BLOOD Plt Ct-112*
[**2144-8-4**] 01:54AM BLOOD PT-36.6* PTT-107.5* INR(PT)-3.9*
[**2144-8-3**] 08:07PM BLOOD PT-32.5* PTT-81.5* INR(PT)-3.4*
[**2144-8-3**] 06:02PM BLOOD Plt Ct-109*
[**2144-8-3**] 02:56PM BLOOD PT-35.5* PTT-90.4* INR(PT)-3.8*
[**2144-8-3**] 08:55AM BLOOD PT-37.0* PTT-82.6* INR(PT)-4.0*
[**2144-8-3**] 02:15AM BLOOD Plt Ct-89*
[**2144-8-2**] 08:46PM BLOOD PTT-82.9*
[**2144-8-2**] 04:57PM BLOOD Plt Ct-101*
[**2144-8-2**] 04:57PM BLOOD PT-43.4* PTT-103* INR(PT)-4.8*
[**2144-8-2**] 02:10PM BLOOD Plt Ct-119*
[**2144-8-2**] 02:10PM BLOOD PT-42.8* PTT-92.6* INR(PT)-4.7*
[**2144-8-2**] 09:27AM BLOOD PTT-80.1*
[**2144-8-2**] 03:07AM BLOOD Plt Ct-120*
[**2144-8-2**] 03:07AM BLOOD PTT-95.1*
[**2144-8-2**] 12:04AM BLOOD PTT-81.5*
[**2144-8-1**] 04:29PM BLOOD PT-34.1* PTT-78.8* INR(PT)-3.6*
[**2144-8-1**] 10:19AM BLOOD Plt Ct-82*
[**2144-8-1**] 10:19AM BLOOD PT-34.2* PTT-87.8* INR(PT)-3.6*
[**2144-8-1**] 04:44AM BLOOD Plt Ct-91*
[**2144-8-1**] 04:44AM BLOOD PT-31.7* PTT-87.3* INR(PT)-3.3*
[**2144-8-1**] 12:00AM BLOOD PTT-94.6*
[**2144-7-31**] 05:06PM BLOOD PT-33.1* PTT-93.2* INR(PT)-3.4*
[**2144-7-31**] 01:20PM BLOOD Plt Smr-LOW Plt Ct-91*
[**2144-8-2**] 04:57PM BLOOD Fibrino-280
[**2144-8-9**] 05:33AM BLOOD Glucose-111* UreaN-10 Creat-0.6 Na-142
K-4.0 Cl-109* HCO3-25 AnGap-12
[**2144-8-8**] 06:07AM BLOOD Glucose-103 UreaN-9 Creat-0.6 Na-144
K-4.0 Cl-111* HCO3-25 AnGap-12
[**2144-8-7**] 04:00AM BLOOD Glucose-114* UreaN-10 Creat-0.7 Na-141
K-3.9 Cl-107 HCO3-26 AnGap-12
[**2144-8-6**] 06:23AM BLOOD Glucose-114* UreaN-9 Creat-0.7 Na-141
K-3.4 Cl-106 HCO3-26 AnGap-12
[**2144-8-5**] 03:24AM BLOOD Glucose-104 UreaN-9 Creat-0.7 Na-141
K-3.6 Cl-108 HCO3-24 AnGap-13
[**2144-8-4**] 01:54AM BLOOD Glucose-120* UreaN-8 Creat-0.7 Na-143
K-4.4 Cl-113* HCO3-21* AnGap-13
[**2144-8-3**] 08:07PM BLOOD K-3.8
[**2144-8-3**] 02:15AM BLOOD Glucose-117* UreaN-7 Creat-0.7 Na-144
K-4.0 Cl-114* HCO3-25 AnGap-9
[**2144-8-2**] 04:57PM BLOOD Glucose-114* UreaN-8 Creat-0.6 Na-140
K-4.1 Cl-110* HCO3-23 AnGap-11
[**2144-8-2**] 03:07AM BLOOD Glucose-308* UreaN-10 Creat-0.7 Na-137
K-4.0 Cl-103 HCO3-26 AnGap-12
[**2144-8-1**] 04:44AM BLOOD Glucose-127* UreaN-10 Creat-0.6 Na-137
K-4.1 Cl-103 HCO3-26 AnGap-12
[**2144-7-31**] 01:20PM BLOOD Glucose-112* UreaN-15 Creat-0.9 Na-138
K-5.0 Cl-100 HCO3-26 AnGap-17
[**2144-8-8**] 06:07AM BLOOD estGFR-Using this
[**2144-7-31**] 01:20PM BLOOD estGFR-Using this
[**2144-8-3**] 02:15AM BLOOD CK(CPK)-865*
[**2144-8-2**] 04:57PM BLOOD CK(CPK)-929*
[**2144-8-2**] 03:07AM BLOOD CK(CPK)-716* TotBili-0.7 DirBili-0.3
IndBili-0.4
[**2144-8-1**] 04:44AM BLOOD CK(CPK)-87
[**2144-7-31**] 01:20PM BLOOD CK(CPK)-53
[**2144-7-31**] 01:20PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2144-8-9**] 05:33AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.4
[**2144-8-8**] 06:07AM BLOOD Calcium-8.4 Phos-3.6 Mg-2.2
[**2144-8-7**] 04:00AM BLOOD Calcium-8.2* Phos-3.4 Mg-2.1
[**2144-8-6**] 06:23AM BLOOD Calcium-8.0* Phos-3.5 Mg-2.1
[**2144-8-5**] 03:24AM BLOOD Calcium-8.4 Phos-3.8 Mg-1.9
[**2144-8-4**] 01:54AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.2
[**2144-8-3**] 02:15AM BLOOD Calcium-7.6* Phos-3.4 Mg-2.1
[**2144-8-2**] 04:57PM BLOOD Calcium-7.4* Phos-4.2 Mg-2.1
[**2144-8-2**] 03:07AM BLOOD Calcium-8.4 Phos-4.2 Mg-2.3
[**2144-8-1**] 04:44AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.1
[**2144-7-31**] 01:20PM BLOOD Calcium-9.9 Phos-4.3 Mg-2.5
[**2144-8-2**] 03:07AM BLOOD Hapto-137
[**2144-8-4**] 07:55AM BLOOD Vanco-6.8*
[**2144-8-4**] 02:25AM BLOOD Type-[**Last Name (un) **] pH-7.42
[**2144-8-3**] 10:22AM BLOOD Type-ART pO2-91 pCO2-43 pH-7.37
calTCO2-26 Base XS-0
[**2144-8-3**] 09:08AM BLOOD Type-ART pO2-82* pCO2-44 pH-7.39
calTCO2-28 Base XS-0
[**2144-8-3**] 02:29AM BLOOD Type-ART pO2-86 pCO2-42 pH-7.42
calTCO2-28 Base XS-2
[**2144-8-2**] 07:09PM BLOOD Type-ART pO2-101 pCO2-44 pH-7.40
calTCO2-28 Base XS-1
[**2144-8-2**] 05:08PM BLOOD Type-ART pO2-86 pCO2-42 pH-7.39
calTCO2-26 Base XS-0
[**2144-8-2**] 03:43PM BLOOD Type-ART Rates-/10 Tidal V-700 FiO2-58
pO2-186* pCO2-41 pH-7.41 calTCO2-27 Base XS-1 Intubat-INTUBATED
[**2144-8-2**] 01:49PM BLOOD Type-ART Rates-/11 Tidal V-700 FiO2-59
pO2-198* pCO2-36 pH-7.47* calTCO2-27 Base XS-3 Intubat-INTUBATED
[**2144-8-2**] 11:06AM BLOOD Type-ART Rates-/10 Tidal V-700 FiO2-86
pO2-235* pCO2-40 pH-7.46* calTCO2-29 Base XS-5 AADO2-356 REQ
O2-62 Intubat-INTUBATED Vent-CONTROLLED
[**2144-8-3**] 03:10PM BLOOD K-3.8
[**2144-8-3**] 09:08AM BLOOD Glucose-115* K-3.5
[**2144-8-2**] 01:49PM BLOOD Glucose-99 Lactate-0.9 Na-139 K-4.0
Cl-106 calHCO3-27
[**2144-8-2**] 11:06AM BLOOD Glucose-104 Lactate-0.9 Na-139 K-4.6
Cl-102 calHCO3-29
[**2144-8-3**] 10:22AM BLOOD O2 Sat-95
[**2144-8-3**] 09:08AM BLOOD O2 Sat-94
[**2144-8-2**] 07:09PM BLOOD O2 Sat-96
[**2144-8-2**] 03:43PM BLOOD Hgb-11.0* calcHCT-33
[**2144-8-2**] 01:49PM BLOOD Hgb-10.4* calcHCT-31
[**2144-8-2**] 11:06AM BLOOD Hgb-11.0* calcHCT-33
[**2144-8-4**] 02:25AM BLOOD freeCa-1.08*
[**2144-8-3**] 09:08AM BLOOD freeCa-1.12
[**2144-8-3**] 02:29AM BLOOD freeCa-1.11*
[**2144-8-2**] 01:49PM BLOOD freeCa-1.10*
[**2144-8-2**] 11:06AM BLOOD freeCa-1.12
[**2144-7-31**] 01:20PM BLOOD HEPARIN DEPENDENT ANTIBODIES-
Brief Hospital Course:
Patient is a 54-year-old female who had a total knee repair 2
weeks ago and subsequently developed heparin induced
thrombocytopenia with a large right iliofemoral DVT and over the
past 3 days. Progressive signs of phlegmasia
cerulea dolens. Despite aggressive anticoagulation with direct
thrombin inhibitors and elevation, the toes were progressively
gangrenous and venous thrombectomy was required to prevent limb
loss. She was not a candidate for thrombolysis, due to her
recent knee replacement. Patient was admitted and placed on
argatroban for anticoagulation and diltiazem. Patient was
transfused 2units x2 for low hct. Patient was taken to the OR
venous thrombectomy to salvage limb. In the OR the patient was
found to have a patent left iliac venous system and patent
inferior vena cava. Uneventful deployment of a Tulip IVC filter.
Successful thrombectomy of the femoral vein of the thigh and
profunda veins along with large amount of thrombus removed from
the right iliac system. The resultant clearing was quite good.
AV fistula was placed from the branch of the anterior saphenous
vein to the superficial femoral artery. Patient tolerated the
procedure well and was transferred in stable condition to CVICU
intubated and given argatatroban.
POD1: swelling on right leg was much improved. Patient was
extubated.
SW was consulted and saw the patient several times for emotional
suppor and to help cope with her illness. Patient was
continued tx of vanco/flagyl for prophylaxis.
POD2: Physical therapy cleared for rehab.
POD3: Patient was started on coumadin anticoagulation. Was
encouraged to be OOB for short periods. Physical therapy was
c/s for dx & tx.
POD4: psychiatry was consulted for assessment and management of
anxiety. Pt was assessed with dx c/w adjustment d/o with mixed
anxiety/depression and recommended ativan 0.5mg PO TID PRN
anxiety. Psychiatry continued to follow during her stay.
POD5: Argatroban was stopped (PTT was 102.0 and INR was 5.1)
and INR checked four hours later to allow the effects of
argatroban to wear off (PTT90.8, INR4.9 at that time). Due to
therapeutic INR, argatroban remained off and patient was
anticoagulated with coumadin only with target INR [**3-1**].
Silvadine was applied to right foot wound. And activity was
increased to touchdown weight bearing of right heel.
POD6: INR 3.7 and PTT 45.9 and coumadin 7.5mg given and
PTT/INR cont to followed.
POD8: INR 4.3 and PTT 54.3, last INR prior to D/C
Medications on Admission:
Advair, Protonix, verapamil 240, baby aspirin.
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Diltiazem HCl 60 mg Tablet Sig: 1.5 Tablets PO QID (4 times a
day).
5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours) as needed.
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q4H (every 4 hours) as needed.
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
13. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
16. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
17. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours).
18. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
19. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
20. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
21. Warfarin 3 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: goal INR [**3-1**].
22. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
23. Insulin
Insulin SC (per Insulin Flowsheet)
Sliding Scale
Fingerstick QACHSInsulin SC Sliding Scale
Q6H
Regular
Glucose Insulin Dose
0-60 mg/dL [**1-29**] amp D50
61-120 mg/dL 0 Units
121-140 mg/dL 2 Units
141-160 mg/dL 3 Units
161-180 mg/dL 4 Units
181-200 mg/dL 5 Units
201-220 mg/dL 6 Units
221-240 mg/dL 7 Units
241-260 mg/dL 8 Units
261-280 mg/dL 9 Units
281-300 mg/dL 10 Units
301-320 mg/dL 11 Units
321-340 mg/dL 12 Units
341-360 mg/dL 13 Units
> 360 mg/dL Notify M.D.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] Hospital [**Hospital1 189**]
Discharge Diagnosis:
Phlegmasia, venous gangrene R lower extremity
OSA
fentanyl usage,
mitral regurgitation/valve prolapse
HTN
obesity
hyperlipidemia
asthma
h/o palpitations and unifocal premature ventricular beats
(followed by cardiology here)
GERD
Discharge Condition:
Good
Discharge Instructions:
- You had-Insertion of Gunther-Tulip IVC filter, jugular
approach,
Venous iliofemoral and femoral popliteal thrombectomy, Right
groin
AV fistula.
- You will resume activities per your prescribed activity
limitations.
- Your R foot wound care per orders.
- FU with Dr. [**Last Name (STitle) **] as scheduled.
- Keep your other FU as scheduled.
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2144-8-19**] 10:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 16827**] Date/Time:[**2144-12-2**] 8:40
Completed by:[**2144-8-10**]
|
[
"E934.2",
"424.0",
"401.9",
"451.19",
"309.28",
"287.4",
"V43.65",
"327.23",
"415.11",
"E878.1",
"997.2",
"785.4",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.29",
"38.09",
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
15699, 15771
|
10501, 12977
|
334, 480
|
16044, 16051
|
1993, 10478
|
16451, 16768
|
1683, 1736
|
13074, 15676
|
15792, 16023
|
13003, 13051
|
16075, 16428
|
1751, 1974
|
270, 296
|
508, 1318
|
1340, 1532
|
1548, 1667
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,060
| 131,182
|
32824
|
Discharge summary
|
report
|
Admission Date: [**2118-2-5**] Discharge Date: [**2118-2-6**]
Date of Birth: [**2098-2-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
EtOH intoxication, intubated for airway protection
Major Surgical or Invasive Procedure:
Intubation
Bronchoscopy
EGD
History of Present Illness:
Mr. [**Known lastname **] is a 19yM with no past medical history who was brought
to the ED with ethanol intoxication. Per report, he had been to
a party on Friday night and had been drinking; he had an episode
of vomiting and retching, fell, and subsequently became less
responsive.
.
On arrival, his vitals were: T98.7F, HR 62, BP 140/70, RR16, Sat
99%. He had slurred speech and decreased responsiveness; he was
intubated for airway protection and a c-spine collar was placed.
CT neck demonstrated air in the anterior neck and anterior
mediastinum. CT surgery was consulted. He underwent
bronchoscopy, which was normal without evidence of perforation
or aspiration, and subsequent EGD, which showed no evidence of
esophageal or pharyngeal injury. He was transferred to the ICU
for further management.
Past Medical History:
None
Social History:
Student at local [**Location (un) **]. Unable to obtain history about
drugs or tobacco.
Family History:
Unable to obtain
Physical Exam:
VITALS: T97.1F, BP 119/57, HR 104, Sat100%
VENT: PSV 5/5, FiO2 0.4
GENERAL: Intubated, sedated
HEENT: MMM, PERRL; no cervical crepitus
NECK: No JVD
CARD: RRR no m/r/g
RESP: CTA bilaterally
ABD: S/NT/ND + Bowel sounds
EXT: No clubbing, cyanosis, edema; 2+ DP pulses bilaterally
Pertinent Results:
[**2118-2-5**] 03:00AM PLT COUNT-192
[**2118-2-5**] 03:00AM NEUTS-66.4 LYMPHS-27.3 MONOS-5.9 EOS-0.3
BASOS-0.1
[**2118-2-5**] 03:00AM WBC-10.4 RBC-4.64 HGB-14.4 HCT-39.1* MCV-84
MCH-31.2 MCHC-36.9* RDW-12.6
[**2118-2-5**] 03:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2118-2-5**] 03:00AM URINE UHOLD-HOLD
[**2118-2-5**] 03:00AM URINE HOURS-RANDOM
[**2118-2-5**] 03:00AM URINE HOURS-RANDOM
[**2118-2-5**] 03:00AM ASA-NEG ETHANOL-251* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2118-2-5**] 03:00AM estGFR-Using this
[**2118-2-5**] 03:00AM GLUCOSE-125* UREA N-17 CREAT-1.0 SODIUM-138
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-22 ANION GAP-17
[**2118-2-5**] 03:59AM TYPE-ART TEMP-36.5 RATES-14/ TIDAL VOL-500
PEEP-5 O2-100 PO2-573* PCO2-52* PH-7.31* TOTAL CO2-27 BASE XS-0
AADO2-109 REQ O2-28 -ASSIST/CON INTUBATED-INTUBATED
.
Bronchoscopy: Normal airways, no evidence of aspiration.
.
EGD: No esophageal tear.
.
[**2118-2-5**] CXR: 1. High position of the endotracheal tube
terminating at the thoracic inlet. The tube should be advanced
for more optimal placement. 2. No pneumonia or CHF.
.
[**2118-2-5**] CT C-spine/Chest: 1. No evidence of fracture or
dislocation.
2. Foci of subcutaneous gas in the soft tissues of the upper
neck of unclear etiology but perhaps related to intubation. 3.
Endotracheal tube terminating in high position at the level of
the thoracic inlet. The tube should be advanced for optimal
placement. Findings
were discussed with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 4:30 a.m. on the date of
dictation.
.
[**2118-2-5**] CT Neck with contrast: 1. Slightly limited study for
assessment of esophageal perforation due to poor distension of
the esophagus with contrast. No evidence for pneumomediastinum
or PO contrast leak. There has been interval clearing of the
majority of the previously seen subcutaneous emphysema within
the soft tissues of the upper neck. 2. No evidence of
pneumothorax or other acute intrathoracic pathology.
.
[**2118-2-5**] CT Head: No evidence of acute intracranial pathology.
Brief Hospital Course:
Mr. [**Known lastname **] is a 19yM with no past medical history presenting with
vomiting/retching, decreased mental status, and subcutaneous air
in the soft tissue of the neck.
.
#) Subcutaneous air. Concerning for tracheal perforation,
esophageal perforation, but tracheal perforation ruled out on
bronchoscopy. No large tear on EGD, but could still have small
perforation not visible. CT with PO contrast without
extravasation. No evidence of perforation of trachea or
esophagus.
.
#) Altered mental status. Overwhelmingly likely to be secondary
to ethanol ingestion. Could consider other drugs (although tox
screen negative), infection, electrolyte abnormalities, trauma
(although head CT negative). Increased responsiveness with time,
following commands. He was extubated in the afternoon and had a
normal mental status. He was ready for discharge the following
morning.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol Intoxication
Subcutaneous air in neck
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with alcohol intoxication and were intubated
to prevent aspiration. You are being discharged to follow up
with your PCP as an outpatient. If you develop any concerning
symptoms, such as chest pain, shortness of breath, or dizziness,
please seek medical attention immediately.
Followup Instructions:
Follow up with your PCP as needed; if you do not have one, you
may call [**Telephone/Fax (1) 250**] ([**Hospital3 **]) to set up a new
patient appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
|
[
"305.01",
"780.09",
"518.81",
"E849.9",
"518.1",
"E860.9",
"980.9",
"578.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"96.71",
"96.04",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
4818, 4824
|
3856, 4734
|
362, 392
|
4914, 4923
|
1705, 3777
|
5265, 5536
|
1374, 1392
|
4789, 4795
|
4845, 4893
|
4760, 4766
|
4947, 5242
|
1407, 1686
|
272, 324
|
420, 1225
|
3786, 3833
|
1247, 1253
|
1269, 1358
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,183
| 170,399
|
34739
|
Discharge summary
|
report
|
Admission Date: [**2149-11-15**] Discharge Date: [**2149-11-20**]
Date of Birth: [**2083-8-6**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 65686**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
66M s/p brain tumor resection and history of recurrent
meningitis presented from rehab with AMS, increased confusion
and weakness x 1 day. He had a Merckel's brain tumor resected
[**2149-8-14**] by [**Doctor Last Name **] which was complicated by small amounts of
hemorrhage and recurrent Serratia meningitis (pansensitive)
treated with meropenem most recently. He had previosuly been
treated with a course of CTX. AMS x 1 day at rehab. Per family
rtepor, pt was first noted to have obvious slowing while eating
his dinner last night ([**2149-11-14**]). Wife noted that he was not
holding his utensils properly and was at time speaking
nonsensically. Today, [**2149-11-15**], at PT, the therapist noted that
he was not follwoing commands and was more pt more "slowed"
physically. At baseline, pt is A&O x 1 (person only). He has a
poor memory of past events, but does recall his wife and
daughter's names, although failed to remember them earlier
today. Pt was also complaining of pain in the front of his head,
which seemed to have resolved by the time he presented to the
ED. Of note, Dr. [**Known lastname 79613**] did have a HA in past with meningitis.
His wife notes that this is similar to his presentation with his
previous episodes of meningitis. On arrival to the [**Hospital1 18**],
initial VS T 98.8, HR 118, BP 98/68, O2 96% on RA and pt able to
follow simple commands. Rectal temp 102, but patient did not
recieve Tylenol. Crani incision noted to be C/D/I. Guaiac
negative. CXR and UA unremarkable. Blood and urine Cx were
drawn. He recieved vanco, CTX 2g, ampicillin, dexamethasone,as
well as IVF. CT Head showed increasing edema in brain. Labs are
notable for 83% PMNs on differential. Pt has not yet has an LP
given brain edema. Pt was seen by both Neurology and
Neurosurgery in the ED. Dr. [**Last Name (STitle) 724**] from Neuro Onc was also
contact[**Name (NI) **]. Neurosurgery and Dr. [**Last Name (STitle) 724**] both requested [**Hospital Unit Name 153**]
admission. VS prior to transfer T 102.2 (rectal), BP 132/70, HR
87, RR 16, sat 100%RA
.
On arrival to the floor, pt denies headache and neck stiffness.
Past Medical History:
# Neuroendocrine small cell cancer likely [**Location (un) 5668**] cell:
- diagnosed in [**7-/2147**] after patient incidentally found a
left axillary lymph node. FNA was positive for malignant cells,
positive for cytokeratin (AE1/3/CAM 5.2), CK20, synaptophysin,
and chromogranin, negative for CD45, CK7, TTF-1, and S-100. The
immunophenotype suggested a neuroendocrine carcinoma. Imaging
studies showed FDG-avid enlarged left axillary lymph node
without other concerning nodes or masses.
- [**8-/2147**]/[**2146**]: 4 cycles of cisplatin and etoposide
- [**11/2147**]/[**2147**]: received radiation
- [**4-/2148**]: imaging study showed no evidence of recurrence of
- [**8-/2149**]: several weeks of AMS --> large L
temporo/parietal/occipital lesion s/p craniotomy by Dr. [**Last Name (STitle) **],
biopsy consistent with [**Location (un) 5668**] cell cancer
#. [**2149-8-14**]: s/p Left parietal-occipital craniotomy for mass
resection. Pathology report was consistent with a
neuroendocrine tumor.
#. Treated for recent UTI and epididymitis as an outpatient
prior to [**2149-8-12**] admission
#. Basal cell carcinoma
#. Left hip pain
#. H/o shooting pain to the left lower extremity after a fall in
college
#. pan-sensitive SERRATIA MARCESCENS meningitis [**2149-8-24**] treated
with ceftriaxone
#. C. diff
#. VRE ? rectal swab
Social History:
Married. Works as a dentist, likes to be called "Doc". No
smoking history.
Family History:
Unable to obtain.
(From OMR) His father did have melanoma and developed brain
metastases. He mother had thyroid disease and congestive heart
failure. He has two sisters, all healthy. History of malignant
melanoma in his maternal aunt.
Physical Exam:
VS: BP:120/76, HR: 83, RR: 19, O2 sat 99% on RA
GEN: Appears comfortable, NAD
HEENT: right pupil 2mm and sluggishly reactive to light, left
pupil 1mm and reactive. Sclera anicteric. Dry MM, OP without
lesions. Able to rotate neck without pain.
RESP: CTA b/l anteriorly
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt
EXT: warm, c/c/e
NEURO: AAOx1, to self only. Slow to respond and gives short
answers to questions, some answers which are nonsensical. No
focal neurological deficit noted.
Pertinent Results:
[**2149-11-18**] 07:50AM BLOOD WBC-5.4 RBC-3.73* Hgb-11.7* Hct-34.0*
MCV-91 MCH-31.3 MCHC-34.3 RDW-17.1* Plt Ct-343
[**2149-11-17**] 07:20AM BLOOD WBC-8.2 RBC-3.75* Hgb-11.6* Hct-34.0*
MCV-91 MCH-31.0 MCHC-34.3 RDW-17.1* Plt Ct-341
[**2149-11-16**] 05:06AM BLOOD WBC-6.4 RBC-3.50* Hgb-11.0* Hct-32.0*
MCV-91 MCH-31.4 MCHC-34.4 RDW-17.1* Plt Ct-352
[**2149-11-15**] 04:55PM BLOOD WBC-7.5 RBC-4.10* Hgb-12.5* Hct-37.3*
MCV-91 MCH-30.5 MCHC-33.5 RDW-18.3* Plt Ct-393#
[**2149-11-15**] 04:55PM BLOOD Neuts-83.8* Lymphs-6.4* Monos-8.4 Eos-0.5
Baso-0.9
[**2149-11-15**] 09:58PM BLOOD PT-11.7 PTT-23.0 INR(PT)-1.0
[**2149-11-18**] 07:50AM BLOOD Glucose-102* UreaN-10 Creat-0.4* Na-139
K-3.6 Cl-104 HCO3-30 AnGap-9
[**2149-11-17**] 07:20AM BLOOD Glucose-95 UreaN-13 Creat-0.4* Na-140
K-3.4 Cl-105 HCO3-27 AnGap-11
[**2149-11-16**] 05:06AM BLOOD Glucose-147* UreaN-8 Creat-0.4* Na-137
K-4.0 Cl-105 HCO3-23 AnGap-13
[**2149-11-15**] 04:55PM BLOOD Glucose-138* UreaN-12 Creat-0.6 Na-136
K-4.7 Cl-101 HCO3-24 AnGap-16
[**2149-11-17**] 07:20AM BLOOD ALT-19 AST-12 LD(LDH)-220 AlkPhos-69
TotBili-0.4
[**2149-11-18**] 07:50AM BLOOD Calcium-9.4 Phos-3.3 Mg-2.1
[**2149-11-17**] 07:20AM BLOOD Albumin-3.1* Calcium-9.9 Phos-4.4 Mg-2.2
[**2149-11-16**] 05:06AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.1
[**2149-11-15**] 04:55PM BLOOD Calcium-9.5 Phos-3.9# Mg-2.1
[**2149-11-15**] 05:10PM BLOOD Lactate-2.5*
.
[**2149-11-15**] CSF: Cerebrospinal fluid:
POSITIVE FOR MALIGNANT CELLS.
Consistent with metastatic [**Location (un) 5668**] cell carcinoma
(history of [**Location (un) 5668**] cell carcinoma).
.
[**2149-11-16**] CSF: DIAGNOSIS: Cerebrospinal fluid:
POSITIVE FOR MALIGNANT CELLS.
Consistent with metastatic [**Location (un) 5668**] cell carcinoma
(history of [**Location (un) 5668**] cell carcinoma).
.
[**2149-11-15**] CT Head: IMPRESSION:
1. Progressive decreased density and size of the left
occipitoparietal
intracranial hemorrhage with surrounding edema. Within
limitations of motion degraded study, no definite areas of new
hemorrhage.
2. Again noted are hypodensities in bifrontal lobes, which
correspond to
signal intensity changes on recent MRI of [**2149-10-20**], and
may represent underlying leptomeningeal disease as well as
underlying ischemic disease.
3. Stable configuration of the ventricles with enlargement of
the left
temporal [**Doctor Last Name 534**].
.
[**2149-11-15**] CXR: IMPRESSION: Stable chest x-ray examination with no
acute process.
.
[**2149-11-17**] EEG: IMPRESSION: Abnormal EEG due to marked slowing
and, at times, voltage reduction over the left posterior
temporal region with extension to the left occipital,
centro-parietal, and right occipital regions, on occasion. No
associated discharging features were seen. This would probably
represent a structural or destructive process.
.
[**2149-11-17**] MRI: IMPRESSION:
1. Rim-enhancing mass in the left parietal/occipital lobes with
central
restricted diffusion, similar to prior. The restricted diffusion
within this mass is similar to the postoperative and
preoperative examinations, likely representing blood products
and residual tumor. Superinfection of this cavity remains a
possiblity, thought the unchanged adjacent FLAIR signal makes
this less likely.
2. Interval expected evolution of the bifrontal
inflammatory/destructive
process compatible with the patient's known meningoencephalitis.
.
[**2149-11-19**] CXR: IMPRESSION: Satisfactory placement of PICC line.
Brief Hospital Course:
66yo M s/p recent resection of Merckel's neuroendocrine tumor
with 2 prior episodes of Serratia meningitis who presents from
rehab with AMS x 1 day and fevers.
.
# AMS: DIfferential includes recurrent meningitis, other
infectious process, or post-ictal confusion. No evidence of new
ICH on CT head. In terms of potential infectious sources that
have been evaluated, CXR is unchanged with no obvious
infiltrate. UA is largely uninmpressive for an infection. Per
d/c summary from last admission, the patient had a seizure while
on the medical floor that was responsive to Ativan, for which he
has since been on Keppra and EEG did not reveal any seizure
focus. Pt recieved empiric coverage for meningitis with Vanco,
CTX 2g, and Ampicillin in the ED. Neurology recommended MRI w
and w/o contrast for further evaluation of evidence of
meningoencephalitis. Additonally, Neurosurgery recommends
holding anti-coagulation. Pt was continued on home Keppra 500mg
[**Hospital1 **]. Pt was initially on Dexamethasone 10mg IV q 6 hours. In
the ICU, pt was started on Meropenem, per ID recs. LP was
performed after the pt already received antibiotics. The
cultures are negtive to date, but cytology was positive for
malignant cells.
.
# C Diff colitis: Pt was cotninued on po vancomycin and per ID
recs, will need to continue until 10 days after the course of
Meropenem is finished.
.
# s/p craniotomy, Merckel's tumor resection: Pt's Dexamethasone
was increased. It will be tapered over the next few days. Pt was
on Bactrim ppx, and its discontinuation will be determined by ID
at the [**Hospital 702**] [**Hospital 3782**] clinic appt.
.
Pt was on pneumoboots for DVT ppx. Pt was full code.
Medications on Admission:
-multivitamin Oral
-Aquaphor Topical
-Colace Oral
-decadron Sig: Two (2) mg twice a day. (2mg PO BID?
-desonide Topical
-Fragmin 5,000 unit/0.2 mL Syringe Sig: One (1) syringe
Subcutaneous once a day.
-Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day.
-Miralax Oral
-Milk of Magnesia Oral
-Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
-Tylenol Oral
-sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
-vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 21 days.
-omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
- Flomax 0.4mg daily, plus another med for urinary retention per
his wife
-Recently completed course of meropenem 1 gram Recon Soln Sig:
Two (2) g Intravenous Q8H on [**2149-11-10**]
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
4. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): until [**2149-12-22**].
5. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)) for 4 days.
6. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)) for 4 days.
7. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
8. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. meropenem 1 gram Recon Soln Sig: Two (2) Intravenous every
eight (8) hours: until [**2149-12-12**].
10. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
12. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO once a day
for 4 days.
13. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO once a day
for 4 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Meningitis
[**Location (un) 5668**] cell cancer
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
Please keep the following appointments:
.
Department: INFECTIOUS DISEASE
When: THURSDAY [**2149-12-4**] at 2:30 PM
With: [**Doctor First Name 1412**] [**Name Initial (MD) **] [**Name8 (MD) 1413**], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: FRIDAY [**2149-12-12**] at 11:00 AM
With: [**Name6 (MD) 2323**] [**Name8 (MD) 2324**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: NEUROLOGY
When: MONDAY [**2149-12-15**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12567**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1844**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2149-11-21**]
|
[
"V15.88",
"707.23",
"707.03",
"348.5",
"008.45",
"320.82",
"348.39",
"112.0",
"V10.83",
"209.75",
"707.05",
"V10.91",
"788.20",
"V13.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
12103, 12173
|
8207, 9893
|
311, 328
|
12265, 12265
|
4728, 6543
|
12439, 13479
|
3959, 4195
|
10833, 12080
|
12194, 12244
|
9919, 10810
|
4210, 4709
|
268, 273
|
356, 2493
|
6552, 8184
|
12280, 12416
|
2515, 3851
|
3867, 3943
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,083
| 193,985
|
11556
|
Discharge summary
|
report
|
Admission Date: [**2122-5-10**] Discharge Date: [**2122-5-14**]
Date of Birth: [**2062-8-29**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins / Tetracyclines / Keflex / Propofol
/ Vancomycin
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Fever, toe "darkeness"
Major Surgical or Invasive Procedure:
incision and drainage of right toe hematoma
History of Present Illness:
59 year old female with a history of IDDM, CKD, chronic lower
extremity edema and morbid obesity who is s/p hammertoe surgery
on [**5-7**] who presented to the ED on POD #3 with reported fevers
at home, increasing right foot pain at the surgical site and
"darkness" of the 5th toe. In the ED, she was given a dose of
clindamycin. Podiatry drained and packed a toe hematoma at the
bedside. They did not suspect infection, but sent wound fluid
for culture. (WBC and lactate wnl). She was hyperkalemic to 5.6,
with no EKG changes. She was given kayexalate x 1. Her
creatinine was at baseline. She was admitted for IV antibiotics
and hyperkalemia.
Past Medical History:
Past Medical History:
diastolic dysfunction with well preserved LVEF
morbid obesity
chronic lower extremity edema
dyspnea on exertion
sleep apnea for which she uses CPAP nightly
type 2 diabetes mellitus
hypertension
hypothyroidism
hypercholesterolemia
chronic kidney disease, (baseline creatinine is approximately
2.3)
neuropathy
retinopathy
Past Surgical History: s/p Arthroplasties of digits 2, 4 and 5
on the right foot on [**2122-5-7**]
Social History:
Smoked from age 16-22, <1ppd, quit and has not smoked since. No
alcohol, no IV drug use.
Family History:
Mother- MVP, hypothyroid. Father- lung CA, smoker, mets to
brain. Brother- healthy, lives in [**Name (NI) 4565**], 3 sons, all
healthy.
Physical Exam:
Admission physical exam:
VS 97.3 116/76 66 24 98% on RA
NAD
HEENT NCAT, MMM
CV Distant heart sounds, RRR, normal S1, S2
Lungs CTAB
Abdomen obese, + BS, nontender
Extremities warm, well perfused with 2+ DP pulses; s/p
amputation of R 1st and 2nd toes, sutured incision on dorsum of
R third toe, necrotic appearing spot on dorsum of R 5th toe; no
calf tenderness or edema
Neuro impaired sensation to light touch over 3 R toes
Pertinent Results:
[**2122-5-10**] 09:22PM BLOOD WBC-7.6 RBC-3.74* Hgb-11.2* Hct-33.5*
MCV-90 MCH-30.0 MCHC-33.4 RDW-13.2 Plt Ct-231
[**2122-5-11**] 04:09AM BLOOD WBC-4.5 RBC-3.99* Hgb-12.4 Hct-36.0
MCV-90 MCH-31.0 MCHC-34.3 RDW-13.1 Plt Ct-251
[**2122-5-12**] 05:59AM BLOOD WBC-11.2*# RBC-3.63* Hgb-11.0* Hct-31.8*
MCV-88 MCH-30.3 MCHC-34.5 RDW-13.0 Plt Ct-254
[**2122-5-13**] 04:09AM BLOOD WBC-12.5* RBC-3.67* Hgb-10.9* Hct-31.7*
MCV-86 MCH-29.7 MCHC-34.4 RDW-13.2 Plt Ct-286
[**2122-5-14**] 06:10AM BLOOD WBC-9.2 RBC-4.14* Hgb-12.1 Hct-37.4
MCV-90 MCH-29.2 MCHC-32.4 RDW-13.1 Plt Ct-381
[**2122-5-10**] 09:22PM BLOOD Neuts-81.5* Lymphs-12.5* Monos-4.3
Eos-1.6 Baso-0.1
[**2122-5-13**] 04:09AM BLOOD Neuts-91.9* Bands-0 Lymphs-5.4* Monos-2.7
Eos-0.1 Baso-0.1
[**2122-5-14**] 06:10AM BLOOD Neuts-67.8 Lymphs-27.6 Monos-4.0 Eos-0.4
Baso-0.1
Swab of toe hematoma drainage:
GRAM STAIN (Final [**2122-5-11**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
WOUND CULTURE (Final [**2122-5-13**]):
STAPH AUREUS COAG +. HEAVY GROWTH.
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN-------------<=0.25 S
PENICILLIN G---------- =>0.5 R
TRIMETHOPRIM/SULFA---- <=0.5 S
.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
.
Blood culture x 4 - no growth to date
Urine culture - no growth
.
Foot x-ray ([**5-10**]): Status post second, fourth and fifth
hammertoe surgery, with expected post- surgical soft tissue
swelling. No evidence of soft tissue air or definitive finding
of osteomyelitis.
.
Chest x-ray ([**5-11**]): There are low lung volumes.
Cardiomediastinal contours are unremarkable. Aside from
atelectasis in the left base, the lungs are clear. There is no
pneumothorax or pleural effusions.
.
Chest x-ray ([**5-11**]): As compared to the previous radiograph,
there are unchanged bilaterally low lung volumes. As a
consequence, the cardiac silhouette is borderline in size. Due
to motion artifact, the morphology of the lung parenchyma cannot
be assessed. There is no evidence of larger pleural effusions.
.
Dopplers of right foot ([**5-13**]): not yet read. Podiatry should
follow this up on her outpatient appointment
[**2122-5-14**] 06:10AM BLOOD WBC-9.2 RBC-4.14* Hgb-12.1 Hct-37.4
MCV-90 MCH-29.2 MCHC-32.4 RDW-13.1 Plt Ct-381
[**2122-5-13**] 04:09AM BLOOD WBC-12.5* RBC-3.67* Hgb-10.9* Hct-31.7*
MCV-86 MCH-29.7 MCHC-34.4 RDW-13.2 Plt Ct-286
[**2122-5-10**] 09:22PM BLOOD WBC-7.6 RBC-3.74* Hgb-11.2* Hct-33.5*
MCV-90 MCH-30.0 MCHC-33.4 RDW-13.2 Plt Ct-231
[**2122-5-14**] 06:10AM BLOOD Neuts-67.8 Lymphs-27.6 Monos-4.0 Eos-0.4
Baso-0.1
[**2122-5-10**] 09:22PM BLOOD Neuts-81.5* Lymphs-12.5* Monos-4.3
Eos-1.6 Baso-0.1
[**2122-5-13**] 04:09AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Burr-OCCASIONAL Ellipto-OCCASIONAL
[**2122-5-14**] 06:10AM BLOOD PT-12.5 PTT-25.5 INR(PT)-1.1
[**2122-5-14**] 06:10AM BLOOD Glucose-60* UreaN-74* Creat-2.5* Na-138
K-4.6 Cl-103 HCO3-24 AnGap-16
[**2122-5-13**] 04:09AM BLOOD Glucose-131* UreaN-79* Creat-2.3* Na-135
K-5.1 Cl-104 HCO3-21* AnGap-15
[**2122-5-11**] 04:30PM BLOOD Glucose-575* UreaN-72* Creat-2.7* Na-132*
K-7.0* Cl-102 HCO3-19* AnGap-18
[**2122-5-14**] 06:10AM BLOOD Calcium-9.6 Phos-5.1* Mg-2.1
[**2122-5-11**] 04:56AM BLOOD Type-ART pO2-102 pCO2-42 pH-7.33*
calTCO2-23 Base XS--3 Intubat-NOT INTUBA
[**2122-5-11**] 03:56AM BLOOD Type-ART pO2-39* pCO2-40 pH-7.35
calTCO2-23 Base XS--3
[**2122-5-11**] 04:56AM BLOOD Lactate-1.1
[**2122-5-11**] 07:05AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2122-5-11**] 07:05AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2122-5-11**] 07:05AM URINE RBC-2 WBC-3 Bacteri-NONE Yeast-OCC Epi-<1
[**2122-5-11**] 07:05AM URINE CastHy-2*
[**2122-5-11**] 07:05AM URINE Mucous-RARE
Brief Hospital Course:
A/P: 59 yo F with IDDM, morbid obesity, s/p arthroplasties of 3
hammertoes on right foot on [**2122-5-7**], admitted to floor with
fevers/chills and transferred to MICU with resp
distress/anaphylaxis after receiving vanco.
.
#) Anaphylaxis to vancomycin: This was likely anaphylaxis to
Vancomycin with flushing, rash, rigors/fever, change in mental
status and resp distress. This is unlikely red man's syndrome
as per discussion with floor resident and RN, pt was clearly in
resp distress prior to first dose of epi and vanco was given
slowly (over 2 hours, pt received <1/2 dose). Pt received epi
IM 0.3 x 2, solumedrol 150 x1, H2 blocker, and benadryl. Her
respiratory quickly recovered and she had no further issues off
of the vancomycin.
.
#) Fevers: Likely source is recent surgical site, and wound cx
is growing MSSA but resistant to clindamycin. WBC has increased
in setting of receiving solumedrol. The patient was successfully
switched to bactrim, to which to MSSA is sensitive. She had no
further fevers. Podiatry would like her to continue on the
Bactrim for a total of 7 days.
.
#) Leukocytosis: Likely due to both her wound infection and
solumedrol 150 mg. Resolved with a WBC of 9 on day of
discharge.
.
#) S/p arthroplasty on R foot, MSSA wound infection: See above,
continue Bactrim. Outpatient podiatry follow-up. [**Date Range 269**] for daily
dressing changes.
.
#) IDDM: Her blood sugars have been high, likely because of
infection and the one dose of solumedrol. Pt was initially
continued on Lantus 40 units twice daily with regular insulin
sliding scale while in house. However, pt's glucose were in the
400's in the MICU, and she was started on an insulin gtt. Pt is
a pt at [**Last Name (un) **]. [**Last Name (un) **] was consulted and recommended to increase
lantus to 45mg [**Hospital1 **] and continue insulin drip overnight with goal
to eventually titrate off. Pt is now off insulin gtt with FS
70s-200s. She has a plan to call her doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] next week
to discuss management of insulin. She will continue on the
Lantus 45 units [**Hospital1 **] for now and check her fingersticks at home.
.
#) Hyperkalemia: Etiology unclear as Creatinine at baseline.
It has been on the high side of normal in the past. Pt was
given kayexalate in ED. In the MICU, pt's K peaked at 7.0 with
more prominent T waves. Pt was treated with calcium gluconate,
insulin, and kayexylate. She was monitored on telemetry with no
events. Her potassium then steadily trended down to 4.6 on
discharge. Lisinopril is being held. Her primary care
physician can address whether or not to resume this medication
in the future.
.
#) HTN: Still elevated off lisinopril. She was switched from
Toprol XL 75mg to Metoprolol 25mg TID in the hospital and
continued on Hydrochlorothiazine 25mg daily in the hospital.
She was told to take the Toprol 75mg daily when she left the
hospital. Her primary care physician should assess her
antihypertensive regimen and make adjustments as needed as an
outpatient.
.
#) Anemia: fluctuates, currently 34. Likely due to chronic renal
disease. Monitor.
.
#) Sleep apnea: uses CPAP nightly, brought her machine with her
from home.
.
#) Chronic kidney disease: (baseline creatinine is approximately
2.3), at her baseline during hospitalization. Was given a renal
diet.
.
#) Hyperlipidemia: contiued simvastatin
.
#) Hypothyroidism: continued levothyroxine
.
#) Neuropathy: continued gabapentin
.
#) FEN/GI - low potassium, low salt, heart healthy diabetic
renal diet
#) PPx - heparin subcutaneous
#) Code - full
#) Dispo - being discharged home [**5-14**], afebrile, ambulating well,
pain free.
Medications on Admission:
Hydrochlorothiazine 25mg daily
Toprol XL 75mg daily
Lisinopril 5mg daily
levothyroxine 0.25 mg daily
gabapentin 100mg qhs
lantus 40 units [**Hospital1 **], Apidra sliding scale
fish oil
aspirin 325mg daily
Topamax 125 mg qhs
Simvastatin 10mg daily
Bupropion SR 150mg daily
Discharge Medications:
1. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Topiramate 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
7. Topiramate 25 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
9. Insulin Glargine 100 unit/mL Cartridge Sig: Forty Five (45)
units Subcutaneous twice a day.
10. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
11. Apidra 100 unit/mL Solution Sig: sliding scale Subcutaneous
sliding scale.
12. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
13. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**First Name5 (NamePattern1) 5871**] [**Last Name (NamePattern1) 269**]
Discharge Diagnosis:
Primary Diagnosis: Anaphylaxis
Secondary Diagnoses: Wound infection, Hyperkalemia, Type 2
Diabetes, Hypertension, Morbid Obesity
Discharge Condition:
stable, afebrile, able to ambulate without pain
Discharge Instructions:
You were admitted for antibiotic treatment of a toe infection
after surgery and developed a serious allergic reaction to
Vancomycin, one of the antibiotics you were given. You were
given epinephrine, IV steroids, an IV antacid and benadryl to
treat this reaction. The level of potassium in your blood was
elevated, but decreased into normal range after treatment. Your
blood sugars were elevated and you received IV insulin while in
the ICU and were then transitioned back to subcutaneous insulin.
- Continue to take your antibiotc as prescribed to treat the toe
infection
- Stop taking your Lisinopril, as it can cause high potassium,
which you had while you were in the hospital.
- Continue all other medications as you were taking them prior
to your hospitalization, with the exception of increasing your
40 units of Lantus to 45 units 2x/day
- Continue to check your blood sugar at home
- Please call your doctor if you develop a fever, chills,
difficulty breathing, chest pain, nausea, vomiting, confusion or
any other questions or concerns.
- Keep all scheduled doctor appointments
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 36766**] can see you tomorrow anytime after 10am,
please call [**Telephone/Fax (1) 36767**] if you would like to schedule a
different or definitel appointment time.
.
Provider: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2122-5-18**] 1:40
Provider: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2122-6-2**] 10:40
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3512**]
Date/Time:[**2122-9-8**] 2:00
|
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11,162
| 192,425
|
22925
|
Discharge summary
|
report
|
Admission Date: [**2162-2-16**] Discharge Date: [**2162-2-25**]
Date of Birth: [**2107-6-10**] Sex: F
Service: MEDICINE
Allergies:
Demerol / Propofol
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
respiratory monitoring after total knee replacement
Major Surgical or Invasive Procedure:
total knee replacement
intubation
History of Present Illness:
The pt. is a 54 year-old female with h/o resp distress following
surgery, asthma, CAD, HTN who was transfrred to the [**Hospital Unit Name 153**] tonight
for closer monitoring. She [**Hospital Unit Name 1834**] an uneventful left TKR
today. Twice int he past, she has had been intubated for resp
distress after surgeries - once a bunionectomy, and another time
after an arthoplasty here in [**4-28**]. During that admission, she
was treated for an asthma flare. She also developed lactic
acidosis thought to be due to propofol.
Past Medical History:
1)Asthma/reactive airway disease for the past 15 years with a
history of at least five intubations, with at least two this
year
after minor operations on her right lower extremity.
2)status post-right knee arthroscopy in [**Month (only) 547**] of this year,
which
is complicated by respriatory failure and two days intubation in
the [**Hospital Unit Name 153**] at [**Hospital3 **].
3) Status post-right toe bunionectomy, complicated by a
respiratory failure at [**Hospital 487**] Hospital earlier this year.
4) s/p cardiac catheterization at [**Hospital3 **] with a
question of coronary artery stenting at that time in
approximately [**Month (only) 205**] of this year.
5)anemia
6)hyperlipidemia
7)hepatic steatosis noted on imaging
8)hypertension, with a history of hypertensive urgency in [**Month (only) 547**]
of this year, an echo in [**Month (only) 547**] of this year showed an EF of 65%
and 1 to 2+ MR.
9) status post-hysterectomy.
10)Status post- appendectomy
11)Status post-perforated colon? cancer, requiring ostomy in the
past.
Social History:
per OMR: She lives in [**Hospital1 487**], alone. She is present today with
her daughter. She is retired. She has a 30 pack year history of
smoking, which she quit smoking five years ago. She had started
smoking at the age of 15. She denies alcohol or elicit drug use.
She has no history of asbestos exposure.
Family History:
per OMR: Non-significant for any pulmonary problems. [**Name (NI) **] father
did have an MI at age 60.
.
Physical [**Name (NI) **]:
Vitals: T:95.8 P: 48 R: 7 on PS 10/5 FIO2 50 BP: 98/41 SaO2:
100%
General: Sedated
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM
Pulmonary: Lungs CTA bilaterally without wheezes
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Neurologic: Very sedated. does not respond to sternal rub.
minimally withdraws to pain.
Pertinent Results:
[**2162-2-16**] 11:03PM TYPE-ART TEMP-35.6 RATES-/10 TIDAL VOL-600
PEEP-5 O2-50 PO2-149* PCO2-44 PH-7.40 TOTAL CO2-28 BASE XS-2
-ASSIST/CON INTUBATED-INTUBATED
[**2162-2-16**] 09:46PM GLUCOSE-190* UREA N-13 CREAT-0.8 SODIUM-141
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-28 ANION GAP-13
[**2162-2-16**] 09:46PM CALCIUM-9.1 PHOSPHATE-3.2 MAGNESIUM-1.8
[**2162-2-16**] 09:46PM WBC-10.9 RBC-3.65* HGB-11.2* HCT-31.9* MCV-87
MCH-30.6 MCHC-35.0 RDW-12.2
[**2162-2-16**] 09:46PM PLT COUNT-168
[**2162-2-16**] 09:46PM PT-13.0 PTT-21.8* INR(PT)-1.1
[**2162-2-16**] 09:46PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2162-2-16**] 09:46PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2162-2-16**] 08:35PM TYPE-ART PO2-202* PCO2-58* PH-7.31* TOTAL
CO2-31* BASE XS-1
[**2162-2-16**] 08:35PM LACTATE-2.0
Brief Hospital Course:
54 yo F with h/o of severe asthma, CAD, HTN admitted for
monitoring after right total knee replacement.
.
# Repiratory distress/asthma: Ms. [**Known lastname 6633**] was intubated in the
OR and was sent to the [**Hospital Unit Name 153**] to be weaned off the ventilator
slowly overnight. She was able to be extubated the following
morning. She was continued on albuterol given her history of
asthma. She received narcotics for pain control and was noted to
be in respiratory acidosis due to hypoventilation several hours
after extubation. She was given narcan 0.4mg X2 and was started
on narcan gtt with good effect. She was briefly placed on bipap
during this episode and quickly weaned to room air with good O2
sats. She had a chest X-ray which was concerning for RLL PNA vs.
atelectasis. At the time, since she had a temp of 101, she was
started on levofloxacin for presumed PNA (7 day course). She was
also given an incentive spirometer to prevent atelectasis. She
was breathing comfortably on room air w/ good O2 sat in the days
before discharge.
.
# CAD/Chest pain: Post extubation, Ms. [**Known lastname 6633**] had an episode of
chest pain. She was given SLNTG X 3, fentanyl 50 mcg X2, ASA and
was started on nitro gtt. The pain resolved after ~30 mins.
There were no EKG changes; however, given her history of CAD and
the fact that she had been off aspirin/plavix for 7 days pre-op,
there was significant concern for ACS. Cardiology was consulted
and recommended checking 3 sets of enzymes and restarting
ASA/plavix. She had another episode of chest pain, was given
ativan and was started on nitro gtt again briefly. She was
changed to imdur and the nitro gtt was then discontinued. Her
cardiac enzymes came back negative. She had another episode of
chest pain after her transfer to the floor. This was described
as being the same pain as she'd had previously. EKG was
unchanged, and enzymes were negative. Given that she had 90%
occlusion in the LAD s/p stent, she received a dobutamine stress
test which was negative (although low quality study). She had
no further episodes, and her cardiologist was made aware of
these events. She was continued on her cardiac meds prior to
discharge.
.
# Anemia: Unclear etiology. In [**Hospital Unit Name 153**], Ms. [**Known lastname 6633**] had an episode
of emesis after receiving narcan. The emesis was brown, so she
[**Known lastname 1834**] an NG lavage which was clear. She received 1u PRBC in
the [**Hospital Unit Name 153**] with appropriate response in hematocrit. On the floor,
her Hct continued to trend down and reached 23.7. She was
transfused 2u PRBC with an appropriate response. Her Hct
remained stable for the remainder of her hospital course.
.
# TKR: [**Hospital Unit Name **] surgery continued to follow the patient and
make recommendations for her wound care and rehab. Her knee was
placed in a continuous motion device and she was seen by
physical therapy who began working with the patient on POD#3.
She continued to improve, and she was given a knee immobilizer
to be worn for at least 6 hours a day. She will also continue
to receive lovenox for 2 weeks and have follow up with ortho in
1 month.
.
# Pain: She had an epidural catheter initially. Given that she
hypoventilated on narcotics, she was given standing percocet and
tylenol with prn oxycodone once the cathether was removed. She
was monitored carefully for sedation given the episode of
oversedation that occurred in the [**Hospital Unit Name 153**]. Her pain was
well-controlled on this regimen.
.
# FEN: Advanced to regular, cardiac, heart healthy diet. Lytes
were checked daily and were repleted prn.
.
# Access: PIV
.
# Prophylaxis: She was given SC lovenox, bowel regimen, PPI.
.
# Code: Full
Medications on Admission:
1. advair
2. lipitor
3. metoprolol
4. plavix
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 2 weeks.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
10. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours).
12. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
16. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q3-4H (Every 3 to 4 Hours) as needed.
17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
18. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
19. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
20. Prochlorperazine 25 mg Suppository Sig: One (1) Suppository
Rectal Q12H (every 12 hours).
21. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
22. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
23. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
24. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - Wood Mill - [**Hospital1 487**]
Discharge Diagnosis:
s/p right total knee replacement
CAD s/p LAD stent
asthma/reactive airway disease
anemia
hyperlipidemia
hypertension
Discharge Condition:
stable, breathing comfortably on room air and knee pain
controlled
Discharge Instructions:
Please make sure to take all your medications as directed. You
should take levofloxacin for 3 more days. Lovenox should be
used for 2 more weeks.
.
You should use your knee immobilizer for at least 6 hours a day.
Also, it is important to continue with physical therapy.
.
Please return for further care if you have fever, chills,
nausea, vomiting, shortness of breath, chest pain, dizziness,
swelling of your knee, uncontrolled pain or any other symptoms
that are concerning to you.
.
The following appointments have been made for you. The details
are provided below. Please call Dr.[**Name (NI) 59235**] office for an
appointment in the next few weeks.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2162-3-5**] 2:40
.
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2162-6-3**] 9:40
.
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2162-6-3**] 10:00
Completed by:[**2162-2-25**]
|
[
"272.4",
"285.9",
"493.90",
"428.30",
"414.01",
"428.0",
"280.0",
"401.9",
"599.7",
"486",
"715.36",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04",
"81.54"
] |
icd9pcs
|
[
[
[]
]
] |
10016, 10097
|
3975, 7722
|
330, 365
|
10258, 10327
|
3057, 3952
|
11034, 11512
|
2333, 3038
|
7818, 9993
|
10118, 10237
|
7748, 7795
|
10351, 11011
|
239, 292
|
393, 922
|
944, 1990
|
2006, 2317
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,412
| 117,412
|
55068
|
Discharge summary
|
report
|
Admission Date: [**2155-9-1**] Discharge Date: [**2155-10-22**]
Date of Birth: [**2088-9-6**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 14689**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
ORIF
Pericaridal Window
Endotrachial Intubation and mechanical ventilation
PEG tube placement
History of Present Illness:
66 year old male with hypopharyngeal mass diagnosed in [**2155-7-4**]
who was in his usual state of health until this morning. He
suffered a mechanical fall this morning while intoxicated
complicated by left humerus and hip fracture. He was evaluated
at an OSH and transferred to [**Hospital1 18**] due to shortness of breath
and his known tumor.
At [**Hospital1 18**] ED, his initial vitals were : 98.8 103 125/57 22 97%
2LNC. He was noted to have increased work of breathing though
without stridor and satting well on room air. He reports he has
had increasing difficulty swallowing for the past several weeks
worsening over the last several days, but is tolerating liquids.
He reports significant weight loss in the past month. He is
having more difficulty breathing. He reports his tumor was found
during a procedure for skin cancer in which there was difficulty
during intubation.
CT scan showed 2-cm exophytic mass in L piriform sinus. Large
submucosal hypopharyngeal/postcricoid/esophageal mass measuring
5 cm TV x 2 cm AP x 8.5 cm SI with focal airway narrowing down
to 1.3 x 0.7 cm, bilateral hyoid and thyroid cartilage invasion.
Bilateral enlarged/necrotic LN. ENT performed laryngoscopy
which showed left exophytic portion of mass clearly viewed on
fiberoptic exam, while right and posterior portion appreciated
as obliteration of right pyriform and post-cricoid space. He was
given Decadron 5 mg IV and transferred to MICU for monitoring.
Orthotrauma was consulted who would like ENT/Anesthesia involved
prior to taking him to the OR.
In the MICU, he had no other complaints. He reports history of
withdrawal seizures but no intubation. He also reports being
anxious about his upcoming operation.
Past Medical History:
Basal cell cancer
Hypothyroidism
Pneumonia
Anemia
ETOH abuse
Hyperlipidemia
Hypopharyngeal mass
Social History:
denies smoking, prior to admission pt reportedly had several
drinks of ETOH daily
Family History:
no history of head and neck cancer
Physical Exam:
Admission Exam
102.1 98 127/65 98%humidified face tent
General: Alert, oriented. Moderate respiratory distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: large anterior cervical mass
CV: Difficult to hear over his upper airway sounds
Lungs: Prominent upper airway sounds. No wheezing
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: Internally rotated left hip and externally rotated left
forearm.
Neuro: CNII-XII intact, 5/5 strength deferred on LUE and LLE due
to pain.
Discharge Exam
VS: 97.7, 130/90, 79, 18, 97%RA
GEN: Cachectic. Awake, NAD
HEENT: Pupils equal. Poor dentition
PULM: CTAB anteriorly, no wheezing, rales, rhonchi
CV: RRR. No murmurs appreciated.
ABD: BS+. Soft. NT. Distended. G-tube bandage C/D/I. No rebound
or guarding.
EXT: Left arm swelling from hand to above left elbow, 2+ DP/PT
pulses bilaterally. No lower extrem edema bilaterally. Left
second metatarsal appears swollen with some erythema around toe.
Neuro: AxOx3
Pertinent Results:
Admission Labs
[**2155-8-31**] 10:50PM BLOOD WBC-16.1* RBC-2.92* Hgb-9.2* Hct-27.5*
MCV-94 MCH-31.4 MCHC-33.5 RDW-14.0 Plt Ct-269
[**2155-8-31**] 10:50PM BLOOD Neuts-93.7* Lymphs-3.2* Monos-2.9 Eos-0.1
Baso-0.2
[**2155-8-31**] 10:50PM BLOOD PT-13.2* PTT-30.2 INR(PT)-1.2*
[**2155-8-31**] 10:50PM BLOOD Glucose-121* UreaN-12 Creat-0.8 Na-130*
K-4.3 Cl-93* HCO3-28 AnGap-13
[**2155-9-1**] 04:13AM BLOOD Calcium-8.4 Phos-4.2 Mg-1.6
Discharge labs:
[**2155-10-22**] 05:44AM BLOOD WBC-2.3* RBC-2.58* Hgb-8.0* Hct-23.7*
MCV-92 MCH-31.2 MCHC-33.9 RDW-15.1 Plt Ct-185
[**2155-10-21**] 06:28AM BLOOD WBC-2.4* RBC-2.63* Hgb-8.4* Hct-24.4*
MCV-93 MCH-31.8 MCHC-34.3 RDW-15.2 Plt Ct-201
[**2155-10-9**] 03:27AM BLOOD Neuts-56.5 Lymphs-28.9 Monos-6.3 Eos-7.4*
Baso-0.9
[**2155-10-22**] 05:44AM BLOOD Gran Ct-1170*
[**2155-10-22**] 05:44AM BLOOD Glucose-106* UreaN-21* Creat-0.6 Na-134
K-4.6 Cl-97 HCO3-32 AnGap-10
[**2155-10-15**] 06:13AM BLOOD LD(LDH)-150 TotBili-0.2
[**2155-10-22**] 05:44AM BLOOD Mg-1.7
CT Neck: 2-cm exophytic mass in L piriform sinus.
Large submucosal hypopharyngeal/postcricoid/esophageal mass
measuring 5 cm TV x 2 cm AP x 8.5 cm SI with focal airway
narrowing down to 1.3 x 0.7 cm,
bilateral hyoid and thyroid cartilage invasion.
Bilateral enlarged/necrotic LN.
CT Pelvis ...
IMPRESSION:
1. Comminuted left intertrochanteric femur fracture with varus
angulation of the distal fracture fragment.
2. Diffusely severely osteopenic bones as described above. The
possibility of an underlying lytic lesion would be difficult to
exclude in this setting.
3. Loss of height of the L5 vertebral body, though no findings
suggestive of acute compression fracture.
4. Degenerative changes noted.
5. Bladder distended, but trabeculated, which may be secondary
to outlet
obstruction or cystitis, correlate clinically.
LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT IN O.R. [**2155-9-1**]
FINDINGS: Multiple fluoroscopic images of the left hip in the
operating room demonstrate interval placement of a dynamic
compression screw with associated fracture plates and screws
fixating an intertrochanteric fracture of the left proximal
femur. The total intraservice fluoroscopic time was 74.9
seconds. There is improved anatomic alignment of the fracture
with no signs of hardware-related complications.
CHEST (PORTABLE AP) [**2155-9-1**]
The ET tube tip is 5 cm above the carina. Cardiomegaly is
unchanged.
Mediastinal silhouette is stable. There is progression of the
left lower lobe consolidation concerning for interval
progression of infectious process. Mild edema is present.
Right basal consolidation has slightly progressed as well.
CHEST (PORTABLE AP) Study Date of [**2155-9-2**]
The ET tube tip is impinging the left tracheal wall and should
be
repositioned, currently 4.5 cm above the carina. Additional
substantial
progression of left lower lung consolidation is noted as well as
of the right lower lobe. No frank edema is seen, although mild
degree of congestion cannot be excluded. Left pleural effusion
is most likely present. No pneumothorax is seen.
CHEST (PA & LAT) Study Date of [**2155-9-3**]
The patient was extubated in the meantime interval. There is
slight interval improvement in the left lower lobe consolidation
consistent with resolution of potentially infectious process or
aspiration. Right lower lobe opacity appears to be unchanged.
There is no appreciable pneumothorax or increase in pleural
effusion demonstrated.
FDG TUMOR IMAGING (PET-CT) [**2155-9-4**]
IMPRESSION: 1. Large FDG avid hypopharyngeal mass inseparable
from esophagus and causing significant narrowing of the airway.
2. FDG avid level II lymph nodes bilaterally and right level
II/III node.
3. Left lower lobe pneumonia.
4. Mediastinal FDG avid lymph node could be reactive to
pneumonia.
5. Small to moderate pericardial effusion.
6. Recent left humerus and femur fractures, as previously seen.
7. Persistent CT contrast in renal collecting system and
bladder from
examination three days prior suggesting delayed clearance.
CHEST (SINGLE VIEW) [**2155-9-4**]
Heart size and mediastinum are grossly similar in appearance.
Left lower lobe consolidation continues to be present,
concerning for infectious process. The major change since the
prior radiograph is interval development of interstitial
pulmonary edema within the last less than 5 hours. No
pneumothorax is seen. Small bilateral pleural effusion cannot
be excluded.
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 112384**],[**Known firstname **] [**2088-9-6**] 66 Male [**-1/3374**] [**Numeric Identifier 112385**]
Report to: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/rate
SPECIMEN SUBMITTED: hypopharyngeal tumor, Left Femoral Neck
Reamings.
Procedure date Tissue received Report Date Diagnosed
by
[**2155-9-1**] [**2155-9-1**] [**2155-9-4**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 1431**]/mn????????????
DIAGNOSIS:
I. Hypopharyngeal tumor biopsy (A-B):
Squamous cell carcinoma, invasive, poorly differentiated,
extending to tissue edges.
II. Left femoral neck reamings (C):
Bone and skeletal muscle with recent hemorrhage consistent with
fracture.
Clinical: Left hip fracture.
Gross: The specimen is received in two parts each labeled with
the patient's name "[**Known lastname 4427**], [**Known firstname 449**]" and the medical record
number.
Part 1 is additionally labeled "hypopharyngeal tumor biopsy".
It was received from the OR and consists of multiple fragments
of tan tissue measuring 1 x 0.5 x 0.5 cm in aggregate. The
specimen was partially submitted for frozen section examination
and the frozen section diagnosis by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10940**] is: "Positive
for carcinoma, favor squamous cell". The specimen is entirely
submitted as follows: A=frozen section remnant; B=remainder of
tissue.
Part 2 is additionally labeled "left femoral neck reamings". It
consists of multiple red/tan tissue fragments that measure 2.1 x
2 x 1 cm in aggregate. The specimen is entirely submitted in
cassette C.
CXR [**2155-9-9**]
Moderate right pleural effusion has increased. Severe bibasilar
consolidation
is unchanged. In addition to persistence of severe gaseous
distention of the
colon in the upper abdomen, there is new definition of the outer
wall of the
bowel, raising serious concern for pneumoperitoneum. This
examination claims
to have been performed with the patient upright. That needs to
be confirmed.
I have paged Dr.[**Last Name (STitle) 112386**] to discuss this.
Heart size is normal. Right PIC line has been withdrawn to the
brachiocephalic vein, several centimeters proximal to its
junction with the
left.
CXR [**2155-9-9**]
FINDINGS: Single AP view of the chest was obtained with the
patient in
semi-upright position. Pulmonary congestion and pleural
effusion is again
seen, unchanged, left greater than right. The pulmonary
vasculature does not
show signs of congestion. The PICC line has been adjusted since
previous
imaging and now is located with the tip 2 cm above the carina.
There is no
pulmonary edema, chest consolidation. The heart size is
unchanged. There is
no pneumothorax or other complications noted. As before, there
is marked gas
distention of the large bowel which raises the question of a
possible
obstruction or ileus. Followup imaging of the abdomen should be
pursued to
further evaluate the large bowel. There is no evidence of free
abdominal air.
The large bowel is much more distended than on previous day.
IMPRESSION: Marked gaseous distention of the large bowel.
Recommend followup
abdominal radiographs to assess for obstruction or ileus.
Pulmonary
congestion and effusion is unchanged from imaging earlier today.
Abdominal X-ray [**2155-9-10**]
FINDINGS: Single frontal image of the abdomen shows some
dilated small bowel
loops with air and stool in the rectum and descending colon.
This represents
possible ileus. Surgical fixation device in the left proximal
femur remains
unchanged. The remainder of the visualized osseous structures
are
unremarkable.
IMPRESSION: Dilated small bowel loops indicating possible ileus
with no
definitive evidence of obstruction.
G tube placement by IR [**2155-9-12**]
CONCLUSION:
Uncomplicated percutaneous gastrostomy placement as above with a
12 French
wills [**Doctor Last Name 12433**] gastrostomy tube.
The tube may be used for feeding in 24 hours.
CXR [**2155-9-16**]
FINDINGS: Single frontal image of the chest demonstrates
bibasilar densities,
unchanged since previous imaging. The left-sided pleural
effusion has
improved slightly. There is no right-sided pleural effusion.
There is no
upper zone distribution. There is no discrete evidence of
pneumonia, but
bibasilar densities could be contributing to the patient's
clinical picture.
Cardiomegaly is again seen.
IMPRESSION: Essentially unchanged chest radiograph with
persistent bibasilar
opacities and left pleural effusion.
Head CT [**2155-9-16**]
FINDINGS: There is no evidence of hemorrhage, edema, masses, or
mass effect.
Encephalomalacic changes are seen in the right frontal lobe,
likely from prior
infarction or trauma. White matter hypodensity in the left
frontal region,
consistent with small vessel ischemic changes. The ventricles
and sulci are
moderately enlarged, consistent with moderate involutional
changes, slightly
advanced for age. The basal cisterns are normal. Mucosal
thickening is seen
in bilateral maxillary sinuses. The mastoid air cells are
clear. The orbits
are unremarkable.
IMPRESSION: Right frontal encephalomalacia. No acute
intracranial pathology.
CXR [**2155-9-22**]
CHEST: Comparison is made with prior chest x-ray of [**2155-9-16**].
Since this
time, there has been increase in the opacities within both bases
and they now
extend into the left upper lobe. These appearances could be due
to an
extending pneumonia, but some failure may also be present.
IMPRESSION: Worsening bilateral infiltrates.
EEG [**2155-9-22**]
CONTINUOUS EEG RECORDING: Began at 21:50 on the evening of [**9-22**] and
continued through 7:00 a.m. the next morning. In this continuous
recording,
there was diffuse background slowing with 6-7 Hz theta activity
superimposed
with delta activity. The video captured several episodes of
right arm and
hand myoclonic jerks, right hand finger minor myoclonus, as well
as left leg
myoclonic jerks. None of those episodes had clear EEG
correlates.
SPIKE DETECTION PROGRAMS: Showed electrode artifact. There were
no
epileptiform discharges.
SEIZURE DETECTION PROGRAMS: There were no electrographic
seizures.
PUSHBUTTON ACTIVATIONS: There were none.
SLEEP: The patient progressed from wakefulness to sleep with no
additional
findings.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: This telemetry captured no pushbutton activations.
The video
captured several episodes of myoclonus with no EEG correlates.
There were no
electrographic seizures or epileptiform discharges. There was
diffuse
background slowing which indicates mild to moderate
encephalopathy.
Medications, metabolic disturbances, and infection are among the
most common
causes.
LUE Extremity Ultrasound [**2155-9-22**]
The internal jugular vein, axillary, subclavian, brachial,
basilic veins are
patent. The cephalic vein was not reliably visualized. There
are innumerable
large aggressive pathological appearing lymph nodes in the neck
and the upper
arm producing degree of mass effect and deviation of vascular
structures,
though no good frank evidence of of DVT . Examination was a
little limited
by the presence of the patient's arm infection/weeping.
CONCLUSION:
No DVT. Cephalic vein not visualized. Pathological
lymphadenopathy.
EEG [**2155-9-23**]
CONTINUOUS EEG RECORDING: Began at 7:01 on the morning of [**9-23**] and
continued through 15:48 afternoon. Throughout, it showed a
mildly
disorganized and slow background with posterior frequencies of
7.5 or so at
maximum. There are also several bursts of generalized slowing.
After 14:20,
the recording was markedly degraded by electrode artifact.
Several episodes
of jerking were recorded on video. They did not have any EEG
correlate.
Several appeared to be isolated jerking of the right arm without
rapid
repetition.
SPIKE DETECTION PROGRAMS: Showed muscle and other artifact, but
there were no
clearly epileptiform features.
SEIZURE DETECTION PROGRAMS: Showed no electrographic seizures.
PUSHBUTTON ACTIVATIONS: There were none.
SLEEP: No normal waking or sleep patterns were evident.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: This telemetry captured no pushbutton activations.
The
background was mildly slow indicating a mild to moderate
encephalopathy. There
were no prominent focal findings. There were no clearly
epileptiform features
or electrographic seizures. Isolated episodes of right arm jerks
were seen on
video without any EEG correlate.
CT Neck [**2155-9-24**]
FINDINGS: The previously identified infiltrative mass in the
postcricoid
space is smaller than the [**2155-9-1**] study measuring 2.5 x
4.4 cm. The
focal narrowing of the supraglottic airway has improved, now
measuring 1.3 x
2.2 cm, increased in caliber from 0.8 x 1.3 cm. The mass in the
left piriform
sinus has decreased in size, now measuring 1 x 1 cm, decreased
from 1.5 x 1.1
cm. The previously identified metastatic cervical lymph nodes
have decreased
in size. The previously measured conglomerate at level IIb on
the left now
measures 11 x 14 mm and the lymph node at level IIb on the right
now measures
13 x 19 mm. Mild fat stranding is present throughout the soft
tissues. No new
masses are identified.
There are calcifications of the bilateral carotid bifurcations,
right greater
than left. The visualized intracranial structures are
unremarkable. There
are bilateral pleural effusions and ground-glass opacities at
the lung apices
bilaterally.
There is no acute fracture or malalignment. Mild degenerative
changes of the
cervical spine.
IMPRESSION:
1. Decrease in size of the postcricoid mass, the left piriform
sinus mass and
the bilateral cervical lymphadenopathy.
2. Pleural effusions and patchy ground-glass opacities in the
visualized lung
apices. Recommend correlation with chest CT of same date
CT Chest [**2155-9-24**]
FINDINGS: The exam is severely limited by noise and streak
artifact from the
patient's left arm, immobile because of humeral neck fracture.
The thyroid
gland is unremarkable. Specifically, evaluation of the left
axilla, where
prominent nodes were seen on the recent ultrasound, is limited
by streak
artifact. There is no mediastinal or hilar adenopathy. The
heart and great
vessels are of normal size and caliber. Mild coronary artery
calcifications
are restricted to the circumflex distribution. A pericardial
effusion is
small. This exam is not tailored to evaluate subdiaphragmatic
structures.
Visualized portions of the upper abdomen are unremarkable.
Large bilateral pleural effusions, substantially enlarged since
[**2155-9-4**]
are responsible for severe atelectasis, collapse in the lower
lobes, non
confluent elsewhere. This and respiratory motion interfere with
evaluation of
the lung parenchyma, but there appears to be some edema in the
upper lobes.
Small regions of ground-glass opacity, for example in both upper
lobes (4:60,
74, 137) could be due to viral infection. Small lung nodules
are likely to be
missed. Impacted left humeral neck fracture is unchanged since
[**8-31**].
There is a prominent lower thoracic Schmorl's node. There are
no concerning
osteolytic or sclerotic bone lesions.
IMPRESSION:
1. Increasing large bilateral pleural effusions, mild
pulmonary.
2. Recent PET CT showed evidence of left lower lobe pneumonia.
On the
current exam left lower lobe consolidation is mostly
attributable to collapse
rather than infection.
3. A PET avid subcarinal lymph node is not well assessed on
this limited CT.
4. Scattered ground glass opacity is likely viral infection.
ECHO [**2155-9-25**]
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 60%). 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 a small to moderate sized pericardial effusion. There
is significant, accentuated respiratory variation in
mitral/tricuspid valve inflows, consistent with impaired
ventricular filling. There is also diastolic invagination of the
right ventricular free wall. Serial clinical and
echocardiographic evaluation is recommended.
Ultrasound Left Axilla [**2155-9-25**]
Exam is limited due to patient mobility due to recent fracture
of the left
humerus. In the left axilla there is a single prominent lymph
node measuring
5 mm in short axis with preserved fatty hilum, but somewhat
irregularly
thickened cortex which measures up to 3 mm. This lymph node has
a nonspecific
appearance. In the medial upper arm between the biceps and
triceps muscles is
a partially calcified ovoid focus measuring 2.3 x 1.3 x 1.5 cm
with multiple
punctate echogenic foci with an additional structure seen more
distally
measuring 5.1 x 1.4 x 1.8 cm with more heterogeneous
echotexture. These
structures insinuate between musculotendinous fibers. No other
suspicious
lymph nodes are seen in the region.
In comparison with prior CT chest, note is made that a
comminuted fracture of
the left proximal humerus is present, and calcified structures
were present in
the soft tissues of upper left arm possibly corresponding to the
above
described structures. Therefore, while calcified metastatic
nodes cannot be
excluded, post traumatic calcifications such as myositis
ossificans could
cause similar findings.
IMPRESSION:
Calcified nodules in the left upper arm, in the setting of
comminuted left
humeral fracture could represent post traumatic calcifications
such as
myositis ossificans although calcified metastases are not
excluded. CT or
radiograph may be helpful to distinguish.
Echo [**2155-9-26**]
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is a small to moderate sized
echolucent, circumferential pericardial effusion. There is
minimal diastolic invagination of the right ventricular free
wall without sustained right atrial or right ventricular
diastolic collapse. There is significant, accentuated
respiratory variation in the mitral valve inflow, consistent
with impaired ventricular filling.
IMPRESSION: Normal global biventricular systolic function. Small
to moderate sized circumferential pericardial effusion with
without frank echocardiographic tamponade.
Compared with the prior study (images reviewed) of [**2155-9-25**],
the findings appear similar.
CXR [**2155-9-27**]
FINDINGS: In comparison with the study of [**9-20**], the right
subclavian PICC
line extends to the lower portion of the SVC. There may be
increase in the
diffuse interstitial prominence seen on the right. On the left,
there is
increasing opacification with reduced area of aeration of the
lung. In the
absence of displacement of the mediastinal structures, this
suggests
combination of pleural effusion and volume loss in the
underlying lung. There
is suggestion of a cutoff of the left main stem bronchus.
Fracture of the left proximal humerus is again seen.
ECHO [**2155-9-29**]
The estimated right atrial pressure is at least 15 mmHg. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). There is no
ventricular septal defect. There is mild pulmonary artery
systolic hypertension. There is a small to moderate sized
pericardial effusion. There are no overt echocardiographic signs
of tamponade. No right ventricular diastolic collapse is seen.
Compared with the prior study (images reviewed) of [**2155-9-26**], no
change.
[**2155-10-6**] Radiology CHEST (PA & LAT)
Moderate right pneumothorax and small left pneumothorax are
stable. Left chest tube remains in place. Mild cardiomegaly and
tortuous aorta are unchanged. Bibasilar opacities , a
combination of large effusions and adjacent consolidations are
unchanged. These consolidations could be due to atelectasis but
superimposed infection cannot be excluded. Right PICC tube is in
the lower SVC.
[**2155-10-7**] Radiology CT NECK W/CONTRAST (EG:
IMPRESSION: 1. Infiltrative tumor in the post-cricoid region
involving the right hypopharynx and esophagus with focal airway
narrowing and effacement again noted. 2. Left piriform sinus
mass is less prominent on today's study. 3. Bilateral cervical
nodal metastases are less prominent on today's study. Thyroid
nodule unchanged from the prior examination. 4. Prominent right
palatine tonsil as well as edema and thickening of the soft
palate and base of the tongue with adjacent mass effect on the
oropharynx. 5. Bilateral pneumothoraces with right pleural
effusion.
[**2155-10-8**] 4:55 AM # [**Telephone/Fax (1) 112387**]
As compared to the previous radiograph, there is no change in
severity and dimension of the known bilateral apical
pneumothoraces. The effusion on the right has minimally
increased. The atelectasis on the left has also increased.
Endotracheal tube and the left-sided chest tube are in constant
position. No signs of tension are seen.
=========
MICRO:
[**2155-10-8**] SPUTUM:
GRAM STAIN (Final [**2155-10-8**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
CULTURES PENDING
[**2155-10-8**] Mini-BAL:
GRAM STAIN (Final [**2155-10-8**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
CULTURES PENDING.
Time Taken Not Noted Log-In Date/Time: [**2155-9-29**] 4:52 pm
TISSUE PERICARDIUM.
GRAM STAIN (Final [**2155-9-29**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2155-10-5**]):
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**5-/3093**] [**2155-9-30**]
3:45PM.
PLEASE REFER TO [**Numeric Identifier 112388**] ([**2155-9-29**]) FOR VORICONAZOLE
RESULTS.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 16437**]. SPARSE GROWTH.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 16437**]. SPARSE GROWTH STRAIN 2.
ANAEROBIC CULTURE (Final [**2155-10-5**]): NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final [**2155-9-30**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2155-9-30**]):
NO FUNGAL ELEMENTS SEEN.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
--------
Time Taken Not Noted Log-In Date/Time: [**2155-9-29**] 4:52 pm
FLUID,OTHER PERICARDIAL EFFUSION.
GRAM STAIN (Final [**2155-9-29**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2155-10-2**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2155-10-5**]): NO GROWTH.
ACID FAST SMEAR (Final [**2155-9-30**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2155-9-29**]):
Test cancelled by laboratory.
PATIENT CREDITED.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
CXR [**2155-10-9**]:
FINDINGS:
Patient is known with head and neck cancer with bilateral
pleural effusions
that are longstanding, moderate on the right side and small on
the left side
with biapical stable minimal pneumothorax. Left-sided chest
tube is in
unchanged position projecting in mid left hemithorax. Bibasilar
heterogeneous
opacities are unchanged since [**10-7**] and could represent
atelectasis
however a superimposed infection or aspiration cannot be
excluded.
Right-sided PICC line ends in lower SVC. Mediastinal and
cardiac contours are
normal.
CONCLUSION:
There is no significant change since prior exam.
1. Bilateral longstanding pleural effusion are unchanged with
minimal
pneumothorax.
2. Bibasilar opacities are unchanged since [**10-7**] and
could represent
atelectasis, however superimposed infection or aspiration cannot
be excluded.
Brief Hospital Course:
66 year old male with hypopharyngeal mass and alcohol abuse
presented with left proximal humerus fracture and femur fracture
who subsequently developed respiratory distress.
# Dysphagia / SOB / Repiratory distress: likely secondary to
extensive hypopharyngeal and piriformis mass. He had
significant upper airway sounds with ? stridor on presentation.
Pt was given 5 mg IV decadron. ENT wanted ICU monitoring in
setting of increase edema and airway compromise. ENT did not
think this was operable and wanted to initiate radiation to help
shrink the tumor and airway compromise. Biopsy was taken of mass
in OR and showed squamous cell carcinoma. Pt monitored overnight
in ICU and extubated the morning after left hip ORIF. ENT
consulted rad onc and heme onc. Speech and swallow was consulted
and through testing saw risk for aspiration. They recommendeded
pt remain NPO including meds. Could not place NG tube in OR.
They thought pt would likely need a peg, however patient
initially resisted PEG placement. PEG placed [**2155-9-12**], and tube
feeds were begun. Breathing improved following chemotherapy,
although patient continued to have intermittent coughing and
difficulty dealing with oral secretions. Pt developed acute
respiratory distress on [**2155-10-7**] early morning and was transferred
to the ICU for management of his airway. He spiked a fever to
102.9F on arrival. Exam was suggestive of upper airway
compromise, and there was concern for obstruction secondary to
tumor mass effect although acuity of decompensation would be
unusual for mass progression. Patient was intubated by ENT soon
after arrival to the ICU. In the peri-intubation period, he
became hypotensive likely related to the medications used for
intubation. He required 1 pressor but was quickly weaned off.
The cause of his acute decompensation remains unclear but per
ENT and repeat CT imaging after intubation, pt had significant
edema and swelling of his soft palate and tonsils but there was
no notable change in the size of his neck mass. Patient had an
easy cuff [**Last Name (LF) 3564**], [**First Name3 (LF) **] he was not given [**Last Name (un) **]/oids. In discussions
with ENT, delirium/altered mental status may have affected Pt's
ability to protect airway from oral secretions. Pt was covered
broadly with vancomycin and meropenem (he previously completed
an 8-day course of vanc/cefepime/clinda earlier in his
hospitalization). Patient has known bilateral pneumothoraces
after bilateral chest tube placement, stable from prior. Pt was
extubated without issue on [**2155-10-8**]. Pt had a sputum on [**10-8**] that
showed gram positive cocci in pairs and clusters but cultures
have not shown any growth to date. [**10-8**] mini-BAL did not show
any organisms on gram stain. Pt was transferred back to the
medical floor for continued management on [**10-9**]. While on medical
floor pt completed full course of IV Vanco/Meropenum and ID
followed pt. ID recommended follow up visit once pt discharged.
# Squamous cell carcinoma
Pathology ultimately revealed SCC of the head/neck. Hem/onc and
radiation oncology were consulted. Patient underwent PET CT
which revealed large FDG avid hypopharyngeal mass inseparable
from esophagus
and causing significant narrowing of the airway. Patient was
transferred to the oncology service for induction chemotherapy.
He received cycle 1 of TPF (docetaxel, cisplatin, 5-FU) on
[**2155-9-8**]. Patient had subsequent anemia requiring transfusions
[**9-14**] and [**9-17**], [**10-17**] thrombocytopenia (which resolved without
necesitating platelet transfusion), and neutropenia (treated
with neupogen earlier in admission). CT of neck and chest [**9-24**]
showed significant improvement in disease burden and degree of
airway narrowing. Pt restarted chemotherapy on [**2155-10-15**] and
started day 1 of 30 of XRT on [**2155-10-14**]. Pt received chemotherapy
on [**2155-10-22**] (day of discharge) and will continue chemo as
outpatient on [**2155-10-29**].
# Left proximal humerus fracture and femur fracture. Taken for
TRF. got 1 unit of blood in the OR and another unit in MICU post
op. Hct stabilized after that. ortho recommended 40mg lovenox
daily starting day after [**Doctor First Name **]. Lovenox will be continued after
discharge for DVT prophylaxis as pt has not been ambulating and
will defer to rehab facility to readdress whether pt needs it
once he is ambulating on own out of bed. Lovenox was briefly
held after chemo when platelet counts fell below 50, but was
then restarted. no range of motion restrictions, no weight
bearing restrictions, humerus non op management with sling for
comfort.
#. Pericardial effusion, pleural effusions: Patient appeared
chronically volume overloaded on exam after transfer to oncology
service, had no known history of cardiac disease. Diuretics
given on multiple occasions, volume status continued to be
challenging to manage. CT of the chest on [**9-24**] showed large
bilateral pleural effusions significantly increased from
previous imaging, as well as small pericardial effusion. Unclear
etiology of effusions, concern for malignant disease, however
thoracentesis done [**2155-9-27**] which removed 1.2L showed fluid that
appeared transudative. Echo done to evaluate for decreased EF,
wall motion abnormalities found pericardial effusion causing
significant, accentuated respiratory variation in
mitral/tricuspid valve inflows, consistent with impaired
ventricular filling. There was also diastolic invagination of
the right ventricular free wall. Pulsus was difficult to measure
due to right sided PICC line and LUE edema secondary to fracture
and lymphadenopathy, but was approximately 8. Serial echos were
stable. Cardiology was consulted, and judged that the effusion
was too small for safe percutaneous drainage. Cardiothoracic
surgery was consulted and decision was made for pericardial
window, which was performed [**2155-9-29**].
#, Hyponatremia: Sodium consistently in the low 130s, with some
readings in the 120s. Response to hydration variable. Response
to diuresis variable. Urine electrolytes showed FENa <1% but
urine Na >40 and concentrated urine. SIADH vs. hypervolemic
state (given peripheral edema, pleural effusions).
# Alcohol Withdrawal with history of seizures. Last drink day
prior to admission. maintained on CIWA scale plus Thiamine. MVI.
He did not score on CIWA throughout hospital course.
# Fever/leukocytosis: Patient developed fever and leukocytosis
[**2155-9-1**]. Patient started on ciprofloxacin for UTI, urine culture
grew Klebsiella sp. CXR later became c/w PNA and given history
of aspiration, he was started on unasyn [**2155-9-2**]. Unasyn was
ultimately discontinued and he was continued on cipro with
continued improvement. Upon to transfer to oncology service and
given continued opacities suggestive of aspiration on CXR,
anitbiotics were switched to levofloxacin and clindamycin
[**2155-9-7**], which were continued for a 5 day course. The patient
developed another fever on [**2155-9-20**], and was broadly covered with
vanc, cefepime and clindamycin given risk for skin infections
due to pressure ulcers as well as aspiration risk. Cultures
negative, antibiotics discontinued [**2155-9-26**]. Pt's pleural
effusion and pericardial tissue but not pericardial effusion
cultures from [**2155-9-29**] grew [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 16437**]. Pt was
started on voriconazole on [**10-4**] but this was switched to
micafungin on [**10-7**] due to concerns about possible QT
prolongation. Voriconazole sensitivities are still pending.
There were concerns by ID service that 2 other patients recently
had [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 16437**] infections after having a pericardial
window procedure. ID followed pt and initially started
Micafungin which was later switched to Fluconazole. Pt to remain
on Fluconazole for several more weeks until his appointment with
ID on [**2155-11-26**]. Pt's PICC line was somewhat erythematous on [**10-7**]
and was removed. Tip culture has remained negative to date. Pt
had a sputum on [**10-8**] that showed gram positive cocci in pairs
and clusters but cultures have not shown any growth to date.
[**10-8**] mini-BAL did not show any organisms on gram stain.
# Myoclonic jerks/altered mental status: patient intermittently
confused during hospitalization. Developed myoclonic jerks of
right side [**9-21**], concerning for seizures given altered mental
status. EEG ordered, showed generalized slowing consistent with
encephalopathy, no seizure activity. Patient's symptoms started
around the same time antibiotics restarted, so possibly a drug
effect. Also with chronic hyponatremia, metabolic alkalosis. No
asterixis on exam. Not uremic.
# Hypertensive urgency: episode of HR 30's BP 220/110 after
peripheral was flushed with Neo in it, Levo stopped, and BP
trended down to 180's systolic and HR stable in the 50's.
# Hypothyroidism
Patient carries diagnosis of hypothyroidism for which he has not
been treated. TSH was WNL. Thyroid hormone supplementation was
not initiated initially. TSH found to be elevated on repeat
testing in course of workup for hyponatremia and thyroid hormone
supplementation was begun.
TRANSITIONAL ISSUES:
======================
- Radiation: pt to continue XRT for a total of 30 days. Day of
discharge was day 8 of therapy therefore pt has 22 more sessions
he will receive as outpatient.
- Chemo: pt to contine chemotherapy, Paclitaxel and Carboplatin.
Days 1, 8 already given on [**10-15**] and [**10-22**]. Pt to receive third
dose on day 15, [**10-29**].
- Pt to follow up with ID as outpt on WEDNESDAY [**2155-11-26**] at
10:00 AM
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Bisacodyl 10 mg PR HS:PRN constipation
3. Docusate Sodium (Liquid) 100 mg PO BID constipation\
4. Fluconazole 200 mg IV Q24H
5. Guaifenesin 10 mL PO Q6H:PRN Cough or Increased secretions
6. Labetalol 100 mg PO BID
hold for SBP <95 or HR<55
7. Levothyroxine Sodium 100 mcg PO DAILY
8. Lidocaine 5% Patch 1 PTCH TD DAILY
apply to left arm
9. Ondansetron 4 mg IV Q8H:PRN nausea
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. senna *NF* 8.8 mg/5 mL Oral [**Hospital1 **]:PRN constipation Reason for
Ordering: Pt has cancer of larynx and unable to swallow pills
12. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
hold for oversedation
13. Outpatient Lab Work
Daily CBC, CHEM7, ANC
14. Morphine Sulfate IR 15 mg PO/NG Q4H:PRN pain
15. Enoxaparin Sodium 40 mg SC DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Hospital1 8**]
Discharge Diagnosis:
Hypopharyngeal Squamous Cell Carcinoma
Pericardial Effusion
Candidiasis
Pneumonia
Hip fracture
Shoulder fracture
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 4427**],
It has been a pleasure taking care of you here at [**Hospital1 18**]. You
were initially admitted with a broken hip and shoulder. Because
of some respiratory symptoms you were having you had several
tests done where it was found that you have cancer of the neck
and head. You were admitted to the oncology service where your
hospital course was complicated by infections, respiratory
distress, and fluid around your heart. You were transferred to
the ICU to stablize you several times. You received treatment
for pneumonia and you required mechanical ventilation. You
initiated chemotherapy while here and are currently receiving
chemo and radiation to shrink the tumor in your neck. You will
continue this treatment as an outpatient. Also it was found that
yeast was growing in your blood for which you will be continued
on Fluconazole until your follow up appointment with infectious
disease on [**2155-11-26**].
Followup Instructions:
Please keep the following appointments:
Daily Radiation Therapy
Every weekday Monday- Friday at 3 pm until [**2155-11-25**]
[**Hospital1 18**] [**Hospital Ward Name 516**]
[**Hospital Ward Name 12573**] Basement
[**Location (un) **]
[**Location (un) 86**], MA
phone: [**Telephone/Fax (1) 9710**]
Chemotherapy Appointment
DEPARTMENT: Oncology
When: [**2155-10-29**]- please call for the appointment time.
Phone: ([**Telephone/Fax (1) 14703**]
[**Hospital Ward Name 23**] 9
[**Hospital Ward Name 516**]
Department: OTOLARYNGOLOGY-AUDIOLOGY
When: TUESDAY [**2155-11-11**] at 2:00 PM
With: [**First Name4 (NamePattern1) 177**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 41**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 895**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2155-11-20**] at 8:40 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2155-11-20**] at 9:00 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**2155-11-26**] 10:00a ID,[**Last Name (un) 23870**] [**Doctor Last Name **]
LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), BASEMENT
PHONE: ([**Telephone/Fax (1) 4170**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
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) 89697**],[**First Name3 (LF) **] L.
Location: [**Hospital3 **] FAMILY MEDICINE
Address: 5 INDUSTRIAL DR [**Last Name (STitle) **], [**Location (un) **],[**Numeric Identifier 88844**]
Phone: [**Telephone/Fax (1) 89698**]
[**Name6 (MD) **] [**Name8 (MD) 10341**] MD [**MD Number(2) 14690**]
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Discharge summary
|
report
|
Admission Date: [**2133-6-29**] Discharge Date: [**2133-7-28**]
Date of Birth: [**2073-8-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
Spinal fusion, lumbar puncture
History of Present Illness:
59 yom with Asthma, CHF, Depression initially presented to
[**Location (un) **] ER [**2133-6-29**] with severe back pain. Per records fell from
chair of [**6-25**] landing backward onto the back of his head. And
complained of back pain since that time. CT T-spine at [**Location (un) **]
ER revealed linear fracture of T9 body and underlying ankylosing
spondylitis. Transferred to [**Hospital1 18**] for further care and ortho
eval.
.
In the ED at [**Hospital1 **] c/o back pain given IV Morphine and
transferred to TSICU. Initially fell injured t and c spine. T
spine concerning for ankylosing spondylitis, also T9 fx. Plan
for T and C spine MRI, unable to tolerate MRI, got T spine but
agitated so came back. Underwent Tspine surgery on [**7-4**] with
fusion. Intubated for repeat C spine, however, pt deemed too
large for MRI and plan was changed to have MRI done at [**Hospital1 2025**] (open
MRI). However this did not happen due to logistic reasons and
per Dr. [**Last Name (STitle) 363**] change to hard collar for 6 weeks. Pt self
extubated [**2133-7-5**] (intubated for ~5 days) and did well so not
reintubated.
.
Patient continued to have signs of delirium and psychosis so
consulted by Neurology and psychiatry. Neuro assessement
decreased mental status most likely confusion consistent with
metabolic encephalopathy and recommended repeat CT head
(negative for ICH), avoid narcotics, and CIWA scale. ICU course
complicated by delirium and psychosis including pulling out NG
tube and disorientation. Psych consult recommendations: On
alprazolam at home and may also have signs of benzo withdrawl.
Recommended alprazolam taper [**7-10**] 0.5mg PO TID, [**7-11**] 0.25 mg PO
TID, [**7-12**] 0.25 [**Hospital1 **], 0.25 mg qhs. Recommended using Haldol 2.5 mg
IV tid:prn and add 1.5mg IV TID standing. Patient also noted to
be aspirating and s/s consulted. ET tube secretions revealed
Ancef sensitive klebsiella thus started on cephalexin(day 1
[**2133-7-5**]).
.
At time of transfer patient denies any complaints. States that
earlier he was hung upside down. States that he is the little
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] hospital. Easily reorientable. Date states [**2133-7-8**]. Able to identify the president. Earlier states hard collar
was uncomfortable so he took it off, but now states that he will
keep it on. Denies any cp/sob. No n/v/d.
Past Medical History:
Asthma
CHF
Depression
OA of b/l Knees
Social History:
Lives with wife, may have been drinking more heaily prior to
admission
Family History:
not contributory
Physical Exam:
General: middle aged male lying in bed restrained.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, mucous membranes dry.
Neck: C-spine collar inplace.
Pulmonary: Lungs CTA anteriorly and laterally.
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, obese.
Extremities: No C/C/E bilaterally.
Skin: no rahes
Neurologic: alert, oriented to place, and person, oriented to
month and year.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted. moves all extremities.
-sensory: No deficits to light touch throughout.
Pertinent Results:
Admission labs:
[**2133-6-29**] 06:15PM BLOOD WBC-8.8 RBC-4.34* Hgb-14.2 Hct-40.9
MCV-94 MCH-32.7* MCHC-34.7 RDW-14.1 Plt Ct-294
[**2133-6-29**] 06:15PM BLOOD Neuts-71.7* Lymphs-19.8 Monos-5.8 Eos-2.2
Baso-0.4
[**2133-6-29**] 06:15PM BLOOD Glucose-111* UreaN-11 Creat-1.1 Na-137
K-3.5 Cl-97 HCO3-32 AnGap-12
[**2133-7-9**] 02:31AM BLOOD Lipase-61*
[**2133-7-9**] 02:31AM BLOOD ALT-20 AST-53* AlkPhos-99 Amylase-42
TotBili-0.5
[**2133-6-29**] 06:15PM BLOOD Calcium-9.2 Phos-2.3* Mg-2.4
[**2133-7-12**] 04:24AM BLOOD calTIBC-248* Ferritn-285 TRF-191*
[**2133-7-9**] 02:31AM BLOOD VitB12-291 Folate-9.8
[**2133-7-9**] 02:31AM BLOOD Ammonia-26
[**2133-7-22**] 07:00AM BLOOD Ammonia-42
[**2133-7-9**] 02:31AM BLOOD TSH-0.91
IMAGING:
Non-contrast CT of the cervical spine with coronal and sagittal
reformations.
FINDINGS: There is no acute fracture. There is extensive
degenerative change at multiple levels with large anterior
osteophytes some of which are bridging. The soft tissues of the
neck appear unremarkable. The lung apices are clear. The
visualized mastoid air cells and paranasal sinuses are clear.
IMPRESSION: Multilevel degenerative change without evidence of
fracture.
Non-contrast head CT.
FINDINGS: There is no intra or extra-axial hemorrhage, shifted
normally midline structures, or hydrocephalus. A 1.7 cm x 2.3 cm
cystic structure posterior to the right cerebellum could
represent an arachnoid cyst. No fractures are seen and there are
no air-fluid levels in the paranasal sinuses. The mastoid air
cells are clear. Soft tissues appear unremarkable.
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect.
2. Likely arachnoid cyst in the posterior fossa on the right.
Thoracic spine:
IMPRESSION:
1. T9 fracture with distracted fracture fragments with small
amount of fluid/blood in between the distracted fragments.
2. Unclear if there is extension of the fracture line into the
posterior elements- correlate with outside CT scan (not
available to us at this time).
3. Small amount of prevertebral soft tissue swelling likely due
to hematoma/anterior longitudinal ligamentous injury.
4. Increased signal intensity in the posterior spinal soft
tissues from T9- T12, unclear if this represents ligamentous
injury.
5. Normal-appearing thoracic spinal cord.
[**7-15**]
MRI OF THE BRAIN: There is mild ventricular and focal prominence
suggestive of mild degree of involutional change. There are no
signal or enhancement abnormalities within the brain parenchyma.
There is no hydrocephalus. The 2.6 x 1.9 cm arachnoid cyst just
to the right of midline in the posterior fossa is unchanged.
The fluid in the mastoid air cells bilaterally persist. Minimal
mucosal thickening of the left maxillary sinus is noted. The
craniocervical junction appears unremarkable.
IMPRESSION:
1. Stable right posterior fossa arachnoid cyst. No signal or
enhancement abnormalities in the brain parenchyma.
2. Fluid within the mastoid air cells bilaterally, as has been
seen on the prior CT scan.
[**7-20**]:
CHEST AP, UPRIGHT: Comparison is made to [**2133-7-15**]. A
right-sided PICC line enters the mid superior vena cava, as
noted previously, its tip again not well visualized. Vertical
spinal fusion rods are again noted. The cardiac and mediastinal
contours are unchanged. The lungs are clear. There are no
pleural effusions or pneumothorax.
IMPRESSION: No acute cardiopulmonary process.
[**7-24**] T spine XR:
A total of five views is compared with recent examination dated
[**2133-7-13**]. Again demonstrated is the fracture deformity of the T9
vertebral body, unchanged. There is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 931**]-type fixation
construct posteriorly with no significant overall change in the
position of the fixation rods and laminar hooks; no cross-piece
is identified. There is no evidence of interval hardware
complication or change in alignment, and no new fracture is
seen.
Brief Hospital Course:
Delirium - Patient was initially admitted after a fall and was
in the TSICU. While there he was treated with benzodiazepines
for presumed alcohol withdrawal and had a persistent delirium.
Then there was thought by psychiatry that it was due to
benzodiazepine withdrawal and he was slowly tapered. However
the delirium persisted out of the ICU and was placed on haldol.
Despite the limiting of sedating medications, he continued to be
disoriented and occasionally agitated. He was evaluated with CT
head, MRI, and LP. With all of these, there were no signs of
either structural abnormalities or signs of infection. However,
the patient remained in delirium. Haldol was stopped and
slowly he has began to recover. He was followed by both
neurology and psychiatry who felt this was consistent with post
surgical delirium vs. EtOH changes. Additionally EEG showed no
significant abnormality.
Trauma: T9 fracture - s/p fusion. C spine MRI inconclusive and
should be maintained on the [**Location (un) 2848**] J collar for 6 months total.
Approximately 2 weeks postop, the wound had mild drainage from
the surgical wound. Though thought to be secondary to a seroma
but was treated empirically with cephalexin for 10 days based on
orthopedics recommendations. Repeat T spine XR [**7-24**] with out
change. Patient will need to follow up with Dr. [**Last Name (STitle) 363**] in 6
weeks. He should wear TLSO brace until then. Also will need T
spine films 2-3 weeks post discharge.
.
# HTN - Clonidine stopped. Continued on metoprolol.
.
# Pneumonia: found to have a pneumonia on CXR and sputum
cultures showed Klebsiella. He was treated for 10 days with
first gen cephalosporin.
# Sinusitis- Treated with clindamycin for 10 days.
.
# anemia - MCV 98, B12, folate normal. Iron studies normal. HCT
low, but stable.
.
# Thrombocytosis: Resolved, thought to be initially due to
infection/ acute stress.
.
# FEN - Per speech and swallow, not at risk for aspiration. Able
to tolerate full diet.
Medications on Admission:
ranitidine 300'',
alprazolam 1''',
nortriptyline 50qam and qpm, 100qhs,
Lasix 20' (started [**2133-6-17**]),
paxil 20',
Percocet 10/650"" (originally taking oxycontin and then weaned
to percocet q6h),
albuterol inh',
flonase inh'
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every six (6) hours as needed for pain.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection three times a day: DVT prophylaxis.
6. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
nebulizer Inhalation Q4-6H (every 4 to 6 hours) as needed.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
9. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 4 days: 10 day course. Day 1: [**2133-7-21**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Cervical fracture
Pneumonia
Delirium
Discharge Condition:
improved mental status.
Discharge Instructions:
You were admitted after a cervical and thoracic fracture. You
had a spinal fusion. Please make all appointments as listed in
the discharge paperwork. Please take all medications as
hospital if you you have fevers, chills, chest pain, shortness
of breath, change in mental status or other concerning symptoms.
Followup Instructions:
Orthopedics:
- follow up thoracic spine xrays in [**3-7**] weeks, please phone
results to Dr. [**Last Name (STitle) 363**] [**Telephone/Fax (1) 3573**]
- follow up with Dr. [**Last Name (STitle) 363**] in clinic in 6 weeks. [**Telephone/Fax (1) 3573**]
- wear TLSO brace until seen by Dr. [**Last Name (STitle) 363**].
Please follow up with your primary care provider [**Last Name (NamePattern4) **] [**2-3**] weeks by
calling [**Last Name (LF) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 22629**]
|
[
"292.81",
"806.25",
"310.0",
"482.0",
"401.9",
"293.0",
"E939.4",
"291.81",
"285.9",
"238.71",
"720.0",
"428.0",
"873.8",
"E884.2",
"473.8",
"998.13",
"311",
"E888.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"81.05",
"03.31",
"81.64",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
10930, 11002
|
7539, 9539
|
319, 352
|
11083, 11109
|
3589, 3589
|
11469, 11980
|
2935, 2953
|
9820, 10907
|
11023, 11062
|
9565, 9797
|
11133, 11446
|
3402, 3570
|
2968, 3385
|
275, 281
|
380, 2769
|
3605, 7516
|
2791, 2831
|
2847, 2919
|
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