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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
32,075
| 187,039
|
34284
|
Discharge summary
|
report
|
Admission Date: [**2178-8-27**] Discharge Date: [**2178-9-6**]
Date of Birth: [**2111-6-11**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Acute shortness of Breath
Major Surgical or Invasive Procedure:
Aortic Valve Replacement (21mm pericardial) [**8-31**]
Cardiac Cath [**8-27**]
History of Present Illness:
67 year old female with severe Aortic Stenosis who presented
with acute dyspnea to [**Hospital3 **]. This morning patient woke
up at 3:15 am with acute dyspnea which did not improve with
rest. At the time she was reaching for a towel. She called 911
and went to [**Hospital3 **]. Received Albuterol and Nitropaste
in ER. Was transferred to [**Hospital1 18**] for cath to assess Aortic
Stenosis and coronary arteries (report below in Medical Decision
making).
Patient describes worsening shortness of breath for 3 weeks
duration. SOB occurs at rest and on exertion. Has not been able
to go recently due to SOB. Describes episodes of paroxysmal
nocturnal dyspnea. The episode this am was more severe and
lasted for over 20 minutes, patient was "very scared". Patient
more comfortable breathing when sitting up right (+ orthopnea).
Describes fatigue over the past 3 weeks. Denies dizziness,
episodes of syncope or pre-syncope. Denies chest pain. Denies
lower extremity edema and palpitations.
Past Medical History:
Aortic stenosis, Hypertension, Hyperlipidemia, COPD, CRI,
Neuropathy, retinal thrombosis, Nephrolithiasis, s/p
Appendectomy, s/p Tonsillectomy
Social History:
She is divorced and lives alone. She smoked 40+ years 1
pack/day, quit 3 years ago. Does not drink. She works part-time
in an office, but has not been able to go recently due to SOB.
Close to sister who is a nurse. Her phone number is
[**Telephone/Fax (1) 78913**].
Family History:
Father died of a stroke at age 79. Mother had mitral valve valve
surgery at age 68. Brother passed away at age 42 secondary to
stroke.
Physical Exam:
VS - 97.5, 136/75, 71, 18, 96 RA.
Gen: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 9 cm.
CV: RRR, [**3-19**] pan-systolic murmur that radiates to carotids and
abdomen. No thrills, lifts.
Chest: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
Abd: Soft, NTND. No tenderness. Positive bowel sounds.
Ext: No c/c/e.
Skin: No stasis dermatitis, ulcers, scars.
Pulses:
Right: DP 2+, PT 2+
Left: DP 2+, PT 2+
Pertinent Results:
Cath [**2178-8-27**]: 1. Selective coronary angiography of this right
dominant system revealed no angiographically significant
coronary artery disease. The LMCA, LAD and RCA had mild diffuse
disease throughout. The LCX had moderate diffuse disease
throughout. 2. Resting hemodynamics demonstrated normal systemic
arterial pressures (136/67). Left (LVEDP 23 mmHg, mean PCW 22
mmHg) and right sided filling pressures (mean RA 10mmHg, RVEDP
15 mmHg) were elevated. There was mild pulmonary hypertension
(mean PAP 32 mmHg). The calculated cardiac index was
1.9l/min/m2. Peak to peak aortic gradient was 76mmHg with a mean
gradient of 55 mmHg. Calculated aortic valve area was 0.4cm2,
indicating critical aortic stenosis. 3. Left ventriculography
was not performed due to the patient's chronic kidney impairment
(baseline Cr 1.2-1.6). FINAL DIAGNOSIS: 1. No angiographically
apparent flow limiting coronary artery disease. 2. Critical
aortic stenosis. 3. Biventricular diastolic dysfunction. 4. Mild
pulmonary hypertension.
5. Reduced cardiac index.
.
CXR [**2178-8-27**] IMPRESSION: 1. No acute cardiopulmonary abnormality.
2. Mild cardiomegaly with suggestion of left atrial and
ventricular enlargement.
.
CAROTID SERIES COMPLETE [**2178-8-27**]: 80-99% proximal right ICA
stenosis.
.
ECHO [**2178-8-31**] PRE BYPASS: No atrial septal defect is seen by 2D
or color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
descending thoracic aorta is mildly dilated. There are complex
(>4mm) atheroma in the descending thoracic aorta. The number of
aortic valve leaflets cannot be determined. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (area <0.8cm2). Severe (4+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. POST BYPASS: There is
preserved biventricular systolic function. There is a well
seated, well functioning bioprosthesis in the aortic position.
No aortic insufficiency is visualized. The remaining study is
unchanged from prebypass.
.
CXR [**2178-9-3**]: As compared to the previous radiograph, there is no
relevant
change. The introducing sheath has been removed from the right
internal
jugular vein. The size of the cardiac silhouette as well as the
blunting of the left costophrenic angle is unmodified. There is
no evidence of newly appeared parenchymal opacities suggestive
of pneumonia. Signs of
overhydration are not present.
[**2178-8-28**] 06:05AM BLOOD WBC-7.8 RBC-3.94* Hgb-10.9* Hct-32.1*
MCV-82 MCH-27.8 MCHC-34.0 RDW-16.2* Plt Ct-187
[**2178-9-3**] 05:55AM BLOOD WBC-9.9 RBC-3.60* Hgb-10.1* Hct-30.1*
MCV-84 MCH-28.0 MCHC-33.5 RDW-15.8* Plt Ct-102*
[**2178-8-28**] 06:05AM BLOOD PT-13.0 INR(PT)-1.1
[**2178-8-31**] 11:38AM BLOOD PT-14.7* PTT-42.5* INR(PT)-1.3*
[**2178-8-28**] 06:05AM BLOOD Glucose-111* UreaN-29* Creat-1.2* Na-145
K-4.5 Cl-107 HCO3-28 AnGap-15
[**2178-9-2**] 09:40AM BLOOD Glucose-120* UreaN-16 Creat-1.1 Na-136
K-3.7 Cl-97 HCO3-28 AnGap-15
[**2178-9-3**] 05:55AM BLOOD UreaN-20 Creat-1.2* K-3.4
[**2178-8-28**] 06:05AM BLOOD Albumin-4.1 Calcium-9.1 Phos-4.2 Mg-2.2
[**2178-8-28**] 06:05AM BLOOD ALT-24 AST-21 LD(LDH)-226 AlkPhos-79
TotBili-0.5
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2178-8-27**] for a cardiac
catheterization in prepearation for an aortic valve replacement.
Her cardiac catheterization revealed critical aortic stenosis
and no significant coronary artery disease. The cardiac surgical
service was consulted and Ms. [**Known lastname **] was worked-up in the usual
preoperative manner. A carotid duplex ultrasound was performed
which showed an asymptomatic 80-99% stenosis of her right
internal carotid artery. No intervention was planned at this
time however vascular follow-up will be needed. An opthalmology
consult was obtained for clearance for heparin given her history
of a retinal hemorrhage. No contraindication for cardiac surgery
or heparin was found on exam and Ms, [**Known lastname **] was cleared for
surgery. On [**2178-8-31**], Ms. [**Known lastname **] was taken to the operating room
where she underwent an aortic valve replacement using a 21mm
pericardial valve. Please see operative note for details.
Postoperatively she was taken to the intensive care unit for
monitoring. Within 24 hours, Ms. [**Known lastname **] [**Last Name (Titles) 5058**] neurologically
intact and was extubated. She was transfused for postoperative
anemia. Beat blockade, aspirin and her pletal were resumed.
Later on postoperative day one, she was transferred to the step
down unit for further recovery. The physical therapy service was
consulted for assistance with her postoperative strength and
mobility. She was gently diuresed towards her preoperative
weight.
She continued to make steady progress and was discharged to
rehabilitation on post-operative day 6. She will follow-up with
Dr. [**Last Name (STitle) **], her cardiologist and her primary care physician as
an outpatient.
Medications on Admission:
Amlodipine 10mg, HCTZ 12.5mg, ASA 81mg, Chilostizal 100mg,
Atenolol 25mg, Lipitor 20mg, Spiriva 18 mcg (inhaler), Albuterol
inhaler, Pletal 100mg [**Hospital1 **]
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
7. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day for 5 days.
Disp:*5 Tablet Sustained Release(s)* Refills:*0*
8. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day:
please take 400mg twice a day until [**9-10**] then decrease to 400mg
daily for 7 days, then decrease to 200mg daily and follow up
with cardiologist .
Disp:*80 Tablet(s)* Refills:*0*
10. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation every six (6) hours as needed for wheezing.
Disp:*qs qs* Refills:*0*
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
12. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO bid () as
needed for maintain preop platelet inhibition for retinal clot.
Disp:*60 Tablet(s)* Refills:*0*
13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
14. Warfarin 2 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 doses: please take 2mg on [**9-7**] - [**Month/Year (2) **] drawn on tuesday [**9-8**] for
further dosing .
Disp:*60 Tablet(s)* Refills:*0*
15. Outpatient [**Name (NI) **] Work
PT/INR for coumadin dosing - goal INR 1.5-2.0 for atrial
fibrillation
first draw tuesday [**9-8**]
16. Outpatient [**Month/Year (2) **] Work
[**Month/Year (2) **] BMP with results to Dr [**Last Name (STitle) **] office # [**Telephone/Fax (1) 170**] and Dr
[**Last Name (STitle) 66033**] office # [**Telephone/Fax (1) 78914**]
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Aortic stenosis s/p Aortic Valve Replacement
PMH: Hypertension, Hyperlipidemia, COPD, CRI, Neuropathy,
retinal thrombosis, Nephrolithiasis, s/p Appendectomy, s/p
Tonsillectomy
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**]
[**Telephone/Fax (1) **] please have drawn thrusday with results to PCP and Dr
[**Last Name (STitle) **]
Followup Instructions:
Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) 4 weeks
Dr. [**Last Name (STitle) 8098**] in [**2-15**] weeks
Dr. [**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) 78915**] in [**1-14**] weeks
Labs BMP with results to Dr [**Last Name (STitle) **] office # [**Telephone/Fax (1) 170**] and Dr
[**Last Name (STitle) 66033**] office # [**Telephone/Fax (1) 78914**]
PT and INR please draw [**9-8**] tuesday goal INR 1.5-2.0 for atrial
fibrillation
Completed by:[**2178-9-9**]
|
[
"424.1",
"V15.82",
"285.9",
"585.9",
"428.23",
"496",
"272.4",
"355.9",
"V12.51",
"403.90",
"428.0",
"433.10",
"V13.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"35.21",
"39.61",
"37.23",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
10505, 10561
|
6123, 7913
|
346, 426
|
10780, 10786
|
2657, 3487
|
11402, 11902
|
1911, 2047
|
8126, 10482
|
10582, 10759
|
7939, 8103
|
3504, 6100
|
10810, 11379
|
2062, 2638
|
281, 308
|
454, 1446
|
1468, 1612
|
1628, 1895
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,076
| 144,044
|
46403+58914
|
Discharge summary
|
report+addendum
|
Admission Date: [**2173-12-5**] Discharge Date: [**2173-12-13**]
Service: SURGERY
Allergies:
Procardia
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Percutaneous cholecystostomy tube
History of Present Illness:
Patient is a [**Age over 90 **] year old man who was discharged recently from
[**Hospital1 18**] ([**2173-11-19**]) after recovering from cholangitis who presented
again on [**2173-12-4**] with a 24-hour history of vague abdominal
discomfort with a fever to 101.0.
Past Medical History:
1. Coronary artery disease status post CABG in [**2161**].
2. Atrial fibrillation on Coumadin.
3. Vestibular schwannoma treated with chemotherapy at [**Hospital 14852**].
4. History of a hiatal hernia.
5. Total radical resection of the prostate.
6. Bilateral inguinal hernia repairs
Social History:
The patient denies any tobacco use, but admits to occasional
alcohol use. He lives alone and is retired. He has a supportive
family (niece, nephew).
Family History:
none
Physical Exam:
Temp 102.0 HR 91 BP 134/45 RR 24 SaO2 97% room air
Alert, oriented
Irregularly irregular rhythm
CTA b/l
Soft, nontender, nondistended. Slightly tender diffusely, +BS
hyperactive.
Rectal guiac negative.
Pertinent Results:
[**2173-12-4**] 08:50PM WBC-7.9# RBC-4.08* HGB-13.0* HCT-35.4* MCV-87
MCH-31.8 MCHC-36.7* RDW-13.7
[**2173-12-4**] 08:50PM NEUTS-89* BANDS-2 LYMPHS-3* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2173-12-4**] 08:50PM PLT COUNT-141*
[**2173-12-4**] 08:50PM PT-21.7* PTT-34.0 INR(PT)-3.4
[**2173-12-4**] 09:06PM LACTATE-4.0*
[**2173-12-4**] 08:50PM GLUCOSE-173* UREA N-16 CREAT-1.0 SODIUM-134
POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-21* ANION GAP-18
[**2173-12-4**] 08:50PM ALT(SGPT)-26 AST(SGOT)-25 ALK PHOS-64 TOT
BILI-0.9
[**2173-12-4**] 08:50PM LIPASE-45
Brief Hospital Course:
The patient was admitted and had a right upper quadrant
ultrasound which showed sludge (s/p previously placed biliary
stent) and a small amount of wall edema. No ductal dilatation,
no U/S [**Doctor Last Name 515**] sign. He was admitted to the Crimson surgery
service for antibiotics, IV fluids and serial exams. ERCP was
contact[**Name (NI) **] and saw the patient. The patient had a HIDA scan which
showed non-filling of the gallbladder. The patient underwent
placement of a percutaneous cholecystostomy tube by
Interventional Radiology. Immediately following the procedure he
had shaking chills and was transferred overnight to the ICU for
close monitoring. Cultures from the bile sample grew E. Coli.
Blood cultures were negative. He was transferred to the floor
and recovered well with chest physical therapy, getting out of
bed to chair. Bowel function slowly returned to [**Location 213**] after a
few days of ileus. The patient did complain of intermittent pain
at the chole tube site, sometimes radiating up toward his right
chest. EKGs were without any changes, 3 sets of cardiac enzymes
were negative, and the patient was otherwise asymptomatic. A
PICC line was placed for a 2 week course of IV Zosyn. His
aspirin and Plavix (for cardiac stents) were restarted on
hospital day 7. His creatinine level increased from baseline 1.1
to 1.8. The previously administered vancomycin was discontinued
and he was adequately hydrated. He tolerated a regular diet,
supplemented with Boost. Physical therapy worked with the
patient. He was deemed fit for discharge to rehab on hospital
day 9.
Medications on Admission:
Amlodipine 5
Trazodone 50
Metoprolol 25 [**Hospital1 **]
ASA 81
Plavix 75
Warfarin
Protonix 40
Colace
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
3. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day): Continue until ambulating
regularly.
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (once):
Titrate to INR 2.0-3.0.
10. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q8H (every 8 hours) for 6 days.
11. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
Hold for loose stools.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Acute cholecystitis
Discharge Condition:
Stable
Discharge Instructions:
Please call or return if you have a fever >101.4, persistent
nausea/vomiting, persistent diarrhea/constipation, redness
swelling or purulent drainage at the percutaneous
cholecystostomy tube, any problems with the drainage tube, or
any other concerns.
Followup Instructions:
Please see Dr. [**Last Name (STitle) **] in 1 week. Call [**Telephone/Fax (1) 2981**] to arrange
an appointment.
Please follow up with your primary care doctor and cardiologist
as directed.
Completed by:[**2173-12-13**] Name: [**Known lastname 15776**],[**Known firstname 5204**] Unit No: [**Numeric Identifier 15777**]
Admission Date: [**2173-12-5**] Discharge Date: [**2173-12-13**]
Date of Birth: [**2079-12-8**] Sex: M
Service: SURGERY
Allergies:
Procardia
Attending:[**First Name3 (LF) 203**]
Addendum:
Pt is also fo follow-up ERCP in [**1-14**] weeks from now.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - [**Location (un) 1409**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 206**] MD [**MD Number(1) 207**]
Completed by:[**2173-12-13**]
|
[
"560.1",
"401.9",
"V58.61",
"V45.81",
"427.31",
"575.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"51.02",
"99.07",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
5894, 6136
|
1896, 3489
|
232, 268
|
4933, 4942
|
1298, 1873
|
5242, 5871
|
1051, 1057
|
3641, 4761
|
4890, 4912
|
3515, 3618
|
4966, 5219
|
1072, 1279
|
178, 194
|
296, 562
|
584, 868
|
884, 1035
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,585
| 124,653
|
48067
|
Discharge summary
|
report
|
Admission Date: [**2146-3-9**] Discharge Date: [**2146-3-25**]
Date of Birth: [**2082-8-9**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 46915**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
colonoscopy
endoscopy
rigid sigmoidoscopy and fecal disempaction
flexible sigmoidoscopy
lumbar puncture
PICC line placement
History of Present Illness:
Mr. [**Known lastname 7203**] is a 63 year old male who is followed by Dr. [**Last Name (STitle) **]
in
behavioral neurology who was brought to the ED today from his
day
care center due to seizures. His history was obtained from the
ED
notes and EMS notes since the patient is now intubated and
sedated. His neurologic history is significant for multiple
strokes with residual global aphasia and right hemiparesis since
[**2127**], SAH, s/p left MCA aneurysm clipping [**2143**], seizure d/o (off
AED's since [**8-23**]), and recent V-P shunt placement [**1-22**] for
hydrocephalus.
This AM, while at his adult day care center, he was noted to
have
right arm shaking. According to witnesses, he appeared awake at
first. After some time (unclear how long) the seizure
generalized to involve "the whole body". This lasted for 3
minutes. When EMS arrived, they found him disoriented
(?baseline
aphasia), but apparently awake and moving all extremities. In
the ambulance, he had another witnessed seizure, was given
Valium
5mg x1, but "right sided shaking" continued so he was given
another 5mg Valium without resolution of seizure activity.
On arrival to the ER, he had right sided (arm and leg) rhythmic
shaking. He was given ativan 2mg x2, paralyzed and intubated
(with Vec, Succ, etomidate, and fentanyl)for airway protection.
He was started on a propofol drip for sedation. He was seen by
the neurology ED resident after he had been medicated and there
was no apparent seizure activity (though exam limited due to
medication administration). He had another episode of right arm
shaking and received another 2mg Ativan in the ER. He was
loaded
with dilantin 1g IV. Just prior to transport to the ICU, he had
another episode of right arm shaking which resolved after a
bolus
of propofol was given.
He arrived in the ICU intubated and sedated on propofol. He had
several occasional episodes of right arm and leg shaking
(rhythmic) which was sometimes associated with right facial
twitching as well. There was no head or eye deviation
associated
with these movements. The episodes were self limited lasting
about 15 seconds each. He was also noted to have frequent,
large,
loose bowel movements both in the ER and ICU.
As per his wife (who speaks limited English), he was in his USOH
today prior to going to his day care center. They had recently
gone on a trip to El [**Country 19118**] together and returned home on
Saturday evening. She says that he did not take any of his
medications while they were away. Other than medication non-
compliance, he has been healthy, no recent fever, night sweats,
appetite change, N/V, diarrhea, change in urinary habits had
been
noted by the family. She indicates that his last seizure was
about two years ago, but the details of the events are not
clear.
He was treated with phenobarbital until [**8-23**] when it was
discontinued due to ongoing cognitive problems and no recent
seizures. At baseline, he is completely non-verbal, though
understands some simple words/directions, has a right HP, but is
able to walk and do basic ADLs such as feed and dress himself.
He
was initially evaluated by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in behavioral neurology for
behavioral and cognitive changes over the past year that were
associated with worsening gait. Work up revealed hydrocephalus
and a VP shunt was placed [**2146-1-25**]. He was discharged home on
[**1-27**]
and has been doing well since.
Past Medical History:
Strokes/SAH/Seizure d/o/Hydrocephalus (with elevated opening
pressure of 28) as above
s/p Left MCA aneurysm clipping [**2143**]
s/p V-P shunt ([**1-22**])
CAD s/p MI
CHF -EF25%
HTN
alchoholic hepatitis
NSVT s/p ablation and pacer/ICD placement
Social History:
Married, lives with his wife. Came to US from El [**Country 19118**] 30
yrs ago. Used to work as a cook. +recent travel to El [**Country 19118**]
last week
Prior to his stroke, he spoke English well.
Family History:
mother DM
Physical Exam:
Gen: alert, pleasant
HEENT: head tilt to the left, VP shunt in R frontal region
CV: RRR, no murmur
PULM: coarse breath sounds throughout.
ABD: soft, NT, no HSM, +BS
EXT: RUE contractures, otherwise WWP, no CCE
NEURO:
MS: alert, follows commands (both midline and appendicular)
though at times with some inconsistencies; answers yes-no
questions consistently; aphasic with minimal speech output
(answers 'bien' to most questions)
CN: EOMI, PERRLA, hearing intact bilat, tongue midline, palate
even
Motor: increased tone in RUE>>RLE; RUE [**Last Name (un) 101365**] paretic; RLE with
[**2-22**] power throughout. Otherwise L side full power.
Coord: no dysmetria with purposeful movements.
Pertinent Results:
[**2146-3-23**] wbc=10.6 hct=45.3 plt=510
[**2146-3-22**] pt=15.2 inr=1.5 ptt=29.7
SUPINE PORTABLE VIEW OF THE ABDOMEN [**2146-3-22**]: There is interval
placement of an NG tube with its tip terminating in the distal
stomach. A VP shunt is again noted coursing across the left side
of the abdomen. Air filled nondilated loops of colon are seen.
There appears to be interval decrease in the amount of stool in
the rectum. The stomach is now decompressed.
IMPRESSION: Status post NG tube placement with interval
decompression of the stomach.
CT OF THE ABDOMEN WITH IV CONTRAST [**2146-3-15**]: There is bibasilar
atelectasis with tiny bilateral pleural effusions. There is a 9
mm hypoattenuating lesion in the right lobe of the liver, as
well as a smaller one in the left lobe. These cannot be further
characterized on this study, but may represent cysts. The
spleen, pancreas, and adrenal glands are unremarkable. There are
multiple bilateral cystic lesions in the kidneys. The largest
measures 16 mm in diameter in the upper pole of the left kidney.
Some are hyperdense, and the presence of enhancement cannot be
excluded on this study. An ultrasound could be helpful for
further characterization if clinically indicated. There is no
mesenteric or retroperitoneal lymph adenopathy, or free air. No
free fluid is seen. There is an air fluid level in the stomach,
but the small bowel appears normal.
However, there is massive dilatation of the rectum and distal
sigmoid colon, with evidence of a distal fecal impaction. The
sigmoid colon is dilated up to 14 cm in diameter. More
proximally in the descending colon and proximal sigmoid is an
area of nondilatation. Apparent intraluminal filling defects
likely represent peristalsis. There is there is a mild focus of
dilatation at the splenic flexure. The cecum is prominent, up to
75 mm in diameter, which can be normal, however. There is no
bowel wall thickening or pneumatosis, and no evidence of
volvulus.
CT OF THE PELVIS WITH IV CONTRAST: The bladder is unremarkable.
The prostate has calcifications but is otherwise within normal
limits. There is no inguinal or pelvic lymphadenopathy. There is
massive dilatation of the rectum with fecal impaction as
described above.
BONE WINDOWS: There are no suspicious lytic or blastic lesions.
The osseous structures are unremarkable.
CT REFORMATS: The sagittal and coronal reconstructions are
helpful in evaluating the anatomy of the bowel. Value grade III.
IMPRESSION: 1. Massive dilatation of the rectum and distal
sigmoid colon, with distal fecal impaction, and possible
pseudo-obstruction. No evidence of volvulus.
2. Numerous bilateral renal cysts, some hyperdense.
3. Tiny bilateral effusions with a slight atelectasis.
4. Small hypoattenuating foci in the liver, which cannot be
further characterized on this study but may represent cysts. The
case was discussed with the house staff caring for the patient.
EEG [**2146-3-9**]: FINDINGS:
ABNORMALITY #1: Throughout the recording there were frequent
bursts of
focal mixed frequency theta and delta slowing in the left
temporal
region with extension to left frontal areas.
BACKGROUND: Background rhythm was dominated by low voltage
faster
record, frequently including beta frequencies. There was no
prominent
assymetry through the background. The background rhythms did not
change
significantly over the course of the recording.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: No normal waking or sleeping morphologies were seen.
CARDIAC MONITOR: Showed a generally regular rhythm with
occasional
PVCs.
IMPRESSION: Abnormal portable EEG due to the prominent focal
slowing in
the left anterior quadrant. This suggests a focal subcortical
abnormality in the left hemisphere, but the recording cannot
specify its
nature. There was no background voltage assymetry to suggest any
prominent effect of a subdural hematoma. There were no
epileptiform
features. The widespread low voltage faster background suggests
medication effect.
CT head [**2146-3-9**]: Comparison is made to a prior CT from
[**2145-3-18**].
There is evidence of post-surgical change with surgical clips in
the region of the left middle cerebral artery. There has been
placement of a drainage catheter from a right frontal approach
terminating within the anterior [**Doctor Last Name 534**] of the right lateral
ventricle. The supratentorial ventricular system appears to have
decreased in size when compared to the prior examination with
ex-vacuo dilatation of the left lateral ventricle. Areas of
infarction are present in the distribution of the left middle
cerebral artery, the right frontal lobe anteriorly, as well as
within the white matter adjacent to the occipital [**Doctor Last Name 534**] of the
right lateral ventricle. There is no CT evidence of acute major
vascular territorial infarction. No evidence of intraparenchymal
hemorrhage or shift of normally midline structures.
Bone windows show no suspicious lytic or sclerotic lesions.
IMPRESSION: No evidence of acute intracranial hemorrhage or mass
effect. The supratentorial ventricular system appears slightly
less dilated when compared to [**2145-3-18**] with interval placement
of a drainage catheter terminating within the right lateral
ventricle.
CT head +/- contrast: Comparison is made to [**2146-3-9**].
TECHNIQUE: 8-MDCT axial images of the head were obtained without
and with IV contrast.
FINDINGS: There is again noted right frontal VP shunt with the
tip in the frontal [**Doctor Last Name 534**] of the right lateral ventricle. This is
unchanged when compared to the prior study. There are again
noted post-surgical changes with surgical clips within the
region of the left middle cerebral artery. The ventricles appear
to be stable when compared to the prior study. There are again
noted areas of infarction present in the distribution of the
left middle cerebral artery, right frontal lobe anteriorly as
well as within the white matter adjacent to the occipital [**Doctor Last Name 534**]
of the right lateral ventricle. There is no evidence of acute
territorial infarct. No abnormal enhancement after IV contrast
is seen to suggest an abscess.
There are again noted opacification of a few anterior ethmoid
cells, which is unchanged when compared to prior study. There is
new thickening of the left maxillary sinus, and also thickening
of bilateral frontal sinus. The thickening of the frontal sinus
is also new when compared to the prior study.
IMPRESSION:
1) No CT evidence of abscess.
2) Sinus disease as described above.
CT/CTA [**2146-3-14**]: HISTORY: History of prior aneurysm with
seizures. CTA to rule out recurrent aneurysm.
TECHNIQUE: Noncontrast head CT scan followed by CT angiography.
FINDINGS: The noncontrast study reveals a large left
temporal/parietal/occipital acute subdural hemorrhage with mild
mass effect, likely dampened by the adjacent large area of
porencephaly resulting from prior infarction, noted on the
previous examination of [**2146-3-10**]. There may be a tiny amount of
intraventricular blood sedimenting in the right occipital [**Doctor Last Name 534**].
This intraventricular blood would likely be due to extension of
the subdural hemorrhage towards the left atrium, via the
porencephalic area of infarcted brain. Other than the mass
effect, there has been no overt change in ventricular size.
There is no shift of normally midline structures. The
ventricular drainage catheter is again seen with its tip near
the septum pellucidum.
CONCLUSION: Interval development of large left
temporal/parietal/occipital acute subdural hemorrhage. We
contact[**Name (NI) **] you immediately following the scan with these results
and agreed that emergent neurosurgical consultation is
warranted.
CT ANGIOGRAPHY
FINDINGS: The area of the previous clipping of the left middle
cerebral artery trifurcation aneurysm is essentially
uninterpretable due to extensive streak artifacts arising from
the surgical clip. Within this significant limitation, no overt
signs for an aneurysm or area of hemodynamically significant
stenosis is appreciated. The right vertebral artery appears
dominant.
CONCLUSION: Technically limited study, as described above, with
no definite sign of an aneurysm.
ADDENDUM: There may be a very small right parietal chronic
subdural fluid collection that, interestingly, was difficult to
appreciate on the prior head CT scan. Also, there is a probable
small chronic right frontal vertex infarction. The latter
pathology lies just posterior to the tract of the ventricular
drainage catheter.
BILATERAL LOWER EXTREMITY DVT STUDY [**2146-3-21**]: [**Doctor Last Name **] scale and
Doppler son[**Name (NI) 1417**] of bilateral common femoral, superficial
femoral, popliteal, and saphenous veins were performed.
There is a small non-occlusive thrombus located in the right
common femoral vein near the insertion of the greater saphenous
vein. It measures approximately 1 x 1 x 1 cm. The greater
saphenous vein is patent. The other vessels examined are patent.
There is no evidence of DVT in the left lower extremity.
IMPRESSION: Small non-occlusive thrombus in the right common
femoral vein.
CXR [**2146-3-23**]: Cardiac and mediastinal contours are unchanged
compared to the prior study. Again, note is made of NG tube and
VP shunt tube. Note is made of faint patchy opacity in bilateral
lower lobes, probably representing aspiration pneumonia. No CHF.
IMPRESSION: Patchy opacity in bilateral lower lobes, probably
representing aspiration vs. aspiration pneumonia. No CHF.
[**2146-3-9**] 04:36PM CEREBROSPINAL FLUID (CSF) PROTEIN-94*
GLUCOSE-63
[**2146-3-9**] 04:36PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-31*
POLYS-0 LYMPHS-33 MONOS-67
[**2146-3-9**] 04:36PM CEREBROSPINAL FLUID (CSF) WBC-7 RBC-39*
POLYS-0 LYMPHS-31 MONOS-69
[**2146-3-9**] 10:12AM WBC-10.5 RBC-5.84 HGB-15.9 HCT-47.4 MCV-81*
MCH-27.2 MCHC-33.5 RDW-13.8
[**2146-3-9**] 10:12AM NEUTS-68.3 LYMPHS-23.4 MONOS-3.5 EOS-4.3*
BASOS-0.6
[**2146-3-9**] 10:12AM PLT COUNT-303
[**2146-3-9**] 05:49PM ALT(SGPT)-8 AST(SGOT)-24 ALK PHOS-53 TOT
BILI-0.3
[**2146-3-9**] 05:49PM GLUCOSE-87 UREA N-14 CREAT-0.8 SODIUM-142
POTASSIUM-4.4 CHLORIDE-113* TOTAL CO2-22 ANION GAP-11
[**2146-3-9**] 05:49PM TSH-0.53
HERPES SIMPLEX VIRUS PCR (CEREBROSPINAL FLUID (CSF))
[**2146-3-9**] 6:51P OLD #S [**Numeric Identifier 101366**] / 65759C / 1436C / 1435C
CHILDREN HOSPITAL MEDICAL CENTER, [**Location (un) **],MA
TEST RESULT
REFERENCE RANGE ---- ------
---------------HERPES SIMPLEX VIRUS PCR
NEGATIVE NEGATIVE
Brief Hospital Course:
1. NEURO- seizures, prior L MCA aneurysm, s/p clip, L MCA
infarct, asymptomatic L SDH
Neuro status much improved from admission. Seizurs on admission
liekly [**12-22**] chronic infarct; infectious etiology ruled out with
CSF studies (including HSV PCR), no SAH on initial CT therefore
unlikely recurrence or development of new aneurysm. Seizures
well controlled with Dilantin with levels [**9-5**]. SDH
incidentally found on [**3-14**] CT head and likely [**12-22**] to either LP
versus hitting head on bed railing on [**2146-3-11**]. SDH stable on
serial CT head. Stroke prophylaxis (ASA 325 qd) held [**12-22**] SDH.
Recommendations are to re-start ASA 325 qd approximately one
month from SDH onset (late [**Month (only) 116**]).
2. Pulm: Initially intubated; extubated without complication,
initial CXR without PNA; developed CHF interittently (with
desaturations to mid-80's) with good response to prn lasix (20mg
IV). Infiltrate noted on CXR [**2146-3-16**], perhaps [**12-22**] multiple
unsuccessful attmepts at NGT placement. There seems to also be
a component of obstructive sleep apnea that may be contributing
to his intermittent evening 02 desaturations.
3. CV - intermittent CHF, pacer
-ROMI with CE x 3sets
-BP stable throughout hospitalization; initially manages with
verapamil, but given bowel obstruction and ? of Ogilve's
(pseudoobstruction), Pt started on beta blocker with good BP
results.
-aggressive monitoring of electrolytes given hx of arrhythmia
with goal K>4.0 and MG>2.0 throuhgout hospitalization.
-ECHO [**3-17**]: EF=55%
4. Endo
-TFTs normal
-RISS
5. ID- initial CXR without evidence of PNA but during last week
of hospitalization and in setting of severly distended bowel, Pt
developed fever with no source on blood cx or urine cx;
empirically started on Levoflox and flagyl; C diff negative x3;
repeat CXR showed new infiltrate and Pt cont to be febrile
therefore Pt started on Zosyn for broader coverage and
defevesced for 3d prior to discharge. Goal is to treat
empirically for with total 10d course.
-stool negative for cx, ova and parasites (since recent travel
to central america),
-C.diff negative x3
-UA/Ucx negative
-CT with contrast showed no intracranial abscess
-CXR [**3-20**] without pneumonia
-[**3-16**] started on Flagyl in addition to levofloxacin in case
fever [**12-22**] gut translocation
- [**3-20**]: fever to 102, started Zosym for broader GI coverage, sent
VRE screen which was negatvie.
5. GI-
-[**3-15**] very distended bowel; fecal impaction of distal rectum
with very large stool sitting in distal colon/rectum; general
surgery placed rectal tube; NGT in place. NPO.
-[**3-17**] s/p rigid sig for decompression/stool removal
-[**3-18**] started on sips of clear
-[**3-22**] Abdominal XRAY with marked improvement of previous colon
and gastric distension.
-[**3-24**] colonoscpoy and endoscopy showed one diverticulus and
several ulcers and erosions (GE junction, gastric mucosa, distal
duodenum, duodenal bulb)
-f/u established as outpatient for anal manometry studies on
[**4-7**] at [**Hospital1 18**]; bowel regimen implemented.
6. DVT-small, non-occlusive R common femoral clot noted on
[**2146-3-21**], was off anti-coagulate due to subdural hemorrhage
-Heparin SC bid, held briefly but restarted [**2146-3-22**]
-IVC filter deferred by Interventional radiology due to fever,
small size of clot
- repeat LENIs [**2146-3-23**] showed no change in clot.
7. PT/OT/Rehab screening and arrangements made to xfer to
[**Hospital6 85**] for ongoing care.
Medications on Admission:
Seroquel 50mg [**Hospital1 **]
Captopril 25mg TID
ECASA 325 qd
Metoprolol 50mg [**Hospital1 **]
Verapamil 120mg qd
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Seizures
Severe fecal impaction
Diverticulosis
gastric ulcers (duodenal bulb, gastric mucosa, GE junction)
sub-dural hematoma
pneumonia
CHF
Discharge Condition:
stable
Discharge Instructions:
Follow-up with all appointments as directed.
Take all medications as directed.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2146-5-12**] 3:30
Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2146-5-12**] 4:00
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) **]: [**Hospital6 29**]
NEUROLOGY Phone:[**Telephone/Fax (1) 657**] Date/Time:[**2146-5-24**] 2:30
Provider: [**Name10 (NameIs) 2166**] ROOM GI ROOMS Where: GI ROOMS
Date/Time:[**2146-4-7**] 10:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2165**] Where: DE [**Hospital1 **] BUILDING ([**Hospital Ward Name **] COMPLEX)
Phone:[**Telephone/Fax (1) 101367**] Date/Time:[**2146-4-7**] 10:30
.
Anomanometry at [**Month/Day/Year 2166**] ROOM GI ROOMS Where: GI ROOMS, [**Hospital Ward Name 5074**] [**Hospital1 18**], [**Hospital Ward Name 2104**] 133. Date/Time:[**2146-4-7**] 9:30. Please give
two Fleet's enemas prior morning of procedure.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 46916**]
Completed by:[**2146-3-25**]
|
[
"453.40",
"342.90",
"V45.2",
"780.39",
"560.39",
"784.3",
"486",
"428.0",
"562.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"96.71",
"96.38",
"45.13",
"38.93",
"45.23",
"96.04",
"45.24"
] |
icd9pcs
|
[
[
[]
]
] |
19580, 19650
|
15888, 19414
|
323, 449
|
19834, 19842
|
5209, 15865
|
19969, 21189
|
4472, 4484
|
19671, 19813
|
19440, 19557
|
19866, 19946
|
4499, 5190
|
276, 285
|
477, 3967
|
3989, 4235
|
4251, 4456
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,289
| 100,513
|
4738
|
Discharge summary
|
report
|
Admission Date: [**2167-10-30**] Discharge Date: [**2167-10-31**]
Date of Birth: [**2134-3-3**] Sex: F
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
ALTERED MENTAL STATUS, HYPONATREMIA
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
33 yo F with h/o asthma, anxiety (not on medication). Has had
BRBPR with blood on toilet paper. Changed diet about 5 days
prior and was reporting feeling light headed. Asked to get
colonoscopy by GI at [**Hospital1 112**], and had bowel prep in progress. Also
drinking lots of GatorAid. Was attempting prep late last night.
About 10pm, started vomiting at home. Called 911, despite
husband's reassurances. Husband believed she was simply anxious.
EMS arrived at 1:30AM, found to be frankful delusional, with
thought of 'limb swelling'. No h/o psychiatric hospitalizations,
not currently taking psychoactive medications.
Upon arrival, was found by ED resident to be crawling across the
floor, crying out for help. Serum osms very low. ? Seizure by ED
resident although no activity observed. Found to be hyponatremic
at 122 and diaphoretic. Serum Tox negative, no h/o ingestion.
Given continued confusion, attempted LP in ED, given Ativan 4mg
in process. Could not obtain by either resident or Attending.
Given Ceftriaxone and Azithromycin for meninigitis to cover
infection. Did get stat head CT without r/o ICH.
Started on hypertonic saline, in consultation with pharmacy -->
350 cc of current hypertonic saline; first 8 hours correct half
(not more than 10u). 45cc x next 8 hours total. Then gets second
half over 24 hours at 15cc/hr. Also getting KCl through IV. HR
60s, SBP 95-115, RR 20s, 99% on RA. Daughter is [**Name2 (NI) **] with fever
(stated to be viral infection by Pediatrician, F 103.2) and Ms.
[**Known lastname 19916**] apparently felt unwell prior to incident.
Past Medical History:
Asthma
Anxiety
G1P1
Social History:
Lives with husband and one daughter who is an infant. No tobacco
use, EtOH or other medications.
Family History:
Non-Contributory
Physical Exam:
96.7, 101, 108/88, 18, 99/RA
GEN: Appears distressed, not responsive to verbal stimuli
HEENT: NCAT, PERRL, symmetric, could not assess oropharynx
CV: Mildly tachycardic, no m/g/r
PULM: CTAB anteriorly and posteriorly without w/r/r
ABD: Soft, active BS, no palpable masses
EXT: WWP with 2+DP pulses bilaterally
NEURO: Withdraws to painful stimuli, does not respond to voice,
withdraws to sternal rub, toes downgoing b/l
PSYCHE: Difficult to assess [**2-14**] mental status
Pertinent Results:
Admission Labs:
[**2167-10-30**] 02:00AM WBC-13.1* RBC-3.98* HGB-12.2 HCT-33.7* MCV-85
MCH-30.7 MCHC-36.2* RDW-12.6
[**2167-10-30**] 02:00AM NEUTS-81.9* LYMPHS-15.9* MONOS-1.8* EOS-0.3
BASOS-0.1
[**2167-10-30**] 02:00AM PLT COUNT-250
[**2167-10-30**] 02:00AM PT-13.8* PTT-36.6* INR(PT)-1.2*
[**2167-10-30**] 02:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2167-10-30**] 02:00AM HCG-<5
[**2167-10-30**] 02:00AM CORTISOL-42.5*
[**2167-10-30**] 02:00AM TSH-3.1
[**2167-10-30**] 02:00AM OSMOLAL-254*
[**2167-10-30**] 02:00AM calTIBC-280 FERRITIN-57 TRF-215
[**2167-10-30**] 02:00AM IRON-108
[**2167-10-30**] 02:00AM LIPASE-22
[**2167-10-30**] 02:00AM ALT(SGPT)-12 AST(SGOT)-24 ALK PHOS-55 TOT
BILI-1.5
[**2167-10-30**] 02:00AM CREAT-0.6 SODIUM-121* POTASSIUM-3.2*
[**2167-10-30**] 02:55AM GLUCOSE-153* LACTATE-3.4* NA+-122* K+-2.9*
CL--91* TCO2-19*
[**2167-10-30**] 02:55AM PH-7.38 COMMENTS-GREEN TOP
[**2167-10-30**] 03:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2167-10-30**] 03:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2167-10-30**] 03:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2167-10-30**] 03:00AM URINE OSMOLAL-314
[**2167-10-30**] 03:00AM URINE HOURS-RANDOM UREA N-272 CREAT-48
SODIUM-59 POTASSIUM-28 CHLORIDE-79
[**2167-10-30**] 05:06AM NA+-120* K+-2.7* CL--95*
[**2167-10-30**] 11:10AM URINE OSMOLAL-504
[**2167-10-30**] 11:10AM URINE HOURS-RANDOM UREA N-222 CREAT-30
SODIUM-175
[**2167-10-30**] 11:10AM OSMOLAL-247*
[**2167-10-30**] 12:42PM ALBUMIN-3.9
[**2167-10-30**] 12:42PM ALBUMIN-3.9
[**2167-10-30**] 12:42PM GLUCOSE-110* UREA N-5* SODIUM-122*
POTASSIUM-3.9 CHLORIDE-92* TOTAL CO2-20* ANION GAP-14
[**2167-10-30**] 05:40PM OSMOLAL-263*
[**2167-10-30**] 05:40PM CALCIUM-8.4 PHOSPHATE-2.5* MAGNESIUM-2.1
[**2167-10-30**] 05:50PM URINE OSMOLAL-74
[**2167-10-30**] 05:50PM URINE HOURS-RANDOM CREAT-7 SODIUM-22
CHLORIDE-19
[**2167-10-30**] 11:15PM URINE OSMOLAL-113
[**2167-10-30**] 11:15PM URINE HOURS-RANDOM CREAT-16 SODIUM-28
CHLORIDE-31
[**2167-10-30**] 11:15PM SODIUM-131*
.
Pertinent Labs:
[**2167-10-31**] 04:14AM BLOOD WBC-8.8 RBC-4.07* Hgb-12.7 Hct-34.2*
MCV-84 MCH-31.1 MCHC-37.0* RDW-12.8 Plt Ct-232
[**2167-10-31**] 04:14AM BLOOD Plt Ct-232
[**2167-10-31**] 12:22PM BLOOD Na-139 K-3.8
[**2167-10-31**] 04:14AM BLOOD Calcium-8.9 Phos-2.4* Mg-2.0
[**2167-10-31**] 12:22PM BLOOD Phos-1.6* Mg-2.1
.
Pertinent Imaging:
.
EEG: This is a normal routine EEG in the waking and drowsy
states. There are no focal, lateralized, or epileptiform
features
noted.
.
Non-Contrast Head CT:
There is no acute intracranial hemorrhage, shift of normally
midline structures, hydrocephalus, major or minor vascular
territorial
infarction. The density values of the brain parenchyma are
maintained. The
soft tissues and osseous structures are intact. The visualized
paranasal
sinuses and mastoid air cells appear well aerated.
IMPRESSION: No acute intracranial hemorrhage.
.
CXR:
Mild increase in interstitial markings at the left base could be
due to
bronchitis. There is no focal area of consolidation. Lungs are
otherwise
clear. The cardiomediastinal silhouette and hilar contours are
normal. There
is no pleural effusion. Mild levoscoliosis is present.
Brief Hospital Course:
33 yo F with PMH reportedly of asthma and anxiety, p/w altered
mental status and hyponatremia of unclear etiology.
# Hyponatremia: The pt presented with acute change in mental
status and was found to be hyponatremic as low as 119 (lab
details above). The patient was initially worked up for acute
change in MS including a negative CT, LP and EEG. The patient
was also given meningeal dosing for Ceftriaxone, Vancomycin and
Acyclovir, which were later dc'd. Urine and serum tox were
negtaive. The patient was initially hypotensive upon admission
to the MICU to SBP in the 80s, however it was unclear what the
patients baseline SBP was in addition the patient had been given
empiric dose of ativan.
Per report, patient was undergoing bowel prep with Golytley when
became acute ill and began vomiting. Her hx indicated that she
was drinking increased hypotonic fluids including Gatorade. The
patients urine osms were low at 314, but not maximally dilute,
also with Na > 50, so not retaining maximum Na. Thus the
etiologies include sodium loss due to a recent change to low
salt diet with excessive water replacement while others included
adrenocortical insufficiency (although increased cortisol in
hemolyzed sample) and SIADH.
The patient was initially given hypertonic saline and later
changed to normal saline. The patient was water restricted and
after 24hrs her mental status cleared to baseline, however she
did not recall the prior days events. The patient was discharged
directly from the MICU to home at her baseline mental status,
only complaining of mild symptoms of nausea and headache (?
secondary to an LP) and able to take adquate but decreased POs.
.
# Anemia: The patient was previously being worked-up by GI for
BRBPR. There was no evidence of bleeding during her admission.
The pt's Hct remained stable in the mid 30s. This should be
followed up as an outpatient. However it should be noted that
the patient appeared to become hyponatremic secondary to her Go
Lytley dosing and thus this should be addressed if the patient
is to undergo further endoscopic evaluations.
.
# Asthma: Per report. No signs of acute respiratory problems.
The pt was continued on her Albuterol PRN
Medications on Admission:
No known outpatient medications
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for wheeze.
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
3. Phenergan 25 mg Tablet Sig: One (1) Tablet PO q4:6hr PRN.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hyponatremia
Altered mental status
.
Secondary:
Asthma
Anxiety
Discharge Condition:
Good. Alert and oriented x3. Tolerating POs.
Discharge Instructions:
You were admitted with confusion and found to have a very low
blood sodium level. This likely occurred due to your bowel prep
for colonoscopy and drinking excess water and other fluids. Your
sodium improved with intravenous fluids and your mental status
returned to baseline. A lumbar puncture was performed without
evidence of meningitis. You developed a headache that was likely
related to the lumbar puncture and should resolve on its own
over the next 24 hours.
.
Please take all medications as prescribed.
.
Call your doctor or return to the ED immediately if you
experience worsening chest pain, shortness of breath, nausea,
vomiting, abdominal pain, sweating, fevers, chills, bleeding, or
other concerning symptoms.
Followup Instructions:
Call your PCP to schedule [**Name Initial (PRE) **] followup appointment within 2 weeks.
.
You should have your blood sodium checked on Monday, [**2167-11-3**],
at your PCP's office.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"349.0",
"276.9",
"780.97",
"300.00",
"276.8",
"E879.4",
"285.9",
"493.90",
"458.9",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
8684, 8690
|
6082, 8278
|
333, 351
|
8806, 8853
|
2659, 2659
|
9624, 9936
|
2134, 2152
|
8360, 8661
|
8711, 8785
|
8304, 8337
|
8877, 9601
|
2167, 2640
|
258, 295
|
379, 1961
|
5396, 6059
|
2675, 4892
|
4908, 5387
|
1983, 2004
|
2020, 2118
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,285
| 166,579
|
4145
|
Discharge summary
|
report
|
Admission Date: [**2125-7-17**] Discharge Date: [**2125-7-24**]
Date of Birth: [**2065-1-9**] Sex: M
Service: SURGERY
Allergies:
Ampicillin / Sulfonamides / Codeine / Percocet / Succinylcholine
Chloride
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
ESRD on HD, admitted for kidney transplant
Major Surgical or Invasive Procedure:
Right heart catheterization
LURT, aborted due to PEA cardiac arrest post-anesthesia
induction
History of Present Illness:
60-year-old man with end-stage renal disease secondary to
hypertension and diabetes. He was on dialysis for approximately
7 months with a right IJ
PermCath. His hypertension and diabetes has been complicated by
nephropathy, and coronary artery disease, for which he underwent
cardiac bypass in [**2123-6-11**]. He also has had AICD placed. He
underwent percutaneous intervention
in the spring of [**2124**] and was recently diagnosed with atrial
flutter prior to his scheduled transplant in [**2125-4-10**]. The
kidney transplant was subsequently postponed after he underwent
ablation of the arrhythmia site and required anticoagulation
postoperatively. [**Known firstname **] also notes lower extremity claudication
of about 1 to 2 blocks. His pretransplant workup encouraged a
stress test that was unremarkable. He underwent a cardiac echo
that demonstrated an EF of 30 to 40% with 2+ mitral
regurgitation. Colonoscopy was performed in [**2125-1-11**] that
demonstrated only benign adenomas. He underwent pulmonary
function tests in [**2125-5-11**] that demonstrated significantly
reduced lung volumes, which are essentially unchanged from those
performed in [**2120**]. He underwent lower extremity Dopplers
noninvasive studies in [**2124-8-11**] that demonstrated
noncompressible muscles bilaterally. He had a marked decrease
in his ankle brachial index with exercise. The interpretation
was severe peripheral vascular disease worsened by ambulation.
Following these pre-operative tests, a decision was made to
proceed with surgery and he was admitted on [**2125-7-17**] to undergo
kidney transplant.
Past Medical History:
CAD s/p CABG (LIMA to LAD, SVG to PDA, SVG to OM1, SVG to Om2),
angioplasty and BMS ([**2-14**])
Hypertension
Hyperlipidemia
Diabetes mellitus, type 2
CHF s/p AICD placement
ESRD on HD. Candidate for renal transplant.
Aflutter s/p cardioversion 2 weeks ago
Eye surgery - 2 days ago
NSTEMI in [**10/2124**]
Anemia
Right eye vitrectomy complicated by intraocular hemorrhages
with temporary blindness of the right eye (currently without
vision in that eye)
s/p left vitrectomy and laser surgery
ESRD due to diabetic nephropathy, currently on hemodialysis
M/W/F at [**Last Name (un) 4029**] in [**Location (un) **] (dialysis catheter in chest)
Resection of colon polyps
Osteomyelitis of 5th metatarsal head, s/p excision
Social History:
Lives alone in [**Hospital1 8**]. Musician and conductor with [**Male First Name (un) **]
music group. Rare alcohol use, denies tobacco use x22 years,
denies illicit drug use.
Family History:
Father died at 79 of an MI, had bypass at age 70
Mother died at age 82 of CHF and DM
Brother had stents placed at age 58
Physical Exam:
Blood pressure was 171/100 mm Hg while seated. Pulse was 67
(paced) beats/min and regular, respiratory rate was (vent SIMV
600 x 12 or 15/5).
There was no xanthalesma and conjunctiva were pink with no
pallor
or cyanosis of the oral mucosa. The neck was supple with JVP of
20 cm. The carotid waveform was normal. There was no
thyromegaly. The were no chest wall deformities, scoliosis or
kyphosis. The lungs had coarse crackles bilaterally with.
Cardiovascular examination revealed RRR, S1/S2, MR murmur,
displaced PMI.
There was no hepatosplenomegaly or tenderness. The abdomen was
soft nontender and nondistended. The extremities had no pallor,
cyanosis, clubbing or edema. There were no abdominal, femoral or
carotid bruits.
There were palpable pulses bilaterally. Lower extremities were
warm.
Neurologically: exam limited by sedation but no spontaneous
movements, no withrawal to pain; no corneal reflexes; no gag.
Pertinent Results:
On Admission: [**2125-7-17**]
WBC-13.4* RBC-3.96* Hgb-12.6* Hct-37.0* MCV-94 MCH-31.9
MCHC-34.1 RDW-15.7* Plt Ct-113*
PT-15.1* PTT-24.0 INR(PT)-1.4*
Glucose-216* UreaN-46* Creat-5.0* Na-137 K-6.0* Cl-107 HCO3-21*
AnGap-15
Calcium-9.1 Phos-2.8 Mg-2.0
On Discharge [**2125-7-23**]
WBC-7.8 RBC-3.43* Hgb-11.0* Hct-31.4* MCV-92 MCH-32.2*
MCHC-35.2* RDW-16.1* Plt Ct-125*
PT-17.5* PTT-48.9* INR(PT)-1.6*
Glucose-98 UreaN-85* Creat-5.9* Na-135 K-4.6 Cl-101 HCO3-21*
AnGap-18
Calcium-9.0 Phos-6.1* Mg-2.5
Brief Hospital Course:
Admitted on [**2125-7-17**], scheduled for kidney transplant, from a
living unrelated
donor. Shortly after anesthesia induction, however, he went into
PEA arrest. CPR was initiated immediately, reportedly with
adequate chest compressions. He was given at least one round of
epinephrine. After 10-12 minutes, cardiac rhythm was regained.
He
was transferred to the ICU; however, concern arose when, 2 hours
after propofol was turned off, he still was not responsive to
sternal rub. Intraoperative ECHO ([**7-17**]) revealed dilation of the
left ventricular cavity was moderately dilated, with severe
global left ventricular hypokinesis (LVEF = 20 %). The right
ventricular cavity was also dilated and right ventricular
systolic function appeared depressed. The aortic valve leaflets
(3) were mildly thickened but aortic stenosis was not present.
The mitral valve leaflets were mildly thickened. Mild (1+)
mitral regurgitation was seen. The tricuspid valve leaflets were
mildly thickened. The pulmonary artery systolic pressure could
not be determined. There is trivial/physiologic pericardial
effusion. Compared with the findings of the prior study (images
reviewed) of [**2125-4-20**], contractile function of the left
ventricle (and probably right ventricle as well) was
significantly further reduced. Due to these findings, he
underwent right heart catheterization performed by entry into a
preexistent left internal jugular vein cordis, using a
thermodilution Swan-Ganz catheter, and advanced to the PCW
position. Findings revealed elevated right sided filling
pressures and elevated Pulmonary capillary wedge pressure. He
was brought to the SICU post-operatively and was evaluated by
the cardiology, nephrology, and neurology services. Cardiology
recommended controlling BP and rechecking TEE. TEE post
resuscitation revealed worse
LV function than preop (Preop LVEF 40; TEE today reportedly LVEF
20), and starting heparin gtt and aspirin. Repeat ECHO on [**7-19**]
revealed dilated left ventricle with severe systolic
dysfunction, dilated right ventricle with at least mild systolic
dysfunction, and mild pulmonary hypertension. Compared with the
prior study (images reviewed) of [**2125-7-17**], the findings were
similar. Neurology recommendations included: CTA of head and
neck (MRI possible due to AICD), IV thiamine 100 mg daily,
avoiding sedating medications, maintaining normothermia,
continuing normoglycemia with insulin drip, allowing BP to
autoregulate until thrombosis and infarct excluded, and
continuing IV heparin until thrombosis excluded. The patient
initially was placed on nitroprusside drip and hydralazine to
control elevated blood pressures.
He was transferred to the floor once stable and was to be
discharged to the care of his cardiologist, appointments were
made.
Medications on Admission:
Coreg 25 mg twice daily
amiodarone 200 mg daily
Imdur 60 mg daily
Diovan 80 mg at bedtime
glipizide 5 mg twice daily
aspirin 325 mg daily
Lipitor 40 mg daily
Plavix 75 mg daily
Renagel 800 mg three times daily
Reglan 10 mg as needed for gastroparesis
omeprazole 20 mg daily
Lantus insulin 15 units every night and Humalog sliding scale
during the day
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. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Insulin
Continue home Insulin regimen
7. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Warfarin 6 mg Tablet Sig: One (1) Tablet PO at bedtime for 1
doses: Have PT/INR checked at your outpatient lab. Fax results
to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
11. Valsartan 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Congestive heart failure
Dilated cardiomyopathy
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: per kidney doctor recommendations
Continue diet and medications per your kidney doctor
Hemodialysis per your schedule, [**Location (un) **] Weds and Friday
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Date/Time:[**2125-8-8**] 8:45
Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Date/Time:[**2125-8-20**] 3:00
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2125-12-24**]
11:30
Dr[**Name (NI) 5786**] office will call you with an appointment.
Completed by:[**2125-8-1**]
|
[
"362.01",
"V45.02",
"427.5",
"412",
"272.4",
"250.40",
"585.6",
"425.4",
"357.2",
"285.21",
"V64.1",
"428.22",
"424.0",
"403.91",
"V58.61",
"427.32",
"428.0",
"E879.8",
"583.81",
"V45.81",
"V49.83",
"250.50",
"250.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"99.60",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
8856, 8862
|
4670, 7466
|
374, 470
|
8954, 8963
|
4148, 4148
|
9286, 9734
|
3066, 3188
|
7867, 8833
|
8883, 8933
|
7492, 7844
|
8987, 9263
|
3203, 4129
|
292, 336
|
498, 2115
|
4162, 4647
|
2137, 2856
|
2872, 3050
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,778
| 106,042
|
38858
|
Discharge summary
|
report
|
Admission Date: [**2186-6-7**] Discharge Date: [**2186-6-12**]
Date of Birth: [**2109-1-11**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Augmentin / Vicodin / Zocor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
[**2186-6-7**]
Aortic valve replacement 19-mm St. [**Hospital 923**] Medical Epic
Biocor tissue valve
Coronary artery bypass grafting x2 with reverse saphenous vein
graft to the marginal branch and the posterior descending
artery.
History of Present Illness:
77 year old female who had been fairly active and had been
limited by fatigue over the previous month. Echo from [**Month (only) 404**]
[**2185**] revealed aortic stenosis with a valve area of 0.83cm2. She
underwent cardiac catheterization [**2186-5-1**] which revealed two
vessel coronary artery disease. She was referred for aortic
valve replacement and revascularization.
Date: [**2186-5-1**] Place: [**Hospital1 18**]
LM- no obstruction
LAD- minimal luminal irregularities
Cx- 85% mid
RCA- 80% mid and distal
[**2186-5-11**] Echo: [**Location (un) 109**] 0.7cm2, pk 65, mn 35
Carotid Ultrasound: 50-69% stenosis of [**Country **]/[**Doctor First Name 3098**]
Past Medical History:
Borderline hyperlipidemia
Aortic stenosis
Psoriasis
Coronary artery disease
Osteoporosis
Gastroesophageal reflux disease
Fibromyalgia
Hepatitis treated in [**2143**]
Sleep apnea-does not use CPAP
4.2 cm abdominal aortic aneurysm
Ectopic pregnancy
Past Surgical History
[**2182**] Right total knee replacement
Tonsillectomy
Appendectomy
Social History:
Race: Caucasian
Last Dental Exam: edentulous
Lives with: husband and daughter
Occupation: Retired
Tobacco: 50 pack years (1ppd until several wks ago)
ETOH: Occasional ETOH and denies illicit drug use.
Family History:
grandmother had "heart condition"
Physical Exam:
Pulse: 74 Resp: 16 O2 sat: 99%RA
B/P Right: 130/69 Left: 136/78
Height: 5'1" Weight: 140lb
General: well developed female in no acute distress
Skin: Dry [x] intact [x] numerous psoriatic plaques- prominent
on
right elbow, bilateral knees and lateral legs (right worse than
left)
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 2/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [] (psoriasis as above) (*LLE likely better for vein
harvest*)
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left:
bruit vs. radiation of cardiac murmur
Pertinent Results:
[**2186-6-9**] 04:45AM BLOOD WBC-12.1* RBC-3.27* Hgb-10.1* Hct-29.8*
MCV-91 MCH-30.9 MCHC-33.9 RDW-13.5 Plt Ct-109*
[**2186-6-9**] 04:45AM BLOOD Glucose-129* UreaN-19 Creat-1.2* Na-135
K-4.7 Cl-104 HCO3-21* AnGap-15
Echo [**2186-6-7**]:
PRE-BYPASS:
The left atrium is dilated. Mild spontaneous echo contrast is
present in the left atrial appendage. The left atrial appendage
emptying velocity is depressed (<0.2m/s). No spontaneous echo
contrast is seen in the body of the right atrium or right atrial
appendage. No mass or thrombus is seen in the right atrium or
right atrial appendage. No atrial septal defect is seen by 2D or
color Doppler.
Right ventricular chamber size and free wall motion are normal.
There are complex (mobile) atheroma in the aortic arch. There
are complex (mobile) atheroma in the descending aorta. The
aortic valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2).
Mild to moderate ([**12-31**]+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results on Ms.[**Known lastname **]
before surgical incision.
POST-BYPASS:
Preserved biventricualr systolic function. LVEF 50%.
Intact thoracic aorta.
The aortic b ioprosthesis is well seated, stable and functioning
well with residual m ean gradient of 15mm of Hg.
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2186-6-7**] for an aortic valve replacement 19-mm
St. [**Hospital 923**] Medical Epic Biocor tissue valve and coronary artery
bypass grafting x2 with reverse saphenous vein graft to the
marginal branch and the posterior descending artery. See
operative note for full details. Overall the patient tolerated
the procedure well and post-operatively was transferred to the
CVICU in stable condition for recovery and invasive monitoring.
A left sided chest tube was placed post operatively for a large
pneumothorax which resolved after placement. POD 1 found the
patient 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. The patient was transferred to the
telemetry floor for further recovery. Chest tubes were placed to
waterseal on POD2 and she subsequently developed significant
left sided subcutaneous emphysema and was placed back on
suction. She remained hemodynamically stable without
respiratory distress. Repeat chest xray on POD 3 showed stable
pneumothorax with decreased subcutaneous air. Chest tubes and
pacing wires were subsequently discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD #5 the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was cleared by Dr. [**Last Name (STitle) **] for discharge to home on
POD#5 in good condition with appropriate follow up instructions.
Medications on Admission:
Motrin 600 mg every 4-6 hours as needed
Omeprazole 20 mg daily
Loratidine 10 mg daily
Aspirin 81mg daily
Allergies: augmentin, vicodin
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
6. Hydrocortisone 0.5 % Cream Sig: One (1) Appl Topical TID (3
times a day) as needed for itchiness.
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
9. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for
7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Aortic Stenosis/ Coronary Artery Disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] on [**7-20**] at 1:00 PM [**Telephone/Fax (1) 170**]
Please call to schedule the following appointments:
Primary Care Dr. [**Last Name (STitle) 3321**] in [**12-31**] weeks
Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] in [**12-31**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2186-6-12**]
|
[
"696.1",
"998.81",
"729.1",
"441.4",
"530.81",
"512.1",
"733.00",
"414.01",
"401.9",
"424.1",
"780.57",
"E878.1",
"V43.65"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
7479, 7534
|
4261, 6023
|
302, 535
|
7619, 7715
|
2780, 4238
|
8339, 8843
|
1830, 1866
|
6210, 7456
|
7555, 7598
|
6049, 6187
|
7739, 8316
|
1881, 2761
|
254, 264
|
563, 1234
|
1256, 1595
|
1611, 1814
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,638
| 112,815
|
35620
|
Discharge summary
|
report
|
Admission Date: [**2189-2-19**] Discharge Date: [**2189-2-27**]
Date of Birth: [**2143-5-24**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
large cystic mass within the abdomen resulting in abdominal
bloating
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy.
2. Radical resection of cystic intra-abdominal mass en bloc
with left hepatic lobe and gallbladder.
3. Intraoperative cholangiogram.
4. [**First Name3 (LF) **]
History of Present Illness:
[**Known firstname **] [**Known lastname 3646**] is a 45-year-old female with a history of
progressive abdominal bloating and discomfort. An abdominal
ultrasound on [**2-5**] showed a
large cystic mass within the abdomen. This was confirmed with
a CT scan of the abdomen obtained on [**2-8**]. This
demonstrated a large complex septated mass centered within
the right abdomen and inseparable from the left hemi liver.
The lesion measured up to 32 cm in maximum size and was
uniform in its attenuation. The findings were most consistent
with either a biliary cystadenoma, a mesenteric or peritoneal
cyst or a rare sarcoma. The imaging findings and her history
were not consistent with hydatid cyst disease. Dr. [**Last Name (STitle) 1924**] did
not feel
that further imaging or a preoperative biopsy would be
helpful in the management of this lesion and so advised up-
front surgery as well as an intraoperative frozen section
biopsy of the mass. She understood the rationale for this
plan of care as well as the risks and benefits of the
procedure and consented to proceed.
Past Medical History:
PAST MEDICAL HISTORY:
1. Asthma.
2. Nephrolithiasis status post lithotripsy as well as status
post ureteroscopy and stone removal in [**2184**].
3. Cellulitis of the left leg x2.
Past Surgical History:
1. Status post C-sections x2.
2. Status post tonsillectomy at the age 19.
3. Status post a liver biopsy by needle for a small cyst
approximately six years ago. The results of this were apparently
a benign cyst and she was told that she needed no further
followup.
Social History:
The patient is married and accompanied to the
visit today by her husband. She has two children aged 19 and
21.
She has a trivial smoking history, having quit several weeks
ago.
She lives in [**Location 9101**] and works as an administrative manager of a
health care agency. She also works part time as a waitress. She
drinks approximately two alcoholic beverages each week.
Family History:
Remarkable for a mother who is alive and well
after treatment for breast cancer. Her father is alive and well
with prostate cancer. He also is a survivor of esophageal and
stomach cancer. A maternal aunt died of melanoma and a maternal
grandmother died of pancreatic cancer. A maternal grandfather
died of bone cancer.
Physical Exam:
At Discharge:
Vitals: 98.7, 71, 106/71, 18, 98% on RA
GEN: NAD, A/Ox3
CV: RRR, no m/r/g
RESP: CTAB
ABD: soft, ND, appropriately TTP-RUQ, +BS, +flatus
Incision: RUQ-OTA with staples, CDI, JP drains x1 RLQ
Extrem: no c/c/e
Pertinent Results:
[**2189-2-27**] 07:10AM BLOOD WBC-9.0 RBC-3.41* Hgb-9.7* Hct-30.1*
MCV-88 MCH-28.5 MCHC-32.3 RDW-15.1 Plt Ct-322
[**2189-2-26**] 07:40AM BLOOD WBC-13.1* RBC-3.70* Hgb-10.8* Hct-32.6*
MCV-88 MCH-29.1 MCHC-33.0 RDW-15.0 Plt Ct-399
[**2189-2-25**] 08:15AM BLOOD WBC-10.8 RBC-3.30* Hgb-9.6* Hct-28.6*
MCV-87 MCH-29.2 MCHC-33.7 RDW-15.0 Plt Ct-280
[**2189-2-22**] 07:40AM BLOOD WBC-12.6* RBC-3.25* Hgb-9.5* Hct-28.3*
MCV-87 MCH-29.2 MCHC-33.6 RDW-15.3 Plt Ct-197
[**2189-2-19**] 11:53PM BLOOD WBC-16.5* RBC-3.30* Hgb-9.7* Hct-27.7*
MCV-84 MCH-29.3 MCHC-34.9 RDW-15.6* Plt Ct-184
[**2189-2-19**] 07:12PM BLOOD WBC-19.1*# RBC-3.58* Hgb-10.4* Hct-30.8*
MCV-86 MCH-29.0 MCHC-33.8 RDW-14.9 Plt Ct-211
[**2189-2-24**] 08:00AM BLOOD PT-13.5* PTT-23.2 INR(PT)-1.2*
[**2189-2-26**] 07:40AM BLOOD Glucose-93 UreaN-7 Creat-0.7 Na-140 K-3.4
Cl-103 HCO3-29 AnGap-11
[**2189-2-25**] 08:15AM BLOOD Glucose-95 UreaN-7 Creat-0.5 Na-141 K-3.5
Cl-106 HCO3-28 AnGap-11
[**2189-2-19**] 11:53PM BLOOD Glucose-222* UreaN-11 Creat-0.6 Na-136
K-4.3 Cl-108 HCO3-21* AnGap-11
[**2189-2-19**] 07:12PM BLOOD Glucose-158* UreaN-12 Creat-0.7 Na-138
K-4.4 Cl-110* HCO3-19* AnGap-13
[**2189-2-27**] 07:10AM BLOOD ALT-41* AST-14 AlkPhos-53 Amylase-185*
TotBili-0.3
[**2189-2-26**] 07:40AM BLOOD ALT-54* AST-17 AlkPhos-59 Amylase-216*
TotBili-0.4
[**2189-2-25**] 08:15AM BLOOD ALT-60* AST-18 AlkPhos-52 Amylase-136*
TotBili-0.4
[**2189-2-27**] 07:10AM BLOOD Lipase-265*
[**2189-2-26**] 07:40AM BLOOD Lipase-360*
[**2189-2-25**] 08:15AM BLOOD Lipase-214*
[**2189-2-27**] 07:10AM BLOOD Albumin-3.0*
[**2189-2-26**] 07:40AM BLOOD Calcium-10.0 Phos-2.7 Mg-1.9
[**2189-2-25**] 08:15AM BLOOD Calcium-9.3 Phos-3.6 Mg-1.9
[**2189-2-24**] 08:00AM BLOOD Calcium-9.1 Phos-2.5* Mg-1.9
[**2189-2-22**] 09:15AM BLOOD Albumin-2.8*
.
CT ABDOMEN W/CONTRAST Study Date of [**2189-2-23**] 6:06 PM
IMPRESSION:
1. Status post left hepatectomy with associated postoperative
changes. JP
drain terminates near the surgical resection site adjacent to
segment VIII.
2. Small air-fluid collection within segment V of the liver.
This appearance could be consistent with surgical packing
material. Correlation with surgical history advised.
3. Small fluid-attenuation collection with a mildly enhancing
rim posterior to the gastric antrum may represent postoperative
fluid collection or early phlegmon.
4. Mild prominence of the right-sided biliary system. Lack of
complete
visualization of the CBD which may be related to postoperative
inflammatory change. Evidence of intra-abdominal and pelvic free
fluid.
5. Pathologically enlarged porta hepatis lymph node, as above,
likely
reactive.
6. A small amount of free intra-abdominal air consistent with
recent surgical history.
7. Left renal hypodense lesion, too small to characterize,
likely
representing a simple cyst.
8. Right hepatic 7-mm lesion, too small to characterize, likely
representing a simple cyst.
9. Probable uterine fibroid. This could be confirmed by pelvic
ultrasound on a non-emergent basis, as clinically indicated.
.
[**Date Range **] [**2189-2-24**]
Impression: Normal major papilla.
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique .A mild diffuse
dilation was seen at the main duct, right main hepatic duct,
left main hepatic duct stump and right intrahepatic biliary
branches with the CBD measuring 10mm in diameter . Mild
extravasation of contrast was noted at the left main hepatic
duct stump A 7cm by 10FR Cotton [**Doctor Last Name **] biliary stent was placed
successfully using a [**Company 2267**] Rx 10 Fr stent introducer
kit
.
Cytology Report CYST FLUID Procedure Date of [**2189-2-19**]
Diagnosis: NEGATIVE FOR MALIGNANT CELLS.
Blood and macrophages consistent with hemorrhagic cyst
contents. No epithelial cells present.
Brief Hospital Course:
Mrs.[**Doctor Last Name 33902**] operative course was complicated by increased blood
loss due to extensive involvement of cyst-like mass within
liver. EBL estimated at about 1800cc. She was transfused with 2
units of PRBC, and transferred for closer monitoring. Her
vitals, and clinical presentation were otherwise stable.
Epidural was initially placed for pain control, but discontinued
due to intra-operative blood loss. Patient was managed on a PCA.
Serial Hct's were monitored. HCT's stable. No other signs of
post-op bleeding noted. She was transferred to Stone 5 for post
op care.
.
Her diet was advanced slowly. RLQ JP drain with bilious ouput.
Bilirubin present in fluid. [**Doctor Last Name **] arranged for concern for
post-op biliary leak. IV Anitbiotics started. Stent placed.
Biliary leak stabilized. Diet advanced slowly once again
post-[**Doctor Last Name **]. Amylase and Lipase elevated related to [**Doctor Last Name **]. Labwork
re-checked. Both Amylase, Lipase, and WBC decreased. HCT stable.
Antibiotics discontinued. Tolerating a regular diet. No N/V.
.
Post-op recovery otherwise stable. Ambulating independently.
Foley removed. Urinating adequates amounts. Passing flatus. Pain
well contolled with oral medication. JP drain care & teaching
provided to patient. Demonstrated competence with care. Visiting
Nurses arranged for discharge to assist with JP care at home.
Patient advised to follow-up with Dr. [**Last Name (STitle) 1924**] in 1 week, and
follow-up with [**Last Name (STitle) **]/GI will be arranged in near future for
possible removal of stent.
Medications on Admission:
Primatene mist PRN
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain for 2 weeks.
Disp:*35 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation for 2 weeks: Take with
Hydromorphone.
Disp:*30 Capsule(s)* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/HA for 2 weeks: Do not exceed 4000mg
in 24hrs.
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Primary:
Large cystic mass arising from the left lobe of the liver,
likely biliary cystadenoma or cystadenocarcinoma.
Post-op blood loss anemia-treated with tranfusion
Post-op biliary leak
Post [**Hospital3 **] pancreatitis
.
Secondary:
1. Asthma.
2. Nephrolithiasis status post lithotripsy as well as status
post ureteroscopy and stone removal in [**2184**].
3. Cellulitis of the left leg x2.
Past Surgical History:
1. Status post C-sections x2.
2. Status post tonsillectomy at the age 19.
3. Status post a liver biopsy by needle for a small cyst
approximately six years ago. The results of this were apparently
a benign cyst and she was told that she needed no further
followup.
Discharge Condition:
Stable
Tolerating a regular diet
Adequate pain control with oral medication
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your staples will be removed at your follow-up appointment with
Dr. [**Last Name (STitle) 1924**]. Steri strips will be applied.
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
JP Drain Care:
-Please look at the site every day for signs of infection
(increased redness, swelling, odor, yellow or bloody discharge,
fever).
-Maintain the bulb deflated to provide adequate suction.
-Note color, consistency, and amount of fluid in drain. Call
doctor if amount increases significantly or changes in
character.
-Be sure to empty & strip the drain every 4 hours.
-You may shower, wash area gently with warm, soapy water.
-Maintain the site clean, dry, and intact.
-Avoid swimming, baths, hot tubs-do not submerge yourself in
water.
-Keep drain attached safely to body to prevent pulling
Followup Instructions:
1. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 7508**] Appointment should be
in [**5-29**] days
2. Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2189-3-20**] 8:00
3. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2189-3-20**] 8:00
Completed by:[**2189-2-27**]
|
[
"E878.6",
"285.1",
"211.5",
"V13.01",
"576.8",
"493.90",
"458.29",
"997.4",
"751.60",
"577.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22",
"87.53",
"50.3",
"51.87"
] |
icd9pcs
|
[
[
[]
]
] |
9114, 9175
|
6989, 8571
|
383, 576
|
9901, 9978
|
3162, 6966
|
12136, 12573
|
2581, 2906
|
8640, 9091
|
9196, 9590
|
8597, 8617
|
10002, 11039
|
11054, 12113
|
9613, 9880
|
2921, 2921
|
2935, 3143
|
275, 345
|
604, 1680
|
1724, 1881
|
2187, 2565
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,440
| 115,867
|
28022
|
Discharge summary
|
report
|
Admission Date: [**2151-6-13**] Discharge Date: [**2151-7-1**]
Date of Birth: [**2095-3-27**] Sex: F
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
SOB
Transfer for Management of Tamponade
Major Surgical or Invasive Procedure:
Pericadriocentesis with Drain Placement ([**6-13**])
Pericardial window procedure with drain ([**6-15**])
Right femoral central venous line ([**6-26**])
History of Present Illness:
56yo F with hx of metastatic ovarian CA s/p pericardial
effusion drained on [**5-19**] is transferred for recurrence of
pericardial effusion with tamponade physiology. The pt
initially presented to [**Hospital1 **] with shortness of breath. Was
found to have a pulsus of 15, HR 120, SBP120. ECHO at OSH
demonstrated tamponade physiology with RV collapse. Referred to
[**Hospital1 18**] for emergent pericardiocentesis. In the ED T 98.8, HR 114,
BP 131/79, RR 29, 100% on 3 LNC and facemask. At 5:00 pm,
underwent multiple sub-xyphoid punctures - 240 cc of bloody
fluid drained. Initial pericardial pressures were 13 mm and were
nearly 0 after removing the fluid. Pulsus was then 11 and HR
117. ECHO was done following the procedure. Pt was scheduled to
see CT surgery for a window as an outpt but develop symptoms
prior to appointment.
.
Patient denied fevers, chills, N/V, or chest pain. No abd pain,
back pain. Does have leg edema. When she had a pericardial
effusion several weeks ago, developed shortness of breath as
weel, was relieved with drainage of the effusion. Had 400 + ccs
of bloody fluid drained. Shortness of breath has been slowly
worsening since her last tap.
.
Past Medical History:
1. Ovarian CA metastatic to lungs originally diagnosed in '[**37**]
at which time the pt underwent TAH with recurrence in '[**45**]:
---s/p hysterectomy in '[**37**]
---s/p chemo with multiple regimens in past.
---hx of recurrent right pleural effusion s/p thoracentesis and
talc sclerosis therapy, plurex catheter placement on 6L chronic
home O2.
---hx of recurrent pericardial effusion with tamponade s/p
pericardiocentesis on [**2151-5-19**], [**2151-6-13**].
2. HTN
3. Hypothyroidism
4. Skin graft to left lower extremity due to opening of wound
of unclear reasons
5. s/p LLE fracture in '[**42**]
Social History:
Used to smoke 1 PPD but quit in [**2125**]. No ETOH. Lives with her
mother in [**Name (NI) 13040**], MA with [**Name (NI) 269**] who comes twice a day.
Family History:
Father: on blood thinners for ?CVA, on home oxygen
Mother: HTN
Physical Exam:
Upon Admission:
VS: 112, 127/84, 30, 90% on 6L NC.
GEN: Middle aged AA female sitting up in bed with pursed lip
breathing. Pt appears older than her stated age and appears to
be in some discomfort. Conversing in short sentences.
HEENT: PERRLA, EOMI, anicteric, no exophthalamus
NECK: JVD appreciated to angle of mandible at 60 to 70 degrees.
CHEST: CTA bilaterally anteriorly. The pt refused to sit up
saying it hurts too much. Drain in place with mild tenderness
to palpation.
ABD: dressing over umbilicus, distended, soft, NT, ND, BS+
EXT: wwp, 3+ edema bilaterally, LLE with erythema and warmth.
wound appears clean with good margins and granulation. No
drainage from wound itself (although pt reports clear drainage).
NEURO: A+O x3.
.
Upon Admission to MICU [**6-26**]:
VS - T98.3, BP 117/88, HR 118, O2 95% 6L
General - sedated, barely arousable female in NAD, breathing
heavily; awakes to loud voice and follows commands only after
repeated stimulation
HEENT - pupils small and minimally reactive, patient not opening
mouth
Neck - enlarged area of left parotid with surrounding erythema
CV - 2-3/6 holosystolic murmur loudest at apex.
Chest - mild wheezes, no crackles anterially (patient will not
sit up for exam)
Abdomen - distended, multiple firms masses bilaterally, +BS,
+wound from recent pericardial drain around epigastric area,
dressing c/d/i; + ascities
Ext - 1+ pitting edema bilaterally, wound bandaged on LLE.
Pertinent Results:
STUDIES:
EKG: sinus tachycardia at 112 bpm, LAD, TWF in I, inversion in
aVL, ? low voltage II, poor R wave progression
.
CK 23 Trop I < 0.04
.
[**2151-6-4**] ECHO: LV hyperdynamic systolic function, EF 75-80%, left
strium - normal, right strium - normal, aortic root - noral,
pericardium - moderate sized pericardial effusion with organized
material on the visceral pericardium, consistent with thrombus
or tumor, aortic valve - thickened, mitral valve - thickened,
tricuspid/pulmonic valves - normal, trace TR
.
[**2151-6-25**] CT Neck -
1. Severe parotitis without a focal sialolith. Etiology may be
infectious, related to chemotherapy, or idiopathic in nature.
No stone is identified. Several lymph nodes are seen in the
region of the enlarged left parotid gland, some of which may be
reactive in nature.
2. Extensive lymphadenopathy seen throughout the neck and
superior
mediastinum as well as the right axilla. Likely, these findings
are all metastatic in nature. Many of these lymph nodes are
calcified and may relate to psammomatous calcification given
history of ovarian cancer.
3. Soft tissue nodules in the right anterior chest and upper
right back are also likely metastatic in nature.
4. Diffuse lung metastases and probable metastatic lesions
within the lower cervical and upper thoracic spine.
Brief Hospital Course:
Patient is a 56 year old female with metastatic ovarian cancer
with history of recurrent pericardial effusions causing
tamponade originally admitted [**2151-6-13**] for SOB [**1-28**] tamponade,
treated with pericardiocentisis then pericardial window on
[**2151-6-15**]. Pt then developed severe right side parotiditis with
sepsis and was transferred to the MICU on [**2151-6-26**].
.
Shortly after her admission to the MICU, the patient became
diaphoretic and developed acute respiratory address (RR 30's, O2
sats 80s), and was intubated due to increased work of breathing.
She subsequently became hypotensive (MAP 50s), with cool,
mottled appearing lower extremities. A right femoral TLC was
placed and patient was begun on vasopressors
(levophed/vasopressin) and IVF boluses. The etiology of her
acute decompensation was felt likely to be sepsis caused by
transient bacteremia seeded from the partoiditis. Pt was status
post a course of nafcillin, and was begun on empiric treatment
with levoquin and unasyn per ENT recommendation.
.
# SEPSIS:
The most likely etiology was felt to be transient bacteremia
from parotiditis. However, evaluation for other sources of
infection included CXR, cultures of blood, urine, sputum, stool
for c. diff, and parotid gland. RUQ and abdominal ultrasound
were unremarkable for hydronephrosis, cholecystitis and ascites
(small amount, insufficient to tap). Evaluation for cardiogenic
sources of shock included enzymes (unremarkable), EKG, and
repeat ECHO. In addition, the femoral TLC (felt to be dirty)
was replaced with a subclavian TLC, and a right arterial line
was placed.
- continue treatment with unasyn/levoquin (started [**6-26**])
empirically.
- pt received single dose of vancomycin to cover for MRSA.
- continue levophed/vasopressin to maintain MAP > 60.
- cardiac enzymes unremarkable.
- hold home metoprolol.
.
# RESPIRATORY FAILURE:
Felt likely [**1-28**] sepsis induced acidemia in the setting of poor
pulmonary reserve (multiple metastatic pulmonary nodules). Pt
seen by ENT and felt that parotiditis was not likely to cause
airway compromise. Pt on 6L home O2 for chronic lung disease
felt likely [**1-28**] metastatic lung disease and treatment.
.
# PAROTITIS:
No stone seen on CT scan. Pt being followed by ENT. Most
common organisms are staph aureus, oropharyngeal flora, or GNR.
Parotid gram stain shows GPR. Plan is to continue treatment
with antiobiotics (unasyn, levo, vancomycin) started on [**6-26**],
warm compresses, massage as tolerated, sialigogues (once no
longer sedated), and agressive hydration.
- concern regarding further swelling of neck resulting in
respiratory obstruction felt unlikely by ENT. pt also at risk
for osteomyelitis of adjacent facial bone.
.
# ARF:
Baseline creatine ~1.2 up to 1.9 upon admission, felt most
likely prerenal (sepsis, prior lasix, poor PO intake). However,
given history of course of nafcillin for LLE cellulitis, urine
examined for eos (AIN). Other casues include post-renal
obstruction (ureter mets from ovarian ca), however abdominal usn
was negative for hydronephrosis.
.
# UGI BLEEDING:
Dark, maroon colored aspirate noted from NGT overnight [**6-26**]
during episode of acute respiratory failure and hypotension.
.
# CARDIAC TAMPONADE:
Pt is s/p repeat pericardiocentesis [**6-13**] (240cc) for recurrent
malignant pericardial effusions casusing tamponade, and
pericardial window procedure [**6-15**] (with removal of an infected
port-a-cath device) with placement of a chest tube for ongoing
drainage of ascites fluid [**1-28**] a presumed connection bewteen
abdominal and pericardial spaces. The chest tube was removed on
6/XX/06.
- EKG [**6-14**] showed q-waves in III and avF suggestive of prior MI.
- given pts recent episode of hypotension, serial cardiac
enzymes were performed to r/o a cardiogenic etiology, and were
unremarkable.
- ECHO ([**6-18**]) LVEF >55%. RV [**Male First Name (un) 4746**] normal. 1+ MR. Trivial
pericardial effusion.
- episode of X overnight [**6-26**], pt started on metoprolol.
.
# HYPOTHYROID:
- continue levothyroxine 62.5mg IV while not taking home dose
(125mcg PO QD).
.
# LLE WOUND:
The 5x2cm wound appears to be clean with good granulation, and
currently without edema/warmth. Pt is s/p a course of nafcillin
starting [**6-13**] for concern over cellulitis, and the wound is
being followed by wound care rn.
.
# METASTATIC OVARIAN CA:
Pt is being followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (covered by Dr. [**Last Name (STitle) **],
and per the most recent note has elected to pursue further
treatment which is being planned to follow the resolution of her
inpatient issues.
Medications on Admission:
ALLERGIES: Morhpine --> nausea
.
MEDICATIONS:
Levothyroxine 125mcg once daily
Lasix 80mg once daily
Aldactone 50mg TID
Coumadin 1mg QHS for port in place for chemo. no hx of DVT or PE
Benzonatate
Megace two teaspons [**Hospital1 **]
Reglan 15mg before meals TID
Pennkinetic suspension
Etoposide 2 pills/day
.
Discharge Medications:
Levothyroxine 125mcg once daily
Lasix 80mg once daily
Aldactone 50mg TID
Coumadin 1mg QHS for port in place for chemo. no hx of DVT or PE
Benzonatate
Megace two teaspons [**Hospital1 **]
Reglan 15mg before meals TID
Discharge Disposition:
Home
Discharge Diagnosis:
1)Cardiac Tamponade
2) Metastatic ovarian cancer
3) Hypertension
4) Hypothyroidism
Discharge Condition:
.
Discharge Instructions:
Please take medications as indicated.
Treatment of ovarian cancer per oncologist (Dr. [**Last Name (STitle) **].
Followup Instructions:
.
Completed by:[**2151-8-9**]
|
[
"244.9",
"196.0",
"584.9",
"428.0",
"518.84",
"V10.43",
"276.52",
"599.0",
"577.0",
"197.6",
"527.2",
"707.05",
"427.1",
"038.9",
"682.6",
"197.0",
"996.62",
"785.52",
"423.0",
"198.89",
"401.9",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.05",
"96.72",
"38.93",
"37.12",
"88.72",
"37.0",
"96.6",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10661, 10667
|
5367, 10061
|
309, 464
|
10794, 10797
|
4026, 5344
|
10958, 10989
|
2494, 2558
|
10421, 10638
|
10688, 10773
|
10087, 10398
|
10821, 10935
|
2573, 2575
|
229, 271
|
495, 1678
|
2589, 4007
|
1700, 2309
|
2325, 2478
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,066
| 150,975
|
21401
|
Discharge summary
|
report
|
Admission Date: [**2183-6-28**] Discharge Date: [**2183-7-12**]
Date of Birth: [**2123-5-13**] Sex: M
Service: CSU
ADMISSION ILLNESS: This is a 60-year-old man with history of
MI at the age of 38 and a triple vessel CABG in [**2168**]. He had
an MI 6 years ago, which presented with chest pain. He has
been treated with medication since his last MI and has been
symptom-free. On the morning of [**2183-6-28**], the patient woke
with chest pain described as heaviness over his chest as well
as nausea without vomiting, palpitations, radiation of pain,
or shortness of breath. He was transferred to [**Hospital1 18**] by
ambulance. En route, he took nitroglycerin to alleviate
chest pain. In total, he presented with chest pain that had
lasted for 1 hour and spontaneously resolved.
PAST MEDICAL HISTORY: MI at age 38 and MI at age 54.
PAST SURGICAL HISTORY: Triple-vessel CABG in [**2168**].
ALLERGIES: No known drug allergies.
MEDICATIONS: On admission,
1. Folic acid 1 mg p.o. q.d.
2. Atenolol 50 mg p.o. q.d.
3. Atorvastatin 20 mg p.o. q.d.
4. Allopurinol, dosage unknown.
5. Norvasc 5 mg p.o. q.d.
6. Aspirin 81 mg p.o. q.d.
PHYSICAL EXAMINATION: On exam, this is a well-developed, 60-
year-old man. Vital signs: Temperature 97.6, heart rate 60,
blood pressure 136/84, respiratory rate 20, saturating 98
percent on room air. General: He is in no acute distress.
HEENT: Pupils equal, round, and reactive to light.
Extraocular eye movements intact. Neck: Benign. Chest:
Lungs are clear to auscultation bilaterally. Cardiovascular:
Regular rate and rhythm, S1 and S2 present, no murmur.
Abdomen: Soft, nontender, nondistended, positive bowel
sounds. Extremities: Full distal pulses, no edema, no
cyanosis.
LABORATORY DATA: On his admission labs, he had a chem-7 and
CBC. Sodium 137, potassium 5.0, chloride 105, bicarbonate
21, BUN 25, creatinine 1.5, glucose 133. White blood cells
8.2, hemoglobin 15.4, hematocrit 44.1, and platelets 194.
Magnesium 2.0, calcium 9.5, phosphorous 3.3. PT 13.6, INR
1.2, PTT 37.6. ALT 31, AST 37, LDH 360, alkaline phosphatase
79, amylase 105, total bilirubin 0.5, CPK 199, CK-MB 5, and
troponin was negative x1. EKG, abnormal Q in leads 3 and
aVF. No ST elevation, no inverted T-waves. QRS duration is
slightly prolonged at 128 ms.
HOSPITAL COURSE: The patient was taken to the cath lab on
[**2183-6-30**]. The assessment and recommendations of the cath lab
were CT Surgery for evaluation for CABG, echocardiogram, and
admission to the Cardiology Service.
While in the hospital, the patient was also followed by the
GI Service for his falling hematocrit and melena. They
performed an EGD on him on [**2183-7-2**], which found normal
esophagus and findings that are compatible with gastritis.
They recommended to follow up on Helicobacter pylori serum
antibody and treatment if positive as well as pantoprazole 40
mg b.i.d. as long as he was on antiplatelet agents as well as
following his hematocrit.
The patient was admitted to the Cardiothoracic Service and
went to the Operating Room on [**2183-7-7**] for a CABG x1,
thoracotomy off pump. He did well in the Surgery with
minimal blood loss and was transferred to the CSRU where he
stayed until [**2183-7-8**] and was transferred to the floor at
that time. He continued to do well on the floor. His diet
was advanced as well as his activity. He was able to void
and move his bowels and was discharged in good condition on
[**2183-7-11**].
DISCHARGE DIAGNOSES: Status post coronary artery bypass
grafting x1, [**6-20**].
Status post coronary artery bypass grafting x3 in [**2168**].
Status post myocardial infarctions.
DISCHARGE MEDICATIONS:
1. Atorvastatin calcium 20 mg tablet p.o. q.d.
2. Aspirin 81 mg p.o. q.d.
3. Folic acid p.o.
4. Oxycodone/acetaminophen 5/325 mg 1-2 tablets p.o. q.4 h.
p.r.n. pain.
5. Clopidogrel bisulfate 75 mg tablet p.o. q.d.
6. Allopurinol p.o.
7. Metoprolol tartrate 25 mg 3 tablets p.o. b.i.d.
FOLLOWUP RECOMMENDATIONS: The patient should follow up with
Dr. [**Last Name (STitle) 70**] in 1 month.
The patient should also follow up with his local cardiologist
in [**7-26**] days.
DR [**First Name (STitle) **] R,[**Doctor Last Name **] 02.358
Dictated By:[**Doctor First Name 4772**]
MEDQUIST36
D: [**2183-7-13**] 06:29:38
T: [**2183-7-13**] 08:00:09
Job#: [**Job Number 56526**]
|
[
"410.71",
"584.9",
"414.01",
"V45.81",
"535.50",
"412",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"88.56",
"36.11",
"99.04",
"88.53",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
3518, 3679
|
3702, 4401
|
2345, 3496
|
889, 1166
|
1189, 2327
|
833, 865
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,766
| 183,472
|
26139
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 64848**]
Admission Date: [**2183-1-12**]
Discharge Date: [**2183-3-12**]
Date of Birth: [**2183-1-12**]
Sex: M
Service: NB
REASON FOR ADMISSION:
1. Prematurity (29-3/7 weeks gestation).
2. Respiratory distress syndrome.
MATERNAL HISTORY: Baby boy [**Known lastname **] was born to 21-year-old G2,
P0+1 mother with prenatal screens: A+, antibody negative,
HBsAg negative, RPR NR, rubella immune, GBS unknown.
Her pregnancy was complicated by pre-term labor for which she
was admitted on [**2182-12-15**]. She received magnesium sulfate
and a complete course of betamethasone. She had premature rupture
of membranes on [**2182-12-27**]. She proceeded for vaginal
delivery on [**2183-1-12**]. She had no significant past
medical history apart from appendectomy in [**2181**].
BIRTH HISTORY: Infant emerged in good condition with good
tone and spontaneous cry. Routine neonatal resuscitation with
drying, bulb suctioning and stimulation was done. Apgars were
9 and 9 at 1 and 5 minutes respectively. Brief CPAP was
applied after 5 minutes of age for retractions. He was
transferred to NICU in view of prematurity and RDS.
PHYSICAL EXAMINATION ON ADMISSION:
weight: 1565 grams (75-90th percentile), length 43 cm (75-90th
percentile), head circumference 28.5 cm (75th percentile).
General: On CPAP with mild retraction and intermittent
grunting, non-dysmorphic, head normal, palate/clavicles
intact. Respiratory: Bilateral good aeration, cardiovascular,
regular rate and rhythm, no murmur, bilateral femoral pulses
palpable; abdomen: Soft, bowel sounds present. GU: Normal
male genitalia. Testes bilateral descended, patent anus.
Spine/extremities: No sacral anomalies, hips stable.
Extremities: Pink and well perfused.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: The
initial course and chest x-rays was consistent with
respiratory distress syndrome. He was started on CPAP soon
after birth but needed intubation in view of respiratory
deterioration. He received 2 doses of Surfactant. He was
successfully extubated to CPAP on the second day of life and
subsequently to nasal cannula oxygen on the third day of
life. However,he had a protracted course with nasal cannula
oxygen requirement up to 36 +6 weeks corrected age after
which he was successfully weaned to room air. At the time of
discharge he has been comfortably breathing in room air for
more than 5 days prior to discharge. He was started on Diuril
for his chronic lung disease along with potassium and sodium
supplements for associated dyselectrolytemia. He continues
on the Diuril therapy at the time of discharge with the aim to
stop the medication in the coming 1-2 weeks once he outgrows his
dose. He also had evidence of apnea of prematurity which was
managed with caffeine. Caffeine was stopped by the third week of
life. He had had no apneas or bradycardias for at least 5 days
prior to discharge home.
Cardiovascular: He showed no evidence of hypotension and
inotropic requirement in the first week of life. He did not
show evidence of significant PDA. He did have intermittent
murmur heard over the last 2 weeks which is felt to be a
benign flow murmur.
Fluids, Electrolytes and Nutrition: Baby [**Known lastname **] was initially
commenced on IV fluids D10-W at 80 mls per kilo per
day. Feeds were introduced on the second day of life and
gradually advanced to a maximum of 150 mls/kd/d of breast
milk 28/PE 28 by one month of age for better weight gain. He
received parenteral nutrition in the first week of life
during the phase of feed advancement. At the time of
discharge he is on ad lib E20 PO feeds taking more then
130 mls/kg/d. Weight at discharge is 3440g.
GI: He had no significant gastrointestinal problem. [**Name (NI) **]
received phototherapy for exaggerated physiologic jaundice
with a maximum bilirubin of 9.2 mg/dl on day of life 6.
Hematology: He received packed red blood cell transfusion on
day of life 19 for anemia of prematurity with a hematocrit of
27. Subsequently he remained well requiring no further
transfusion. His last hematocrit was 26.5 on [**2183-2-27**].
Infectious Diseases: He received intravenous antibiotics for
the first 48 hours of life for sepsis rule out. He had no
episodes of suspected or proven sepsis.
Neurology: Cranial ultrasound scan on DOL 5, 30 and at discharge
were all normal. However, over the last 2-3 weeks there have been
concerns about his neurological examination in the form of
involuntary clonic jerks of all 4 limbs when awake as well as
with hypertonia of limbs. In view of the clinical
concerns despite normal head ultrasound scans he was evaluated by
the neurology team at the [**Hospital3 1810**]. The investigations
included serum electrolytes, liver function tests, ammonia,
lactate and urine organic acid and amino acids. Most of these
results have proved to be normal. Serum organic acid/aminoacid is
pending at the time of the discharge. He will also need an MRI
scan at term age which will be organized by the neurology
department at [**Hospital3 1810**].
Ophthalmology: His last ROP screening on [**2183-2-24**] has
immature zone 3 ROP. A follow-up examination is scheduled in 3
weeks time.
Psychosocial: [**Hospital1 18**] social work has been involved with the family
to provide support. There are currently no social concerns.
CONDITION ON DISCHARGE: Well.
DISCHARGE DISPOSITION: Home.
PRIMARY CARE PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) 4320**] [**Last Name (NamePattern1) **], Tel: [**Telephone/Fax (1) 13770**].
CARE RECOMMENDATIONS: 1. Feeds at discharge: ad lib p.o.
feeds of E20 with a minimum of 130 mls per kilo per day
2. On diuril therapy: Should outgrow the dose in [**12-16**] weeks after
which it may be stopped if baby continues to be well from
respiratory standpoint.
MEDICATIONS:
1. Ferrous sulphate (25mg/ml) 0.5 ml po once daily
2. Diuril 32 mg po twice a day
Car seat position screening - passed.
State newborn screening status - normal to date.
IMMUNIZATIONS: Received:
Hepatitis B vaccine on [**2183-2-5**]
Synagis on [**2183-1-30**] and [**2183-3-12**]
Pediarix, PCV7 & HIB vaccine [**2183-3-11**]
Immunizations recommended:
1. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following 3 criteria: 1. Born at less than 32 weeks, 2.
Born between 32 and 35 weeks with 2 of the following:
Daycare during RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities, or school
age siblings; or 3. With chronic lung disease.
2. Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age (and for the first 24 months of the child's life),
immunization against influenza is recommended for household
contacts and out of home caregivers.
Follow-up appointment scheduled or recommended:
1. Primary care pediatrician - 2 to 3 days following
discharge.
2. VNA
3. Neonatal Neurology Program-[**Telephone/Fax (1) 36468**]
4. IFUP Program
5. ophthalmology ROP screen followup
DISCHARGE DIAGNOSIS:
1. Prematurity (29-3/7 weeks gestation).
2. Respiratory distress syndrome and chronic lung disease.
3. Apnea of prematurity.
4. Hyperbilirubinemia
5. Anemia of prematurity.
6. Hypertonia and clonus - normal cranial ultrasound scan.
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Name8 (MD) 64849**]
MEDQUIST36
D: [**2183-3-12**] 07:31:26
T: [**2183-3-12**] 08:59:18
Job#: [**Job Number 64850**]
|
[
"782.3",
"V29.0",
"776.6",
"769",
"E944.4",
"V05.3",
"781.0",
"775.5",
"770.81",
"779.3",
"765.25",
"770.7",
"765.16",
"V50.2",
"779.89",
"553.1",
"V30.00",
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icd9cm
|
[
[
[]
]
] |
[
"64.0",
"96.71",
"99.04",
"96.6",
"93.90",
"99.83",
"99.15",
"96.04",
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icd9pcs
|
[
[
[]
]
] |
5396, 5542
|
7161, 7651
|
5565, 5574
|
1802, 5340
|
5588, 6155
|
6182, 7140
|
1199, 1773
|
5365, 5372
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,424
| 138,646
|
50120
|
Discharge summary
|
report
|
Admission Date: [**2114-3-7**] Discharge Date: [**2114-3-12**]
Date of Birth: [**2069-4-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
hypertension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient initially presented to the emergency department on the
morning of admission with 2 days of abdominal pain, nausea, and
vomiting. Regarding the vomiting, she reports emesis with
yellow/green without food and with occasional streaks of blood.
Her emesis has improved with zofran in the ED. Additional review
of systems was notable for the following:
- malaise
- subjective fevers, night sweats, and chills
- decreased PO intake x 2 days due to nausea
- patient's xanax was recently discontinued by her PCP (at least
one week ago), and she then received valium from the ED on
[**2114-2-27**] for abdominal pain
- last heroin use one week ago
.
Upon arrival to the ED, temp 96.5, HR 94, BP 241/157, RR 18, and
99% RA. While in the [**Name (NI) **], pt received zofran 2mg IV x 2,
promethazine 25mg IV x 1, Clonidine .3mg PO x 1, Hydralazine
20mg IV x 2, diazepam 5mg PO x 1, morphine 2mg IV x 1, ativan
2mg IV x 2, and nitro gtt. She also received approximately 3L of
NS. CXR and labs were unremarkable. While in the ED, her blood
pressure remained elevated from 180-230/130-150, her heart rate
increased from 90s to 120-130s, and she developed an oxygen
requirement of approximately 4L. Her blood pressure was 222/58
and she was 96% on 4L upon transfer to the [**Hospital Unit Name 153**].
Past Medical History:
1. Hypertension
2. Asthma
3. Hepatitis C
4. IVDU
5. Chronic Pain - possible diagnoses of fibromyalgia or lupus
Social History:
Home: was previously staying at homeless shelter and recently
moved in with her sister and sister's family
Occupation: previously employed as a dog groomer, has not worked
in several years
EtOH: previous history of alcoholism while patient worked as a
bartender in the 80s; previous drink of choice was whiskey
Drugs: history of IVDU, primarily heroin, last use was 1 week
ago but was previously clean x 5 years
Tobacco: [**12-13**] cigs/week, history of 20 PPY history
Family History:
Noncontributory
Physical Exam:
T 98.4 / RR 12 / BP 178/116 / HR 127 / RR 15 / Pulse ox 99% 4L
Gen: resting comfortably in bed, NAD
HEENT: dry mucous membranes, 2cm white rounded lesion on hard
palate with erythematous surroundings
NECK: Supple, No LAD, No JVD
CV: RR, tachycardic. NL S1, S2. No murmurs, rubs or gallops
LUNGS: CTA, BS BL, No W/R/C
ABD: Obese, Soft, NT, ND. NL BS. No HSM
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions or IV marks noted
NEURO: A&Ox3. Appropriate. CN 2-12 intact. Preserved sensation
throughout. 5/5 strength throughout. Normal coordination. Gait
assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2114-3-11**] 08:00AM BLOOD WBC-3.2* RBC-5.35 Hgb-15.2 Hct-45.8
MCV-86 MCH-28.4 MCHC-33.1 RDW-13.3 Plt Ct-481*
[**2114-3-7**] 08:40AM BLOOD WBC-7.1 RBC-5.76* Hgb-16.1* Hct-48.5*
MCV-84 MCH-28.0 MCHC-33.2 RDW-13.1 Plt Ct-543*
[**2114-3-10**] 07:45AM BLOOD Neuts-36* Bands-2 Lymphs-40 Monos-14*
Eos-3 Baso-2 Atyps-2* Metas-0 Myelos-1*
[**2114-3-7**] 08:40AM BLOOD Neuts-75.7* Lymphs-19.6 Monos-3.0 Eos-1.3
Baso-0.5
[**2114-3-11**] 08:00AM BLOOD Plt Ct-481*
[**2114-3-9**] 05:24AM BLOOD PT-12.0 PTT-29.7 INR(PT)-1.0
[**2114-3-8**] 05:53AM BLOOD PT-17.7* PTT-38.6* INR(PT)-1.6*
[**2114-3-11**] 08:00AM BLOOD UreaN-9 Creat-0.8 Na-138 K-4.2 Cl-105
HCO3-21* AnGap-16
[**2114-3-7**] 08:40AM BLOOD Glucose-181* UreaN-7 Creat-0.8 Na-133
K-4.3 Cl-94* HCO3-23 AnGap-20
[**2114-3-7**] 08:40AM BLOOD ALT-21 AST-30 AlkPhos-118* TotBili-0.5
[**2114-3-7**] 08:40AM BLOOD Lipase-16
[**2114-3-10**] 07:45AM BLOOD Mg-1.8
[**2114-3-8**] 05:53AM BLOOD Calcium-9.3 Phos-3.3 Mg-1.8
[**2114-3-8**] 05:53AM BLOOD Osmolal-277
[**2114-3-7**] 08:40AM BLOOD Acetone-TRACE
[**2114-3-8**] 05:53AM BLOOD TSH-0.41
[**2114-3-9**] 05:24AM BLOOD Cortsol-9.3
[**2114-3-7**] 08:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2114-3-8**] 12:09PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.006
[**2114-3-8**] 12:09PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2114-3-7**] 11:30AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.014
[**2114-3-7**] 11:30AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2114-3-7**] 11:30AM URINE RBC-0 WBC-0-2 Bacteri-MOD Yeast-NONE
Epi-[**2-14**]
[**2114-3-8**] 10:33PM URINE Hours-RANDOM UreaN-566 Creat-65 Na-217
[**2114-3-10**] 11:56AM URINE UCG-NEGATIVE
[**2114-3-8**] 10:33PM URINE Osmolal-644
[**2114-3-8**] 12:09PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2114-3-8**] 8:24 am SWAB Source: roof of mouth. R/O HSV AND
VZV.
GRAM STAIN (Final [**2114-3-8**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
WOUND CULTURE (Final [**2114-3-10**]):
MODERATE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES)
CONSISTENT
WITH OROPHARYNGEAL FLORA.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed (including a screen for Pseudomonas
aeruginosa,
Staphylococcus aureus and beta streptococcus).
Susceptibility will be performed on P. aeruginosa and S.
aureus if
sparse growth or greater.
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Final [**2114-3-8**]):
SPECIMEN NOT PROCESSED DUE TO: DUPLICATE TEST REQUEST.
PLEASE REFER TO VARICELLA-ZOSTER CULTURE.
TEST CANCELLED, PATIENT CREDITED.
VARICELLA-ZOSTER CULTURE (Preliminary): No Virus isolated
so far.
AP PORTABLE CHEST, [**2114-3-7**] AT 09:01 HOURS
HISTORY: [**Female First Name (un) **] drug abuse with chills, nausea, and fever.
COMPARISON: None.
FINDINGS: The lungs are well expanded and clear. The mediastinum
is unremarkable. The cardiac silhouette is within normal limits
for size. No effusion or pneumothorax is evident. The visualized
osseous structures are unremarkable.
IMPRESSION: No acute pulmonary process.
NON-CONTRAST HEAD CT: There is no hemorrhage, hydrocephalus, or
shift of normally midline structures. The visualized paranasal
sinuses and mastoid air cells remain normally aerated.
IMPRESSION: No hemorrhage.
Cardiology Report ECG Study Date of [**2114-3-8**] 10:37:50 AM
Sinus rhythm. Non-specific T wave flattening. Poor R wave
progression.
Compared to tracing #1 the T wave flattening is new and the ST
segment
depression is less pronounced.
TRACING #2
Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
80 156 78 394/429 72 65 71
Cardiology Report ECG Study Date of [**2114-3-7**] 7:45:00 AM
Sinus rhythm. Tall inferior P waves. Possible right atrial
abnormality.
Non-specific inferior ST segment depression. Compared to the
previous tracing
of [**2113-9-22**] ST segment changes are new and the P waves are
taller.
TRACING #1
Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
93 150 76 358/415 77 61 74
([**Numeric Identifier 104628**])
Brief Hospital Course:
1. Hypertension - unclear why BP was so high. Pt denied med
noncompliance. Creatinine was stable. Possibilities include
benzodiazepine withdrawal as pt reports that she was recently
taken off of alprazolam, however was given diazepam within the
last week. Shortly after admission to the ICU, her blood
pressures improved to the 110s/80s; however after restarting her
first dose of clonidine and an increased dose of HCTZ 25, her
blood pressures decreased to 80s/40s. Her blood pressure
improved with IVF and she was then continued on
hydrochlorothiazide 25 alone.
On floor, she was hypertensive to 190SBP. Hence started on
nifedipine and HCTZ. However, BP dropped with this to SBP 80's
and responded to fluids. The patient BP was labile and could
have been from abrupt stopping of clonidine in ICU. Low dose
clonidine was started and fair BP control was achieved.
The patient (on he floor) denied any illicit drug use. SW
visited the patient.
Noted to have a palate ulcer, seen by ENT who recommended swab
(neg as above) and magic mouthwash. ENT follow up arranged on
day of discharge to biopsy this ulcer if indicated.
Asthma remained stable.
Leucopenia and abnormal differential was noted. Pt was advised
to follow up in PCP's office.
The patient was not given a narcotic prescription at discharge
due to concerns noted in PCP/PNP notes at [**Company 191**].
Medications on Admission:
1. Hydrochlorothiazide 12.5mg PO qdaily
2. Clonidine 0.3mg PO tid
3. Valium 5mg 1 tablet PO q6h (last filled on [**2114-2-27**] - 15
pills)
4. Motrin 600mg (12 pills on [**2114-2-27**])
5. Percocet (15 pills - [**2114-2-27**])
6. Citalopram 40mg PO daily
7. Albuterol neb prn
8. Albuterol inhaler prn
9. Advair (500/50)
10. Promethazine 25mg
11. Singulair 10mg daily
Discharge Medications:
1. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*0*
2. Maalox/Diphenhydramine/Lidocaine
Maalox/Diphenhydramine/Lidocaine 5 mL PO QID prn
swish and spit. Do not swallow.
for 7 days.
3. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
6. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
four times a day as needed for shortness of breath or wheezing.
7. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Inhalation twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertension, malignant
Abnormal differential count
Oral ulcer
Leucopenia
Discharge Condition:
stable
Discharge Instructions:
You were treated for very high blood pressure. The medications
have been adjusted and please refer to the new list for
medications.
Follow up with your primary care doctor, nurse practioner for
further BP checks. You will also need a follow up blood
test(CBC, diff) with your primary care doctor. This was abnormal
here in the hospital and should be rechecked at the next
appointment on [**2114-3-13**]. If abnormality remains you may need
further work up.
Follow up with the ENT specialist for the ulcer in your mouth.
Followup Instructions:
Please follow-up with your ENT doctor Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 66245**] at 2:30pm
on Monday [**3-12**] at 2:30pm. His office is located at [**Location (un) **].
Provider: [**Name10 (NameIs) 4617**] [**Name8 (MD) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 7976**] Date/Time:[**2114-3-13**]
2:45
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5259**], [**Name12 (NameIs) 1046**] Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2114-3-19**] 12:30
|
[
"493.90",
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"V10.01",
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"V15.81",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10088, 10094
|
7577, 8945
|
327, 333
|
10212, 10221
|
2985, 6494
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10791, 11311
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2297, 2314
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9363, 10065
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10115, 10191
|
8971, 9340
|
10245, 10768
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2329, 2966
|
275, 289
|
361, 1658
|
6503, 7554
|
1680, 1793
|
1809, 2281
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,561
| 151,520
|
15983
|
Discharge summary
|
report
|
Admission Date: [**2159-8-1**] Discharge Date: [**2159-8-12**]
Date of Birth: [**2082-11-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2159-8-3**] Cardiac Catheterization
[**2159-8-7**] Aortic Valve Replacement(21mm Pericardial Valve) and
Mitral Valve Replacement(31mm Tissue Valve)
History of Present Illness:
This is a 76 yo female w/ PMH of severe AS, MR secondary to
rheumatic heart disease presenting with progressive dyspnea on
exertion much worse since Monday. Pt. started noticing chest
discomfort which she is unable to characterize, tingling down
both arms and feeling of racing heart a/w dyspnea while walking
short distances on monday. These symptoms lasted about 5 minutes
and resolved after sitting down to rest. Pt. noticed these
symptoms came on this morning around 7:30 at rest and did not
resolve until around noon. These symptoms were not a/w
diaphoresis or nausea. Pt. had a minor heart attack while
hospitalized for elective knee surgery, she states that it did
not feel like these symptoms, she did not feel pain at that
time, she just had a sensation of not being able to get
comfortable in bed. Pt. also complains of a feeling of the room
spinning as she went to sleep last night, there was only one
episode of this. Pt. denies lightheadedness/syncope. Denies
orthopnea, PND, sleeps on 1 pillow. Her leg edema is at
baseline. She currently denies shortness of breath and chest
discomfort. She was admitted to the [**Hospital1 18**] under the cardiology
service.
Past Medical History:
Diabetes type 2, dx 5ya
CHF - EF 30% - Class I-II
h/o Rheumatic heart disease with mod-sev AS (peak gradient 60,
mean gradient 30, [**Location (un) 109**] 0.7 cm2), and mod MS (MVA 1.2cm2)
LBBB
Hypercholesterolemia.
Osteoarthritis.
Rotator cuff tear
Fibroid uterus.
Venous insufficiency.
Diverticulitis.
Aortic stenosis.
Atrial fibrillation on chronic anticoagulation
PAST SURGICAL HISTORY:
1. Status post bowel resection for her diverticulitis.
2. Status post TAH/BSO.
3. Status post total knee replacement, bilateral
Social History:
She is from [**Country 2559**], bilingual but speaks mostly
Italian. She is married, lives with her husband, has two grown
children. She is a retired cafeteria worker among others. No
tobacco use, no alcohol use, no drug use.
Family History:
Positive for CAD in several family members,
positive for an unknown malignancy in her father, and positive
for leukemia in her mother. [**Name (NI) **] family history of diabetes or
hypertension.
Physical Exam:
VS - 97.8, 124/83, 79, 18, 97% RA
Gen: Comfortable appearing women in NAD, breathing comfortably
HEENT: Mucous membranes mildly dry
Neck: JVD to earlobes
CV: High pitched crescendo/decrescendo murmur at ULSB radiating
to carotids.
Chest: Crackles to midlung, decreased resonance to percussion to
midlung bilaterally
Abd: Soft, NT, ND, ? hepatojugular reflux.
Ext: Chronic stasis changes in lower extremities bilaterally,
varicose veins in lower extremities.
Skin: stasis dermatitis
Pertinent Results:
[**2159-8-1**] 05:45PM BLOOD WBC-9.9 RBC-3.52* Hgb-10.1* Hct-31.3*
MCV-89 MCH-28.8 MCHC-32.3 RDW-15.1 Plt Ct-368
[**2159-8-1**] 03:31PM BLOOD PT-25.6* INR(PT)-2.5*
[**2159-8-1**] 05:45PM BLOOD Glucose-132* UreaN-27* Creat-1.0 Na-141
K-4.7 Cl-106 HCO3-27 AnGap-13
[**2159-8-1**] 05:45PM BLOOD CK(CPK)-40
[**2159-8-1**] 05:45PM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2159-8-2**] 11:18AM BLOOD %HbA1c-6.4*
[**2159-8-2**] 07:10AM BLOOD Triglyc-115 HDL-35 CHOL/HD-3.5 LDLcalc-64
[**2159-8-1**] 05:45PM BLOOD TSH-1.0
[**2159-8-1**] EKG: Atrial fibrillation, mean ventricular rate 86. Left
bundle-branch block.
[**2159-8-1**] CXR: Since the prior study, the degree of pulmonary
vascular congestion and increased interstitial markings has
increased. There is no pneumothorax or pleural effusion. Severe
cardiomegaly persists.
[**2159-8-2**] ECHO:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is moderate global left ventricular
hypokinesis (LVEF = 35 %) (Quantitative biplane EF 41%).
Transmitral Doppler and tissue velocity imaging are consistent
with Grade III/IV (severe) LV diastolic dysfunction. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic arch is mildly
dilated. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is severe aortic valve
stenosis (area <0.8cm2). Trace aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. There is mild
valvular mitral stenosis (area 1.5-2.0cm2). Moderate (2+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
[**2159-8-3**] Cardiac Cath:
1. Selective coronary angiography of this right dominant system
revealed
no angiographically apparent obstructive coronary disease.
2. Resting hemodynamics recorded during AF with a ventricular
rate of
90, demonstrated elevated left and right sided filling pressures
(mean
PCW 29 mmHg, RVSP 68 mmHg, RVEDP 12mmHg). There was moderately
severe
pulmonary hypertension (PA s/d/m = 66/30/47 mmHg). The
calculated
cardiac index was 2.6 l/min/m2. The catheter was not advanced to
the LV
to assess transaortic gradients or LV pressures as the main
purpose of
this limited study was to assess her coronary anatomy.
3. Left ventriculography was not performed.
[**2159-8-4**] Chest CT Scan:
1. Dense aortic valve and aortic root calcifications. Mild
calcifications
involving ascending aorta, and aortic arch. Mitral valve
calcifications.
2. 10-mm nodule in the left lower lobe, concerning for
malignancy. If no
prior studies are available for comparison, FDG - PET/CT can be
performed to further evaluate this nodule.
3. Diffuse predominantly perihilar ground-glass opacity, likely
reflecting
presence of congestive failure in the setting of cardiomegaly.
[**2159-8-12**] 07:00AM BLOOD WBC-7.9 RBC-2.83* Hgb-8.6* Hct-24.3*
MCV-86 MCH-30.5 MCHC-35.5* RDW-15.9* Plt Ct-229
[**2159-8-12**] 07:00AM BLOOD Plt Ct-229
[**2159-8-12**] 07:00AM BLOOD PT-18.1* PTT-30.6 INR(PT)-1.7*
[**2159-8-12**] 07:00AM BLOOD Glucose-116* UreaN-22* Creat-0.7 Na-136
K-3.9 Cl-100 HCO3-29 AnGap-11
Brief Hospital Course:
Mrs. [**Known lastname 45777**] was admitted under cardiology and started on a
Lasix drip for worsening heart failure. She ruled out for
myocardial infarction. She underwent right and left heart
catheterization which found minimal coronary artery disease and
revealed moderate pulmonary hypertension and moderate
biventricular diastolic dysfunction. Given the above findings,
cardiac surgery was consulted and further evaluation was
performed. Workup was notable for a one centimeter left lower
lobe non-calcified pulmonary nodule, concerning for malignancy.
This pulmonary nodule will be further evaluated as an outpatient
following surgery. Preoperative evaluation was otherwise
unremarkable and she was cleared for surgery. On [**8-7**],
Dr. [**Last Name (STitle) 914**] performed aortic and mitral valve replacments. For
surgical details, please see seperate dictated operative note.
She was transferred to the intensive for further hemodynamic
monitoring. Amiodarone was started for ventricular tachycardia
post op which she converted after it was bolused. POD 1 she was
extubated with out complications and weaned from pressors. She
continued to progress and was transferred to the floor POD 2.
Physical therapy worked with her on strength and mobility. She
was transfused POD 4 for decreased hematocrit with no
complications. She was ready to transfer to rehab on POD 5.
Medications on Admission:
ATORVASTATIN [LIPITOR] - 20 mg Tablet - 1 (One) Tablet(s) by
mouth once a day
DIGOXIN - 125 mcg Tablet - one tab by mouth once a day
FUROSEMIDE [LASIX] - 40 mg Tablet - 1 Tablet(s) by mouth once a
day as needed for as needed for swelling
LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth once a day
METFORMIN - 500 mg Tablet - 1 Tablet(s) by mouth twice a day
METOPROLOL SUCCINATE - 100 mg Tablet Sustained Release 24 hr -
one Tablet(s) by mouth twice a day
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth qam Take on an empty stomach. Wait 15-20min prior to
eating or drinking anything.
WARFARIN - 3 mg Tablet - 1 Tablet(s) by mouth once a day as
prescribed
Medications - OTC
CYANOCOBALAMIN [VITAMIN B-12] - 1,000 mcg Tablet - 1 Tablet(s)
by
mouth once a day
Discharge Medications:
1. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day:
please check INR biweekly, goal INR 2-2.5 for atrial
fibrillation.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours): twice a day for 1 week then decrease to daily, monitor
weight and edema .
9. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours): twice a day then decrease to daily with lasix.
10. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
14. medications
unable to start ACE inhibitor due to blood pressure - discussed
with Dr [**First Name (STitle) 437**] will start as outpatient
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Aortic and Mitral Valve Disease/Rheumatic Heart Disease
Chronic Atrial Fibrillation s/p LAA ligation
Acute on Chronic Systolic heart failure
Remote Myocardial Infarction
Dyslipidemia
Type II Diabetes Mellitus
Pulmonary Nodule
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) 914**] in [**3-24**] weeks, call for appt
Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] in [**1-21**] weeks, call for appt
Dr. [**Last Name (STitle) **] in [**1-21**] weeks, call for appt
Currently scheduled appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2159-12-4**] 10:30
Completed by:[**2159-8-12**]
|
[
"459.81",
"412",
"416.8",
"746.9",
"272.0",
"427.1",
"250.00",
"428.23",
"E878.8",
"427.31",
"396.8",
"715.90",
"398.91",
"V43.65",
"401.9",
"518.89",
"V58.61",
"426.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.70",
"35.21",
"37.23",
"39.61",
"35.23",
"99.04",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
10193, 10287
|
6510, 7894
|
340, 493
|
10557, 10564
|
3217, 6487
|
11075, 11537
|
2501, 2699
|
8733, 10170
|
10308, 10536
|
7920, 8710
|
10588, 11052
|
2111, 2241
|
2714, 3198
|
281, 302
|
521, 1697
|
1719, 2088
|
2257, 2485
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,754
| 146,152
|
20609
|
Discharge summary
|
report
|
Admission Date: [**2111-2-1**] Discharge Date: [**2111-2-22**]
Date of Birth: [**2043-2-6**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Left humerus fracture
Major Surgical or Invasive Procedure:
Open reduction and internal fixation of L humerus fracture.
History of Present Illness:
Ms [**Known lastname 4610**] is a 67yo woman with a history notable for renal
cell carcinoma diagnosed [**2107**] s/p left nephrectomy. She has
known mets to brain, bone, lungs, adrenal gland and abdominal
cavity. She is currently s/p 2 cycles of chemotherapy. On [**1-28**],
she felt her arm give way while pushing open a door, and was
taken to [**Hospital3 **] Hospital, where she was diagnosed with a left
humerus fracture. She was transferred to [**Hospital1 18**] on [**2-1**] to the
orthopedic service. A skeletal survey showed a right distal
humeral metastatic lesion as well. The patient underwent an
uncomplicated ORIF on [**2111-2-3**] preceded by a "preembolization" of
the lesion by IR. Radiation oncology saw her and planned on
doing outpatient xrt. However approximately 3 days post-op, she
developed abdominal distension, decreased bs, and then began
vomiting bilious liquid. A CT head to look for increased ICP was
done and was negative and additionally the known cerebellar
lesion seen on MRI was not seen. She was diagnosed with an ileus
and NGT was placed to suction. General surgery began following
the patient. She developed decreased UOP and was transferred on
[**2-9**] to the SICU for closer fluid management. The patient
received > 8 L of fluid (difficult to track exact amount) while
in the ICU and CVPs were consistently 15. Patient had CT torso
while in the unit which showed adynamic ileus, no large/small
bowel obstruction, new pulmonary, mesenteric, right adrenal
metastases. Patient was transferred to the floor on [**2-10**] with
NGT which is now clamped with low residuals of about 100 cc
every four hours. She was started on TPN during this time and
has continued on this. She has begun to have liquid stools and
flatus. She has had continued decreased urine output that has
not responded to .5-1 L boluses but has responded to IV lasix.
She has been markedly hypokalemic and has required aggressive
repletion.
The patient currently reports no chest pain, no sob, slight
abdominal tenderness in mid epigastrium. NO fevers or chills or
sweats.
Past Medical History:
Renal cell carcinoma
-dx [**2107**] s/p left nephrectomy
-recurrence [**1-30**] with noted ulmonary mets and adrenal mass
-s/p IL2 x 2 cycles
-MRI with cerebellar met [**8-2**], s/p SRS but lesion still present
-s/p path fx left humerus on this admit and ORIF
Hypertension
S/p appendectomy
S/p lap chole
S/p hysterectomy
S/p D+C
Social History:
The patient is single. Her brother is her hcp. She previously
worked in the family business which was real estate.
+ tobacco use, quit 5 years ago, 20 p-y history
-no history of heavy etoh use, none now
Family History:
Non-contributory.
Physical Exam:
PE:
VS T 97.9 Tm 98 BP 110/60 (102-110/60) HR 70-92 RR 20 98% 2 L
91% RA
GEN: obese, mild resp distress, + wheeze, aaox3
HEENT: PERRL, EOMI, dry mm
CV: RRR S1S2 distant hs no mrg appreciated
LUNGS: anterior clear, no wheezes
ABD: obese, nondistended, bruising from sq hep, very rare bs,
mild tenderness to palpation diffusely, no rebound/guarding
EXT: 2+ edema b/l LE to shins
Pertinent Results:
wbc 9 - hct 33.3 -plt 199
na 142 - k 2.3 - cl 108 -co2 28 -bun 23 -- cr 1.0
ca 7.7 -- mg 1.5 -- p 2.7
ucx [**2-12**] > 100,000 enterococcus, >100,000 gram positive cocci
ua [**2-12**]> 1.010 mod bld 15 rbc 2 wbc occ bact
ct torso [**2-9**]
CT OF THE ABDOMEN WITH IV CONTRAST: There is a new pleural-based
mass at the right base measuring 2.0 x 3.9 cm. Adjacent
atelectatic changes and a tiny right-sided pleural effusion are
also present. Otherwise, the appearance of multiple pulmonary
nodules noted at the left base is similar. The large cystic
lesion in the liver has an unchanged appearance. Surgical clips
are seen in the gallbladder fossa consistent with prior
cholecystectomy. The pancreas and spleen are unremarkable. The
right kidney is unremarkable. There is a new right adrenal mass
measuring 10 x 25 mm. The size of the previously described
lesion in the left nephrectomy bed, however, is somewhat smaller
and measures 3.5 x 4.4 cm in axial dimensions.
There are new mesenteric masses in the upper abdomen. One
measures 17 x 36 mm and the second one 12 mm in diameter. There
is no retroperitoneal lymphadenopathy or free air. A small
amount of perihepatic ascites is noted, however. Edema seen
extensively in the subcutaneous soft tissues.
A nasogastric tube lies in suitable position with its tip in the
distal stomach. Contrast passes into the proximal jejunum only.
More distally, the small bowel is mostly filled with fluid.
There is fecal material and gas in the colon. There are areas of
mild small bowel dilatation, and segments of mild colonic
dilatation as well, most notably in the transverse colon.
However, no transition point is seen, and the overall pattern is
consistent with adynamic ileus.
CT OF THE PELVIS WITH IV CONTRAST: There is a Foley catheter in
the urinary bladder. There is no pelvic lymphadenopathy or free
fluid. Subcutaneous edema is noted. Fluid and fecal material are
seen in the rectum and sigmoid.
BONE WINDOWS: There are no suspicious lytic or blastic lesions.
IMPRESSION:
1) Likely adynamic ileus with no evidence of small or large
bowel obstruction.
2) More extensive metastatic disease as described.
[**2-8**] ct head
FINDINGS: There is no intra or extra-axial hemorrhage, shift of
normally midline structures, or change in the size of the
ventricles. The [**Doctor Last Name 352**]-white matter differentiation remains
intact. There is no new evidence of a major vascular territorial
infarct. There is a stable area of low attenuation in the left
basal ganglia, which could represent a lacunar infarct. The
known left cerebellar hemisphere and cerebellar vermis masses
are not appreciated on this study. There is no new mass effect.
The paranasal sinuses and osseous structures are unremarkable.
IMPRESSION: No intracranial hemorrhage or new mass effect. The
known cerebellar masses are not appreciated on this study. Note
should be made that MRI is the preferred method of modality to
evaluate the posterior fossa.
Brief Hospital Course:
##Ortho: pt underwent ORIF without complications as described in
the HPI. She remained stable and B arms were made non-weight
bearing. She also has tumor in right humerus and should be moved
carefully given high risk of pathologic fracture of right
humerus. She will receive radiation to her arms by rad onc as
described below. She will follow up with ortho in 2 weeks with
Dr. [**First Name (STitle) 4223**] ([**Telephone/Fax (1) 55088**].
.
## GI: As described above, she had a KUB that showed adynamic
ileus. After bowel rest with NGT to suction for several days she
began passing liquid stools. She continued to have some nausea
and preferred not to take solid po's for this reason. She had no
vomiting. Her abdominal exam remained with some slight
tenderness in the LUQ and periumbilical region, but there was no
rebound or guarding. She complained mostly of gas and bloating
with diarrhea which continues to improve slowly day by day. She
was treated with anzimet and simethicone with some relief. Her
diet should be advanced as tolerated and TPN weaned as more po's
are tolerated. Diarrhea should be monitored and anti-motility
agents held.
.
## Respiratory: The pt continued to complain of SOB and DOE. She
appeared clinically volume overloaded, although CXR was
difficult to interpret [**12-31**] her size. She was diuresed with lasix
20mg IV tid and showed significant improvement. She also had
audible wheezes on exam although she states she has no h/o
asthma or COPD. She was treated with RTC albuterol and atrovent
nebs and improved clinically. Volume status should be evaluated
and maintenance dose of lasix 40mg po qd should be adjusted as
needed.
.
## Rad Onc: attempt was made to get an MRI to prepare the
patient for SRS. However, the pt would not tolerate an MRI [**12-31**]
discomfort with lying flat (felt SOB) and pain with having to
pull her arms in tightly. She was given morphine and ativan but
still was unable to tolerate the exam. Rad onc decided that her
brain met was not critical at this time and the pt could
possibly undergo the MRI at a later date when she was feeling
better. Subsequently, they tried to perform the planning/marking
procedure to prepare her arms for radiation, however, she was
unable to tolerate this procedure as well. Her rad onc doctor
decided it would be best to wait until she was more comfortable
to proceed with further radiation. She will follow up with rad
onc on Tuesday, [**3-3**]. She may need to be admitted after
this for repeated rad onc treatments. Please call the rad onc
office to discuss this before her appointment.
.
## HTN: BP's were originally slightly high and ACEi and beta
blocker were restarted and BP's returned to good range. With
diuresis her BP's started to trend more on the lower side, and
these meds were held. Her BP should be monitored and if it
trends back up the ACE and BB should be restarted.
.
## ID: Pt had a urine cx with enterococcus and GPC. However,
there was no significant pyuria so the pt was not treated with
antibiotics. No evidence of bacteremia - blood cultures were
negative. She remained afebrile and foley was changed and pt
remained asymptomatic.
.
##Hypokalemia: the pt developed diarrhea and required aggressive
potassium regimen to keep her K level up. Her K was stable after
adjusting her TPN accordingly. This should be followed as the
pt's diet is advanced and she no longer requires TPN. Likely
while she remains on lasix she will need some potassium
replacement.
.
## FEN: the pt was started on TPN and has continued on this
while she has not been able to take adequate po's. Efforts were
made to restrict the amt of fluid given and the solution was cut
down to 1500ml. She may need further adjustments to keep up with
her electrolytes.
.
##PPx: pt was given SQ heparin, and PPI.
.
## Code status: Full code
.
## Access: PICC placed in R antecubitus on [**1-18**].
Medications on Admission:
Meds on Transfer
1. Lasix 20 iv x 2 doses
3. Mg
3. ISS
4. Protonix 40
5. Metoprolol 25 [**Hospital1 **]
6. Morphine 1 mg
7. SQ heparin tid
8. Quinapril 6 mg qd
Discharge Medications:
1. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
2. Hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
3. Quinapril HCl 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. 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*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
L humerus fracture
Discharge Condition:
Good.
Discharge Instructions:
Please take all medications as prescribed. Do not drive while
taking narcotic pain medications. IF you develop fever, chills,
worsening arm pain/swelling, discharge from the wound, or other
concerning symptoms, please contact our office. Please follow up
with Dr [**First Name (STitle) 4223**] in 3 weeks, please call her office to schedule
that appointment.
Followup Instructions:
Please follow up with Dr [**First Name (STitle) 4223**] in 3 weeks, please call her
office to schedule that appointment.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"560.1",
"791.9",
"997.4",
"V10.52",
"198.5",
"276.8",
"733.11",
"197.6",
"197.0",
"584.9",
"428.0",
"198.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.82",
"96.07",
"84.55",
"38.93",
"99.15",
"79.31",
"38.98"
] |
icd9pcs
|
[
[
[]
]
] |
11089, 11168
|
6490, 10375
|
292, 354
|
11231, 11238
|
3484, 6467
|
11645, 11899
|
3052, 3071
|
10586, 11066
|
11189, 11210
|
10401, 10563
|
11262, 11622
|
3086, 3465
|
230, 254
|
382, 2463
|
2485, 2815
|
2831, 3036
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,907
| 114,688
|
25065
|
Discharge summary
|
report
|
Admission Date: [**2133-9-27**] Discharge Date: [**2133-9-29**]
Date of Birth: [**2103-5-24**] Sex: M
Service: NEUROSURGERY
Allergies:
Inapsine
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Fulminant hepatic failure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
30y/o M with HIV presented to [**Hospital 11485**] Hospital on AM of
admission with nausea/vomiting x2 days, abdominal pain. 5 days
PTA, pt felt that his ears were blocked with decreased hearing.
Went to PCP 3 days PTA, who diagnosed him with swimmer's ear and
asthma given his wheezing. He was given a nebulizer and a Rx
for his ears and an inhaler; pt did not fill prescription. Pt's
partner left town; pt states he felt worse the following day.
By 2 days PTA, pt was confused, with slurred speech and
inappropriate responses to questions. Called ambulance to come
to the hospital.
Pt's partner states that pt has not been receiving pain meds for
his BKA and amputated toes, as he was told this was phantom pain
and he was instructed to take Tylenol. For the past 5 years,
pt's partner has been buying him a bottle of 50 tablets weekly.
More recently, pt's partner has been finding empty bottles of
tylenol, as well. 2 days PTA, also found 2 empty bottles of
aspirin.
Over the past few years, pt has been more depressed due to BKA
and decreased functionality. Has lost a few jobs. Pt's partner
feels that he is not suicidal. In addition, pt has not taken
HAART during the last few days.
At [**Name (NI) 11485**], pt's labs were notable for INR 10.6, lactate 16.1,
anion gap 38. RUQ ultrasound revealed gallstones. Pt was given
8 units FFP, 2 doses mucomyst. He was intubated, sedated, and
paralyzed, and eventually required levophed prior to his
transfer. In addition, he had an episode of coffee-ground
emesis during intubation, and his Hct dropped from 54 to 36. In
addition, he was noted to be hypoglycemic into the 30s, which
responded with D50.
Past Medical History:
1. HIV - CD4 count 600s about 6 months ago, VL ~60,000
2. s/p BKA in setting of sepsis/renal failure thought to be [**3-4**]
brown recluse
3. Burkitt's lymphoma - [**2127**], s/p chemo, thought to be in
remission
Social History:
Pt has partner of >10 years. + tobacco, more recently, up to
about 2ppd, total duration 14 years. No alcohol. Occasional
MJ, more in the last few years. Does office work, has been
working temp jobs recently.
Family History:
DM2 - father, PGM
no liver disease
Physical Exam:
VS: 99.5 127/46 133 30 95% AC 450x30/15/1.0
Gen: intubated, sedated, paralyzed
HEENT: pupils dilated, reactive to light; mild chemosis; ear
canals with blood and erythema bilaterally, difficult to
visualize tympanic membranes
Neck: no cervical LAD
CV: tachycardic, regular, nl S1/S2, no murmurs appreciated
Pulm: coarse breath sounds bilaterally, monophonic whistle at L
base; no diffuse wheezes
Abd: soft, mildly distended, +hepatomegaly to about 4
fingerbreadths below the costal margin and fullness detected in
midline; + BS, no other masses
Ext: warm, 2+ distal pulse in LLE; RLE with BKA; stigmata of
skin graft on L anterior leg; toe amputations on LLE; no
splinter hemorrhages noted
Neuro: sedated, paralyzed - could not assess further
Pertinent Results:
Admission labs:
CBC:
WBC-8.1 RBC-3.82* HGB-13.7* HCT-39.3* MCV-103* MCH-36.0*
MCHC-34.9 RDW-14.7
NEUTS-90.3* BANDS-0 LYMPHS-8.9* MONOS-0.8* EOS-0 BASOS-0
PLT SMR-NORMAL PLT COUNT-63*
coags:
PT-23.7* PTT-38.0* INR(PT)-3.7
electrolytes:
GLUCOSE-152* UREA N-21* CREAT-1.3* SODIUM-145 POTASSIUM-3.6
CHLORIDE-111* TOTAL CO2-19* ANION GAP-19
ALBUMIN-3.5 CALCIUM-8.0* PHOSPHATE-5.1* MAGNESIUM-1.9
LFTs:
ALT(SGPT)-4833* AST(SGOT)-4359* LD(LDH)-6600* ALK PHOS-164*
AMYLASE-216* TOT BILI-3.4* LIPASE-344*
ABG:
7.09 63/81 on AC 450x30/15/1.0
CXR: bilateral airspace disease, no effusions, R IJ and NG tube
in proper place
.................
CT Head [**2133-9-28**]
Reason: BLOWN RT PUPIL, ? HERNIATION
[**Hospital 93**] MEDICAL CONDITION:
30 year old man with blown pupil
REASON FOR THIS EXAMINATION:
Herniation
CONTRAINDICATIONS for IV CONTRAST: None.
PROCEDURE: CT HEAD WITHOUT CONTRAST.
INDICATION: 30-year-old male with fulminant hepatic failure and
blown pupil. Question herniation.
TECHNIQUE: Non-contrast CT of the head was performed.
CT OF THE HEAD WITHOUT CONTRAST: There is global hypodensity of
the brain parenchyma with loss of [**Doctor Last Name 352**]-white matter
differentiation, as well as diffuse effacement of the sulci and
basilar CSF spaces. Increased density is also noted within the
basal cistern spaces. There is no shift of the normally midline
structures, or CT evidence of brain herniation. There is a focus
of encephalomalacia within the right occipital lobe from likely
prior traumatic or ischemic insult. Bone window show no
suspicious lesions. Mucosal sinus soft tissue thickening is seen
within the imaged portions of the maxillary, ethmoid, and
sphenoid sinuses. This is likely secondary to the patient's
intubation.
IMPRESSION:
1. Global edematous swelling of the brain parenchyma with loss
of the [**Doctor Last Name 352**]- white differentiation. Findings could relate to a
global hypoxic/ischemic event with secondary diffuse infarction.
However, this could represent diffuse swelling without
infarction in a patient with fulminant hepatic faliure, in which
case return to normal is possible.
2. Increased density of the basilar cistern spaces, which may be
artifactual in appearance given the adjacent low density of the
brain parenchyma. However, the possibility of subarachnoid blood
or meningeal infection cannot be excluded. Recommend correlation
with CSF fluid sampling if clinically appropriate.
....................
[**2133-9-28**]
RUQ US
IMPRESSION:
1. Normal son[**Name (NI) 493**] appearance of the liver.
2. Cholelithiasis. Edematous gallbladder wall. These findings
are frequently seen in patients with liver failure and
hypoalbuminemia. The gallbladder is not abnormally distended.
3. Mild splenomegaly.
...................
Brief Hospital Course:
A/P: 30y/o M with HIV presents with fulminant hepatic failure
after tylenol overdose.
.
# Respiratory failure/ARDS - Likely etiology was
multifactorial, including fulminant hepatic failure, possible
aspiration, PNA, shock. Pt remained intubated and paralytics
were removed but the patient was unable to remain synchronized
with the ventilator so these were restarted. Maintained on low
tidal volume strategy with HOB elevated. Pt had borderline
acceptable oxygenation and ventilation and required high levels
of PEEP and FIO2 to maintain O2 sats. Ceftazidime for poss
Pseudomonal ear infx as below, azithromycin, and vancomycin for
empiric coverage of pneumonia given bilateral opacities were
started. Bronch was planned for when patient was stable.
However, the patient clinically worsened. He was noted to have
a blown pupil and CT Head was done which showed diffuse brain
edema, poor [**Doctor Last Name 352**]/white matter differentiation, and new stroke.
With such poor prognosis d/t fulminant hepatic failure with
resultand increased intracranial pressure and elevated INR, bolt
was not placed. The patient was DNR and a family discussion was
had with mother and partner where it was decided to removed
endotracheal tube in setting of poor prognosis. The patient had
a respiratory arrest approx 20 minutes after ETT was removed.
He was pronounced dead at 0030 on [**2133-9-29**]
# Fulminant hepatic failure - Likely cause was tylenol
hepatotoxicity. HAART could also have contribution, as
efavirenz can cause transaminitis, and Combivir can cause
hepatomegaly, hyperbilirubinemia, transaminitis, and
hyperamylasemia. Liver team was involved who recommended FFP PRN
and Vit K daily. Initially full workup was planned with [**Doctor First Name **],
AMA, hep serologies, HCV, alpha antitrypsin. Liver transplant
team was contact[**Name (NI) **] but the patient was not deemed a candidate
d/t HIV status. RUQ ultrasound with Dopplers performed which
excluded vascular causes of FHF. Supportive treatment was
maintained but the patient continued to decline and developed
increased intracranial pressure as above.
.
# Upper GI bleed - Pt with coffee ground emesis at OSH, but
presented with stable Hct and this remained stable. Likely
cause d/t coagulopathy in setting of liver failure. [**Hospital1 **] IV PPI
given, 2 large bore IV's, typed and crossed. Did not continue
to bleed, so no EGD was done.
.
# HIV - HAART held, as some meds may have contributed to
hepatotoxicity.
.
# Otitis externa - pt with bilateral ear bleeding, difficult to
visualize TMs; appeared that pt had erythematous ear canals.
Plan was for further workup by ENT, but this did not happen
before death.
.
# Acidosis - Respiratory acidosis, anion gap metabolic acidosis
due to lactate and renal failure. Supported intravascular
volume, treated infection with above antibiotic regimen.
.
# Acute renal failure - Pt with Cr 0.5 at OSH, presented to
[**Hospital1 18**] at 1.3 here. Likely was d/t tylenol toxicity and
hypoperfusion in setting of hypotension.
.
# Code - DNR
.
# Communication: partner [**Name (NI) **] ([**Telephone/Fax (1) 62907**] (home) - HCP
mom [**Name (NI) 2894**] ([**Telephone/Fax (1) 62908**]
Medications on Admission:
sustiva 600mg po qHS
combivir 150mg/300mg po bid
tylenol
Discharge Medications:
In-hospital medications:
Acetylcysteine (IV) 4900 mg IV Q4H
Ceftazidime 2g IV Q 8H
Vancomycin HCl 1000 mg IV Q 12H
Azithromycin 500 mg IV Q24H
Midazolam HCl 0.5-2 mg/hr IV DRIP INFUSION
Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION
Norepinephrine 0.03-0.25 mcg/kg/min IV DRIP TITRATE TO titrate
to MAP > 60
Pantoprazole 40 mg IV Q12H
Vitamin K 10mg SC daily x3 days
Discharge Disposition:
Expired
Discharge Diagnosis:
Fulminant hepatic failure d/t tylenol toxicity
ARDS
Renal failure
Coagulopathy
Increased intracranial pressure
Discharge Condition:
Deceased
Discharge Instructions:
Deceased. No autopsy desired by family.
|
[
"E850.4",
"995.94",
"380.10",
"578.9",
"042",
"570",
"431",
"V49.75",
"286.7",
"965.4",
"200.20",
"518.81",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"99.05",
"96.6",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
9845, 9854
|
6112, 9345
|
299, 305
|
10008, 10018
|
3311, 3311
|
2487, 2523
|
9452, 9822
|
4045, 4078
|
9875, 9987
|
9371, 9429
|
10042, 10085
|
2538, 3292
|
234, 261
|
4107, 6089
|
333, 2003
|
3328, 4008
|
2025, 2242
|
2258, 2471
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,123
| 177,717
|
53429
|
Discharge summary
|
report
|
Admission Date: [**2143-7-22**] Discharge Date: [**2143-8-2**]
Service: MEDICINE
Allergies:
Coreg Cr
Attending:[**First Name3 (LF) 10842**]
Chief Complaint:
Drop in HCT and generalized weakness
Major Surgical or Invasive Procedure:
Selective coronary artery angiography with right and left heart
catheterization and percutaneous coronary intervention
History of Present Illness:
Ms. [**Known lastname 48684**] was admitted to the medical floor after presenting
with a drop in her Hct and generalized weakness x 1 week. In the
ED her initial vitals were T 98 BP 134/73 AR 82 RR 18 O2 sat 98%
RA. Denies bloody or black tarry stools. Upon transfer to the
medical floor, she became acutely SOB. Her BP was 170/90 with
oxygen saturation of 84-85% on RA. Cxray at the time consistent
with pulmonary edema. She was given Lasix 20mg IV x2 and
Morphine with mild improvement in her symptoms. She was
transferred to the MICU for non-invasive ventilation and closer
monitoring. ABG at this time was 7.34/44/56. She was immediately
placed on non-invasive ventilation.
.
Upon further questioning the patient denies any fevers, chills,
chest pain, SOB, PND, or orthopnea. She does admit to increasing
LE edema over the past several days. She has been compliant with
all her medications.
Past Medical History:
1)CAD s/p MI ([**2115**], [**2120**])
2)Monomorphic VT s/p ablation
3)Hypertension
4)Hyperlipidemia
5)OSA on BiPap
6)Diabetes mellitus, type 2
7)Osteoporosis
8)Recent shingles
10)Vertigo
Social History:
No history of alcohol use. Smoked 3pks/day for 30yrs, quit 25yrs
ago.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Physical Exam:
vitals T 93 BP 153/85 AR 101 RR 26 O2 sat 87% NRB
Gen: Patient in severe respiratory distress, breathing rapidly
HEENT: MMM
Heart: Distant heart sounds
Lungs: Course breath sounds throughout
Abdomen: soft, NT/ND, +BS
Extremities: [**11-27**]+ pitting edema bilaterally
Rectal: Guiac positive
Pertinent Results:
[**2143-7-23**] 10:15AM BLOOD WBC-6.4 RBC-3.59* Hgb-10.5* Hct-31.2*
MCV-87 MCH-29.2 MCHC-33.6 RDW-15.3 Plt Ct-190
[**2143-7-24**] 05:00AM BLOOD PT-15.5* PTT-35.7* INR(PT)-1.4*
[**2143-7-23**] 04:41PM BLOOD Glucose-165* UreaN-15 Creat-0.8 Na-128*
K-3.4 Cl-90* HCO3-29 AnGap-12
[**2143-7-23**] 12:40AM BLOOD CK(CPK)-48
[**2143-7-23**] 10:15AM BLOOD CK(CPK)-57
[**2143-7-23**] 04:41PM BLOOD CK(CPK)-54
[**2143-7-22**] 02:40PM BLOOD Calcium-8.8 Phos-4.0 Mg-1.9
[**2143-7-23**] 12:40AM BLOOD VitB12-839
[**2143-7-23**] 01:19AM BLOOD Type-ART pO2-56* pCO2-44 pH-7.34*
calTCO2-25 Base XS--2
.
[**2143-7-22**] EKG:
Technically difficult study
Probable sinus arrhythmia
First degree A-V block - intraventricular conduction delay
Late R wave progression - consider anterior myocardial
infarction
QT interval prolonged for rate
ST-T wave changes are nonspecific
Since previous tracing of [**2143-5-13**], QTc interval may be
miscalulated on last tracing
.
[**7-23**] CXR:
FINDINGS: Comparison to the previous study from [**2143-7-23**] at
8:16 a.m. Interstitial densities in the lungs bilaterally are
essentially unchanged or slightly worse compared to the previous
exam, possibly reflecting mild worsening in pulmonary edema. The
cardiomediastinal silhouette is unchanged. Retrocardiac opacity
is compatible with consolidation and/or atelectasis. There is a
left-sided pleural effusion. No pneumothorax is seen. Hilar
contours are stable. Osseous structures are within normal
limits.
IMPRESSION:
Slight increase in interstitial markings is compatible with
slightly worsened pulmonary edema. Retrocardiac opacity
compatible with consolidation and/or atelectasis. Left-sided
pleural effusion, stable.
.
[**2143-7-24**] Cardiac cath:
COMMENTS:
1. Coronary angiography in this right-dominant system revealed
two-vessel disease.
--The LMCA had no angiographically apparent disease.
--The mid-LAD had a 60% tubular lesion with a small aneurysm.
--The LCx had no angiographically apparent disease.
--The RCA was a large dominant vessel with a complex 90%
stenosis in the
mid-RCA.
2. Resting hemodynamics revealed mildly elevated RVEDP of 9
mmHg.
Elevated left-sided filling pressures were observed, with a PCWP
mean of
20 mmHg. There was mild pulmonary arterial systolic
hypertension with
PASP of 39 mmHg. The PVR was mildly elevated at 168
dynes-sec/cm5. The
SVR was within normal limits at 1053 dynes-sec/cm5. Systemic
arterial
pressures were normal. The cardiac index was preserved at 2.6
L/min/m2.
3. Successful PTCA and stenting of the mid RCA with a Driver
(3.5x24mm)
bare metal stent which was postdilated to 3.75 mm. Final
angiography
revealed a focal 10% residual stenosis, no angiographically
apparent
dissection and TIMI III flow (See PTCA comments).
FINAL DIAGNOSIS:
1. Two-vessel coronary artery disease.
2. Elevated left-sided filling pressures
3. Mild pulmonary arterial systolic hypertension.
4. Successful PTCA and stenting of the mid RCA vessel with a
bare metal
stent.
5. Patient should be maintained on aspirin 325mg daily.
Patient should
also remain on plavix 75mg po daily for a minimum of 1 month,
preferably
3-6 months.
.
[**2143-7-25**] ECHO:
The left atrium is mildly dilated. The estimated right atrial
pressure is 5-10 mmHg. There is mild symmetric left ventricular
hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is severely depressed (LVEF= 25 %). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened. 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. The pulmonary artery
systolic pressure could not be determined. Significant pulmonic
regurgitation is seen. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2143-5-2**],
left ventricular function appears similar.
.
[**7-29**] CXR:
There is continued mild congestive failure, although this
appears to be slightly improved since the prior study. There is
continued moderate opacification of the right upper lobe, which
could represent focal pneumonia. The heart is mildly enlarged.
Small right pleural effusion, improved with residual minimal
blunting of the right costophrenic angle.
IMPRESSION:
1. Improved congestive failure.
2. Right upper lobe infiltrate concerning for pneumonia.
.
Labs on discharge:
WBC 3.8
HCT 30.2
PLTs 205
INR 2.1
Glucose UreaN Creat Na K Cl HCO3 AnGap
119* 18 0.8 130* 3.4 91* 30 12
HgA1c 6.7
TSH 28
Ft4 0.78
Brief Hospital Course:
Ms. [**Known lastname 48684**] is an 84yo female with PMH significant for CAD, DM
2, and HTN who originally presented for work up for low Hct and
weakness. She subsequently became acutely SOB on the floor and
was found to have flash pulmonary edema. Pt was transferred to
the MICU. An EKG showed new ST depressions in the inferior leads
suggestive of underlying ischemia. Pt was started on heparin
gtt, and her asa, BB were continued. At that time, pt refused
any interventional measures such as a cath. Subsequently, pt
had a recurrent episode of SOB and tachypnea and found to have a
recurrent episode of pulmonary edema. The EKG showed new T wave
inversions in teh anterior/septal leads. Pt was treated with
Lasix, morphine, nitro and asa and the heparin gtt continued. Pt
evaluated by cardiology and an echo was performed she went to
cath were a BMS was placed in her RCA.
.
NSTEMI: BMS to RCA. Peak CK 57, peak trop 0.07. Initially on
ASA/plavix/heparin but was crossed over from heparin to coumadin
(given h/o PE) and ASA stopped as her hct was trending down and
she was found to have guiac + stool (has not had a colonoscopy).
Never had chest pain during her hospital course. Continued on
Atorvastatin 40 mg daily.
.
Blood-loss and iron-deficiency anemia: Patient was initially
admitted to [**Hospital1 **] given drop in Hct from low 30's to 28. In
addition, she has been feeling more weak and tired. Per OMR and
patient, she has not had a colonscopy. Vitamin B12 levels
suboptimal in the past (<200) but currently not on any
supplements. Guiac positive on admission. She was transfused 2
U PRBC w/ appropriate bump in hct. Iron supplementation was
started. MMA level pending on discharge. Hematocrit should be
followed as an outpatient and consideration for colonscopy
should be discussed.
.
Leukopenia: she was noted to be leukopenic with WBC count as low
as 2.4 during hospital course (ANC 1650). Hematology was
consulted and no cause for her leukopenia could be identified
except for possibly captopril use.
- Her WBC could should continue to be followed as an outpatient
w/ hematology follow-up.
.
Hypothyroidism: she was found to have TSH of 20 with a FT4 of
0.78. Endocrine was consulted and she was started on
Levothyroxine 25 mcg daily, to be increased to 50 mcg daily in 2
weeks. Likely from amiodarone. Will follow-up with Dr.
[**Last Name (STitle) **] in clinic in 8 weeks. Anti TPO and anti TG antibodies
were neg. Antiparietal cell AB neg.
.
Hyponatremia: Patient presented with Na of 123. Per OMR, this is
a chronic problem for the patient and likely [**12-28**] CHF. Her Na
has decreased to as low as 122 on a prior admission. Her level
improves once she is appropriately free water restricted.
- Free water restriction~1-1.5L/day
.
DM2: Oral agents held until 2 days after cath at which point
metformin/glyburide was re-started. SSI was continued prn.
Last HgA1c 6.7.
.
Chronic pulmonary emboli: Patient was found to have incident
pulmonary embolus prior to admission and was subsequently
started on anticoagulation with Coumadin. Concerned whether
acute respiratory decline is due to extension of her PE given
subtherapeutic INR, but less likely now given setting of acute
ischemia that may account for decline in respiratory status.
Therapeutic on coumadin on D/C. O2 sats 98% on RA on discharge.
.
Hypertension: Patient on beta-blocker as outpatient.
Uncontrolled SBPs may have resulted in her acute respiratory
distress.
-switched from metoprolol [**Hospital1 **] to XL, valsartan added with
excellent BP control by discharge.
.
OSA: BiPAP at night with home mask.
.
Anxiety: low dose ativan prn w/ buspirone
Medications on Admission:
Atorvastatin 40 mg
Aspirin 81 mg QD
Metoprolol Tartrate 25 [**Hospital1 **]
Docusate Sodium 100 mg [**Hospital1 **]
Senna 8.6 mg [**Hospital1 **]
Lorazepam 0.5 mg QHS
Amiodarone 400 mg QD
Rosiglitazone 2mg PO daily
Warfarin 2.5mg PO HS
Glyburide-Metformin 5-500mg PO daily
Lasix 3x/week
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Buspirone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): It is very important that you take this every day.
Disp:*30 Tablet(s)* Refills:*2*
4. Valsartan 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Glyburide-Metformin 5-500 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
7. Senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as
needed for constipation.
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
9. Rosiglitazone 2 mg Tablet Sig: One (1) Tablet PO once a day.
10. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)): as prescribed for goal INR [**12-29**].
11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
12. Oxycodone 5 mg Tablet Sig: [**11-27**] - 1 Tablet PO Q6H (every 6
hours) as needed for pain.
13. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily): until [**8-11**], then increase to 50 mcg daily.
Disp:*60 Tablet(s)* Refills:*2*
14. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
17. Outpatient Lab Work
Please check TSH, Free T4 one week prior to appointment with Dr.
[**Last Name (STitle) **] and fax result to ([**Telephone/Fax (1) 86540**].
18. Outpatient Lab Work
INR on [**2143-8-5**]
Please fax to Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 107964**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1)CAD s/p MI ([**2115**], [**2120**]), now s/p PCI with BMS to RCA
2)Monomorphic VT s/p ablation
3)Hypertension
4)Hyperlipidemia
5)OSA on BiPap
6)Diabetes mellitus, type 2
7)Osteoporosis
8)Recent shingles
10)Vertigo
11)Hypothyroidism
12) Leukopenia
13) Blood-loss Anemia
14) Chronic Pulmonary Emboli
Discharge Condition:
Hemodynamically stable. Ambulatory.
Discharge Instructions:
You were admitted with heart failure, which was treated by both
revascularizing your right coronary artery and by diuretics to
improve your breathing.
Please check your weight daily and call your doctor if your
weight increases by more than 3 pounds.
You had a bare metal stent placed in your coronary artery. You
must take Plavix every day for at least the next month to
prevent a clot from forming and causing a severe heart attack or
even death because of this stent. Continue taking the Plavix
until your cardiologist recommends stopping it.
Please seek medical attention immediately if you develop fever,
chills, shortness of breath, chest pain or any other concerning
symptoms.
Followup Instructions:
Call Dr [**Last Name (STitle) **] when you get home for an appointment within the
next week. [**0-0-**].
Please make a follow-up appointment with Dr. [**Last Name (STitle) **]
(Endocrinologist) in 8 weeks to manage your hypothyroidism. Tel
([**Telephone/Fax (1) 9072**]. Please have thyroid function labs drawn 1 week
prior and faxed to ([**Telephone/Fax (1) 86540**].
|
[
"780.4",
"414.01",
"244.9",
"276.1",
"327.23",
"428.0",
"250.00",
"415.19",
"401.9",
"288.50",
"427.31",
"410.71",
"733.00",
"288.8",
"285.21",
"053.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"37.23",
"00.45",
"36.06",
"99.04",
"00.40",
"88.57",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
12718, 12776
|
6801, 10460
|
253, 374
|
13120, 13158
|
2036, 4791
|
13893, 14267
|
1612, 1694
|
10797, 12695
|
12797, 13099
|
10486, 10774
|
4808, 6611
|
13182, 13870
|
1724, 2017
|
177, 215
|
6630, 6778
|
402, 1298
|
1320, 1508
|
1524, 1595
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,284
| 118,883
|
11527
|
Discharge summary
|
report
|
Admission Date: [**2158-10-14**] Discharge Date: [**2158-10-28**]
Date of Birth: [**2122-7-14**] Sex: M
Service: [**Hospital6 733**]
HISTORY OF PRESENT ILLNESS: The patient is a 36-year-old
male transferred out of the Medical Intensive Care Unit on
[**10-23**] to the East Service after being treated for
end-stage liver failure complicated by new onset renal
failure.
HOSPITAL COURSE: The patient was admitted on [**10-14**]
with abdominal pain and found to be in end-stage liver
failure. The patient had a prolonged hospital course, but
ultimately, per discussion with family, was deemed to be made
do not resuscitate/do not intubate and comfort measures only.
He was transferred to the floor where the patient was
observed for several days, but ultimately succumbed to his
illness. The patient passed away on [**2158-10-28**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22604**], M.D. [**MD Number(1) 22605**]
Dictated By:[**Last Name (NamePattern1) 1213**]
MEDQUIST36
D: [**2158-12-24**] 13:23
T: [**2158-12-29**] 09:47
JOB#: [**Job Number 36719**]
|
[
"571.2",
"584.5",
"789.5",
"572.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"89.64",
"38.95",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
406, 1135
|
179, 388
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,715
| 174,198
|
53693
|
Discharge summary
|
report
|
Admission Date: [**2126-3-25**] Discharge Date: [**2126-4-8**]
Date of Birth: [**2070-9-28**] Sex: M
Service: O-MED
HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old
male with recently diagnosed abdominal carcinomatosis. The
patient presented with abdominal pain and bloating and was
found to have a large omental mass. Biopsy revealed
adenocarcinoma. Histochemical stains are consistent with
hepatobiliary origin. Endoscopies were negative except for
an extrinsic mass present on the stomach.
The patient presents with increased abdominal pain and poor
oral intake as well as generalized weakness. On
presentation, the patient denied chest pain, shortness of
breath, and cough.
PAST MEDICAL HISTORY:
1. Benign prostatic hypertrophy.
2. Osteoarthritis.
3. Gastrointestinal adenocarcinoma (as noted in History of
Present Illness).
MEDICATIONS ON ADMISSION: Colace, Senna, Dulcolax, Tylenol,
oxycodone as needed, Ambien, and Protonix.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Mother had adrenal cancer. Father had
coronary artery disease.
SOCIAL HISTORY: The patient was employed as a salesman. He
denied the use of tobacco and drugs. He uses alcohol
occasionally. The patient is married with two children.
REVIEW OF SYSTEMS: Review of systems was significant for
progressive abdominal discomfort, decreased oral intake, and
weakness in the past nine weeks.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed temperature was 96.9, heart rate was 121, blood
pressure was 122/86, respiratory rate was 22, and oxygen
saturation was 96% on room air. In general, the patient
looked acutely and chronically ill. Head, eyes, ears, nose,
and throat examination revealed the oropharynx was clear.
Sclerae were anicteric. Mucous membranes were moist.
Cardiovascular examination revealed tachycardic first heart
sound and second heart sound. No murmurs, rubs, or gallops.
Lungs revealed decreased breath sounds and dullness to
percussion in the left lung base. The abdomen was distended
and firm. Positive bowel sounds. Extremity examination
revealed no clubbing, cyanosis, or edema.
IMPRESSION: This was a 55-year-old gentleman with recently
diagnosed abdominal carcinomatosis admitted with increased
abdominal pain and poor oral intake. The patient was
admitted to the O-MED Service for further management.
HOSPITAL COURSE: The patient was admitted to the O-MED
Service. He was placed on a patient-controlled analgesia for
pain control. He was administered intravenous fluids and
oral diet as tolerated.
On the night of [**3-26**], the patient complained of increased
vomiting. He also complained of increased shortness of
breath and "difficulty catching his breath." On room air,
the patient's oxygen saturation was 80%. His saturation
increased to 87% on a nonrebreather. A chest x-ray disclosed
a left pleural effusion. The patient was bolused with
intravenous heparin due to concern for pulmonary embolism.
The patient expressed a desire to be full code, so he was
transferred to the Intensive Care Unit.
The patient became more comfortable being seated upright with
nebulizer treatments. An angiogram was done which disclosed
possible subsegmental pulmonary emboli of the upper lobes as
well as infiltrates consistent with aspiration pneumonia.
The patient was placed on Flagyl and Levaquin for treatment
of pneumonia. He was continued on heparin for treatment of
the pulmonary emboli.
While in the Intensive Care Unit, the patient was noted to
have increasing abdominal distention. On [**3-28**] the patient
underwent an abdominal ultrasound with paracentesis, and 5
liters of fluid were removed.
On [**3-29**], the patient was transferred back to the O-MED
Service. Due to persistent gastric secretions, an
nasogastric tube was placed for decompression. The patient
was noted to have a functional ileus. Octreotide was
initiated in an attempt to decrease the gastric secretions.
On [**4-7**], the patient's respiratory status declined further.
He was noted not have an increasing left-sided pleural
effusion. A thoracentesis was done with removal of 1.5
liters of fluid. A paracentesis was repeated with removal of
2.5 liters of fluid.
On the night of [**4-7**], the patient continued to decline.
The family decided to pursue comfort measures. Morphine was
administered to insure patient's comfort. The patient
expired at 6 p.m. on [**4-8**].
FINAL DISCHARGE DIAGNOSES:
1. Gastrointestinal adenocarcinoma; primary unknown (likely
hepatobiliary).
2. Aspiration pneumonia.
3. Pulmonary emboli.
4. Hypoxia.
5. Dehydration.
6. Ileus.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], M.D. [**MD Number(1) 8654**]
Dictated By:[**Last Name (NamePattern1) 5092**]
MEDQUIST36
D: [**2126-4-8**] 19:24
T: [**2126-4-13**] 05:00
JOB#: [**Job Number 110248**]
|
[
"600.0",
"155.1",
"507.0",
"415.19",
"197.6",
"276.5",
"560.1",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
1026, 1091
|
893, 1009
|
2405, 4456
|
1285, 2387
|
4483, 4929
|
162, 711
|
733, 866
|
1108, 1264
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,677
| 123,319
|
49400
|
Discharge summary
|
report
|
Admission Date: [**2145-9-1**] Discharge Date: [**2145-9-6**]
Date of Birth: [**2096-12-24**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 20506**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
48yo right handed woman with h/o R MCA infarct w residual left
hemiparesis presents, lupus, presents with seizures. Pt was at
[**Hospital1 18**] ophthalmology dept for routine eye exam yesterday, she had
dilating eye drops instilled into her eyes and went to sit in
the waiting room. While waiting with her son she noted left 5th
digit was rhythmically flexing. She exclaimed "someone must be
controlling my arm" to her son. This finger flexion spread to
her other fingers and was causing her hand to contract. She
suddenly felt nauseated and had the urge to move her bowels. She
was found in the bathroom of the [**Hospital **] clinic
"shaking." She was transferred to a wheel chair where a more
clearly described event occured consisting of left head turn and
leftward eye deviation, here left arm was flexed and she was not
responsive for a period of [**3-21**] minutes. A code blue was called
and she was transferred to [**Hospital1 18**] ED for further care.
In the ED, a similar episode occurred while in triage of left
head turn, left eye deviation lasting 2-3minutes- she was given
ativan 2mg IV. In the CT scanner she had another event of head
turning and was given 4mg ativan and intubated out of concern
for airway protection. She was later loaded with dilantin 1g IV.
Overnight events from admission to ICU include no evidence of
further seizure activity. She was successfully extubated this
morning at 10am and was following commands, somewhat
impersistent.
She was interviewed with her family at bedside prior to transfer
to the floor. At present she denies any memory of yesterday's
episode aside from her left hand rhythmic contractions. Per
family she has been feeling "better than ever" in the last few
weeks, going on daily walks, eating well. Denies preceding
f/c/NS, no N/V, change in bowel habits, bladder habits. No
behavior/personality changes. No headache, weakness, numbness,
tingling. She nor her family report any recent changes in sleep
patterns or medication regimen. She has been taking plaquenil
for some time.
.
She normally receives her care at [**Hospital1 112**]-
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 46742**]/Dr. [**First Name (STitle) **] (Kalem) [**Doctor Last Name **]= [**Hospital1 112**] neurologist
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 95192**]= [**Hospital1 112**] internist at BIMA.
Dr. [**Last Name (STitle) 60459**]= [**Hospital1 112**] rheumatology
Past Medical History:
R MCA stroke ([**6-/2143**]) in settinf of R ICA thrombosis seen at the
[**Hospital1 756**], on Coumadin since- residual L hemiparesis (arm > leg),
able to walk, R parieto-occipetal hemorrhage attributed to
conversion of infarct while on coumadin.
Antiphospholipid Ab syndrome
Lupus- followed by Dr. [**Last Name (STitle) 60459**] at [**Hospital1 112**] rheum- on plaquenil
Hyperthyroidism
Social History:
She is from [**Location (un) 4708**], moved to US at age 6, lives in [**Location 686**].
She lives
with her youngest daughter. She ambulates without assist at
baseline. She is independent of her activities of daily living.
She has no recent travel history
or sick contacts. She does not smoke or drink ETOH.
Family History:
No family hx of stroke, CAD, DM, or autoimmune disease.
Rheumatoid arthritis and thyroid disease in her mother.
Physical Exam:
T-99.6/99.6 BP-106/69 HR-97 RR-18 O2Sat-98 (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: Arousable to voice but quite sedated, somewhat
cooperative with exam, normal affect. Oriented to person,
place,
and date. Cannot state [**Doctor Last Name 1841**] backwards or WORLD backwards.
Speech
is fluent with normal comprehension and repetition; naming
intact. No dysarthria. Registers [**3-20**], cannot recall [**3-20**] in 5
minutes. No right left confusion. No evidence of apraxia or
neglect.
Cranial Nerves:
Pupils equally round and reactive to light, 2 to 1 mm
bilaterally. Visual fields cannot be tested because of
inattention. Extraocular movements intact bilaterally, no
nystagmus. Sensation intact V1-V3. Facial movement asymmetric
with L-side nasal flood flattening. Palate elevation
symmetrical,
although difficult to see. Sternocleidomastoid and trapezius
could not tested. Tongue midline, movements intact.
Motor:
Decreased bulk diffusely. Tone increased in L arm and leg. No
observed myoclonus or tremor. Pronator not able to be tested.
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 NT 5 NT NT NT NT NT NT NT NT NT
L 4- 4+ 5 NT 3 3 NT NT NT NT NT NT NT NT
NT=not tested because of inattention. Lower extremities move
spontaneously, but could not be tested formally.
Sensation: Intact to vibration in lower extremities.
Reflexes:
+2 on R and 3+ on L UEs. 2+ symmetric in L and R LEs.
Toes upgoing bilaterally.
Coordination: finger-nose-finger normal on R and too weak to
test
on L. RAMs normal on R and slow on L.
Gait: Not tested.
Romberg: Not tested.
Pertinent Results:
[**2145-9-1**] 06:00PM BLOOD WBC-7.4 RBC-3.65* Hgb-10.4* Hct-30.5*
MCV-83 MCH-28.5 MCHC-34.2 RDW-16.5* Plt Ct-268
[**2145-9-3**] 06:40AM BLOOD WBC-7.7 RBC-4.31 Hgb-12.7 Hct-36.5 MCV-85
MCH-29.4 MCHC-34.7 RDW-16.6* Plt Ct-291
[**2145-9-1**] 06:00PM BLOOD Neuts-76.4* Lymphs-20.1 Monos-2.5 Eos-0.3
Baso-0.8
[**2145-9-3**] 06:40AM BLOOD PT-31.7* PTT-63.2* INR(PT)-3.4*
[**2145-9-3**] 03:54PM BLOOD Glucose-106* UreaN-6 Creat-0.7 Na-139
K-3.3 Cl-106 HCO3-18* AnGap-18
[**2145-9-1**] 06:00PM BLOOD Glucose-81 UreaN-12 Creat-0.7 Na-140
K-3.6 Cl-106 HCO3-24 AnGap-14
[**2145-9-1**] 06:00PM BLOOD CK-MB-5 cTropnT-<0.01
[**2145-9-2**] 02:50AM BLOOD CK-MB-6 cTropnT-<0.01
[**2145-9-3**] 03:54PM BLOOD Calcium-9.1 Phos-2.2* Mg-1.8
[**2145-9-1**] 06:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2145-9-6**] 10:20AM BLOOD PT-18.0* PTT-42.6* INR(PT)-1.7*
CT HEAD W/O CONTRAST [**2145-9-1**] 3:35 PM
There is evidence of a remote ischemic infarct in the right MCA
territory. Signs indicative of this are loss of cortical tissue
in the right parietal and frontal region, some of which
demonstrate a connection to the right lateral ventricle. There
is associated ex vacuo dilatation of the right lateral ventricle
and slight (2 mm) midline shift to the right due to volume loss.
There are extensive periventricular and deep white matter
hypodensities, also in the right MCA territory. There is no CT
evidence of acute left-sided ischemia. The [**Doctor Last Name 352**]-white matter
differentiation on the left is preserved. There is no acute
intracranial hemorrhage. Bony structures and surrounding soft
tissue structures are unremarkable. Visualized paranasal sinuses
and mastoid air cells are clear.
IMPRESSION:
1. Old right MCA infarct corresponds to the history reported by
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20562**] in ED.
2. No CT evidence of acute ischemic infarct, although a subtle
area of new infarction on the right would be difficult to
discern on the background of the remote changes.
3. No acute intracranial hemorrhage.
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST
Correlation was made with previous CT of [**2145-9-1**]. Again, areas
of encephalomalacia are seen in the right posterior
temporoparietal region and in the right frontal lobe, indicating
chronic infarct in the region of right middle cerebral artery.
There are chronic blood products seen in the right parietal lobe
with ex vacuo dilatation of the right lateral ventricle. On
diffusion images, no evidence of slow diffusion seen adjacent to
the area of chronic infarct or in other part of the brain to
indicate acute infarct. There is no midline shift seen or
hydrocephalus identified.
IMPRESSION: Chronic right middle cerebral artery territorial
infarct with encephalomalacia and chronic blood products in the
right parietal region. No evidence of acute infarct.
MRA OF THE HEAD:
Head MRA demonstrates normal flow signal within the arteries of
anterior and posterior circulation.
IMPRESSION: Normal MRA of the head.
EEG [**2145-9-3**]
This is an abnormal EEG due to the presence of a somewhat slow
and disorganized background suggestive of a mild encephalopathy
of toxic, metabolic, or anoxic etiology. The voltage asymmetry
suggests a broad area of disturbance involving the right
hemisphere such as can be seen in the context of an epidural or
subdural fluid collection, or with a large cortical or
subcortical lesion in this hemisphere. Clinical correlation is
recommended. No areas of ongoing or potential epileptogenesis
were seen.
Brief Hospital Course:
Ms. [**Known lastname 103440**] is a 48 year old woman with a history of right MCA
infarction resulting in residual left arm > leg hemiparesis, on
Coumadin since the stroke
for R ICA thrombosis and antiphospholipid antibody syndrome, who
presented with multiple seizures. The day of admission she
developed rhythmic left arm flexion with left head turning and
became unresponsive for a period of [**5-27**] minutes. These episodes
were witnessed by her family, ophthalmology clinic staff and
emergency department staff. While in the CT scanner she had her
third witnessed seizure event whereby she was intubated for
airway protection. In addition to ativan IV, she was loaded
1,000mg dilantin and monitored in the neuro ICU overnight. She
was promptly extubated the following morning without event. She
did not have any further seizure activity in the inpatient
setting.
1) Seizure-
There were no apparent triggers such as infection, metabolic
derangement or new structural lesion to explain the onset of
seizure. Therefore her prior right MCA infarct was the likely
substrate for seizure. Head CT obtained on admission was without
hemorrhage. MRI was without evidnence of new infarction. The
semiology of event with left head turn and eye deviation
supports epileptogenic focus from her site of prior infarct. She
was continued on dilantin 100mg TID, then titrated on Keppra
given interaction with coumadin. Her INR did elevate to 4.3
following the dilantin load on admission, her coumadin was held,
and her INR returned to 1.7 the day of discharge. She was
restarted on coumadin and will have a repeat INR in two days,
fax the results to [**Hospital6 **] [**Hospital 197**] Clinic where she
is normally followed. Routine EEG did not reveal any frank
epileptiform activity, but showed a
slow and disorganized background suggestive of a mild
encephalopathy of toxic, metabolic, or anoxic etiology. The
voltage asymmetry suggests a broad area of disturbance involving
the right hemisphere such as can be seen in the context of an
epidural or subdural fluid collection, or with a large cortical
or subcortical lesion in this hemisphere.
2) Stroke-
MRI/A Head was without evidence for new acute infarction. She
was continued on coumadin anticoagulation given prior R ICA
thrombosis. BP control with atenolol. She was made a follow up
appointment with her primary neurologist at [**Hospital6 13185**].
3) Lupus
Initially plaquenil was held, then restarted prior to discharge.
She will follow up with her rheumatologist in [**Month (only) **] at [**Hospital1 112**].
Medications on Admission:
Hydroxychlorquine 200mg PO BID
Atenolol 25mg PO Daily
Warfarin 3mg QHS
Simvastatin 40mg QHS
Methimazole 10mg daily
Ferrous Sulfate 325mg daily
Multivitamin daily
Discharge Medications:
1. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Methimazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day:
Please have INR drawn on Wednesday [**9-8**]. Fax results to coumadin
clinic at [**Hospital6 **].
9. Plaquenil 200 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Outpatient Physical Therapy
Please evaluate and treat
11. Outpatient [**Name (NI) **] Work
PT/INR to be drawn on Wednesday [**2145-9-8**].
Please fax results to [**Hospital6 **] coumadin clinic and
adjust coumadin dose accordingly.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Seizure
Secondary:
right MCA infarct
antiphospholipid antibody syndrome
lupus
hypercholesterolemia
Discharge Condition:
Stable. residual left arm > leg hemiparesis. ambulates
independantly
Discharge Instructions:
You were admitted to the hospital for a seizure. This was likely
related to your prior stroke. You were started on a new seizure
medicine. You did not have a new stroke based on your MRI.
Please have your PT/INR (coumadin) checked on Monday as it's
levels can change with the new medication you are taking.
Continue to take all medications as listed in this discharge
paperwork.
Please call your doctor or 911 for any new weakness, tingling,
numbness, further seizures, chest pain, shortness of breath or
any other concerning symptoms.
Followup Instructions:
You have a follow up appointment with your primary neurologists
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 46742**] and Dr. [**First Name (STitle) **] (Kalem) [**Doctor Last Name **] at [**Hospital1 **]. [**9-9**] at 2pm in the [**Hospital 878**] clinic located on
'the Pike' at [**Hospital6 **]. Please call the neurology
clinic with any questions [**Telephone/Fax (1) 41067**].
Please keep your appointments with Dr. [**Last Name (STitle) 95192**] and Dr.
[**Last Name (STitle) 60459**] at [**Hospital6 **] in early [**Month (only) **].
|
[
"780.39",
"710.0",
"438.89",
"795.79",
"272.0",
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icd9cm
|
[
[
[]
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[
"38.93",
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icd9pcs
|
[
[
[]
]
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13062, 13068
|
9297, 11864
|
324, 331
|
13221, 13292
|
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4080, 4080
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|
3247, 3560
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,549
| 120,315
|
39080
|
Discharge summary
|
report
|
Admission Date: [**2171-3-8**] Discharge Date: [**2171-3-10**]
Date of Birth: [**2111-12-5**] Sex: F
Service: MEDICINE
Allergies:
Omeprazole / Prochlorperazine
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a 59 year-old female with a history of advanced
pancreatic cancer who presents with hematemesis. Pt vomited 1
cup of bright red blood this am after eating breakfast. She was
profoundly weak and called EMS who had to break into her
appartment. VS on arrival 80/46, 100, R 20. She has chronic RUQ
and epigastric abd pain which has worsened over the last week.
No F/C/NS.
.
She originally presented to [**Hospital1 1474**] Hosptial where VS were
97/46 and P 99, where HCT of 26.1. Labs from [**Hospital1 **] on
[**2171-2-26**] showed HCT 39, tbili 1.1, cr 0.7. She received 2 units
of RBC and 2000cc IVF. She was transfered to [**Hospital1 18**] for further
evaluation.
.
In the ED VS showed T98, HR 93, BP 114/62, 20, 99%3L. She
received famotidine 40mg IV. HCT was 27.7 after the 2 units
received in transient. She was seen by GI. NG lavage was refused
by the patient. VS prior to transfer 91, 134/70, 18, 100% RA. Pt
noted to be guiac positive with brown stool.
.
Upon arrival to the floor she remained hemodynamic stable. She
had a 1 L BM of BRBPR with clots.
.
Of note [**2171-1-31**] she had a similar episode of hematemesis with
HCT drop to 22 for which she was admitted to the OSH ICU.
Endoscopy showed bleeding ucleration at the site of the tumor
growth over the duodenel stent. She was given 4 units of RBC
with spontaneous resolution of the bleed. However 1 week after
being d/ced on protonix she developed a whole body rash.
.
Her cancer was discovered after a CT obtained at the time of an
appendectomy showed diffuse hepatobiliary dilatation in [**3-21**]. IN
[**Month (only) **] she had an EUS which showed a 2-cm mass in the pancreas
involving the portal vein. FNA was positive for malignant cells.
GIven encasement of the gastric duodenal artery she was felt not
to be a surgical candidate. She underwent 3 cycles of
gemcitabine but had ongoing enlargement of the pancreatic mass.
A doudenal stent was placed in 5/[**2170**]. This was followed with
stereotactic body radiotherapy, 2400 cGy in 3 fractions,
completed [**2170-10-12**]. She had 1st cycle of XELOX
(capecitabine plus oxaliplatin) on [**2-22**] for progressive disease
with tumor overgrowth of teh doudenal stent.
ROS: The patient denies any fevers, chills. + 12 lb weight loss.
+ nausea, vomiting, abdominal pain. No diarrhea, constipation,
chest pain, shortness of breath, lower extremity edema, cough,
urinary frequency, urgency, dysuria, , focal weakness, vision
changes, headache, rash or skin changes.
Past Medical History:
anemia
duodenal ulcer at tumor site (present with hematemesis [**1-18**])
hyperlipidemia
HTN
DM2, currently not on treatment
obesity
appendectomy
pancreatic cancer
Social History:
The patient works in tech support for State Stree Bank. She is a
lifelong non-smoker and does not drink alcohol. She lives
independently at home.
.
Family History:
Father died at 65 from a CVA. Mother died at 70 from liver
disease; she also had DM and HTN. The has had two sisters with
breast cancer, one of whom has died.
Physical Exam:
GEN: Alert, no acute distress
HEENT: EOMI, PERRL, sclera icteric, MMM, OP Clear
NECK: No JVD, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, mild RUQ tenderness without rebound or gaurding, ND,
+BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities.
SKIN: mild jaundice. No cyanosis, or gross dermatitis. No
ecchymoses.
Pertinent Results:
[**2171-3-8**] 06:30PM WBC-11.3*# RBC-3.23*# HGB-9.2*# HCT-27.7*#
MCV-86 MCH-28.5 MCHC-33.2 RDW-17.6*
[**2171-3-8**] 06:30PM NEUTS-82.4* BANDS-0 LYMPHS-14.1* MONOS-3.1
EOS-0.1 BASOS-0.3
[**2171-3-8**] 06:30PM PLT SMR-NORMAL PLT COUNT-326#
[**2171-3-8**] 06:30PM HYPOCHROM-OCCASIONAL ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-OCCASIONAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2171-3-8**] 06:30PM GLUCOSE-138* UREA N-32* CREAT-0.8 SODIUM-137
POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-25 ANION GAP-12
[**2171-3-8**] 06:30PM CALCIUM-8.5 PHOSPHATE-3.6 MAGNESIUM-2.2
[**2171-3-8**] 06:30PM ALT(SGPT)-71* AST(SGOT)-67* ALK PHOS-377* TOT
BILI-8.5*
[**2171-3-8**] 06:30PM LIPASE-14
.
INDICATION: 59-year-old female with pancreatic cancer, new
abdominal pain and
upper GI bleeding.
COMPARISON: [**2171-1-15**].
TECHNIQUE: Helical MDCT images were acquired from the lung bases
through the
greater trochanters with intravenous and oral Gastrografin
contrast. 5-mm
axial, coronal, and sagittal multiplanar reformats were
generated.
FINDINGS: Mild atelectasis is noted at the lung bases. There are
no pleural
effusions. The heart is normal in size, with trace pericardial
effusion.
Note is made of a small sliding hiatal hernia.
ABDOMEN: A hypo-enhancing mass in the head of the pancreas has
increased in
size to 3.2 cm TV x 2.4 cm AP x 2 cm SI, previously 3 cm TV x
2.2 cm TV x 1.7
cm SI. Fiducial seed is noted at the inferior aspect of this
mass. There is
extensive local infiltration, with heterogeneous soft tissue
density extending
inferolaterally and obscuring fat planes along the C-sweep of
the duodenum.
There is complete encasement of the proximal portal vein,
approximately 270
degrees of involvement at the portosplenic confluence, and 180
degree abutment
of the proximal superior mesenteric vein. However, there is no
evidence of
thrombosis; the main, left, and right portal and hepatic veins,
splenic vein,
and superior mesenteric vein all remain patent. The distal
pancreas is
atrophic, without significant ductal dilation to suggest
obstruction.
There is new massive intrahepatic and common biliary ductal
dilation,
measuring up to 17 mm. The liver enhances homogeneously, without
focal
lesions identified on this single phase examination. A 4-mm
calcified stone
is noted in a partially distended gallbladder, which
demonstrates minimal wall
edema and trace pericholecystic fluid. The spleen is normal in
size.
The adrenals are normal. The kidneys enhance and excrete
contrast promptly
and symmetrically, without masses or hydronephrosis. Bilateral
renal cysts
and hypodensities are present, measuring up to 2.5 cm in the
left interpole.
The stomach is partially collapsed. A metal stent is noted in
the second
portion of the duodenum, with persistent irregular soft tissue
ingrowth within
the stent walls. However, enteric contrast traverses this
region, and there
is no evidence of transition point to suggest obstruction.
Enteric contrast
has progressed to the level of mid ileal loops in the pelvis. A
4 x 2 cm
ovoid filling defect in a pelvic ileal loop (3:52 and 300B:38),
was not
visualized on prior examination, and likely represents ingested
contents.
There are no extraluminal contrast, fluid, or air collections to
suggest
perforation. No focal fat stranding or abnormal enhancement to
indicate acute
inflammation. There is no pneumatosis or mesenteric/portal
venous gas to
reflect ischemia.
PELVIS: The appendix is surgically absent. A moderate amount of
retained
fecal material is noted throughout the colon and rectum. The
bladder is
normal. Bilateral ureteral jets are visualized. The uterus and
adnexa are
unremarkable.
Mesenteric and retroperitoneal lymph nodes are not
pathologically enlarged.
CXR [**3-9**]
Lung volumes are low, no pneumonia or pulmonary edema. Heart
mildly enlarged.
No appreciable pleural effusion. Tip of the infusion port ends
in the low
SVC.
No suspicious lytic or sclerotic osseous lesions are identified.
Moderate
multilevel degenerative changes are present in the thoracolumbar
spine.
IMPRESSION:
1. Interval increase in size of pancreatic head mass, with new
massive
intrahepatic and common biliary ductal dilation indicating
obstruction.
Significant vascular encasement, without evidence of venous
thrombosis.
2. Duodenal stent, with evidence of soft tissue ingrowth, but no
bowel
obstruction or perforation.
Brief Hospital Course:
This is a 59 year-old female with a history of pancreatic cancer
who presents with hematemesis and hematochezia secondary
ulcerated tumor at the duodenal stent found to have common bile
duct obstruction and gallbladder distension from progression of
pancreatic cancer.
.
# Goals of care. At time of admission code status extensively
discussed with patient. It was explained that without
intervention a major bleed may be fatal without intubation. At
discussions end, patient confirmed DNR/ DNI code status and
ultimately opted to return home with hospice services. At her
request she has agreed to continued antibiotics as well as
palliative transfusions. At time of discharged prescriptions for
antibiotics as well as short term anti-emetics, analgesics
written for. Proper DNI/DNR paper work was filled out.
.
# GI bleed: Likely source: ulcerated tumor at the duodenal stent
site. NG lavage negative suggesting against gastric cause.
Patient transfused as needed and serial hematocrits monitored.
Patient opted against further invasive intervention to control
the bleed. Hematocrit stable at time of discharge. Desires
palliative transfusions once home.
.
# Common bile duct obstruction, gallbladder distension. Imaging
consistent with intrahepatic, CBD and GB distension likely
secondary to extrahepatic conpression from the pancreatic mass.
Though no fevers to suggest active cholangitis patient covered
with empiric unasyn to prevent cholangitis which was
transitioned to PO ciprofloxacin and flagyl at time of discharge
.
# Pancreatic cancer. Likely causative factor of both bleed and
obstruction. Primary oncologist contact[**Name (NI) **]. [**Name2 (NI) **] to return
home with hospice
.
# Hypertension. Held home atenolol during stay. At discharge
instructed to discontinue medication.
.
# Comm: [**Name (NI) 1154**], daughter, [**Telephone/Fax (1) 86621**]
Medications on Admission:
atenolol 25mg PO daily
Reglan 10mg PO TID
ranitidine 300mg PO BID
oxycodone prn
xeloda capecitabine
Xelox on [**2-22**]
Discharge Medications:
1. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for shortness of breath or wheezing.
Disp:*4 Tablet(s)* Refills:*0*
2. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*28 Tablet(s)* Refills:*0*
3. Flagyl 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*28 Tablet(s)* Refills:*0*
4. morphine concentrate 20 mg/mL Solution Sig: 5-20 mg PO q1hour
as needed for pain: Please call [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**] if pain becomes
severe.
Disp:*1 30cc vial* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Old [**Hospital **] Hospice
Discharge Diagnosis:
Primary Diagnosis: Duodenal ulcer, Biliary tract obstruction
Secondary Diagnosis: Metastatic Pancreatic Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname **],
It was a pleasure taking care of your during your stay here at
[**Hospital1 18**].
Regarding your episodes of bleeding, it is thought that you have
persistent bleeding from an ulcer in your duodenum. It is
possible that you may rebleed again. If so please contact your
hospice providers and they can arrange for you to receive
transfusions as needed.
In addition, your biliary tract was found to be obstructed,
likely secondary to worsening pancreatic cancer. A percutaneous
cholecystostomy was offered but you opted to forego further
intervention and instead use antibiotics to treat any
potentional infection.
Hospice will follow along with you at home to ensure your
comfort.
Changes to your medications
To treat potential infection:
Start taking Ciprofloxacin 500mg tablets. Please take one tablet
twice daily
Start taking Metronidazole 500mg tablets. Please take one tablet
twice daily
To treat shortness of breath/anxiety
Start taking Ativan 0.5mg PO at night time.
To treat pain;
Start taking Morphine concentrate as needed every hour: 5-20mg
Q1hr sublingual or by mouth for pain control
- this medicine can be swallowed or dropped under the tongue for
pain control.
- If you are having severe pain plase contact [**Name (NI) 2270**] [**Name (NI) 1764**]
guarding increasing dosage.
Stop taking your atenolol
.
Again please do not contact the ICU or [**First Name8 (NamePattern2) 2270**] [**Name (NI) 1764**] if any
questions arise.
Followup Instructions:
You will be coming home with hospice. Please contact the ICU and
[**First Name8 (NamePattern2) 2270**] [**Name (NI) 1764**] if you have any questions or concerns after
discharge.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2171-3-10**]
|
[
"197.4",
"278.00",
"157.0",
"V49.86",
"576.2",
"401.9",
"285.9",
"532.40",
"272.4",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10965, 11023
|
8346, 10217
|
308, 316
|
11178, 11178
|
3939, 8323
|
12828, 13174
|
3211, 3371
|
10387, 10942
|
11044, 11044
|
10243, 10364
|
11329, 12805
|
3386, 3920
|
257, 270
|
344, 2842
|
11126, 11157
|
11063, 11105
|
11193, 11305
|
2864, 3029
|
3045, 3195
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,911
| 134,350
|
49835
|
Discharge summary
|
report
|
Admission Date: [**2129-9-18**] Discharge Date: [**2129-10-4**]
Date of Birth: [**2062-11-15**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Codeine
Attending:[**First Name3 (LF) 7141**]
Chief Complaint:
dyspnea, ascites
Major Surgical or Invasive Procedure:
Examination Under Anesthesia, Exploratory Laparotomy, Total
Abdominal Hysterectomy, Bilateral Salpino-oophorectomy, Lymph
Node Dissection, Staging, Bilateral Theraputic Thoracentesis,
Port-a-cath Placement
History of Present Illness:
66 yo G3P3 ho breast cancer ( s/p partial mastectomy, XRT) with
recent onset ascites and new dx of pelvic mass 13x8x12 cm R
adnexa. Pt reports increased abdominal girth over past few wks.
From [**Date range (1) 104125**] seven lb weight gain. Unable to button
clothes. Pt presents today with worsening abdominal discomfort
poor po intake and dyspnea. No f/c/n/v/cp. no flatus or BM
past few days.
Past Medical History:
PMH/PSH:
- breast CA s/p L part mastectomy, SN biopsy and axillary
sampling/XRT ( [**8-27**]); on Tamoxifen since [**2125-12-18**]
- HTN
-Hypothryoidism ( s/p RAI in [**2103**])
-tubal ligation
- L matacarpal fx c fixation/pins
Gyn hx:
menopause age 50
no STDs
remote hx abn pap
OB hx:
NSVD x3
Social History:
married; husband ( MD - opthomologist)
3 children
no T/E/D
Family History:
breast cancer
Physical Exam:
98.6 104 123/59 17 93%Ra
NAD
CTA B c decreased BS @ bases
RR, tachy
non-tender, distended, slightly tense, + peripheral dullness
pelvic deferred
no edema/NT
Pertinent Results:
[**2129-9-18**] 11:30AM PT-13.2 PTT-22.9 INR(PT)-1.2
[**2129-9-18**] 11:30AM PLT COUNT-990*
[**2129-9-18**] 11:30AM NEUTS-93.1* LYMPHS-3.3* MONOS-3.2 EOS-0.3
BASOS-0.1
[**2129-9-18**] 11:30AM WBC-16.0* RBC-3.40* HGB-10.9* HCT-31.7*
MCV-93 MCH-32.1* MCHC-34.4 RDW-13.2
[**2129-9-18**] 11:30AM ALT(SGPT)-10 AST(SGOT)-40 ALK PHOS-148*
AMYLASE-35 TOT BILI-0.3
[**2129-9-18**] 11:30AM GLUCOSE-135* UREA N-15 CREAT-0.9 SODIUM-132*
POTASSIUM-5.9* CHLORIDE-97 TOTAL CO2-24 ANION GAP-17
[**2129-9-18**] 11:45AM URINE AMORPH-FEW
[**2129-9-18**] 11:45AM URINE HYALINE-0-2
[**2129-9-18**] 11:45AM URINE RBC-0 WBC-[**1-29**] BACTERIA-FEW YEAST-NONE
EPI-<1
[**2129-9-18**] 11:45AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2129-9-18**] 11:45AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.037*
[**2129-9-18**] 11:45AM URINE GR HOLD-HOLD
[**2129-9-18**] 11:45AM URINE HOURS-RANDOM
[**2129-9-18**] 05:00PM POTASSIUM-4.4
Brief Hospital Course:
66 G3P3 F w/ h/o breast CA and known pelvic mass presented prior
to scheduled OR due to increasing ascites, dyspnea, abdominal
pain and decreased po intake. Pt underwent ex-lap, TAH/BSO,
omentectomy, pelvic/para-aortic LN sampling for pelvic mass,
likely ovarian CA on [**9-21**]. EBL 400 IVF 2700 + 2UPRBC U/O 400
Studies: CA125 670; CXR B pleural effusions
Pelvic U/S: 13x8x12 R adnexal mass. EM 1.1 cm.
CT abd: 3.1cm L adrenal mass,pelvic mass, ascites, B pleural
effusions, adrenal mass (incidental; repeat study in 6 mo)
CTA in ER - neg for PE; +pl effusions
Plan:
1) Neuro/Delirium:
- Pain: fentanyl patch/dilaudid IV (0.5-1mg) for breakthrough
- confused-?delirium/narcotics->improving w/ less narcs
- neg head CT [**9-20**]
2) CV
- HTN -> Restarted Lisinopril [**10-1**]. BP's stable.
2) Pulm/ Decreased O2 sat:
- neg CTA on admission
- Sent to ICU after OR for close monitoring of o2 sat. Extubated
in ICU. Had +b/l pleural effusions - [**9-25**] CXR: effusions may be
slightly larger compared w/ [**9-24**]
-[**9-27**] R-sided therapeutic thoracentesis -1200 cc
-11/3 L sided therapeutric thoracentesis -1000cc per pt
-[**10-1**] - O2 Weaned to RA -> 92-94%
-Pleural fluid positive for carcinoma
3) GI/Ileus:
- NGT placed then d/c'd [**9-26**]
- Pt started on TPN after surgery ->d/c TPN on [**9-30**]
- ADAT -> tol po on discharge
4) Heme:
- s/p 2 U PRBC; Hct stable 28 ([**10-1**])
- thrombocytosis improved over stay
5) FEN
- IVF 75cc/hr & TPN ( d/c'ed [**9-30**])
- s/p Poracath placement Wed [**9-21**]([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 23793**])
6) Endocrine
- Levoxyl dose increased - 125 mcg/d
7) Renal
-d/c Foley [**9-28**]
-Incontinent Urine (pt cannot get to BR in time)
-s/p Lasix 10/27,[**9-23**], [**9-25**] (x3), [**9-27**] x1, [**9-28**] x1
7) ID
- s/p Kefzol pre-op; no further abx
- Ucx negative
8) PPx
- SCD/Heparin/Protonix
9) Access: L ext jug, Portacath, PIV
-reaccessed Port [**9-28**]
10) Dispo: OTD ambulating, tol po, afebrile, hemodynamically
stable on [**2129-10-4**].
Medications on Admission:
Lisinopril 5', Effexor 75', Levoxyl 0.1', Tamoxifen 20', Fosamax
q week
Discharge Medications:
1. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO DAILY (Daily).
2. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*20 Patch 72HR(s)* Refills:*0*
4. Tamoxifen 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Heparin Flush 100 unit/mL Kit Sig: Five (5) ml Intravenous
once a month.
Disp:*500 ml* Refills:*0*
8. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain: ONLY USE FOR BREAKTHROUGH PAIN IF
FENTANYL PATCH NOT COVERING PAIN.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Ovarian Carcinoma
Discharge Condition:
Stable
Discharge Instructions:
-No heavy lifting or exercise for 6 weeks.
-Nothing in vagina for 6 weeks.
- No driving or lifing while on pain medications.
-Resume all home medications.
-[**Name8 (MD) **] MD if you have temp > 100.4, increasing shortness of
breath, nausea/vomitting, redness/pus from wound or other
concerns.
-Flush portacath every month with 5 ml of provided Heparin
solution.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] B. GYN ONC PPS (SB) Date/Time:[**2129-10-11**] 4:30
|
[
"244.9",
"197.6",
"553.1",
"599.0",
"584.9",
"401.9",
"511.9",
"V10.3",
"286.7",
"276.52",
"183.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.23",
"38.93",
"99.15",
"99.04",
"65.61",
"70.23",
"40.3",
"53.49",
"68.4",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
5662, 5720
|
2594, 4637
|
299, 506
|
5781, 5789
|
1561, 2571
|
6201, 6313
|
1351, 1366
|
4759, 5639
|
5741, 5760
|
4663, 4736
|
5813, 6178
|
1381, 1542
|
243, 261
|
534, 940
|
962, 1259
|
1275, 1335
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,590
| 116,879
|
45758+58851
|
Discharge summary
|
report+addendum
|
Admission Date: [**2132-1-21**] Discharge Date: [**2132-2-7**]
Date of Birth: [**2080-12-23**] Sex: M
Service: [**Last Name (un) **]
REASON FOR ADMISSION: The patient is admitted for a
potential liver transplant.
HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old
male with HIV diagnosed in [**2115**] with advanced HCC who was
recently evaluated for a hepatic mass. He was status post
chemoembolization of hepatic mass at [**Hospital1 2177**] in the setting of
elevated AFP. CT scans have shown hepatic mass with question
of thrombus in adjacent hepatic vein. CT-guided biopsy of the
involved area did not show tumor. Repeat CT in [**2131-11-18**]
was unchanged. He was subsequently listed for liver
transplant for advanced liver cirrhosis and unresectable HCC.
PAST MEDICAL HISTORY: HIV, well controlled, undetectable
viral load. On [**2131-12-19**], CD4 count was 245. HCV was
diagnosed 5-6 years ago. History of upper GI bleed,
hypertension, hypercholesterolemia, polysubstance abuse,
sober since [**2128**]. History of CVA in [**2129-8-17**] with
residual right leg weakness. DVT. Per report, able to walk 1-
2 blocks prior to claudication.
MEDICATIONS ON ADMISSION: Pravachol 10 mg daily, Diovan 40
mg daily, aspirin 81 mg daily, Reyataz 300 mg daily, Pletal
150 mg b.i.d., Viread 300 mg daily, Pepcid 20 mg daily,
cilostazol 50 mg daily, thalidomide 50 mg q.h.s., Videx 250
mg daily, vitamin E 400 international units daily, vitamin C
and multivitamins.
ALLERGIES: Lisinopril with which the patient gets mouth and
lip swelling.
SOCIAL HISTORY: He lives alone, no children. He smokes half
a pack per day. No alcohol since [**2128**]. No IV drug use since
[**2115**].
REVIEW OF SYSTEMS: He denies recent infections including
fevers, chills, rigors. He denies a change in bowel function.
No change in urinary symptoms. He denies headaches, visual
changes. He reports right leg weakness which is baseline. He
denies chest pain shortness of breath. Recent echocardiogram
in [**2131-7-19**] demonstrated ejection fraction of greater
than 60%, no ventricular septal defects, mild pulmonary
artery systolic hypertension.
EXAMINATION: General: The patient is comfortable in no acute
distress. HEENT anicteric. No nystagmus. Mucosa are clear, no
lesions,. No lymphadenopathy. Lungs are clear to auscultation
bilaterally, no CVA tenderness. CV is regular rate and
rhythm, normal S1 and S2 without murmurs, rubs or gallops.
Abdomen is soft, nontender and nondistended, no organomegaly.
Extremities - no C/C/E, no calf tenderness. Pulses are 2+ AT
and dorsalis pedis. Neuro exam - cranial nerves II through
XII are intact. Upper extremities are [**3-21**] throughout
bilaterally. Right lower extremity is [**1-20**] proximally. No
deficits in the left lower extremity.
LABORATORY DATA: On admission, his labs were the following:
WBC of 4.1, hematocrit 33.8, platelets 145, sodium 137, 3.3,
105, 23, BUN and creatinine of 16 and 1.6, glucose 90. AST
was 118 and ALT 72. Alkaline phosphatase was 229. Total
bilirubin is 1.5. INR is 1.5.
HOSPITAL COURSE: The patient went to the OR on [**2132-1-21**]
in which the patient had a cadaveric liver transplant,
piggyback, portal vein to portal vein anastomosis, common
hepatic artery to common hepatic artery, QDA branch patch,
bile duct to bile duct performed by Doctors [**Last Name (Titles) 816**], [**Name5 (PTitle) **] and
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3446**]. Please see operative note for more details
of the surgery. The patient had 2 [**Doctor Last Name 406**] drains placed to the
right quadrant area, one underneath the right lobe of the
liver and one underneath the liver hilum. The drains were
secured to skin with nylon sutures. The skin was closed with
staples. The patient was transferred, still intubated, to the
intensive care unit in stable condition. The patient was kept
intubated, placed on insulin, Unasyn, ganciclovir, heparin,
MMF and Solu-Medrol 500 IV x1. Ultrasound was performed the
same day demonstrating unremarkable duplex Doppler ultrasound
of the transplanted liver. The patient had a chest x-ray
status post liver transplant for NG tube placement which
demonstrated moderate layering right pulmonary effusion and a
small left pleural effusion. There was a left lower lobe
atelectasis/consolidation.
On the following day, the patient had another ultrasound with
confirmed vascular flow which demonstrated a 13.7 x 7 x 11 cm
subhepatic hematoma, moderate ascites, patent hepatic
vasculature, no evidence of hydronephrosis. The patient was
extubated on postop day 1. LFTs on [**2132-1-22**] were the
following: AST 1324, ALT 566, alkaline phosphatase 126. The
patient was on a Lasix drip. The patient was waiting for
clears. HIV medications were held and subcutaneous heparin
was restarted. It was noted on the chest x-ray on [**2132-1-26**] that the patient had a new right lower lobe infiltrate,
most likely representing pneumonia. In the appropriate
clinical setting, could also represent aspiration or
pulmonary hemorrhage. The patient was started on caspo, levo
and the patient was reintubated for a gas of 7.45, 28, 60, 18
and -4. Dobbhoff was placed for tube feeds. The patient's
antibiotics were changed to Zosyn and vancomycin. Renal and
ID were consulted. On [**2132-1-26**], a bronchoscopy was
performed in the ICU for a presumed diagnosis of pneumonia.
The patient continued to be intubated, sedated with propofol,
p.r.n. morphine, treated for right pneumonia. The patient
continued on tube feeds. Caspo and levofloxacin were started.
The patient extubated on [**2132-1-28**]. The bronchial
washings on [**2132-1-26**] demonstrated that the Gram stain
showed 1+ polymorphonuclear leukocytes, no microorganisms
seen. Respiratory culture was negative with no growth.
Legionella culture was not isolated. Fungus culture was not
isolated. There was no acid-fast bacilli seen on direct smear
nor concentrated smear. Viral culture for cytomegalovirus is
pending. The patient was seen by physical therapy who felt
that the patient would be an excellent candidate for rehab.
On [**2132-1-30**], the patient had the following labs: WBC of
15.1, hematocrit of 36.6, platelets 222, sodium 146, 3.7,
111, 21, BUN and creatinine of 69 and 2.9, glucose 106. AST
was 35, ALT 63, alkaline phosphatase 101, total bilirubin of
4.0. The patient had an AFP of 711. On [**2132-1-30**], the
patient had an ERCP demonstrating that there was a normal
distal pancreatic duct. The cholangiogram revealed a non-
dilated native and donor bile duct. A bile leak was seen at
the level of the anastomosis. The intrahepatic ducts appeared
normal. A 10-French 8 cm Cotton-[**Doctor Last Name **] biliary stent was
placed successfully across the anastomosis into the donor
bile duct and bile was seen draining into the duodenum.
On [**2132-2-1**], the patient returned to the OR for re-
exploration after liver transplant, abdominal washout, Roux-
en-Y hepaticojejunostomy and a wedge biopsy of the liver
performed by Doctors [**Last Name (Titles) **], [**Name5 (PTitle) 816**] and [**Name5 (PTitle) **]. Please see
operative note for more details of the procedure. Of note,
the old JP drains were removed and two fresh [**Doctor Last Name 406**] drains
were placed, one directly underneath the right lobe of the
liver and the other below the biliary anastomosis. The
patient was transferred still intubated to the postop
recovery area. The patient was seen on [**2132-1-31**] by
neurology because of residual right leg weakness and
difficulty with ambulation. They felt that his weakness could
be mechanical due to irritation from pneumo boots. However,
he does have significant weakness in his distal right leg and
they felt that because of the liver transplant, it is
possible to have worsening of old deficits like his residual
stroke. There were no other recommendations per neurology and
they had signed off from the consult. On [**2132-2-6**], the
patient had a routine postop cholangiogram demonstrating
patent hepaticojejunostomy and anastomosis with normal
appearance of the hepatic ducts. There was no extravasation
of the contrast. The patient had continued with TPN post-
surgery from [**2132-2-1**].
On [**2132-2-6**], the patient was introduced to clears,
tolerated it well, and was advanced to a regular diet. So,
post-cholangiogram procedure, the T-tube was capped. On [**2132-2-5**], the patient continued his vanco, Zosyn, caspo and
levo. The patient was on MMF 1000, prednisone 20 mg daily and
tacrolimus 0.5 and hold for a level of 3.6. The patient was
afebrile and vital signs were stable, good I's and O's, JP
drains medial put out 15 and lateral put out 50. Labs on
[**2132-2-5**] were the following: The patient had a WBC of
13.8, 30.6, 276, sodium 142, 3.4, 112, 19, BUN and creatinine
65 and 3.1, glucose 127. AST was 30, alkaline phosphatase 84,
ALT 34, total bilirubin 1.2 and INR 1.1. On [**2132-2-7**],
hospital day 18, continued on vancomycin, Zosyn,
levofloxacin, fluconazole, MMF, prednisone. The patient is
afebrile and vital signs are stable. The T-tube is capped.
The patient is awake and alert. Lungs are clear to
auscultation bilaterally. CVA - regular rate and rhythm.
Abdomen - well-healed incision, distended. Extremities - the
patient had +3 edema bilaterally in lower extremities. Lasix
was increased from 20 b.i.d. to 20 t.i.d. The patient was
placed on a regular diet. Labs on [**2132-2-7**] were the
following: WBC of 19.9, hematocrit of 32.6, platelets 397,
sodium 142, 3.2, 109, 19, BUN and creatinine 61 and 2.7 with
a glucose of 207. ALT was 33, AST 28, alkaline phosphatase
97, total bilirubin 1.1 and albumin 2.4.
So, the patient is potentially going to rehab to [**Hospital1 **] on
the following medications: albuterol nebs, 1 neb q.4 hours
p.r.n., didanosine chewable 125 mg daily, Anzemet 12.5 IV q.8
hours p.r.n., fluconazole 200 mg q.24, Lasix 40 mg IV t.i.d.,
Valcyte 450 mg every other day, heparin 5000 units
subcutaneously b.i.d., insulin sliding scale, levofloxacin
250 p.o. q.48 hours p.r.n., lopinavir-ritonavir 2 tablets
p.o. b.i.d., Percocet 1-2 tablets q.4-6 hours p.r.n., MMF
1000 mg p.o. b.i.d., nystatin oral suspension 5 ml q.i.d.,
Protonix 20 mg daily, Bactrim SS one tablet 3 times a week,
tacrolimus potentially should be 0.5 b.i.d., tenofovir 300 mg
b.i.d. on Sunday, Wednesday. The patient is to follow up with
Dr. [**Last Name (STitle) **] on the following dates: [**2132-2-14**] at 11:20
a.m., [**2132-2-21**] at 10 a.m., [**2132-2-28**] at 11:40 a.m.
The patient is to call transplant surgery immediately at [**Telephone/Fax (1) 28347**] if any fevers, chills, nausea, vomiting, abdominal
pain. Also, if the patient is not able to drink or eat or
having difficulty with urination. The patient should also
call if there is any increased redness to incision, any
discharge or any edema from the incision. The patient should
have labs every Monday and Thursday in which a CBC, Chem-10,
AST, ALT, alkaline phosphatase, albumin, total bilirubin and
Prograf level to be drawn. The patient has been eating well,
urinating without difficulty, and also using the commode and
getting out of bed with physical therapy. So, the patient is
ready to go to rehab.
FINAL DIAGNOSIS: A 51-year-old male with HIV/HCV, cirrhosis,
end-stage liver disease with HCC status post liver transplant
on [**2132-1-21**].
SECONDARY DIAGNOSIS: Biliary leak, biliary aspiration, right
infiltrate seen on the x-rays, treated for pneumonia.
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 4841**]
Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D: [**2132-2-7**] 09:18:22
T: [**2132-2-7**] 11:18:04
Job#: [**Job Number 97502**]
Name: [**Known lastname 15553**],[**Known firstname **] SR Unit No: [**Numeric Identifier 15554**]
Admission Date: [**2132-1-21**] Discharge Date: [**2132-2-27**]
Date of Birth: [**2080-12-23**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 852**]
Addendum:
Patient was not discharged on [**2132-2-7**] R/T diarhea, Cdiff
positive x1, [**2132-2-18**] started on flagyl and follow up 1:3
negative C-diff. [**2132-2-21**] started on vancomycin. Post pyloric
tube placed and TF started at 60cc/hr with banana flakes, and
boost TID. Did not tolerate TF with intermitent diarhea changed
to TPN via PICC line [**2-13**]. TPN cycled, no diarhea, OOB and
activity increased. Nocturnal increase glucose followed by
[**Last Name (un) 616**], SS adjusted.
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
S/p OLt on [**2132-1-21**]
bronchoscopy on [**2132-1-26**]
s/p ERCP on [**2132-1-30**]
S/p Rouxen-Y-jejeunostomy on [**2132-2-1**]
s/p cholangiogram [**2132-2-6**]
Pertinent Results:
[**2132-2-27**] 03:36AM BLOOD WBC-18.8* RBC-2.78* Hgb-8.5* Hct-26.0*
MCV-94 MCH-30.6 MCHC-32.7 RDW-17.5* Plt Ct-248
[**2132-2-27**] 03:36AM BLOOD Plt Ct-248
[**2132-2-27**] 03:36AM BLOOD Glucose-198* UreaN-70* Creat-2.0* Na-139
K-4.6 Cl-110* HCO3-19* AnGap-15
[**2132-2-27**] 03:36AM BLOOD ALT-58* AST-53* AlkPhos-160* TotBili-0.6
[**2132-2-26**] 06:00AM BLOOD ALT-58* AST-57* LD(LDH)-293* AlkPhos-156*
Amylase-44 TotBili-0.6
[**2132-2-25**] 05:45AM BLOOD ALT-54* AST-58* AlkPhos-141* Amylase-41
TotBili-0.6
[**2132-2-26**] 06:00AM BLOOD Lipase-21
[**2132-2-27**] 03:36AM BLOOD Albumin-2.7* Calcium-9.0 Phos-2.7 Mg-2.2
[**2132-2-12**] 06:00AM BLOOD Triglyc-246*
[**2132-2-27**] 03:36AM BLOOD FK506-11.0
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO once a day.
3. Lopinavir-Ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
4. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO once a day.
5. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
6. Tacrolimus 0.5 mg Capsule Sig: hold Capsule PO once a week:
To be dosed by transplant office weekly per levels. check with
Transplant office [**Telephone/Fax (1) 242**].
7. Valcyte 450 mg Tablet Sig: One (1) Tablet PO once a day.
8. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO 2x a week:
Please make sure daily tacrolimus level is done daily.
9. Prednisone 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): thru [**2132-3-2**]
stop on [**2132-3-3**].
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
12. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): thru [**2132-3-5**]
stop on [**2132-3-6**].
13. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed.
15. Didanosine 100 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO DAILY (Daily).
16. Dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
17. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1)
Intravenous Q8H (every 8 hours) as needed.* * Refills:*0*
18. Insulin Regular Human 100 unit/mL Solution Sig: follow
sliding scale Injection four times a day: Fingerstick
QACHSInsulin SC Fixed Dose Orders
Bedtime
Glargine 18 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular Regular Regular Regular
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70 mg/dL [**11-19**] amp D50 [**11-19**] amp D50 [**11-19**] amp D50 [**11-19**] amp D50
71-120 mg/dL 0 Units 0 Units 4 Units 0 Units
121-160 mg/dL 2 Units 3 Units 7 Units 5 Units
161-200 mg/dL 4 Units 6 Units 9 Units 8 Units
201-240 mg/dL 6 Units 8 Units 11 Units 10 Units
241-280 mg/dL 8 Units 10 Units 13 Units 12 Units
281-320 mg/dL 10 Units 12 Units 15 Units 14 Units
> 320 mg/dL Notify M.D. Notify M.D. Notify M.D. Notify M.D.
.
19. Insulin Glargine 100 unit/mL Solution Sig: 18 units
Subcutaneous at bedtime.
20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed: per port/PICC line
care.
21. TPN
Non-Standard TPN For Date: [**2132-2-27**] Volume(ml/d)1800 Amino
Acid(g/d) 105 Branched-chain AA(g/d)0 Dextrose(g/d)350
Fat(g/d)40
1800 105 0 350 40
Trace Elements will be added daily
Standard Adult Multivitamins
NaCL ) NaAc 140 NaPO4 15 KCl 0 KAc 0 KPO4 0 MgS04 10 CaGluc3
Zinc(mg)
10
Cycle over (hrs.) Start at Decrease rate to (ml/h) at Stop at
14 6 PM 0 0 0
Ordered by [**Last Name (LF) **],[**First Name3 (LF) **], APN Beeper#: [**Numeric Identifier **] on [**2-27**]
@ 1213
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
Discharge Diagnosis:
DX:51 yo with HIV/HCV cirrhosis and HCC s/p OLT on [**2132-1-21**]
Secondary Dx: biliary leak, bile aspiration
right infiltrate
Discharge Condition:
good
Discharge Instructions:
Patient is to call transplant surgery immediately at
[**Telephone/Fax (1) 242**] if any fevers, chills, nausea, vomiting, abdominal
pain. Also call immediately if not able to drink, eat, or having
difficulty with urination. Please call if there is any increase
reddness to incision, any discharge, or edema
Patient needs to have labs drawn every Monday and Thursday in
which a CBC, Chem 10, AST, ALT, alk phosp, albumin, T. bili, and
Prograf drawn every Monday and Thursday starting on [**2132-2-7**].
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 853**], MD Phone:[**Telephone/Fax (1) 242**]
Date/Time:[**2132-3-6**] 10:40
Provider: [**First Name11 (Name Pattern1) 399**] [**Last Name (NamePattern4) 2801**], MD Phone:[**Telephone/Fax (1) 242**]
Date/Time:[**2132-3-10**] 3:40
[**Name6 (MD) **] [**Last Name (NamePattern4) 853**] MD [**MD Number(2) 854**]
Completed by:[**2132-2-27**]
|
[
"584.5",
"V08",
"998.12",
"305.1",
"996.82",
"V58.65",
"486",
"719.7",
"570",
"070.54",
"518.81",
"438.40",
"155.2",
"V58.67",
"038.9",
"293.0",
"576.8",
"008.45",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"50.59",
"51.37",
"96.6",
"96.04",
"50.12",
"87.54",
"96.71",
"00.93",
"51.87",
"45.51",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
16840, 16921
|
12701, 12867
|
17107, 17114
|
12886, 13590
|
17667, 18097
|
13613, 16817
|
16942, 17086
|
1206, 1572
|
3092, 11264
|
11282, 11410
|
17138, 17644
|
1732, 3074
|
12653, 12663
|
265, 794
|
11432, 12636
|
817, 1179
|
1589, 1712
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,720
| 170,771
|
48167
|
Discharge summary
|
report
|
Admission Date: [**2115-7-12**] Discharge Date: [**2115-7-18**]
Date of Birth: [**2056-9-7**] Sex: F
Service: MEDICAL MICU
REASON FOR ADMISSION: Dyspnea and left lung collapse.
HISTORY OF THE PRESENT ILLNESS: This is a 58-year-old woman
with a 90 pack year smoking history who had worsening dyspnea
and cough for several months which worsened in the three days
prior to admission at [**Hospital 1562**] Hospital on [**2115-7-9**]. She
had chest x-ray in [**2114-11-6**] showing no abnormalities
besides healing rib fractures. She had endorsed losing 15
pounds over the six months prior to admission because of loss
of appetite.
On admission to [**Hospital1 1562**], the chest x-ray showed complete
opacification of the left lung. She was taken to
bronchoscopy where a left main stem bronchus neoplasm was
found. The patient did not tolerate the bronchoscopy well
and was coughing with 02 desaturations. She was intubated
and underwent biopsies of the left main stem bronchus lesion.
She was then transferred to [**Hospital1 18**] for a rigid bronchoscopy
with possible stent intervention by Dr. [**First Name (STitle) **] [**Name (STitle) **].
PAST MEDICAL HISTORY:
1. Alcohol abuse.
2. History of narcotic dependence.
3. History of pneumonia.
4. Adult ADHD.
5. History of reactive airways disease/asthma.
6. History of a left hip fracture in [**2114**].
FAMILY HISTORY: Mother had "[**Name2 (NI) **] cancer" and MI.
SOCIAL HISTORY: Ninety pack year smoking history, quit in
[**2114**]. History of alcohol abuse in the past but reportedly
sober for one year, according to the daughter of the patient.
The patient has also been requiring narcotics for her left
hip fracture since last year and had evidence of dependence.
MEDICATIONS UPON TRANSFER:
1. Morphine drip.
2. Versed drip.
OUTPATIENT MEDICATIONS:
1. Effexor.
2. Prempro.
3. Seroquel.
4. Ativan.
5. Ritalin.
PHYSICAL EXAMINATION UPON PRESENTATION: Vital signs:
Temperature 99.4, heart rate 106, BP 127/67. Ventilator
settings at AC 400 by 12 at a PEEP of 5 and 100% FI02.
General: She was a well appearing intubated woman in no
apparent distress. HEENT: Anicteric sclerae and dry
oropharynx. There was some red bloody secretions in the
endotracheal tube. Chest: The chest revealed some very
decreased breath sounds at the left upper lobe. The right
lung field was clear. Cardiac: The cardiac examination
revealed a grade II/VI systolic murmur at the right upper
sternal border radiating to the carotids. Abdomen: Soft,
nontender, no distention. Extremities: No pedal edema. She
had good dorsalis pedis pulses. Neurologic: The patient
moves all extremities and is intermittently agitated and will
try to sit up from the bed. She does not respond to voice
nor follows commands but is currently sedated.
LABORATORY DATA UPON PRESENTATION: White count 13.2,
hematocrit 32, platelets 626,000. The Chem 7 is unremarkable
with a normal bicarbonate at 22. CK at the outside hospital
was 130 with a negative troponin. The ABG on this setting
was 7.31, PC02 49, P02 135 on 100% FI02. Her coagulations
were normal. Microbiology results at the outside hospital
showed MSSA from the sputum in the bronchoscopy as well as
[**Female First Name (un) 564**].
HOSPITAL COURSE: 1. LEFT BRONCHIAL MASS: The patient was
kept intubated for signs of hypoventilation upon arrival to
the [**Hospital1 18**] and MICU. She was stable over the weekend and did
not experience significant [**Hospital1 **] loss from the biopsy at the
outside hospital. She continued to have agitation while on
the ventilator but was easily sedated with Ativan, morphine,
and propofol drips.
She was taken for CT of the airway with reconstruction as
well as rigid bronchoscopy on [**2115-7-15**] where the left
main stem bronchus lesion showed a 70% luminal narrowing and
no distal airway patency. A metal stent was placed with no
resulting inflation of the lung postprocedure. She remained
intubated showing signs of hypoventilation. She was also
treated for MSSA pneumonia with Oxacillin initially. She
also was treated with vancomycin for a temperature while on
Oxacillin. Additional Gram's stain revealed gram-negative
rods and she was started on ciprofloxacin and then switched
to levofloxacin for concern of gram-negative rod coverage.
The day postbronchoscopy, the family was informed of the
ineffectiveness of the stent regarding her ability to
ventilate that lung. The patient's family was informed of
the poor prognosis regarding weaning off mechanical
ventilation. She continued to spike low-grade fevers while
on the Oxacillin and Fluoroquinolone.
She was watched for one day post stent with no improvement in
chest x-ray appearance of the left lung collapse. It was
determined at this time that the patient probably would not
improve on the ventilator and the patient's daughter agreed
to extubation and comfort measures only for the patient.
It should also be noted that a pleural effusion was noted on
the left lung and 800 cc were drained in the OR during rigid
bronchoscopy when a left chest tube was placed to that side.
Cytology is pending on that specimen but was thought to be
most likely a malignant pleural effusion.
The patient underwent extubation on [**2115-7-17**] and was
administered Ativan and morphine drips, titrating up for
sedation and comfort. The patient expired early
approximately 5:30 a.m. on [**2115-7-18**]. The family was
notified and they declined a postmortem examination.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Name8 (MD) 4064**]
MEDQUIST36
D: [**2115-7-18**] 03:22
T: [**2115-7-23**] 17:18
JOB#: [**Job Number 101541**]
|
[
"493.20",
"518.81",
"197.2",
"162.2",
"482.41",
"280.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.01",
"96.04",
"33.24",
"96.05",
"96.72",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
1406, 1453
|
3293, 5770
|
1848, 3275
|
1193, 1389
|
1470, 1824
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,636
| 112,461
|
18383+18384
|
Discharge summary
|
report+report
|
Admission Date: [**2119-9-8**] Discharge Date: [**2119-9-17**]
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old
gentleman with a history of chronic obstructive pulmonary
disease, also with a history of hypertension and chronic
obstructive pulmonary disease, who had the sudden onset of
shortness of breath at approximately 4 p.m. today that was
refractory to his usual inhalers.
Per Emergency Medical Service notes, no chest pain or recent
illnesses. His systolic blood pressure was 240/120,
respiratory rate was 30, and his oxygen saturation was 92% on
a nonrebreather. En route to [**Hospital 882**] Hospital the patient
was given, nitroglycerin, Ativan, and supplemental oxygen.
At [**Hospital 882**] Hospital the patient was noted to be diaphoretic
but could communicate. Improved breathing to 100% on
nonrebreather. Initial arterial blood gas was 7.18/100/499 on
100% nonrebreather and was electively intubated despite the
clinical improvement.
Vital signs revealed the patient's blood pressure was
220/100, his respiratory rate was 32 to 40, and his oxygen
saturation was 92% on nonrebreather. The patient's white
blood cell count was 18 with 2 bands. His hematocrit was 45.
His bicarbonate was 37. Creatine phosphokinase and troponin
levels were negative. Electrocardiogram there showed sinus
tachycardia. No ST changes. Orogastric tube and Foley
catheter were placed and showed poor urine output. The
patient was given intravenous Lasix. A chest x-ray was
consistent with chronic obstructive pulmonary disease. The
patient had blood cultures, urine cultures, and sputum
cultures sent. The patient was given intravenous Levaquin
500 mg, intravenous Solu-Medrol 125 mg total, Ativan 7 mg,
and approximately 7 liters of normal saline. A repeat
arterial blood gas was 7.28/73/118.
The patient was transferred to [**Hospital1 188**] Emergency Department where he arrived intubated and
sedated He was afebrile. The patient's blood pressure was
91/65, tachycardic to 120, his heart rate was 97, his
respiratory rate was 14, and his oxygen saturation was 94% on
an FIO2 of 0.4. His chest x-ray showed no acute infiltrates.
The patient was given 500 mg intravenous Flagyl and 2 mg of
Ativan, and his ventilator was set synchronized intermittent
mandatory ventilation pressure support 5, positive
end-expiratory pressure 5, volume 600, rate 14, and FIO2 of
0.4. Arterial blood gas was 7.32/58/112. Thick tan
secretions were obtained.
Of note, the patient is normally cared for at the [**Hospital6 50626**] Center, and his medical records there
are more detailed.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease.
2. Hypertension.
3. Diastolic heart failure.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Hydrochlorothiazide.
2. Colace.
3. Tylenol.
4. Atrovent.
5. Albuterol.
6. Prednisone.
7. Theophylline.
8. Potassium.
FAMILY HISTORY:
SOCIAL HISTORY: The patient lives [**Location (un) 6409**] with his wife
of many years. An extensive history of smoking. The patient
has not drank alcohol in many years.
PHYSICAL EXAMINATION ON PRESENTATION: In general, the
patient was intubated and sedated. The patient's temperature
was 95.8 degrees Fahrenheit, his heart rate was 102, his
blood pressure was 108/71, his respiratory rate was 14, and
his oxygen saturation was 100%. Head, eyes, ears, nose, and
throat examination revealed pupils 2 mm and equally reactive.
Neck examination revealed no lymphadenopathy. Cardiovascular
examination revealed a regular rate and rhythm. First heart
sounds and second heart sounds were very distant. No
murmurs, rubs, or gallops. Pulmonary examination revealed
clear to auscultation anteriorly and laterally. No wheezes.
Abdominal examination revealed the abdomen was obese,
moderately distended, with midline surgical scars. Extremity
examination revealed the extremities were warm. There was
trace bilateral edema. No clubbing. Neurologic examination
revealed the patient was intubated and sedated. Skin
examination revealed no lesions or rashes.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission revealed the patient's white blood cell count was
18.2, his hematocrit was 45.7, and his platelets were 512.
Differential revealed neutrophils of 82, lymphocytes of 10,
bands of 3. His INR was 1.7. His partial thromboplastin
time was 29.7. Sodium was 141, potassium was 4.2, chloride
was 97, bicarbonate was 37, blood urea nitrogen was 20,
creatinine was 0.6, and his blood glucose was 202. Total
protein was 7.3. His albumin was 4. His total bilirubin was
0.3, his alkaline phosphatase was 71, his AST was 30, and his
ALT was 33. Creatine kinase was 95. Troponin T was less
than 0.01.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray revealed
endotracheal tube was in place, biapical bolus, diaphragmatic
flattening, bibasilar atelectasis, small bilateral pleural
effusions.
Electrocardiogram revealed sinus tachycardia at 120 beats per
minute. Normal axis. Early repolarization. Normal
intervals. Inferolateral T wave flattening.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The
patient is an 83-year-old gentleman with hypercarbic
respiratory failure in the setting of a chronic obstructive
pulmonary disease exacerbation complicated by diastolic heart
failure, hypertension, and a pneumonia.
1. RESPIRATORY FAILURE ISSUES: The patient was intubated
for respiratory acidosis and hypoxemia for retained
secretions most likely due to a chronic obstructive pulmonary
disease exacerbation.
Several trials have been made to optimize his blood pressure
and heart rate which were unsuccessful and then being able to
extubate him upon awakening. The patient had very labile
hypertension where his systolic blood pressures would go from
the 120s to 130s and all the way up to the 200s.
The patient was started on Lopressor and removed all of his
diltiazem to control his heart rate, and the patient was
started on captopril to control his blood pressure. Trials
using diltiazem drips and nitroglycerin to control his blood
pressure and heart rates were unsuccessful.
On [**9-16**], the patient became profoundly hypotensive, so
at this time the cardiac medications were being held. The
patient has been receiving fluid boluses with target central
venous pressures of 12.
2. PNEUMONIA ISSUES: The patient grew out Staphylococcus
aureus (coagulase-positive) from two sputum cultures which at
this time is being treated with a course of oxacillin for 14
days. The patient is currently on day four.
3. CHRONIC OBSTRUCTIVE PULMONARY DISEASE/BRONCHITIS ISSUES:
the patient was continued on Solu-Medrol, Atrovent, and
albuterol for his chronic obstructive pulmonary disease and
bronchitis flare. He received a 7-day course also of
Levaquin, but no pathogens were grown out except the
Staphylococcus aureus from his sputum, for which he was
placed on oxacillin.
4. MILD CONGESTIVE HEART FAILURE ISSUES: The patient had an
echocardiogram which showed the left ventricular cavity size
was normal and regional left ventricular wall motion was
normal. His overall ejection fraction was greater than 55%.
The aortic root was moderately dilated. The tricuspid and
aortic valves were structurally normal. Trivial mitral
regurgitation.
Therefore, the patient was felt to be in diastolic heart
failure and optimizing of his blood pressure and heart rate
were attempted to be obtained before extubation so that he
would try to prevent flash pulmonary edema which we thought
might be leading to him having wheezes rather than just his
chronic obstructive pulmonary disease exacerbation.
5. HYPOTENSION ISSUES: On [**9-16**], the patient became
profoundly hypotensive. It was felt to be unclear whether he
was volume depleted or had been septic. Blood cultures were
sent and were still pending. The patient received several
fluid boluses with goals of obtaining a central venous
pressure of 12, and his hypertensive medications were held.
CONDITION AT DISCHARGE: The patient was still intubated and
in the Medical Intensive Care Unit. This is an interval
Discharge Summary. The patient is currently hypotensive from
an unclear etiology.
DISCHARGE STATUS: The patient is still in the Medical
Intensive Care Unit at [**Hospital1 69**].
MEDICATIONS ON DISCHARGE: Deferred.
DISCHARGE INSTRUCTIONS/FOLLOWUP: Deferred.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D.
[**MD Number(1) 3091**]
Dictated By:[**Name8 (MD) 26705**]
MEDQUIST36
D: [**2119-9-16**] 13:34
T: [**2119-9-16**] 14:21
JOB#: [**Job Number 50627**]
Admission Date: [**2119-9-8**] Discharge Date: [**2119-9-28**]
Service: MICU
ADENDUM TO PREVIOUS DISCHARGE SUMMARY DATED [**2119-9-17**].
Therefore, this dictation covers events from [**2119-9-18**], to
[**2119-9-28**].
HOSPITAL COURSE:
1. Respiratory failure - Due to the patient's intercurrent
illnesses and diminished lung reserve, it was felt by the
MICU team that he would take a prolonged period of time to
extubate. Therefore, he underwent tracheostomy placement on
[**2119-9-19**]. The patient tolerated this procedure well. In the
interim, he was continued on a regimen of Atrovent and
Albuterol meter dose inhalers. He underwent aggressive
pulmonary toilet and chest physical therapy. Overall, he
tolerated tracheostomy procedure well. At the time of
discharge, the patient was being weaned slowly from
ventilation settings, mainly by decreasing his positive and
expiratory pressure requirement. He had several trach collar
trials. He will be continued on a weaning regimen after
discharge to the rehabilitation facility with the ultimate
goal of having the patient off mechanical ventilation.
2. Hypotension - As outlined in the previous dictation
summary on [**2119-9-16**], the patient became profoundly
hypotensive. It was unclear at that time if the patient was
suffering from sepsis versus intravascular volume depletion
from another cause. As the patient was exhibiting signs of
auto PEEP on vent settings, esophageal balloon studies were
performed to ascertain his intravascular volume setting. The
results of these studies were indicative of decreased
intravascular volume. In light of the patient's hemodynamic
instability, his antihypertensive medications of Metoprolol
and Captopril were held. He was bolused aggressively with
intravenous fluids. He transiently required Levophed to
maintain systolic blood pressure in the 120 to 130 systolic
range. After intravenous fluid resuscitation, the patient's
blood pressure stabilized. At the time of discharge, the
patient's pressure actually tended to be hypertensive. He
was restarted on Metoprolol and the dose at the time of
discharge was titrated up to a level of 75 mg three times a
day. In the outpatient setting, the patient's blood pressure
should be continually monitored with antihypertensive
medications titrated to maintain systolic blood pressure in
the 120 to 130 systolic range.
3. Recurrent bacteremia - In light of the patient's acute
hypotension on [**2119-9-16**], he was pancultured. Blood cultures
from that date grew two out of four bottles with coagulase
positive Staphylococcus aureus. Sensitivities on this
organism revealed it to be Oxacillin sensitive. While
waiting for sensitivities, the patient was started
empirically on Vancomycin over concern for possible
Methicillin resistant Staphylococcus aureus sepsis. Although
the cultures ended up growing Oxacillin sensitive
Staphylococcus aureus, this was a concern as the patient had
been on Oxacillin at the time of culture. He had actually
already received three to four days of Oxacillin therapy for
his previous Methicillin sensitive Staphylococcus aureus to
tracheobronchitis during this same hospitalization. In light
of the patient's recurrent bacteremia of Oxacillin sensitive
Staphylococcus aureus while he was on Oxacillin, infectious
disease service was consulted. The infectious disease
service recommended discontinuing Vancomycin and continuing
Oxacillin therapy. A source of the patient's recurrent
bacteremia was aggressively sought. His right subclavian
central venous line was discontinued. Culture from the
patient's right subclavian line catheter tip failed to grow
any organism. He underwent transthoracic echocardiogram
which was negative for vegetations or any evidence of
endocarditis. He also underwent transesophageal
echocardiogram which was also negative for any evidence of
endocarditis or vegetations. Surveillance cultures dated
[**2119-9-18**], [**2119-9-21**], [**2119-9-22**], all exhibited no growth at the
time of this dictation. Urine culture was also negative.
Sputum culture and gram stain demonstrated greater than 25
polymorphonuclear cells, 0 epithelial cells. No
microorganism was identified on sputum gram stain.
Respiratory culture demonstrated rare growth of oropharyngeal
flora. Therefore, the patient completed a second seven day
course of Oxacillin. At the time of discharge, all
surveillance cultures were negative. The patient's white
blood cell count had normalized. He was afebrile.
4. Acute renal failure - The patient demonstrated an acute
elevation in his creatinine level from his baseline of 0.7 up
to a value of 1.4 to 1.5. Concern was for prerenal
intravascular volume depletion versus acute tubular necrosis
which might have occurred during his period of hypotension on
[**2119-9-16**]. There was also concern that the patient might be
exhibiting a renal insult secondary to his Oxacillin therapy.
Urine eosinophils study was negative. The patient's urine
was spun and sediment examined demonstrating red blood cells,
granular casts. There is no evidence of any muddy brown
casts indicative of acute tubular necrosis. Urine
electrolyte analysis was suggestive of a prerenal state. In
light of this, the patient's Captopril was held in order to
prevent further renal insult. His medications were renally
dosed. Albumin at a dose of 25 grams intravenously twice a
day was used to expand his intravascular volume. He
demonstrated good urine output with albumin therapy. At the
time of discharge, his creatinine remained at values ranging
from 1.4 to 1.5 consistently. Upon discharge to
rehabilitation facility, the patient's creatinine should be
frequently monitored.
5. Fluid, electrolytes, nutrition - In light of the
patient's prolonged hospitalization and complicated
illnesses, he is unable to tolerate oral feedings.
Throughout his hospital course, he was maintained on tube
feeds via nasogastric or orogastric tubes. He underwent
percutaneous gastrostomy tube placement on [**2119-9-26**]. He
tolerated this procedure well without any complications.
Status post percutaneous endoscopic gastrostomy tube
placement, the patient's tube feeds were reinstated. At the
time of discharge, he was tolerating them well.
CONDITION ON DISCHARGE: Fair. Oxygenation saturation stable
on current ventilator settings. Attempting to wean the
patient off ventilator via decreasing PEEP requirement and
daily trach collar trial. Renal function stabilized at a
creatinine level of 1.4 to 1.5. The patient is tolerating
gastrostomy tube feeds. Transesophageal echocardiogram and
blood cultures negative.
DISCHARGE STATUS: The patient was discharged to an extended
care rehabilitation facility.
DISCHARGE DIAGNOSES:
1. Acute respiratory failure.
2. Congestive heart failure secondary to diastolic
dysfunction.
3. Chronic obstructive pulmonary disease, acute
exacerbation.
4. Sepsis.
5. Methicillin sensitive Staphylococcus aureus
tracheobronchitis.
6. Hypertension.
7. Pneumonia secondary to Staphylococcus aureus.
8. Arrhythmia secondary to wandering atrial pacemaker.
9. Status post tracheostomy.
10. Status post percutaneous gastrostomy tube placement.
11. Acute renal failure.
MEDICATIONS ON DISCHARGE:
1. Tylenol 325 mg one to two tablets p.o. q4-6hours as
needed for fever, pain.
2. Dulcolax 10 mg p.o. once daily p.r.n. as needed for
constipation.
3. Heparin 5,000 units subcutaneous q8hours for deep vein
thrombosis prophylaxis.
4. Albuterol meter dose inhaler one to two puffs inhaled
q2hours.
5. Atrovent meter dose inhaler two puffs inhaled q4hours.
6. Lansoprazole 30 mg p.o. once daily.
7. Regular insulin sliding scale.
8. Percocet 5/325 per 5ml solution, 5 to 10cc q4-6hours as
needed for pain, fever.
9. Lactulose 30cc p.o. q6hours as needed for constipation.
10. Fluticasone 110 mcg meter dose inhaler two puffs inhaled
twice a day.
11. Prednisone 10 mg one tablet p.o. once daily. The patient
is to continue Prednisone taper at extended care facility.
12. Metoprolol 75 mg p.o. three times a day.
13. Ativan 1.5 to 2 mg q4hours as needed for agitation,
anxiety.
FOLLOW-UP PLANS: In light of the patient's diagnosis of
congestive heart failure secondary to diastolic dysfunction,
he should adhere to a two gram sodium diet with fluid
restriction of 1500cc a day. He is to follow-up with his
primary care physician at the VA within seven to ten days
after discharge from rehabilitation facility. His primary
care physician can then arrange for pulmonary follow-up care
either at the VA or at the [**Hospital1 188**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D. [**MD Number(1) 3091**]
Dictated By:[**Last Name (NamePattern1) 257**]
MEDQUIST36
D: [**2119-9-27**] 19:02
T: [**2119-9-27**] 19:28
JOB#: [**Job Number 50628**]
cc:[**Last Name (NamePattern1) 50629**]
|
[
"482.41",
"584.9",
"038.11",
"491.21",
"428.0",
"401.9",
"518.84",
"785.52",
"428.33"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"88.72",
"31.1",
"96.56",
"96.72",
"43.11",
"38.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2944, 2944
|
15474, 15949
|
15975, 16859
|
2798, 2927
|
8941, 14982
|
8412, 8924
|
5173, 8048
|
8063, 8339
|
16877, 17629
|
118, 2621
|
2643, 2772
|
2961, 5139
|
15007, 15453
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
109
| 151,240
|
14858
|
Discharge summary
|
report
|
Admission Date: [**2142-5-15**] Discharge Date: [**2142-5-18**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet / Morphine
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Headache, Hypertensive urgency
Major Surgical or Invasive Procedure:
Hemodialysis x 2
History of Present Illness:
24 year old female with SLE, ESRD on HD, hx malignant HTN, h/o
SVC syndrome, h/o posterior reversible encephalopathy syndrome
(PRES) and prior intracerebral hemorrhage, recently admitted
[**Date range (1) 17717**] with diarrhea, hypertensive urgency. Treated at that
time with nicardipine drip for a short period and then to her
home regimen. Yesterday onset of nausea with emesis and
inability to tolerate home meds including antihypertensives.
Diarrhea mild as prior. No fever, chills, no hematemesis or
hematochezia. No melena. Today reports onset of headache
therefore to the ED.
In the ED, initial vs were 280/160, 99.4, 105, RR 18. She was
given dilaudid 2 mg PO x 2. Hydral 20 mg x 3 for BP. Calcium
gluconate 1 gram. Insulin 10 units, D 50 [**1-12**] amp, sodium
bicarbonate, kayexalate for K 6.7 (dialysis dependent
Tues/thurs/sat) but with report of peaked T waves. Renal
dialysis fellow was not contact[**Name (NI) **]. HCT 33.4, WBC 4.6, trop 0.10.
Admitted for hypertensive urgency to ICU. No gtt was started. Of
note usualy BP 160/100.
Review of sytems:
patient tearful complaining of frontal headache and nausea
Past Medical History:
1. Systemic lupus erythematosus since age 16 complicated by
uveitis and end stage renal disease since [**2135**].
-s/p treatment with cyclophosphamide and mycophenolate and now
maintained on prednisone
2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD
and now HD with intermittent refusal of dialysis, currently only
agrees to be dialyzed one time/wk
3. Malignant hypertension with baseline SBP's 180's-120's and
history of hypertensive crisis with seizures.
4. Thrombocytopenia
5. Thrombotic events with negative hypercoagulability work-up
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
11. Thrombotic microangiopathy
12. Obstructive sleep apnea on CPAP
13. Left abdominal wall hematoma
14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**],
[**2142**].
15. Pericardial effusion
16. CIN I noted in [**2139**], not further worked up due to frequent
hospitalizations and inability to see in outpatient setting
Social History:
Denies any substance abuse (EtOH, tobacco, illicits). She lives
with her mother. On disability for multiple medical problems.
Family History:
No known autoimmune disease but there is a history of
cardiovascular disease and cerebrovascular accident in her
grandfather
Physical Exam:
Vitals: BP 240/146, 101, 98.6,
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachycardic, 3/6 SEM RUSB
Abdomen: soft, diffusely tender, no rebound or gaurding.
Ext: cachectic, warm, 2+ DP pulse no clubbing, cyanosis or edema
Pertinent Results:
[**2142-5-15**] 05:45AM GLUCOSE-83 UREA N-54* CREAT-7.6* SODIUM-138
POTASSIUM-6.7* CHLORIDE-103 TOTAL CO2-23 ANION GAP-19
[**2142-5-15**] 05:45AM CK(CPK)-96
[**2142-5-15**] 05:45AM cTropnT-0.10*
[**2142-5-15**] 05:45AM CK-MB-NotDone
[**2142-5-15**] 05:45AM WBC-4.6 RBC-3.66* HGB-10.8* HCT-33.4* MCV-91
MCH-29.6 MCHC-32.4 RDW-17.9*
[**2142-5-15**] 05:45AM NEUTS-65.4 LYMPHS-25.1 MONOS-4.8 EOS-4.1*
BASOS-0.7
[**2142-5-15**] 05:45AM PLT COUNT-128*
[**2142-5-15**] 05:45AM PT-14.2* PTT-36.4* INR(PT)-1.2*
[**2142-5-15**] 07:14AM K+-6.0*
[**2142-5-15**] 12:17PM K+-5.3
Images:
CXR: Persistent severe cardiomegaly.
Head CT: Normal brain CT.
Brief Hospital Course:
24 yo female with ESRD on HD, malignant hypertension with hx of
intracerebral hemorrhage, SLE, chronic abdominal pain, and SVC
syndrome admitted due to hypertensive urgency after developing
N/V and being unable to take her po medications.
# Hypertensive urgency: The patient was admitted to the MICU the
night of admission where she was placed on a labetolol drip and
her home medications were restarted. head CT was negative for
intracranial bleed. She was continued on her home regimen of
Aliskiren 150 mg po bid, Clonidine 0.4 mg/24 hr Patch Weekly,
Labetalol 1000 mg po TID, Nifedipine 60 mg Tablet Sustained
Release QPM and 90 mg Tablet Sustained Release QAM, and
Hydralazine 100 mg PO Q8H. During her stay her blood pressure
fluctuated, occasionally becoming relatively low due to grouping
of her medications together. Blood cultures were sent but have
been no growth to date and she remained without signs of
infection (afebrile with no leukocytosis). She was discharged
on her home regimen.
# Nausea/vomiting: The patient did not experience further
vomiting, but occasionally complained of nausea. The cause of
her nausea was unclear. She was able to tolerate po intake
prior to discharge.
# Abdominal pain/Diarrhea: The patient has chronic abdominal
pain with previous negative workups. During this hospitalization
her pain was at its baseline. Since admission she denied
diarrhea. She was continued on her outpatient regimen of [**2-14**] mg
po dilaudid q4h as needed.
# ESRD on HD: She was hyperkalemic in the emergency room and was
given kayexalate. She underwent two sessions of dialysis during
this hospitalization.
# SLE: Stable, without symptoms. She was continued on 4 mg of
prednisone daily.
# History of thrombotic events/SVC syndrome: She is
anticoagulated with warfarin as an outpatient, however her INR
was subtherapeutic on admission at 1.2. Previous documentation
in OMR states she does not need to be bridged while
subtherapeutic. She was initally continued on coumadin 4 mg po
daily, however her INR rose quickly to the therapeutic range, so
this was decreased to 3 mg po daily.
# OSA: She is on CPAP at a setting of 7 as an outpatient and was
continued on this during her hospitalization.
Medications on Admission:
Medications: as per last discharge summary
-Aliskiren 150 mg Tablet [**Hospital1 **]
-Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday)
-Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
-Labetalol 200 mg Tablet Sig 5 tab TID
-Nifedipine 60 mg Tablet Sustained Release QPM
-Nifedipine 90 mg Tablet Sustained Release QAM
-Citalopram 20 mg Tablet Sig daily
-Hydromorphone 2 mg Tablet Sig [**1-12**] Q4 PRN
-Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
-Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H
-Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO BID PRN
-Prednisone 4 mg daily
-Coumadin 4 mg daily at 4 PM
Discharge Medications:
1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
3. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times
a day).
5. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QPM (once a day (in the evening)).
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
9. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
10. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
12. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for hypertension.
13. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary -
Hypertensive urgency
End-stage renal disease on dialysis
Secondary -
Systemic lupus erythematous
History of thombosis and Superior vena cava syndrome
Obstructive sleep apnea
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital due to dangerously elevated
blood pressure due to inability to take your medications
secondary to nausea. It is very important that you take your
blood pressure medications reguarly. Your nausea was controlled
with medication and your blood pressure decreased once back on
your home medication regimen.
You underwent two sessions of dialysis during your
hospitalization. It is extremely important that you attend
dialysis three times weekly as an outpatient.
Medication changes:
You should be taking 3 mg of coumadin daily. You will need to
have your INR checked at dialysis.
Otherwise continue your outpatient medications as prescribed.
Call your primary doctor, or go to the emergency room if you
experience fevers, chills, worsening headache, vision change,
inability to take your medications, blood in your stool, or dark
black stool.
Followup Instructions:
It is very important that you keep your previously scheduled
appointments:
You have an appointment with gynecology to evaluate an
abnormality recently seen on PAP smear. Provider: [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-5-25**] 9:30
Provider: [**First Name8 (NamePattern2) 2353**] [**Last Name (NamePattern1) 4758**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2142-6-1**] 2:00
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2142-5-19**]
|
[
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"287.5",
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] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8632, 8689
|
4428, 6663
|
323, 342
|
8918, 8927
|
3745, 4377
|
9856, 10479
|
3202, 3328
|
7466, 8609
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8710, 8897
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6689, 7443
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8951, 9449
|
3343, 3726
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9469, 9833
|
253, 285
|
1440, 1500
|
370, 1422
|
4387, 4405
|
1522, 3043
|
3059, 3186
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,899
| 172,060
|
37068
|
Discharge summary
|
report
|
Admission Date: [**2173-7-21**] Discharge Date: [**2173-7-27**]
Date of Birth: [**2112-2-5**] Sex: M
Service: MEDICINE
Allergies:
Lorazepam
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Palpitations, abdominal pain
Major Surgical or Invasive Procedure:
Therapeutic paracentesis
History of Present Illness:
Mr. [**Known lastname 65240**] is a 61 year old gentleman with HCV and cirrhosis,
HCC discharged from the Liver service on [**7-16**] presenting with
sudden onset palpitations while waking from sleep this morning,
with associated burning sensation in his chest and epigastrium.
He acknowledges a history of arrythmia, but has not had a
feeling like this before. He reports intermittent cramping
abdominal pain with loose stools since increased feeding with
via NG tube (replaced [**7-20**]) in the last 5 days since paracentesis
and discharge.
.
In the ED, initial vs were: 96.6 84 115/82 24 100 sat. Patient
developed what was determined to be an SVT to the 150s and was
given adenosine 6mg x1 which converted him to a junctional
rhythm in the 30s. Cards and EP reviewed his EKGs and tele
strips and diagnosed him with atrial flutter, recommending low
dose 2.5mg of metoprolol followed by 5mg with control to the
120s and 2L NS, morphine & dilaudid. He was intermittently
hypotensive to the 80s independent of rate. On transfer, 130s,
124/94, 22 100% 3L
.
On the floor, the patient was initially comfortable, but
developed a repeat of his chest discomfort corresponding to a
rate at 130. He also reports dyspnea which he attributes to
fluid in his lung (known R effusion), and abdominal distention
that is not as bad as prior to his recent therapeutic
paracentesis. He also endorses weakness and edema; intermittent
dysuria and urinary infrequency with great effort.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough or wheezing.
Denies nausea, vomiting, constipation. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
1. h/o SVT since age 39
2. HCV cirrhosis, HCC:
- HCV dx [**2150**], genotype 3, presumably [**1-19**] IVDU
- [**11/2169**] liver biopsy showed cirrhosis, s/p Pegylated
Interferon-Ribavirin x48 weeks, became aviremic but lost to f/u
x1 year, no documented SVR
- abnl LFTs noted [**9-/2172**] when hospitalized for unrelated
illness
- AFP [**2172-11-6**]: 14.8
- CT [**2172-11-20**]: ill-defined 5.6cm mass in superior right lobe of
liver
- Bx [**2172-12-4**]: moderately-differentiated HCC, with broad bands
of fibrosis
- Not transplant candidate (lesion outside [**Location (un) 6624**] criteria), not
resection or chemoembolization candidate (tumor thrombus)
- s/p CyberKnife [**1-/2173**] to tumor thrombus
- Cirrhosis well-compensated, with evidence of portal
hypertension (varices) and ascites seen on last CT scan
3. Biliary colic since [**11/2172**] (on ursodiol)
4. peripheral neuropathy - he has numbness of the soles of his
feet and the tip of his second toe bilaterally, appears to be
[**1-19**] interferon treatment
5. Hypertension
6. history of alcohol use
7. history of IV drug use
8. Seasonal allergies
9. s/p knee surgery age 16
Social History:
He is married and has one daughter, age 24. [**Name2 (NI) **] has a distant
history of moderate alcohol use but quit 20 years ago. He smoked
cigarettes but quit in [**2163**]. He currently lives in the [**Location (un) 83563**].
Family History:
Denies any family history of hepatitis or hepatocellular
carcinoma. Grandfather died from heart disease and his
grandmother had an unknown cancer.
Physical Exam:
Vitals: T: 97.1 BP: 121/80 P: 120 R: 20 O2: 95% RA
General: Alert, oriented although eyes closing. Jaundiced
HEENT: Sclera icteric, MM dry, oropharynx clear, NG tube in
place
Neck: Prominent Carotid pulse, JVP elevated. no LAD
Lungs: Decreased breath sounds on the R, clear on Left.
CV: S1 & S2 regular, fast, no murmur appreciated at this rate
Abdomen: Distended, tense, icteric, non-tender with mild fluid
wave.
GU: no foley
Ext: 2+ DP, ankle edema bilaterally
Pertinent Results:
[**2173-7-21**] 10:41PM ASCITES TOT PROT-3.6 LD(LDH)-144 ALBUMIN-1.5
[**2173-7-21**] 10:41PM ASCITES WBC-125* RBC-1200* POLYS-4* LYMPHS-53*
MONOS-0 MESOTHELI-1* MACROPHAG-42*
[**2173-7-21**] 09:46PM LACTATE-1.9
[**2173-7-21**] 09:38PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-2* PH-5.0 LEUK-TR
[**2173-7-21**] 09:07PM GLUCOSE-90 UREA N-87* CREAT-1.5* SODIUM-134
POTASSIUM-5.6* CHLORIDE-100 TOTAL CO2-25 ANION GAP-15
[**2173-7-21**] 09:07PM CK(CPK)-31* DIR BILI-15.0*
[**2173-7-21**] 09:07PM CK-MB-2 cTropnT-0.03*
[**2173-7-21**] 09:07PM TSH-1.3
[**2173-7-21**] 01:22PM cTropnT-0.03*
[**2173-7-21**] 10:30AM ALT(SGPT)-84* AST(SGOT)-95* ALK PHOS-206* TOT
BILI-21.0*
[**2173-7-21**] 10:30AM LIPASE-37
[**2173-7-21**] 10:30AM WBC-5.6 RBC-3.02* HGB-9.6* HCT-29.0* MCV-96
MCH-31.9 MCHC-33.3 RDW-21.6*
Images:
Liver U/S Doppler:
overall no change from previous studies. portal system is
thrombosed as before
.
CXR: Worsening R sided effusion compared to prior
.
EKG: Multiple EKGs include: NSR at 74, atrial flutter at 121,
and sinus arrythmia with PVCs
Brief Hospital Course:
1) Atrial Flutter with rapid rate: The patient's rate was
initially tachycardic with a rate in the 130s associated with
continued discomfort that did not initially respond to 10mg of
Metoprolol IV. His tachycardia improved after a therapeutic
paracentesis was performed, but returned shortly thereafter.
Tachycardia was intermittent but improved with stepwise
escalation of his metoprolol to a final dose of 100mg tid as
well as the addition of daily Diltiazem.
2) Abdominal Pain: The patient's abdominal pain improved
slightly with therapeutic paracentesis but eventually required
high doses of dilaudid for pain control. Once comfort care was
initiated he was transitioned to a morphine PCA with great
improvement.
3) Dyspnea with pleural effusion: Dyspnea improved initially
with therapeutic paracentesis but returned with recurrence of
his tachycardia. Some component of anxiety as well. Improved
with heart rate control with metoprolol and transition to
morphine PCA.
4) HCV Cirrhosis/HCC complicated by ascites, PVT(and smv
thrombosis) with hyperbilirubinemia: Initially therapeutic
paracentesis was performed, with ascites negative for SBP.
After discussion with patient, family, oncology and hepatology,
decision was made to transition to comfort measures only and
DNR/DNI. Pallitative care was actively involved. Patient was
surrounded by family and friends during his remaining days. All
efforts were made to make patient comfortable. He passed away
the morning of [**2173-7-27**].
7) Chronic Pain: Initially managed on dilaudid, then
transitioned to morphine PCA followed by morphine drip.
Medications on Admission:
Ciprofloxacin 500 mg PO Daily until [**7-18**]
Docusate Sodium 100mg PO BID
Hydromorphone 2-4 mg Tablet PO Q4 PRN pain
Lidocaine 5 %(700 mg/patch) Adhesive Patch TP Daily
Metoprolol Tartrate 25mg PO TID
Omeprazole 20mg PO daily
Prochlorperazine Maleate 10mg PO Q8
Sennosides [Senna] PRN
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Liver Cirhosis
Hepatocellular Carcinoma
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
|
[
"572.3",
"584.9",
"477.8",
"356.9",
"456.21",
"338.29",
"401.9",
"427.32",
"338.19",
"285.22",
"511.9",
"518.82",
"789.59",
"511.89",
"V13.02",
"571.5",
"155.0",
"452",
"070.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
7280, 7289
|
5302, 6914
|
298, 324
|
7373, 7382
|
4164, 5279
|
7435, 7442
|
3518, 3666
|
7251, 7257
|
7310, 7352
|
6940, 7228
|
7406, 7412
|
3681, 4145
|
1845, 2088
|
230, 260
|
352, 1826
|
2110, 3255
|
3271, 3502
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,073
| 111,109
|
2367
|
Discharge summary
|
report
|
Admission Date: [**2151-8-17**] Discharge Date: [**2151-8-20**]
Date of Birth: [**2099-5-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 52 year old female with extensive PVD s/p
recent interventions, as well as known CAD and multiple
cardiovascular risk factors (HTN, IDDM), who is transferred from
[**Hospital6 33**] where she presented this a.m. from rehab
with chest pain and hypotension. She was recently discharged
from [**Hospital1 18**] after a stay from [**7-22**] - [**8-16**] during which time she
underwent multiple revascularization procedures of the RLE,
culminating with a R BKA on [**2151-8-10**] after multiple thrombosis of
stents/bypasses which had been placed. She had a PICC placed
for intended 2 weeks of vancomycin (through [**8-30**]) - when exactly
this was placed is unclear, however appears to have been
sometime between [**7-27**] and [**8-9**], and was transferred to [**Hospital 38**]
rehab on [**8-16**]. Her hospital course also appears notable for a
UTI, treated with cipro from [**8-10**] through [**8-13**].
The patient says that she woke up this morning with a [**10-11**]
fleeting chest pain, lasting only seconds. At that time, her
blood pressure was noted to be 60/palp, T 99.5. Labs at
[**Location (un) 38**] were wbc 9.9, HCT 27.1, plt 672, BUN 24, creat 1.7.
She was transferred to [**Hospital6 33**] for further
management. At [**Hospital3 **] her pressure was 86/palp and labs
were notable for WBC count of 23.1, hct 26.5 (stable), platelets
547, BUN/creat 25/2.1. 1st set of cardiac enzymes were negative
and an EKG was unchanged from baseline. CXR was without
infiltrates, and possibly mild congestion. She was given 1.5 L
NS, 1 dose of levaquin, and transferred to [**Hospital1 18**].
In the [**Hospital1 18**] ED her vitals were T 100.1, BP 73/30
non-invasively, HR 86, 99% on RA. She was started on IVF, and
multiple A-line attempts were unsuccessful. She had received 4
L lactated ringers in the ED prior to transfer to the [**Hospital Unit Name 153**], as
well as a dose of vancomycin. She was started on dopamine with
increase of her blood pressure to around 110-120 systolic. A
second set of cardiac enzymes were negative. [**Hospital Unit Name **] surgery
saw the patient in the ED.
On review of systems the patient denies any recent cough,
shortness of breath, abdominal pain. She does say she has had
dysuria, but denies hematuria. She also is complaining of L 5th
toe pain. ROS otherwise negative.
Past Medical History:
1. Severe peripheral [**Hospital Unit Name 1106**] disease status post right and left
femoral-popliteal bypass, underwent Rsided venous bypass in
[**10-6**] which failed, then underwent amputation below knee.
2. Status post thoracic aortic replacement for thoracic aortic
dissection approximately 10 years ago.
3. COPD.
4. CAD with 90% RCA and 60% LAD lesions by recent
catheterization.
5. Severe hyperlipidemia, cholesterol level of about 600 and
triglycerides of approximately 3,000.
6. Insulin dependent diabetes.
7. Hypothyroidism.
8. Hypertension.
9. h/o Pancreatitis.
10. Degenerative joint disease status post laminectomy.
11. Status post cholecystectomy.
12. Status post right femoral embolectomy.
13. Obesity.
Social History:
She admits to a 45 pack year history of tobacco, however she
quit smoking about 2 months ago. She denies any IVDU or alcohol
use. She lives alone. She has 3 children.
Family History:
Non-contributory.
Physical Exam:
VS: T 101.0, HR 82, BP 100/45 non-invasive L wrist, 97% on 2L,
on dopa 12.
Gen: Obese spanish speaking female appearing slightly lethargic
but responding to verbal stimuli appropriately.
MS: Says she is at [**Hospital1 18**], [**2151**], doesn't know the month or the
president.
HEENT: PEARL, moist MM, anicteric sclerae
Neck: JVP not visible secondary to body habitus. Bilateral
carotid bruits.
Chest: ? subclavian bruit on L.
Cor: RR, normal rate, 2/6 systolic murmur heard best at RUSB but
heard throughout the pre-cordium, with radiation to carotids.
Lungs: CTA anteriorly. Mild end-expiratory wheezes.
Abd: NABS, soft, NT/ND.
Extr: R BKA site with mild area of erythema, area around
incisions non-erythematous, no exudate able to be expressed. L
DP non-palpable but present with doppler, PT non-dopplerable. L
5th toe with slight mottling.
Lines: R PICC line with mild erythema, no exudate or
fluctuance.
Pertinent Results:
[**2151-8-17**] 11:54PM GLUCOSE-139* UREA N-16 CREAT-1.1 SODIUM-144
POTASSIUM-5.3* CHLORIDE-112* TOTAL CO2-22 ANION GAP-15
[**2151-8-17**] 11:54PM CK(CPK)-223*
[**2151-8-17**] 11:54PM CK-MB-2 cTropnT-<0.01
[**2151-8-17**] 02:30PM cTropnT-<0.01
[**2151-8-17**] 02:30PM CK-MB-3
[**2151-8-17**] 11:54PM CALCIUM-9.0 PHOSPHATE-3.5 MAGNESIUM-1.8
[**2151-8-17**] 11:54PM CORTISOL-40.8*
[**2151-8-17**] 09:53PM URINE HOURS-RANDOM CREAT-16 SODIUM-71
[**2151-8-17**] 03:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2151-8-17**] 02:47PM LACTATE-0.7
[**2151-8-17**] 02:30PM WBC-8.8 RBC-3.18* HGB-8.6* HCT-28.1* MCV-88
MCH-27.2 MCHC-30.8* RDW-16.1*
[**2151-8-17**] 02:30PM PT-13.9* PTT-21.3* INR(PT)-1.3
Brief Hospital Course:
In the [**Hospital Unit Name 153**], non-invasive blood pressure was thought to be
unreliable in this patient given her known severe PVD. She was
mentating well, with adequate UOP, making non-invasive BP seem
even less reliable. Multiple a-line attempts were unsuccessful.
Patient was not tachypneic, not tachycardic, repeat WBC count
was within normal limits and lactate was 0. 2 sets of enzymes
were negative, EKG was unchanged and patient did not appear to
be in failure. A cortisol stimulation test was performed and
the patient's response was determined to be adequate, ruling out
adrenal insufficiency. The patient's hematocrit was stable and
there were no obvious sources of bleeding or volume loss. Blood
and urine cultures were sent. A repeat chest X-ray showed a
small pleural effusion, was consistent with mild congestive
heart failure but was not consistent with pneumonia. Vancomycin
was continued to cover staph/strep for presumed stump
cellulitis. Dopamine drip was continued.
R BKA site was with mild erythema, no exudate or fluctuance and
the PICC site was only mildly erythematous. Patient did have a
murmur on exam that has been present on past hospitalizations.
Patient's BUN/creatinine was 25/1.9 which was elevated from
13/0.9 on [**2151-8-14**], concerning for an intrinsic renal process,
such as vancomycin nephrotoxicity. However, with hydration,
patient's Creatinine decreased to 0.9 by hospital day 2.
Patient's blood pressure medications (lisinopril and beta
blocker) were held but niacin and gemfibrozil were continued.
Patient was complaining of left 5th toe pain, with mild mottling
on exam, concerning for thrombus vs. embolus vs. pressor
related. [**Date Range **] surgery was consulted and on exam the
appearance of the toe was thought to be due to ischemia.
On hospital day 2, patient was transferred to medicine service
from the intensive care unit. She was normotensive and afebrile
upon transfer. Urine culture returned negative. Blood pressure
medications continued to be held as patient's pressure was not
elevated.
On hospital day 3, patient was complaining of severe LE pain so
pain regimen was switched to MS contin 30mg [**Hospital1 **] with dilaudid
2-4mg Q4-6hours as needed for breakthrough pain. The pain was
thought to be more neurogenic so her gabapentin was increased
from 300mg QD to 300mg [**Hospital1 **]. A physical therapy consult was
obtained. ON discharge, it was noted that pt was on lower dose
of neurontin while in-house; this may have contributed to
increased pain. Pt was restarted on home dose of neurontin. Pt
should try trial off ms contin to see if pain better controlled
on higher dose of neurontin; if not, should restart ms contin.
Patient's hematocrit was 24 so patient was transfused 1 unit
packed red blood cells as patient has known CAD. Iron studies
were consistent with iron deficiency, which requires further
evaluation as outpatient.
Medications on Admission:
SQ heparin
gemfibrozil 600 mg [**Hospital1 **]
Neurontin 1200 mg Q8
Atenolol 50 mg qday
Vancomycin 1 g IV Q12
Quetiapine 25 mg QHS
Senna 1 tab PO QHS
Protonix 40 mg qday
Zocor 80 mg QHS
Niacin 100 mg daily
rosiglitazone 4 mg [**Hospital1 **]
Colace 100 mg PO BID
ECASA 325 mg daily
lisinopril 10 mg daily
hydromorphone 8 mg Q 3 PRN
Discharge Medications:
1. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Niacin 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed.
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
10. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. glargine Sig: One (1) 45U qPM.
12. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: One (1)
Subcutaneous four times a day: AS DIRECTED.
13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Fifteen (15)
ML PO Q6H (every 6 hours) as needed.
14. Hydrocortisone 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed.
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
16. Ibuprofen 400 mg Tablet Sig: 1-1.5 Tablets PO Q8H (every 8
hours) as needed.
17. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed.
18. 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.
19. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours): last day is [**8-30**].
20. Gabapentin 800 mg Tablet Sig: 1.5 Tablets PO three times a
day.
21. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
once a day.
22. MS Contin 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
1. Hypovolemia
2. Peripheral [**Location (un) **] Disease status-post multiple
interventions including recent right below the knee amputation.
3. Coronary artery disease
Discharge Condition:
1. Afebrile, vital signs stable
2. Normotensive
3. Improved pain management
Discharge Instructions:
1. Please return to Emergency Room, call your PCP [**Last Name (NamePattern4) **] 911 if you
have chest pain, shortness of breath, fevers/chills or become
dizzy, lightheaded or pass out.
2. Please call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12300**] for a follow up appointment
within 2-3weeks.
3. Please attend all follow up appointments.
4. Please take all of your medications regularly. You will be
going to the rehabilitation facility on a new medication, MS
contin 30mg po BID for your pain. Your dose of gabapentin has
also been increased from 300mg po QD to 300mg po BID.
Followup Instructions:
1. Please call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12300**] at his office (phone # [**Telephone/Fax (1) 12301**]) for a follow up appointment within 2-3weeks.
2. Provider: [**Name10 (NameIs) **] STUDY Where: CC CLINICAL CENTER RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2151-10-26**] 11:00
3. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2151-10-26**] 1:00
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
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"E878.5",
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"440.32",
"440.20",
"997.62",
"428.0",
"486",
"530.81",
"250.70",
"285.29",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10834, 10931
|
5468, 8393
|
321, 328
|
11145, 11223
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4652, 5445
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8419, 8752
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11247, 11856
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3707, 4633
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270, 283
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356, 2726
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2748, 3469
|
3485, 3657
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,513
| 162,503
|
16967
|
Discharge summary
|
report
|
Admission Date: [**2112-6-30**] Discharge Date: [**2112-7-3**]
Date of Birth: [**2112-6-28**] Sex: F
Service: NEONATOLOGY
HISTORY OF THE PRESENT ILLNESS: Baby girl [**Known lastname **] [**Known lastname **]
delivered at 38 2/7 weeks gestation with a birth weight of
3,745 grams and was admitted to the Intensive Care Nursery on
day of life number two for evaluation and management of
emesis and bloody stools.
The mother is a 35-year-old gravida II, para I now II woman
with estimated date of delivery [**2112-7-9**]. Prenatal screens
included blood type O positive, antibody screen negative, RPR
nonreactive, hepatitis B surface antigen negative, and group
B strep negative. The pregnancy was complicated by
diet-controlled diabetes mellitus. The mother presented with
spontaneous labor. Membranes were artificially rupture with
clear fluid around four hours prior to delivery. No maternal
fetal. The delivery was by cesarean section under epidural
anesthesia for a failed vacuum and presumed CPD. The infant
was vigorous at delivery, was bulb suctioned for bloody
secretions and received free-flow oxygen briefly.
At around five minutes of age, the stomach was suctioned for
a large amount of bloody amniotic fluid. Apgar scores were
nine and nine at one and five minutes respectively.
PHYSICAL EXAMINATION ON ADMISSION: Pink, active, alert
infant. Well perfused and saturated in room air. The skin
was without lesions. Mild parieto-occipital caput, no
evidence of fracture on physical examination. Ears, nose,
and throat were within normal limits. The neck was soft and
supple without tracks or sinuses. Normal heart sounds. No
murmur. The lungs were clear. The abdomen was soft,
nondistended, nontender, positive bowel sounds. Genitalia:
Normal term female. Neurologic: Nonfocal, age appropriate.
Face symmetric with good suck and root. Normal cry. Moves
all extremities equally. No skeletal injuries. Grasp times
four. Pupils equal and reactive to light. Hips stable.
HOSPITAL COURSE: RESPIRATORY: No issues.
CARDIOVASCULAR: Heart rate 140s to 150s without murmur.
Blood pressure 67/41 with a mean of 53. Cardiovascularly
stable throughout the hospital stay.
FLUIDS, ELECTROLYTES, AND NUTRITION: The infant's blood
glucose was monitored following delivery secondary to
maternal history of diabetes mellitus. The initial glucose
was 36 and the infant was fed formula and it increased to 47
and thereafter was greater than 50. The infant initially fed
with Enfamil 20 in the Newborn Nursery as the mother was
unable to breast feed initially. The infant developed bloody
stools in the first 24 hours of life and the formula was
changed to Prosobee as the mother was unable to breast feed.
The patient continued to pass bloody stools with the onset of
nonbilious emesis which prompted admission to the Intensive
Care Nursery. On admission, the infant's abdominal
examination was normal. The x-ray of the abdomen was normal
bowel gas pattern. No pneumatosis. With a history of the
bloody amniotic fluid in the infant's stomach in the Delivery
Room, the bloody stools were thought to be due to maternal
blood versus milk protein intolerance.
The infant was n.p.o. for several hours with IV fluids
running during the workup and then the feeds were restarted
again with Prosobee. The stools have now been negative for
48 hours for both physical blood and the Guaiac test. At
discharge, the mother is breast feeding and supplementing
with Prosobee.
GASTROINTESTINAL: See above for bloody stools.
The bilirubin on day of life number three was total 14.4,
direct 0.3. [**Known lastname **] has been treated with a bili blanket with a
bilirubin on the day of discharge, [**2112-7-3**], total 13.1,
direct 0.3. Recommend follow-up bilirubin in the doctor's
office after discharge.
HEMATOLOGY: The hematocrit on admission was 49. A follow-up
hematocrit the following day done due to bloody stools was
48%.
INFECTIOUS DISEASE: A CBC and blood culture was done on
admission to rule out infection. The CBC showed a white
count of 12,000 with 48 polys, no bands, platelets 160,000.
Blood culture was negative. The infant was not treated with
antibiotics.
NEUROLOGY: Around 34 hours of age, the infant's bassinet
tipped over onto the floor with [**Known lastname **] remaining in the
bassinet. The infant was examined with no evidence of
injury. A CAT scan was done that showed no evidence of
intracranial injury or bleeding. From this study it was
unclear whether an occipital fracture was present. Skull
films were done which ruled out this possibility in the area
of concern.
SENSORY: Hearing screening was performed with automated
auditory brain stem response. The infant passed both ears.
CONDITION ON DISCHARGE: A five day old term infant with
physiologic jaundice, feeding well.
DISCHARGE DISPOSITION: Discharged home with parents.
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21448**], telephone number
[**Telephone/Fax (1) 37814**].
CARE AND RECOMMENDATIONS:
1. Feeds: Ad lib breast feeding. Parents may supplement
with Prosobee if [**Doctor First Name **] seems hungry after breast feeding.
2. Medications: None.
3. State newborn screen was done on day of life number three
and is pending.
4. Immunizations: Received hepatitis B immunization on
[**2112-6-28**].
FOLLOW-UP APPOINTMENTS: The parents will call pediatrician
tomorrow, [**2112-7-4**], to make an appointment for [**Known lastname **] to be
seen. A follow-up bilirubin off phototherapy is recommended.
DISCHARGE DIAGNOSIS:
1. AGA term female.
2. Bloody stools, swallowed maternal blood versus milk
intolerance.
3. Physiologic jaundice.
4. Rule out sepsis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (NamePattern1) 36138**]
MEDQUIST36
D: [**2112-7-3**] 03:46
T: [**2112-7-3**] 16:02
JOB#: [**Job Number 47739**]
|
[
"V29.0",
"V05.3",
"774.6",
"E884.4",
"V30.01",
"V29.3",
"578.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.55"
] |
icd9pcs
|
[
[
[]
]
] |
4887, 5066
|
5630, 6048
|
2045, 4769
|
5092, 5405
|
5430, 5609
|
1358, 2027
|
4794, 4863
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,313
| 141,826
|
29816
|
Discharge summary
|
report
|
Admission Date: [**2174-2-22**] Discharge Date: [**2174-2-26**]
Date of Birth: [**2145-5-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1974**]
Chief Complaint:
heel ulcer, ESRD.
.
Major Surgical or Invasive Procedure:
heel ulcer debridement
History of Present Illness:
HPI: 28 yo M type I DM(diagnosed approx age 13), diabetic
nephropathy, with creat of 3.3 in [**9-12**], h/o type IV RTA, not
compliant w/ meds, not taking insulin for 1 month, presented
today with increased lower ext swelling and mild facial edema.
Acute on chronic renal failure, Cr 6.1 K of 6.7. On admission,
he endorsed polyuria, watery diarrhea of 2 week duration and
decreased PO intake (denies N/V). He reports that he was told he
had kidney problems a year ago from DM and had sugars out of
control but was lost to follow up. He has had prior
hospitalizations at [**Hospital1 2177**] for DMI and noncompliance. States that
his vision has been "worse" in past year.
.
In the ED, he had a FS of 301 and was found to have a foot ulcer
on his right heel. He received 10units of insulin in the ED and
an amp of bicarb. Kayexalate was given for K of 6.7. He also
received 1.5L NS and Unasyn for his presumed infected ulcer.
Received 20mg IV Labetalol. Pt was admitted to MICU for
hyperkalemia, hyperglycemia and worsening renal failure. While
in the MICU, pt was started on Levo/Amp-sulbactam for heel ulcer
had plain film w/o si of osteo, was maintained on SSI w/good
control of BS and started on Labetolol/Hydral for BP control. Pt
was also found to have BL pleural effusions on CXR thought to be
[**3-11**] nephrosis, but [**Doctor First Name **]/ANCA sent to r/o SLE. HCT 21 on
admission- iron studies showed ACD. Pt was transferred to
medical floor for further management of ESRD and w/u of pleural
effusions.
.
Currently denies HA/dizzyness, CP/SOB, abdominal pain,
fever/chills.
Past Medical History:
IDDM
Diabetic nephropathy
.
Social History:
Lives with his mother and brothers. Unemployed. Spends his days
at home- not active. Ex-alcoholic, now sober >1 year. Used to
smoke lots of marajuana, now sober. Used to smoke cigarettes
(1ppd x several years) now quit >1ye ago. No current drug use or
alcohol abuse. .
.
Family History:
FH: DM both sides of the family.
.
Physical Exam:
PE: 98 184/94 106 14 96% O2 Sats RA
Gen: WD man in bed in NAD
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. Soft [**3-15**] diastolic murmur (chronic
according to pt), no rubs or [**Last Name (un) 549**]
LUNGS: CTA, BS BL, No W/R/C
ABD: Soft, NT, ND. NL BS. No HSM
EXT: No edema. 2+ DP pulses BL
SKIN: 2 x 3 cm ulcer on right heel; diffuse vitilligo
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**2-8**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred.
PSYCH: Listens and responds to questions appropriately, pleasant
.
Pertinent Results:
[**2174-2-22**] 10:59PM URINE HOURS-RANDOM CREAT-53 SODIUM-82 TOT
PROT-658 PROT/CREA-12.4*
[**2174-2-22**] 10:59PM URINE OSMOLAL-328
[**2174-2-22**] 08:22PM GLUCOSE-59* UREA N-50* CREAT-6.1* SODIUM-143
POTASSIUM-5.0 CHLORIDE-115* TOTAL CO2-20* ANION GAP-13
[**2174-2-22**] 08:22PM calTIBC-178* VIT B12-796 FOLATE-9.9
FERRITIN-485* TRF-137*
[**2174-2-22**] 08:22PM TSH-2.8
[**2174-2-22**] 01:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-21-50
[**2174-2-22**] 01:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-500
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2174-2-22**] 01:00PM PLT COUNT-468*
[**2174-2-22**] 01:00PM ALBUMIN-2.7* CALCIUM-6.8* PHOSPHATE-5.2*
MAGNESIUM-1.7
[**2174-2-22**] 01:00PM ALBUMIN-2.7* CALCIUM-6.8* PHOSPHATE-5.2*
MAGNESIUM-1.7
[**2174-2-22**] 01:00PM LIPASE-55
[**2174-2-22**] 01:00PM ALT(SGPT)-37 AST(SGOT)-46* ALK PHOS-162*
AMYLASE-128* TOT BILI-0.2
[**2174-2-22**] 01:00PM GLUCOSE-199* UREA N-53* CREAT-6.1* SODIUM-138
POTASSIUM-8.3* CHLORIDE-109* TOTAL CO2-20* ANION GAP-17
[**2174-2-22**] 02:47PM LACTATE-0.7 K+-6.7*
[**2174-2-22**] 08:22PM PTH-315*
.
EKG NSR, No ST Changes
.
CXR [**2-22**]: IMPRESSION: Cardiomegaly with mild central pulmonary
vascular congestion. Left lung base opacity could represent
confluent edema, however consolidation cannot be excluded. A
followup chest radiograph after treatment for congestive heart
failure is recommended.
.
Foot AP/Lat [**2-22**]: IMPRESSION: Lateral right foot ulcer with no
radiographic evidence of bony involvement.
.
LLE Dopplers: IMPRESSION: Negative left lower extremity DVT
study.
.
Echo [**2-23**]- left atrium is mildly dilated. No atrial septal
defect is seen. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function appears normal (LVEF>55%).
There is no left ventricular outflow obstruction at rest or with
Valsalva. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are structurally normal. Mild to moderate ([**2-8**]+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is a moderate sized pericardial
effusion. There are no echocardiographic signs of tamponade.
IMPRESSION: Symmetric LVH. Mild to moderate mitral
regurgitation. Moderate, circumfirential pericardial efffusion
without tamponade.
.
CT chest [**2-23**]: IMPRESSION:
1. Moderate-sized pericardial effusion.
2. Bilateral pleural effusions, moderate on the right and small
on the left with associated compressive atelectasis.
3. No evidence of hiatal hernia.
.
.
Brief Hospital Course:
28 yo M type I DM, diabetic nephropathy, h/o type IV RTA, not
compliant w/ meds, not taking insulin who was admitted to the
MICU with ARF on CRF and possible DKA and possible PNA.
.
# IDDM: Poorly controlled DM. He has no gap but protein in
urine, symptoms associated with hyperglycemia, ulcer on foot,
worsening of vision. [**Last Name (un) **] followed throughout hospitalization.
RISS and NPH 10units at bedtime and 10units in am, checked BS
QACHSContinued to closely monitor lytes. SW consulted for med
noncompliance.
.
# Acute on chronic renal failure- Cr 6.1 K of 6.7. in the
setting of DKA in pt w/nephrotic syndrome p/w facial edema.
prot/cr ratio 12.4 c/w nephrotic syndrome. PTH 315, iron studies
show ACD [**3-11**] ESRD. AG 11 this AM. Renal U/S showed CRI, no
hydronephrosis. Renal followed throughout admission, vein
mapping completed for future HD. Nurse [**First Name (Titles) **] [**Last Name (Titles) 3782**] setup of HD met
w/pt. Pt felt that he did not want to make a decision wrt his HD
during this admission though he was advised of the significance
of this issue.
.
# Foot ulcer: [**3-11**] Longstaning DM. Podiatry debrided [**2174-2-23**],
wound care per podiatry recs.
.
# Pleural/Pericardial effusions- on CXR and CT, no clinical
evidence of tamponade and no evidence of tamponade on [**2-23**] TTE.
Probable [**3-11**] nephrosis, ARF. Pt HDS, pulsus [**9-16**] w/o sx- final
read on Echo pending. Pt afebrile w/o cough, no clinical sx of
PNA. Stable.
.
# Hypertension- Improved. Continued Labetalol at 100mg [**Hospital1 **] pt
received doses of Hydral PRN.
.
# Anemia: secondary to renal insufficiency- Iron studies show
ACD; TSH, B12, Folate WNL. Continue EPO, iron supplementation
per renal.
.
# LFT Abnormalities: No specific pattern. Probably secondary to
malnurishment and poor insulin compliance.
.
# CODE: FULL CODE
Medications on Admission:
Insulin (off for >1 month)
Discharge Medications:
1. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Capsule(s)* Refills:*2*
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
6. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension
Sig: One (1) 14 Subcutaneous QAM.
Disp:*30 QS* Refills:*2*
8. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension
Sig: One (1) 8units Subcutaneous QPM.
Disp:*30 QS* Refills:*2*
9. Accustrips
Please dispense QS for 30days.
Refills#2
10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 12 days.
Disp:*12 Tablet(s)* Refills:*0*
11. Clindamycin HCl 150 mg Capsule Sig: One (1) Capsule PO four
times a day for 12 days.
Disp:*48 Capsule(s)* Refills:*0*
12. Outpatient Lab Work
Please go to Dr. [**First Name (STitle) 4102**] [**Name (STitle) **] office for CBC, chem 10 within 1
week of discharge. Call if questions: [**Telephone/Fax (1) 3637**].
Discharge Disposition:
Home
Discharge Diagnosis:
Mature Onset Diabetes of Youth ([**Doctor Last Name **])
Discharge Condition:
stable
Discharge Instructions:
You have a condition called mature onsed diabetes of youth. It
is important that you follow up with your [**Last Name (un) **] Diabetes
appointments as well as your other appointments for follow up of
this condition. It is also important that you check your blood
sugars at home and record them for management of this disease.
You have a glucometer and glucose strips that you should use for
this purpose.
Please present to the hospital or speak with your physician if
you have chest pain or shortness of breath, fever or chills,
headache or dizziness.
Please take all of your medications as directed and follow up
with your appointments.
It is very important that you have your labs tested within 1
week of discharge. You have been given a prescription to take to
Dr.[**Name (NI) 14277**] office to have these labs checked.
Followup Instructions:
You have the following appointments:
Please follow up with Dr. [**Last Name (STitle) 7537**], we have called to try to make
you an appointment. You should call them to make sure that your
appointment has been made [**Telephone/Fax (1) 7538**].
Provider: [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) 15351**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2174-3-10**] 2:00
[**Last Name (un) **] Diabetes Center follow up with Dr. [**First Name (STitle) 71320**] Wednesday [**Hospital **]
clinic within the next 2 weeks [**Telephone/Fax (1) 2384**]. Please call with
regard to follow up appointment.
Please also call the [**Last Name (un) **] psychologist for an appointment the
number is [**Telephone/Fax (1) 60675**].
Please call Dr. [**First Name (STitle) 4102**] [**Name (STitle) 4090**] to follow-up regarding your kidney
function, please call [**Telephone/Fax (1) 3637**] for this appointment.
|
[
"285.21",
"585.9",
"403.90",
"250.40",
"584.9",
"707.14"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9165, 9171
|
5868, 7721
|
336, 360
|
9272, 9281
|
3047, 5845
|
10154, 11082
|
2336, 2373
|
7798, 9142
|
9192, 9251
|
7747, 7775
|
9305, 10131
|
2388, 3028
|
276, 298
|
388, 1978
|
2000, 2030
|
2046, 2320
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,623
| 131,200
|
320
|
Discharge summary
|
report
|
Admission Date: [**2183-7-23**] Discharge Date: [**2183-7-30**]
Date of Birth: [**2105-12-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Left non-small cell lung cancer diagnosed in 6/[**2182**].
Major Surgical or Invasive Procedure:
[**2183-7-23**]: bronchoscopy and mediastonoscopy
[**2183-7-25**]: LUL segmentectomy, LLL wedge resection
History of Present Illness:
Mr. [**Known lastname 2970**] is a 77-year-old gentleman, referred by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1391**] to Dr. [**Last Name (STitle) **] for advice and options regarding a
carcinoma of the lung detected during recent hospitalization for
coronary disease and a large aortic aneurysm in [**2183-5-8**]. A
lesion in the left lung was discovered in the upper lobe and a
needle biopsy confirmed non-small cell carcinoma. He underwent
a PET scan, which showed extreme hypermetabolism with an SUV of
17 at the site of the lung primary lesion. There is sparse
uptake within the mediastinum, not considered of pathologic
significance, as well as active inflammation around the
abdominal graft.
He presented to [**Hospital1 18**] on [**2183-7-23**] for an operation to address his
left non-small cell lung cancer.
Past Medical History:
Significant for coronary disease, status
post an infarction. He has aortic aneurysm, increased serum
cholesterol, prostate cancer, and carcinoma of the sigmoid
colon.
PAST SURGICAL HISTORY: Sigmoid colectomy in [**2171**], radical
prostatectomy in [**2169**], and the tube graft repair of his
abdominal
aortic aneurysm.
Social History:
He has substantial prior smoking history, just recently quit.
He has no active alcohol issues.
Physical Exam:
VITAL SIGNS: Weight of 148 pounds. He is afebrile, blood
pressure 140/83, pulse 74 and regular, and room air saturation
is
95%.
LUNGS: His lung fields are surprisingly clear.
HEART: Regular rhythm and rate without murmur or gallop.
NECK: There were no carotid bruits.
ABDOMEN: Soft and nontender with good healing ridge along the
wound.
EXTREMITIES: He has no peripheral edema.
Brief Hospital Course:
The patient presented to [**Hospital1 18**] on the day of planned surgery.
He was noted to have significant bradycardia prior to starting
the operation. He did undergo a flexible bronchoscopy and
mediastinoscopy that was complicated by substantial
intraoperative bleeding. He was subsequently ruled out for a
cardiac event, and remained
hemodynamically and neurologically stable on POD#1. On HD#3, the
decision was made to proceed with a segmental resection given
the T2 size of the lesion and his limited baseline lung
function. Please refer to both operative notes of [**2183-7-23**] and
[**2183-7-25**] for further details of the procedures. An epidural was
placed for postoperative pain control on [**2183-7-25**]. Two left-sided
chest tubes were placed intraoperatively, and a post-operative
chest radiograph showed a moderate left sided pneumothorax.
On [**2183-7-25**], he was transfused 1 unit of packed RBCs for a
hemtocrit of 27.6. The Acute Pain Service continued to follow
the patient for management of the epidural catheter. He was
admitted to the CSRU for a day after surgery and was transferred
to the floor on [**7-26**] after he was deemed to be stable. His chest
tubes were placed to water seal, and a chest radiograph showed
very slight increase in left pneomothorax.
On [**7-27**], his anterior chest tube which was placed
intraoperatively was removed without incident, and his second
tube was put to bulb suction. A chest radiograph that was done
after these changes were made showed no acute or concerning
changes in the left pneumothorax. His epidural catheter was
removed and he was given oral pain medications.
On [**7-28**], the patient's foley catheter was discontinued, but the
patient failed to void 12 hours after removal. He was
administered tamsulosin and his foley catheter was replaced. A
PA and lateral chest radiograph showed decreased left-sided
pneumothorax and interstitial edema since the prior examination,
with small bilateral pleural effusions.
On [**2183-7-29**], he underwent a video swallow study which revealed a
left vocal cord paralysis. The speech consultant recommended the
following:
1. Diet of thin liquids and soft solids
2. Swallow w/chin tucked to chest for all consistencies
3. Pills whole in applesauce
4. ENT consult to evaluate vocal cord mobility to r/o Left
vocal cord paresis/paralysis
An otolaryngology consult was obtained for evaluation and
treatment for this condition, the recommendation which were to
observe strict chin-tuck adherence and strict aspiration
precautions as the patient was thought to be at great aspiration
risk; and twice-daily proton pump inhibitor. A chest radiograph
performed on [**2183-7-29**] showed further improvement in the small
left apical pneumothorax and improvement in the interstitial
edema.
On [**2183-7-30**], he underwent another voiding trial after his foley
was discontinued, and this time, he voided 500cc. The patient
was discharged to rehabilitation facility in good condition,
with instructions for follow-up care with thoracic surgeon, Dr.
[**Last Name (STitle) **], and otolaryngologist, Dr. [**Last Name (STitle) **].
Medications on Admission:
Include atenolol, Lipitor, Percocet, and an aspirin.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every four
(4) hours as needed.
2. Insulin Regular Human 100 unit/mL Solution Sig: [**12-9**] units
Injection ASDIR (AS DIRECTED).
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days.
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
6. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain. Tablet(s)
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 2971**] Rehabilitation and Nursing Center - [**Hospital1 1474**]
Discharge Diagnosis:
Left lung lesion
Coronary artery disease
History of prostate cancer
History of colon cancer
History of abdominal aortic aneurysm
Discharge Condition:
Stable
Discharge Instructions:
You may resume your pre-hospital medications.
Call Dr. [**Last Name (STitle) **] or come to the emergency room if you have:
* fever above 100.5
* nausea, vomiting or diarrhea that doesn't stop
* chest pain, shortness of breath, or dizziness
* any other symptoms that concern you.
Followup Instructions:
See Dr. [**Last Name (STitle) **] in clinic in [**12-9**] weeks. Call [**Telephone/Fax (1) 170**] for an
appointment.
See otolaryngologist Dr. [**Last Name (STitle) **] in clinic in 3 weeks. Call
[**Telephone/Fax (1) 41**] for an appointment.
Completed by:[**2183-7-30**]
|
[
"E879.8",
"V10.46",
"414.01",
"478.31",
"427.89",
"997.1",
"162.3",
"V10.05",
"998.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"99.04",
"34.04",
"40.11",
"32.4",
"34.22"
] |
icd9pcs
|
[
[
[]
]
] |
6513, 6616
|
2251, 5400
|
381, 489
|
6789, 6798
|
7127, 7402
|
5504, 6490
|
6637, 6768
|
5426, 5481
|
6822, 7104
|
1581, 1713
|
1841, 2228
|
282, 343
|
517, 1366
|
1388, 1557
|
1729, 1826
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,000
| 145,080
|
32370
|
Discharge summary
|
report
|
Admission Date: [**2173-11-2**] Discharge Date: [**2173-11-8**]
Date of Birth: [**2098-2-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 5188**]
Chief Complaint:
splenic rupture
Major Surgical or Invasive Procedure:
emergent splenectomy
History of Present Illness:
76yM transferred from [**Hospital6 2910**] with history
of myelodysplastic syndrome. He developed abdominal pain on
[**10-30**] after a severe coughing fit. CT scan at outside hospital
showed a contained splenic rupture. He was transferred to NEBH
for management and planned elective splenectomy on [**11-2**]. His
mental status deteriorated and he became tachycardiac and
hypotensive. He was transferred here for further management.
CAT SCAN: 20cm spleen with active contrast extrav and
significant free fluid in the abdomen
Past Medical History:
MDS
DM Type 2, NIDDM
HTN
CHF
Hypercholesterolemia
Physical Exam:
HR 123 BP 124/66 13 98% 4 Liters
AAOx3, confused
S1S2 no murmurs
course Breath sounds
abdomen tight and tense, diffusely tender
Pertinent Results:
[**2173-11-1**] 11:59PM WBC-11.6* RBC-3.19* HGB-10.3* HCT-29.7*
MCV-93 MCH-32.4* MCHC-34.8 RDW-16.9*
[**2173-11-1**] 11:59PM GLUCOSE-264* UREA N-45* CREAT-2.5* SODIUM-138
POTASSIUM-5.2* CHLORIDE-106 TOTAL CO2-19* ANION GAP-18
[**2173-11-1**] 11:59PM CALCIUM-6.9* PHOSPHATE-7.7* MAGNESIUM-2.2
[**2173-11-2**] 12:00AM LACTATE-1.7
[**2173-11-1**] 11:59PM PT-14.0* PTT-30.1 INR(PT)-1.2*
Brief Hospital Course:
Patient was admitted to [**Hospital1 18**]. He was immediately typed and
crossed for multiple units of blood, platelets and FFP. He was
taken to the OR immediately for emergent splenectomy.
OPERATIVE REPORT
INDICATIONS FOR SURGERY: This is a 75-year-old male who
presented from an outside hospital with hemodynamic shock.
His history of myeloproliferative disorder was known and he
had a CAT scan done at the outside institution which revealed
severely injured and spontaneous rupture of his spleen, as
well as significant amount of free fluid in the abdomen. Upon
arrival to the [**Hospital6 256**] he had a
hematocrit of 23, heart rate of 130 and blood pressure of
80/40. It was decided to bring the patient emergently to the
operating room.
PROCEDURE IN DETAIL: The patient was placed in the supine
position on the operating room table. A left subcostal
incision was used and brought over slightly to the right of
the midline. Dissection was carried down to the fascia to the
muscles. The peritoneum was identified and opened up.
Approximately 2 L of old and new blood quickly was suctioned
out from the abdomen. The spleen appeared to be significantly
enlarged and was actively bleeding. It was clear that a
portion of the spleen had ruptured. Using left hand, the
ligamentous attachment to the spleen to the diaphragm and the
posterior peritoneum, as well as the kidney were bluntly
dissected free. The stomach was then retracted medially and
the gastrosplenic ligament was taken down. Any of the vessels
which were encountered in this ligament were tied in
continuity with 3-0 silk ties. The lesser sac was also
entered to aid in visualization. The remainder of the
posterior attachments were taken bluntly with the left hand.
The spleen was brought into the wound. The tail of the
pancreas could be easily seen into the splenic hilum. The
splenic hilar vessels were then taken using [**Doctor Last Name 1356**] clamps. The
vessels were doubly ligated with a 0 Vicryl tie and then a 2-
0 suture ligature. Care was taken not to injure the tail of
the pancreas. Some omental attachments were also taken off
the spleen. The spleen was then removed and passed off the
field. At this point, there was no evidence of any active
bleeding. Copious amounts of irrigation were used in the left
upper quadrant. There was a mild diffuse ooze from the
posterior abdominal wall. This was packed off. The remainder
of the abdomen was inspected. There was free fluid over the
liver which was old blood and was suctioned out and
irrigated. There was some old blood in the pelvis which was
suctioned out and irrigated.
Attention was then placed again to the left upper quadrant
where there was still slight diffuse ooze. Layers of Surgicel
were placed and the area was packed again. After examination
in 2 minutes it appeared that the bleeding had stopped. The
stomach was visualized. There was no evidence of any bleeding
from the short gastrics. The pancreas was visualized and
examined and there was no evidence of injury to the tail of
the pancreas. The colon was examined where the splenocolic
ligament was divided. There was no evidence of injury to the
colon. The sponge and instruments were all removed. The
abdomen was closed. The posterior layer of the fascia along
with the peritoneum was closed with running #1 PDS suture.
The anterior fascial layer was closed with interrupted 0
Vicryl suture. The skin was closed using staples. Needle and
sponge count were correct. Dr. [**Last Name (STitle) 5182**] was present and
scrubbed for the entire operation. The patient was
transferred to the ICU in guarded condition.
post-op the patient was transferred to the ICU for further
management
Neuro: Initially the patient was kept sedated until he was ready
for extubation. Post-extubation he did exhibit signs and
symptoms of delirium. Geriatrics was consulted and we followed
their advice. We limited narcotics, benzos, and restraints. He
gradually improved and was back to his baseline prior to
transfer to the floor
Cardiovascular: Post-op he was tachycardiac into the 160s. EKG
showed what appeared to be multifocal atrial tachcardia. His
Rate was controlled with IV lopressor and then PO once he was
tolerating a diet. Eventually his HR decreased to the 80s after
titrating up his PO lopressor significantly.
Pulm: He was extubated POD 1 and did well. He did require a few
doses of IV lasix over the course of his hospital stay to
decrease some pulmonary edema he developed from his aggressive
resuscitation. Eventually he was weaned to room air, and did
not have any further complications.
GI: He was kept NPO with a NGT initially. Once he began passing
gas and moving his bowels, his NGT was removed. He was started
on sips and slowly advanced to a regular diabetic diet. His
abdomen became less distended and he was more comfortable.
GU: Foley was kept in place until we felt he had diuresed
enough. The catheter was removed and his urine was sent
multiple times for UA and culture due to the cloudy appearence
of it. His cultures to date have all been negative. Due to his
questionably positive UA, he was treated emiprically with 3 days
of PO Cipro.
Heme: His hematologist did see [**Last Name (un) **] initially when he came into
the hospital and made some recommendations. He did require a
few more units of platelets due to his drifiting platelet count.
Once his bleeding risk was no longer high, we decreased our
threshold for transfusion to 20,000 as he appeared to be at his
baseline. He was vaccinated prior to discharge
ID: He was given a few doses of Keflex for what appeared to
intially be a wound infection but later appeared to be dependent
erythema. He was also given 3 days of cipro for empiric UTI
treatment. He never had any positive cultures
Endo: Initially was on SSI. Once he was taking POs he was
started back on his home regimen of glyburide and metformin.
Dispo: PT was consulted and they believed that he was strong
enough to go home with a home safety evaluation and some home
PT. He did not require rehab at this point.
he was instructed to follow up with Surgery and Hematology in
the next few weeks.
PATHOLOGY REPORT
DIAGNOSIS:
1. SPLENOMEGALY WITH EXTENSIVE EXTRAMEDULLARY HEMATOPOIESIS
CONSISTENT WITH CHRONIC MYELOPROLIFERATIVE DISORDER. SEE NOTE.
2. CAPSULAR DISRUPTION CONSISTENT WITH SPLENIC RUPTURE.
3. MULTIFOCAL SPLENIC INFARCTIONS, OLD.
Note: There is extensive extramedullary hematopoiesis. This
finding, combined with massive splenomegaly, is consistent with
a chronic myeloproliferative disorder. Reportedly, the patient
had previously been diagnosed with a chronic myeloproliferative
syndrome, but no further clinical details were available at the
time of admission or thereafter, as his routine health care is
conducted at an institution outside of the [**Hospital1 18**] network.
Further clinical and laboratory studies are required for a
nosological diagnosis.
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: HLA-DR, FMC-7,
Kappa, Lambda, and CD antigens: 2, 3, 5, 7, 10, 19, 20, 23, 45.
RESULTS:
three-color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.
CD19-positive B-cells are scant in number precluding evaluation
of clonality.
INTERPRETATION
Non-diagnostic study. Clonality could not be assessed in this
case due to extreme paucity of numbers of B-cells. Cell marker
analysis was attempted, but was non-diagnostic in this case due
to insufficient numbers of B-cells. Correlation with clinical
findings and morphology (see S07-[**Numeric Identifier 75599**]) is recommended. Flow
cytometry immunophenotyping may not detect all lymphomas due to
topography, sampling or artifacts of sample preparation
Medications on Admission:
actos
glyburide
glucophage
procrit
humalog
neulasta
folic acid
Vit B6
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
Disp:*60 Tablet(s)* Refills:*0*
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain: use only if Tylenol is not enough.
Disp:*20 Tablet(s)* Refills:*0*
4. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Home Care services
Discharge Diagnosis:
myelodysplastic syndrome
splenic rupture
s/p emergent splenectomy
Discharge Condition:
Stable. Platelets and Hematocrit low, but at baseline and
stable prior to discharge. Blood sugars slightly elevated but
home medications restarted prior to discharge.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Increased abdominal pain that is not improving within [**7-4**]
hours or becoming progressively worse, or inadequately
controlled with the prescribed pain medication.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* If your belly is distended
* Change in bowel habits such as diarrhea or constipation
* Separation of wound edges, green or yellow drainage from the
wound, or increased redness swelling, warmth or pain of the
incision
* Shortness in breath
* Swelling of your legs
* Any serious change in your symptoms, or any new symptoms that
concern you.
You may resume all home medications.
*Pain: You will be treated with pain medications after discharge
from the hospital, and this should relieve any discomfort that
you may experience. As your discomfort lessens, you may switch
to regular Tylenol (acetaminophen). Do not combine Tylenol with
your prescription pain medication (i.e. Vicoden, Percocet), as
this already contains Tylenol. If you need the prescription pain
medicine, be sure to take it with food to prevent upset stomach.
You should also take Colace, a stool softener, while you are
taking narcotics to prevent constipation. Do not drive while
taking narcotics.
*Incision: You have staples that will be removed at you hospital
follow-up appointment. Please call if you experience redness,
drainage or separation at the incision site.
*Bathing: You may shower, but avoid prolonged water exposure
(i.e baths and/or swimming). When you finish bathing or
showering, be sure to "pat dry" the area of surgery.
Followup Instructions:
please call Dr.[**Name (NI) 6045**] Office to schedule a follow up appt
in 2 weeks. Call ([**Telephone/Fax (1) 15350**] to schedule an appt.
You should also call your Hematologist at [**Telephone/Fax (1) 27580**] and see
them within the next 2 weeks
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]
|
[
"250.00",
"289.59",
"272.0",
"785.59",
"293.0",
"428.20",
"401.9",
"427.89",
"238.75",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.5"
] |
icd9pcs
|
[
[
[]
]
] |
10133, 10199
|
1568, 9360
|
331, 353
|
10309, 10480
|
1151, 1545
|
12563, 12925
|
9480, 10110
|
10220, 10288
|
9386, 9457
|
10504, 12540
|
1002, 1132
|
276, 293
|
381, 914
|
936, 987
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,704
| 163,846
|
52415
|
Discharge summary
|
report
|
Admission Date: [**2132-1-12**] Discharge Date: [**2132-1-12**]
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Morphine /
Aspirin
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
found unresponsive
Major Surgical or Invasive Procedure:
intubation prior to arrival
History of Present Illness:
Mr. [**Known firstname 108323**] is a [**Age over 90 **] year old man with hx of CAD s/p CABG, s/p
pacer insertion, AAA who presented to the ED after his wife
heard him fall in the bathroom. EMS was activated by his wife
and on arrival he was found in to be in VT. He was shocked
twice to PEA. He was given 4mg Epi, 3mg Atropine total. On
arrival to the ED, he was found to have a spontaneous pulse and
CPR was stopped. He was intubated in the field. Total out of
hospital CPR time was 30 minutes.
.
In the ED, initial BP was 130/62, HR 112. The post-arrest team
and cardiology consult were called. He was given Amiodarone
150mg bolus with a drip at 1mg/min. His blood pressures dropped
to 77/54 and he was started on peripheral dopamine, maxed out at
20mcg/kg/min. His blood pressure increased to 92/35, HR 59. A
CXR was done showing the tube to be too deep and it was pulled
back 2cm. After discussion with the family, they did not want
further heroic measures. A central line was not placed and he
did not have a head CT.
Past Medical History:
PMH:
# CAD s/p CABG times two with sternal osteo as a complication.
# PPM
# Parkinson's with [**Last Name (un) 309**] Body Dementia c/b Visual Hallucinations.
(details unknown)
# iron deficiency anemia
# spinal stenosis
# macular degenration
#GI bleed: AVMs
.
PSurgHx:
# Femur fracture s/p fall [**2127**]
# R TKR in [**2117**]
# L TKR in [**2127-4-27**] (c/b post-op confusion and AF-RVR)
# L hip repair [**11-30**]
# Right inguinal hernia repair
# Pilonidal cyst I&D.
Social History:
Per OMR records, unable to confirm: The patient lives with his
wife in a 1 story apartment. He has difficulty walking [**1-29**] leg
stiffness due to Parkinsons. His wife takes care of him. He is
able to eat and dress by himself. His daughter lives down the
street. He quit smoking in [**2094**]. He has occassional sips of
wine.
Family History:
unknown.
Physical Exam:
VS: BP=85/69 HR=72 RR=15 O2 sat= 100% on vent 100% FIO2, 10
PEEP
GENERAL: Non-responsive to verbal or painful stimulus,
intubated.
HEENT: C-collar in place. Pupils fixed and dilated,
non-responsive. Doll's eyes not able to be tested due to collar
in place. Corneal reflexes absent. Multiple facial
lacerations.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: Mottled in appearance with IO access in left leg.
Pertinent Results:
[**2132-1-12**] 01:42AM BLOOD WBC-16.5* RBC-3.62* Hgb-8.6* Hct-34.0*
MCV-90 MCH-25.4* MCHC-26.4* RDW-17.8* Plt Ct-168
[**2132-1-12**] 01:42AM BLOOD PT-41.9* PTT-57.6* INR(PT)-4.4*
[**2132-1-12**] 01:42AM BLOOD Glucose-215* UreaN-28* Creat-1.2 Na-142
K-4.9 Cl-104 HCO3-16* AnGap-27*
[**2132-1-12**] 01:42AM BLOOD Lipase-90*
[**2132-1-12**] 02:08AM BLOOD Glucose-205* Lactate-10.1* Na-138 K-6.2*
Cl-105 calHCO3-12*
.
ECG:
An atrial paced rhythm with one native junctional beat. Diffuse
non-specific ST-T wave abnormalities. Poor R wave progression.
Cannot rule out old anteroseptal myocardial infarction. Low QRS
voltage in the limb leads. No previous tracing available for
comparison.
.
CXR IMPRESSION:
1. Endotracheal tube tip 1.5 cm from the carina, and should be
slightly
withdrawn.
2. Confluent opacities throughout both lungs, likely reflect
pulmonary edema.
Brief Hospital Course:
Mr. [**Known firstname 108323**] is a [**Age over 90 **] year old man with CAD who had an
out-of-hospital arrest and prolonged period with no perfusion.
He was resuscitated and admitted. After discussion with the
family, they wished to withdraw care due to his poor prognosis.
The patient was extubated and died within 5 minutes. The family
declined an autopsy. Time of death was 5:00am on [**2132-1-12**].
Medications on Admission:
unknown at the time of admission
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"V45.01",
"441.4",
"V66.7",
"414.00",
"V45.81",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
4495, 4504
|
3969, 4380
|
293, 322
|
4555, 4564
|
3081, 3946
|
4620, 4630
|
2249, 2259
|
4463, 4472
|
4525, 4534
|
4406, 4440
|
4588, 4597
|
2274, 3062
|
235, 255
|
350, 1390
|
1412, 1884
|
1900, 2233
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,354
| 130,670
|
32913
|
Discharge summary
|
report
|
Admission Date: [**2188-2-18**] Discharge Date: [**2188-3-9**]
Date of Birth: [**2106-10-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Percocet
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Chest tightness
Major Surgical or Invasive Procedure:
[**2188-2-18**] Cardiac Catheterization
[**2188-2-25**] CABGx4(LIMA-LAD, SVG-Diag, SVG-OM, SVG-PDA)
History of Present Illness:
Patient is an 81 year old male with past medical history of
hypertension, and hyperlipidemia who presented to [**Hospital **]
Hospital on [**2188-2-17**] with four day history of chest tightness and
shortness of breah. He reports that approx 5 days ago he started
to have chest discomfort which he attributed to "the flu." He
describes this as substernal chest pressure with no radiation
with associated severe shortness of breath, "gasping" for air
with minimal exertion on walk to mailbox. He denies diaphoresis,
no nausea or lightheadedness. He denies having these symptoms in
the past. Reports having a fever on [**2-15**] to 101.5 which
resolved. No fever. Cough productive of clear sputum. An EKG
completed upon arrival to [**Hospital **] Hospital demonstrated ST
depressions anterolaterally - leads I, V4-V6, and a troponin was
found to be 20.57, down to 18, then elevated to 22.8. BNP was
also elevated to 868. CXR showed mild vascular congestion and he
was treated with Lasix 20 mg IV overnight on [**12-13**] due to
some shortness of breath and chest pain. He put out 1100cc of
urine. Additionally, he received a loading dose of Plavix 600mg,
placed on a heparin drip, continued on atenolol, and nitropaste
applied for chest pain. At time of transfer, he was chest pain
free, in no distress, with bilaterally diminished lung sounds.
CXR completed at OSH was consistent with CHF. He was transferred
to [**Hospital1 18**] for cardiac catheterization.
Past Medical History:
- Hypertension
- Hyperlipidemia
- Osteoarthritis
- s/p Hip replacement
Social History:
Pt is a past smoker, quit in [**2143**], smoked [**2-24**] ppd for approx 10
years. No EtOH.
Pt lives with his wife. [**Name (NI) **] is currently employed as an
accountant and also runs a candy store. Performs ADL without
difficulty.
Family History:
[**Name (NI) **] father died of an MI at age 65. No family hx of
diabetes or cancer.
Physical Exam:
VS - T 98.4 BP 107/87 HR 73 RR 24 O2 94% RA
Gen: WD/WN male in NAD. Alert & Oriented x3. Mood, affect
appropriate. Able to speak full sentences without becoming SOB.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 10 cm - lying flat.
CV: PMI located in 5th intercostal space, midclavicular line. RR
with ectopic beats, normal S1, S2. No m/r/g. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, few crackles at
bases bilaterally
Abd: Soft, NTND. No HSM or tenderness. No bruit, no masses, no
guarding or rebound tenderness
Ext: No c/c/e. No femoral bruits. R groin no hematoma or thrill,
pulses 2+ dp and pt bilaterally.
Pertinent Results:
[**2188-2-18**] Cardiac Cath:
1. Selective coronary angiography of this right dominant system
demonstrated a severe three vessel CAD. The LMCA had mild
non-obstructive disease. The LAD was completely occluded. The
LCx was
diffusely diseased and had a 90% mid vessel stenosis and a 90%
stenosis
of the OM1. The RCA was a tortuous vessel with a 100% mid
vessel
occlusion. The distal RCA, as well as the LAD territory, were
supplied
by the collaterals from the acute marginal (that itself had mild
disease). RCA conus branch had a separate ostium and gave
collaterals to
the LAD as well.
2. Resting hemodynamics revealed severely elevated filling
pressures
with an RVDP of 22 mmHg and a mean PCWP of 30 mm Hg. The
cardiac index
was depressed at 1.84 l/min/m2. There was a moderate pulmonary
systolic
arterial hypertension with a PASP of 50 mm Hg. The systemic
arterial
systolic pressure was normal at 117 mmHg. Patient was noted to
be in
and out of atrial fibrillation during the case.
3. Left ventriculography with a manual contrast injection
revealed an
LVEF of 20% with a global LV hypokinesis. No significant MR was
noted.
[**2188-2-19**] Abdominal US:
1. Diffusely echogenic liver consistent with fatty infiltration.
More advanced liver disease including significant hepatic
fibrosis/cirrhosis cannot be excluded on this study.
2. Ectasia of the distal abdominal aorta measuring up to 3 cm.
One-year followup is recommended.
3. At least two simple cysts are seen within the right lobe of
the liver measuring up to 1.4 cm.
4. Right pleural effusion.
[**2188-2-20**] Transthoracic ECHO:
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. The right atrial pressure is indeterminate. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is top normal/borderline dilated. There is moderate
to severe global left ventricular hypokinesis (LVEF = 25-30 %)
with inferior akinesis. No masses or thrombi are seen in the
left ventricle. Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
[**2188-3-8**] 08:45AM BLOOD
WBC-11.3* RBC-3.56* Hgb-10.1* Hct-31.2* MCV-88 MCH-28.3
MCHC-32.2 RDW-15.6* Plt Ct-565*
[**2188-3-9**] 07:10AM BLOOD
PT-32.8* INR(PT)-3.4*
[**2188-3-9**] 07:10AM BLOOD
Creat-2.1*
[**2188-2-18**] 09:48PM
URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.014
URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
Brief Hospital Course:
Mr. [**Known lastname 76598**] was admitted with NSTEMI. He underwent cardiac
catheterization which revealed severe three vessel coronary
artery disease(see result section for further detail). Cardiac
surgery was consulted and additional preoperative evaluation was
performed. Carotid ultrasound was unremarkable while abdominal
ultrasound was notable for ectasia of the distal abdominal aorta
measuring up to 3 cm. Preoperative echocardiogram showed
moderate to severe global left ventricular hypokinesis (LVEF =
25-30 %) with inferior akinesis, trace aortic insufficiency and
only mild mitral regurgitation. He awaited Plavix washout prior
to surgery and remained pain free on a Heparin drip for
intermittent atrial fibrillation.
On [**2-25**], Dr. [**Last Name (STitle) 1290**] performed coronary artery bypass
grafting surgery. For surgical details, please see seperate
dictated operative note. Within 24 hours, he awoke
neurologically intact and was extubated. He was intermittently
transfused to maintain hematocrit near 30%. On postoperative day
two, he developed rapid atrial fibrillation which was initially
treated with Amiodarone and beta blockade. He otherwise
maintained stable hemodynamics and transferred to the SDU on
postoperative day two. Despite medical therapy, he continued to
experience paroxsymal atrial fibrillation. He was eventually
started on Warfarin with a temporary Heparin bridge. The EP
service was consulted. Cardioversions were performed on [**2-29**] and 13th without much success. He continued to experience
paroxsymal atrial fibrillation. For the remainder of his
hospital stay, Amiodarone and beta blockade were titrated
accordingly. His INR was followed very closely and dosed for a
goal INR around 2.0 - 3.0. Due to a supratherapeutic INR,
Warfarin was held for several days to allow the INR to
improve(see result section for lab values). His renal function
remained relatively stable ranging between 1.5 to 2.1. The
remaineder of his postoperative course was uneventful and he was
discharged to rehab on postoperative day 10. On DC INR is 3.4 /
Start Coumadin [**3-10**]. Follow closely
Medications on Admission:
- Atenolol 100mg po daily
- Triamcinolone/HCTZ 50/25 po daily
- Simvastatin 40mg po daily
- Aspirin 325mg po daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day): x 1 week, then [**Hospital1 **] x 1 week, then qd there after.
7. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: 1600
hrs / please start on [**3-10**].
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days. Tablet(s)
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 12414**] Healthcare Center - [**Location (un) 12415**]
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
Acute Systolic Heart Failure
Pre and Postoperative Atrial Fibrillation
Postoperative Anemia
Chronic Renal Insufficiency
Hypertension
Hyperlipidemia
Discharge Condition:
Stable.
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
6)INR should be followed several times per week until INR
stablizes. Coumadin should be dosed for goal INR between 2.0 -
3.0. Please make arrangements with Dr. [**Last Name (STitle) **] who will monitor
Coumadin as an outpatient prior to discharge from rehab.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] 4-5 weeks, call for appt
Dr. [**Last Name (STitle) **] 2-3 weeks, call for appt
Dr. [**Last Name (STitle) **] 2-3 weeks, call for appt
Completed by:[**2188-3-9**]
|
[
"414.01",
"272.4",
"585.9",
"403.90",
"410.71",
"584.9",
"428.0",
"998.0",
"428.21",
"285.9",
"997.1",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.23",
"36.15",
"39.61",
"88.53",
"99.61",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
9363, 9456
|
6190, 8321
|
291, 393
|
9681, 9691
|
3163, 6167
|
2245, 2331
|
8487, 9340
|
9477, 9660
|
8347, 8464
|
9715, 10264
|
10315, 10512
|
2346, 3144
|
236, 253
|
421, 1881
|
1903, 1976
|
1992, 2229
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,990
| 133,918
|
24632
|
Discharge summary
|
report
|
Admission Date: [**2147-4-13**] Discharge Date: [**2147-4-18**]
Date of Birth: [**2069-7-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
Cardiac catheterization with rotational atherectomy of RCA and
bare metal stenting of proximal and mid right coronary artery.
History of Present Illness:
77M PMH COPD, HTN, hypertrophic CM--HOCM/IHSS, recently admitted
to [**Hospital3 417**] with syncope. Pt notes that he was walking to
the bathroom when he felt SOB, then LOC x 1 min. No LH, CP,
palpitations. Stayed home over the weekend, then continued to
feel increasing SOB, LH; and came in to [**Hospital3 **]. While in the
ED at [**Hospital3 **], he was noted to have SVT with stable vitals. He
was give adenosine, then started on a dilt gtt overnight. In
the AM on [**4-11**], he was noted on labs to have a trop increase
from 0.56 to 1.82 (CK 86-->115, MB 5.2-->6.6). He was medically
managed initially, then transferred to [**Hospital1 18**] for cath.
.
In the cath lab, he was noted to have a tortuous and heavily
calcified mid RCA that was unable to be expanded with the
balloon. Rotational atherectomy was performed, but still with
suboptimal balloon expansion. Attempt to deliver an 18mm CYPHER
stent was unsuccessful, so 3 small bare metal stents were placed
overlapping, with good flow afterwards.
Past Medical History:
HCM--IHSS
Squamous cell ca skin, mets to R hypopharynx, s/p XRT and
radical neck dissection [**9-5**].
HTN
Irregular heart beat
Smoking history (60 pack-years)
No family history of cardiac disease/sudden death
Social History:
Current smoker
Family History:
NC
Physical Exam:
G: Elderly male, NAD
HEENT: MMM, Clear OP
Neck: No JVD
Lungs: Crackles BL at bases, No W/R]
CV: RRR, S1S2, No appreciable murmur
Abd: Soft, NT, BS+
Ext: No edema
Neuro: A&Ox3, appropriate. No focal deficits.
Pertinent Results:
Admission Labs:
[**2147-4-13**] 07:30PM BLOOD WBC-9.3 RBC-3.79* Hgb-11.9* Hct-34.4*
MCV-91 MCH-31.5 MCHC-34.7 RDW-14.7 Plt Ct-266
[**2147-4-13**] 11:40AM BLOOD PT-13.2 INR(PT)-1.2
[**2147-4-13**] 07:30PM BLOOD Plt Ct-266
[**2147-4-13**] 10:39PM BLOOD Glucose-184* UreaN-15 Creat-0.8 Na-136
K-4.3 Cl-101 HCO3-29 AnGap-10
[**2147-4-13**] 10:39PM BLOOD CK(CPK)-54
[**2147-4-14**] 05:41AM BLOOD ALT-10 AST-15 LD(LDH)-158 CK(CPK)-47
AlkPhos-68 TotBili-0.8
[**2147-4-13**] 10:39PM BLOOD CK-MB-NotDone
[**2147-4-14**] 05:41AM BLOOD CK-MB-NotDone
[**2147-4-13**] 10:39PM BLOOD Calcium-8.2* Phos-3.3 Mg-1.6
[**2147-4-14**] 05:41AM BLOOD Albumin-3.4 Calcium-8.1* Phos-3.1 Mg-1.6
Cholest-129
[**2147-4-14**] 05:41AM BLOOD Triglyc-77 HDL-40 CHOL/HD-3.2 LDLcalc-74
[**2147-4-14**] 05:41AM BLOOD TSH-1.5
[**2147-4-14**] 05:41AM BLOOD Free T4-1.1
[**2147-4-13**] 03:12PM BLOOD Type-ART pO2-64* pCO2-37 pH-7.45
calHCO3-27 Base XS-1 Intubat-NOT INTUBA
Discharge Labs:
[**2147-4-18**] 07:12AM BLOOD WBC-6.9 RBC-3.92* Hgb-12.0* Hct-35.5*
MCV-91 MCH-30.7 MCHC-33.9 RDW-14.4 Plt Ct-294
[**2147-4-18**] 07:12AM BLOOD Plt Ct-294
[**2147-4-18**] 07:12AM BLOOD PT-12.7 PTT-25.1 INR(PT)-1.1
[**2147-4-18**] 07:12AM BLOOD Glucose-92 UreaN-22* Creat-0.9 Na-137
K-4.1 Cl-103 HCO3-23 AnGap-15
[**2147-4-18**] 07:12AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.0
Cath Results: CO 4.21/CI 2.27
PCW M/A/V: 31/30/38
RA M/A/V: [**2153-9-12**]
Ao: S/D/M: 210/79/126
PA: S/D/M: 64/24/42
LV: S/D/E: 209/13/26
RV: S/D/E: [**2106-5-14**]
HR 60s
MV: Grad 9.27, Flow 149.4, area 1.30, index 0.70
Fluoro x 125 min
Contrast 465 cc
LVgraphy: Not performed due to severe PA HTN
R dom: LMCA, LAD, LCX non-obstructed
OM: lower pole severe diffuse disease in a small
vessel
RCA: 90% prox and mid vessels.
*
Echo: MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.9 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *6.0 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *6.0 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.8 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.6 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: >= 70% (nl >=55%)
Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.2 cm (nl <= 3.4 cm)
Aorta - Arch: 2.8 cm (nl <= 3.0 cm)
Aortic Valve - Peak Velocity: *2.2 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 20 mm Hg
Aortic Valve - Mean Gradient: 10 mm Hg
Mitral Valve - Mean Gradient: 3 mm Hg
Mitral Valve - Pressure Half Time: 124 ms
Mitral Valve - MVA (P [**12-4**] T): 1.9 cm2
Mitral Valve - E Wave: 1.4 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A Ratio: 1.40
Mitral Valve - E Wave Deceleration Time: 380 msec
TR Gradient (+ RA = PASP): *44 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Severe symmetric LVH. Normal regional LV
systolic function. No
resting or inducible LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Normal ascending aorta
diameter. Normal
aortic arch diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3).
Minimally increased
gradient c/w minimal AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular
calcification. Mild thickening of mitral valve chordae. Mnimally
increased
gradient consistent with trivial MS. Mild to moderate ([**12-4**]+) MR.
[Due to
acoustic shadowing, the severity of MR may be significantly
UNDERestimated.]
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Moderate PA
systolic hypertension.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor parasternal
views. Based on
[**2138**] AHA endocarditis prophylaxis recommendations, the echo
findings indicate
a moderate risk (prophylaxis recommended). Clinical decisions
regarding the
need for prophylaxis should be based on clinical and
echocardiographic data.
Conclusions:
The left atrium is mildly dilated. There is severe symmetric
left ventricular
hypertrophy with relative sparing of the inferior and
inferolateral walls and
normal cavity size.. Regional left ventricular wall motion is
normal. There is
no left ventricular outflow obstruction at rest or with
Valsalva. Right
ventricular chamber size and free wall motion are normal. The
aortic valve
leaflets (3) are mildly thickened. There is a minimally
increased gradient
consistent with minimal aortic valve stenosis. Trace aortic
regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
prominent
mitral annular calcification leading to minimal functional
mitral stenosis.
Mild to moderate ([**12-4**]+) mitral regurgitation is seen. [Due to
acoustic
shadowing, the severity of mitral regurgitation may be
significantly
UNDERestimated.] There is moderate pulmonary artery systolic
hypertension.
There is no pericardial effusion.
IMPRESSION: Hypertrophic non-obstructive cardiomyopathy with
preserved
regional systolic function. Pulmonary artery systolic
hypertension.
Mild-moderate mitral regurgitation. Minimal aortic stenosis and
minimal mitral
stenosis.
Brief Hospital Course:
CARDIAC:
.
A) Cor: NSTEMI, s/p rota atherectomy of RCA with placement of 3
bare metal stents. Other coronary anatomy includes R dominant
system only otherwise significant for diffusely diseased OM. Pt
was started on aspirin, plavix, statin, beta blocker, and
integrillin x 18 hours post cath. His ACEI was initially held
given concerns about dye nephropathy from prolonged exposure,
but this was restarted as his renal function was stable.
.
B) Pump: History of IHSS. Echo from OSH reveals severe septal
hypertrophy, mitral stenosis (peak 10, mean 5) mild MR [**First Name (Titles) **] [**Last Name (Titles) **],
EF > 75%, RVH, Peak LVOT gradient 14mmHg, mean 9, no evidence
[**Male First Name (un) **]. The patient was transferred to the floor with BPs in the
200 systolic. He was started on a nitro drip, and oral
antihypertensives were gradually added back. His echo was
significant for a lack of apparent LV outflow tract
obstruction/gradient, and his response to blood pressure
medications did not indicate that this was a significant issue.
He was eventually discharged on a regimen of HCTZ, lisinopril,
nifedipine, atenolol, all of which can be titrated as an
outpatient.
.
C) Rhythm: The patient continued to have brief episodes of
atrial fibrillation while on telemetry. He was seen by EP, and
started on amiodarone (to be tapered as an outpatient) and well
as titrated up on nodal agents. He was also without major risk
factors for sudden death, and was determined not to be a
candidate for ICD placement. His heart rate was in the low 60s
on discharge. He was also started on coumadin, after his
hematocrit was determined to be stable (see below), and can have
his INR followed as an OP. He is discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of
Hearts monitor.
*
RENAL: Pt exposed to large dye load (500cc) during the cath, and
there was a concern for dye nephropathy; however, his creatinine
remained stable throughout. He was also given IV bicarbonate
and mucomyst post cath.
*
GI: The patient was noted to have had a decrease in Hct several
days post cath. His stool was brown (not melanic or BRBPR), but
was guaiac positive. An NGT lavage was clear with no blood or
bile. He was transfused 1 unit of PRBCs with a good response in
Hct, and remained stable throughout. He should have a GI workup
for this as an outpatient.
*
NEURO: ? age indeterminant infarct on head CT, although pt not
aware of CVA. Neuro exam only notable for L facial droop. No
active issues during this hospitalization. Continued on aspirin.
*
DERMATOLOGY: The patient had an extended cath time with fluoro
exposure lasting greater than 100 minutes. He is to follow up
with dermatology as an outpatient.
*
COPD: No symptoms during this admission.
*
Medications on Admission:
Outpatient med list unavailable on admission
Discharge Medications:
1. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 4 weeks: After 4 weeks, you need to reduce your
dose to 1 tablet daily.
Disp:*56 Tablet(s)* Refills:*1*
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-4**]
Puffs Inhalation Q6H (every 6 hours) as needed.
5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
10. Atenolol 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertrophic cardiomyopathy
Coronary artery disease
Supraventricular tachycardia
Discharge Condition:
Good
Discharge Instructions:
Take all of your medications as directed.
You need to quit smoking. This will not be easy, but it is the
most important thing you can do to protect your heart. Please
talk with Dr. [**Last Name (STitle) 16004**] about nicotine replacement options.
Please have your blood drawn (Hct, PT/INR) in 3 days and follow
up the results with Dr. [**Last Name (STitle) 16004**].
Followup Instructions:
We recommend the following:
Please make an appointment with Dr. [**Last Name (STitle) 16004**] within 2-3 days of
discharge. You will need to have your blood pressure checked on
your new medication regimen. Dr. [**Last Name (STitle) 16004**] should also draw your
blood to check your INR after restarting your coumadin.
You should also have your liver enzymes, thyroid function tests
and pulmonary function tests monitored over time. You were
started on amiodarone which requires these tests.
Finally, Dr. [**Last Name (STitle) 16004**] should also schedule you to have another
colonoscopy given you were noted to have blood in your stool
during your hospital stay.
You will be sent home with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts Monitor to follow
your rhythm.
You need to call Dr.[**Name (NI) 33490**] office to schedule an appointment
with him. His number is ([**Telephone/Fax (1) 16005**]. He will receive the
results of your [**Doctor Last Name **] of hearts monitor.
You will need to return for followup with electrophysiology
within four weeks of discharge.
Provider: [**First Name8 (NamePattern2) 6715**] [**Last Name (NamePattern1) **] Where: [**Hospital6 29**] DERMATOLOGY
Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2147-5-15**] 2:30
[**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
|
[
"427.31",
"305.1",
"416.8",
"414.01",
"V10.02",
"427.0",
"792.1",
"410.71",
"394.0",
"425.4",
"593.9",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.01",
"36.06",
"88.56",
"37.78",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
11697, 11703
|
7446, 10228
|
323, 451
|
11828, 11834
|
2050, 2050
|
12253, 13693
|
1802, 1806
|
10323, 11674
|
11724, 11807
|
10254, 10300
|
11858, 12230
|
3002, 7423
|
1821, 2031
|
276, 285
|
479, 1496
|
2066, 2986
|
1518, 1754
|
1770, 1786
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,947
| 114,152
|
6552
|
Discharge summary
|
report
|
Admission Date: [**2158-8-28**] Discharge Date: [**2158-9-2**]
Date of Birth: [**2083-1-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 75 yo male with a past medical history
remarkable for ESRD [**3-8**] IgA nephropathy on HD Tu/Th/Sat,
cirrhosis, diet-controlled DM and dementia, with multiple recent
admissions for unresponsiveness in part due to high ammonia
levels secondary to Lactulose non-compliance, now presenting
with depressed mental status for 5 days.
*
The history was obtained from the patient's daughter [**Name (NI) **]. [**Name2 (NI) **]
daughter, Mr. [**Known lastname **] was noted to be less responsive about 4
days PTA. He transiently improved following dialysis on [**8-24**],
then declined again on [**8-26**]. She notes that he was
non-talkative at home, non-ambulatory, and was not able to
recognize familiar faces (his visiting nurse). He had one
episode of incontinence on the couch yesterday, which is largely
unusual. Of note, Mr. [**Known lastname **] was recently diagnosed with lumbar
compression fractures, and started on Percocet on [**8-20**]. Per
daughter, he has been getting 1 tablet PO TID for pain control,
up to 4 tablets on [**8-27**]. No other recent medication changes.
Low grade fever up to 100 on [**8-25**], without recurrence. No URI
symptoms. Mild abdominal discomfort this AM. Per daughter, has
been getting intermittent Lactulose at home. Last BM 1 day PTA.
*
EMS called given depressed MS, and recorded vitals were 90/40,
HR 56, RR 20, Sat 100% on room air, BS 209. In the ED, BP
dropped to 70/35 with HR 55, and patient was given Naloxone 0.4
mg IV X 1 with improvement in BP to 116/40 as well as
significant improvement in mental status. He received an
additional dose, with similar improvements, and was subsequently
started on a Naloxone drip 0.6 mg IV/hours. IVF X 2 liters of NS
given. He was also given Kayexalate and Lactulose for
hyperkalemia.
.
ALL: NKDA
Past Medical History:
1. ESRD [**3-8**] IgA nephropathy on HD Tu, Th, Sat
2. Cryptogenic cirrhosis complicated by grade 3 esophageal
varices
3. Known LBBB, PR prolongation and LAD.
4. Hypertension
5. Diet-controlled DM type 2
6. Dementia
7. Psoriasis
8. Gout
9. Diverticulosis and internal hemorrhoids
10. History of line infection with Staph Aureus
11. History of Hepatitis B infection
10. History of blood dysplasia secondary to allopurinol; not MDS
12. Status post herniorraphy
13. Status post prostate surgery
Social History:
Patient lives with his daughter [**Name (NI) **]. At baseline, he able to
ambulate with a cane, feed himself, communicate appropriately.
120 pack year smoking history, quit 17 yrs ago. No h/o IVDU.
Family History:
Sisters had liver and lung cancer.
Brother had a history of MI and CABG.
Physical Exam:
VITALS: BP 89/36 on Naloxone 0.6 mg/hour, HR 58, RR 16, Sat 100%
on room air.
GEN: Awake, responds to questions. Language barrier.
HEENT: Anicteric. EOMI. MMM.
Neck: JVP difficult to assess. No carotid bruit. Neck supple,
without meningismus.
RESP: Chest CTA bilaterally.
CVS: RRR, bradycardia. Normal S1, S2. No S3, S4. SEM at heart
base heard throughout precordium. No rub.
GI: Mild abdominal distension. BSNA. Abdomen soft. Mild diffuse
tenderness, no reboud or guarding.
EXT: Without edema. Cool. Pedal pulses palpable RLE, unable to
palpate pulses LLE. Chronic skin changes LLE. LEft arm AV
fistula.
Neuro: + asterixis. Moves all 4 extremities. Follows commands.
Pertinent Results:
Admission Labs: [**2158-8-28**]
.
GLUCOSE-211* UREA N-41* CREAT-8.4*# SODIUM-136 POTASSIUM-7.0*
CHLORIDE-109* TOTAL CO2-17* ANION GAP-17
AMMONIA: 45
LACTATE: 2.2* K+-5.9*
LFT's: ALT(SGPT)-25 AST(SGOT)-59* CK(CPK)-179* ALK PHOS-231*
TOT BILI-1.1
WBC-7.4 RBC-3.84* HGB-13.5* HCT-39.9* MCV-104* MCH-35.2*
MCHC-33.8 RDW-14.9 PLT COUNT-88*
ASA-NEG ETHANOL-NEG ACETMNPHN-7.4 bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
.
*****
IMAGING:
[**2158-8-28**] CXR: No acute cardiopulmonary process.
.
[**2158-8-22**] Lumbar spine X-ray: Compression fractures of the L2 and
L3 vertebral bodies. Diffuse osteopenia and vascular
calcification.
.
[**2158-8-30**] CT Head: No evidence of intracranial hemorrhage or
edema.
.
[**2158-8-30**]: Abdominal US: Limited 4-quadrant [**Month/Day/Year 950**]
demonstrates no ascites within the abdomen.
*****
Cardiology:
[**2158-8-29**]: EKG Sinus bradycardia. P-R interval prolongation. Left
anterior fascicular block. Intraventricular conduction delay.
since the previous tracing of [**2158-8-29**] the rate is slower.
.
Discharge labs: [**2158-9-1**]
CBC: WBC-3.4* Hgb-11.6* Hct-34.3* MCV-105* Plt-48* 66%N
Chem-7: Glu-103 BUN-44* Cr-8.3* Na-141 K-4.9 Cl-109* HCO3-20*2
AG-17
.
Vit B12: 1436*
.
PSA: 4.8
.
Ammonia: 33
.
TSH: 2.8
.
UA: Blood: LG Nitrite: POS Protein: >300 Glu: NEG Ketone: TR
Bili: MOD Urobili: 0.2 pH: 6.5 Leuks LG - No reflex done to look
for bacteria
.
[**2158-8-28**]: Blood cxs 1 of 4 grew Coag negative staph - thought to
be contaminant
[**2158-8-31**]: Blood cxs: NGTD
[**2158-8-31**]: Urine Cx: NGTD
**** OF NOTE - Patient does NOT have a documented MRSA infection
or colonization. Patient does NOT require MRSA precautions.
Brief Hospital Course:
1. Altered Mental Status:
Following admission to the MICU, the patient was continued on a
nalaxone drip given suspicion that his change in mental status
was secondary to narcotic toxicity. This was discontinued the
day prior to transfer to the floor. Work-up of potential
infectious etiologies included blood cultures, U/A and urine
culture, and chest X-ray. His chest X-ray did not suggest an
infectious etiology. Blood cultures from [**2158-8-28**] grew [**2-7**]
bottles of coag negative staphylococcus, however, follow-up
blood cultures were negative, suggesting that prior growth was
the result of contamination. Given that his urinalysis was
positive (culture pending at time of dictation), he received 3
days of ciprofloxacin for suspected urinary tract infection. A
prostate exam was not suggestive of prostatitis, although the
prostate was noted to be firm and irregular. A head CT scan was
negative for acute process. His ammonia was not significantly
elevated on admission, however, he was continued on lactulose
for a goal [**4-7**] bowel movements per day, given possible
contributor of hepatic encephalopathy (at time of discharge,
ammonia level was 33). His aricept was also discontinued, given
concern that its anticholinergic effect could be contributing to
his acute change in mental status. TSH was within normal limits;
vitamin B12 was elevated. Following transfer to the floor, the
patient's mental status rapidly improved. At time of discharge,
he had not been requiring sitters for >48 hours and is
appropriate and ready for discharge to a [**Hospital1 1501**]. It is recommended
that the patient does NOT receive any narcotics for pain
control.
.
2. Hypotension:
The hypotension noted on admission improved following a Narcan
drip and several boluses of fluid. The most likely etiology was
narcotic intoxication. At the time of discharge, the patient's
blood pressure remained stable with systolic pressures in the
110s-130s. A cortisol stimulation test was performed in the
MICU, which was not suggestive of adrenal insufficiency. Sepsis
was felt to be unlikely, and infectious work-up was carried out
as above.
.
3. ESRD:
The patient was followed closely by the Renal team throughout
his admission. He tolerated dialysis well on [**2158-8-30**]. His
[**2158-9-1**] dialysis session was limited by mild hypotension, likely
due to the fact that he received nadolol prior to dialysis. In
the future, nadolol should be dosed only after dialysis. The
patient's next dialysis session is [**2158-9-5**].
.
4. Cirrhosis w/grade III varices:
The patient was continued on lactulose for hepatic
encephalopathy. Once the patient was hemodynamically stable,
nadolol was restarted. Nadolol should be dosed after dialysis.
.
5. Compression Fracture: The patient was recently diagnosed with
compression fractures. His narcotics were discontinued given
concern for narcotic intoxication as the cause of his change in
mental status/hypotension. He was maintained on standing
acetaminophen (<2g/day) and was started on a trial of SC
Calcitonin for pain related to a compression fracture.
Additionally, on physical exam the patient's prostate was found
to be hard and nodular and his PSA was 4.8 concerning for
Prostate CA. The etiology of this patient's compression fracture
is unknown and will require outpatient workup. He received Vit D
and Calcium supplementation in house, but a bisphosphanate was
not started given his known esophageal varices.
.
6. DM-II: The patient was written for a sliding scale > 200, but
his blood sugars were generally well controlled with diet
control. The patient in encouraged to continue diet control and
to continue monitoring with outpatient PCP.
.
7. Pancytopenia: Patient has a baseline pancytopenia (baseline
hematocrit 33-35, plt 40-60, wbc [**3-10**]. His anemia is likely
secondary to ESRD, for which he receives erythropoietin at
dialysis. His thrombocytopenia is likley secondary to liver
dysfuntion/portal hypertension. At time of discharge, wbc 3.4,
HCT 34.2, plt 48.
.
8. FEN - [**Doctor First Name **]/renal diet
.
9. Dispo: Patient to be discharged to [**Hospital3 1186**] nursing
center.
Medications on Admission:
Aricept 5 mg PO QHS
Calcium carbonate 500 mg Po TID
PhosLo 667 mg PO TID
Lactulose 30 cc PO TID
Folic acid 1 mg Po QD
Protonic 40 mg Po QD
Nadolol 10 mg Po QD
Vitamin E
Vitamin C
Percocet 1 tablet q 6-8 hours
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): titrate to [**4-7**] daily bowel movements.
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours): maximum 2 grams per day.
5. Calcitonin (Salmon) 200 unit/mL Solution Sig: Fifty (50) IU
Injection DAILY (Daily) as needed for bone pain.
6. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): Please
dose after dialysis.
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
8. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: sliding
scale Subcutaneous QAC and QHS: check fingersticks before each
meal and at bedtime. If <200 give 0 units, if 201-250 give 2
units, if 251-300 give 4 units, if 301-350 give 6 units, if
351-400 give 8 units, if >400 give 8 units and [**Name8 (MD) 138**] MD.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary: narcotic intoxication
Secondary: end stage renal disease, cryptogenic cirrhosis,
hypertension, Type Ii diabetes, dementia, urinary tract
infection, Hepatitis B.
Discharge Condition:
Good. Patient is alert, hemodynamically stable.
Discharge Instructions:
Please take all medications as prescribed. Please avoid
narcotics.
Followup Instructions:
Please follow-up with your primary care physician (Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] [**Telephone/Fax (1) 14918**]) within one week following discharge.
Please continue Tuesday, Thursday, Saturday dialysis at
[**Location (un) 4265**]-[**Location (un) **]. Next dialysis Tuesday [**2158-9-5**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
|
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icd9cm
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[
[
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[
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[
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25,256
| 193,857
|
12442
|
Discharge summary
|
report
|
Admission Date: [**2162-9-20**] Discharge Date: [**2162-9-30**]
Date of Birth: [**2123-3-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
leukocytosis and tachycardia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 38598**] is a 39 year-old male with hx of non-Hodgkin's
lymphoma s/p allsoSCT s/p DLI, complicated by PTLD treated with
rituxan, GVHD of the gut, liver, and lung with BOOP/pulmonary
fibrosis with chronic trach and vent brought from [**Hospital1 **] with
tachycardia to the 130's-140's, from baseline increaseing sputum
production and leukocytosis.
.
Mr [**Known firstname **] is well known the [**Hospital Unit Name 153**] with multiple stays here for BOOP
exacerbations and pseudomonal pneumonia. He is well known to
our infectious disease service for his greatly resistant
psuedomonas. After his last hospitalization he was followed in
OPAT for IV administration of colistin, doripenem, micafungin
and inhaled colistin. Per the patient the doctors [**First Name (Titles) **] [**Last Name (Titles) **]
sent out special sensitivities and his psuedomonas may be
susceptible to an "older drug" though he doesnt know the name,
though it appears doxycyline is a new drug on his med list. He
had been doing well until yesterday when he noted tachycardia,
increased sputum production, and leukocytosis.
Past Medical History:
Past Oncologic History:
- [**4-/2154**] p/w fevers, night sweats, and weight loss in the
setting of a left inguinal lymph node.
- CT scan: 15x14x10cm mass in the LUQ.
- Bx grade II/III follicular lymphoma.
- Treated with six cycles of CHOP/Rituxan with good response,
but showed evidence for relapse in [**12/2154**] and was treated with
MINE chemotherapy for two cycles.
- [**3-/2155**]: Underwent stem cell mobilization with Cytoxan followed
by autologous stem cell transplant in
- [**7-/2155**]: Noted for disease recurrence. He was initially treated
with a course of Rituxan without response followed by Zevalin
with
- [**3-/2156**]: Noted progression of his disease. He was treated with
one cycle of [**Hospital1 **] followed by one cycle of ESHAP.
- [**2156-7-29**]: Nonmyeloablative allogeneic stem cell transplant
with a [**5-30**] HLA-matched unrelated donor with Campath conditioning
- Six-month follow-up CT noted for disease progression.
- [**1-/2157**]: Received donor lymphocyte infusion in , complicated by
acute liver/GI GVHD grade IV, for which [**Known firstname **] required a
prolonged hospitalization in the summer of [**2156**].
- Multiple GI bleeds requiring ICU admissions and multiple
transfusions and embolization of his bleeding.
- Noted to have CNS lesions felt consistent with PTLD and this
was treated with a course of Rituxan. No evidence for recurrence
of the PTLD.
- Acute liver GVHD, on CellCept, prednisone, and photophoresis.
- [**2157-12-28**] Photophoresis was d/c'd due to episodes of
bacteremia and eventual removal of his apheresis catheter.
- [**2158-6-13**] restarted photopheresis on a weekly basis on , but
then discontinued this again on [**2158-9-7**] as this was felt not
to be making any impact on his liver function tests.
- undergone phlebotomy due to iron overload with corresponding
drop in his ferritin. He has continued with transient rises in
his transaminases and bilirubin and has remained on varying
doses of CellCept and prednisone which has been slowly tapered
over the time.
- [**2160-1-10**] CellCept discontinued.
- [**2159-1-19**] admission due to increasing right hip pain. MRI
revealed edema and infiltrating process in the psoas muscle
bilaterally. After extensive workup, this was felt related to an
infection and required several admissions with completion of
antibiotics in 03/[**2158**].
- [**7-/2160**]: Last scans showed no evidence for lymphoma and he has
remained in remission.
- [**2160-10-20**]: URI and treatment with course of Levaquin.
- [**2160-11-13**] completed a 4 week course of Rituxan to treat his
GVHD.
-In [**5-/2161**], noted to have tiny echogenic nodule on abdominal
[**Year (4 digits) 950**]. MRI of the liver also showed this nodule but was not
as concerning on review and he is due to have a repeat MRI
imaging in early [**Month (only) **].
-- GI varices and attempts at banding have been unsuccessful due
to difficulty with passing the necessary instruments. He has
been on a low dose beta blocker as well as simvastatin, which
was started on [**2161-7-7**] to help with medical management of his
varices.
-On [**2161-8-3**], worsening cough and was noted to have a small
new pneumothorax in the left apical area. This has essentially
resolved over time
- Issues with weight loss (followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]);
multiple tests done with no etiology found; question
malabsorption related to GVHD
- Has on and off respiratory infections and has been treated
with antibiotics (now colistin inhaled and IV) for resistant
pseudomonas. Question underlying exacerbations of pulmonary GVHD
in setting of his URIs.
- Currently receives IVIG every month.
.
Other Past Medical History:
1. Non-Hodgkin's lymphoma s/p allo SCT
2. Grade 4 Acute GVHD of GI/liver following DLI with GI bleed,
chronic transaminitis, portal HTN with esophageal varices (not
able to band)
3. History of intracranial lesions felt consistent with PTLD.
4. Extensinve chronic GVHD of lung, liver, skin, mucous
membranes.
5. Grade II esophageal varices, intollerant to beta blockade.
6. HSV in nasal washing [**11/2159**](completed course of Valtrex)
7. Hypothyroidism
8. hx of Psoas muscle infection
9. Recurrent resistant Pseudomonal PNAs on long term inhaled
Colistin
Social History:
Smoke: never
EtOH: none currently; occassional use prior to NHL dx
Drugs: never
Born in [**Country **] and moved to the U.S. for college ([**Hospital1 **]).
Married in [**2160-8-25**] and lives in [**Location **]. No children.
Stays at home and writes (currently writing a book on being
diagnosed with cancer at young age).
Family History:
No lymphoma or other cancers in the family. Father had CAD s/p
PCI.
Physical Exam:
GEN: NAD
VS:
HEENT: MMM, no OP lesions, JVP ??cm, neck is supple, no
cervical, supraclavicular, or axillary LAD
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or HSM, no stigmata of chronic
liver disease
LIMBS: No LE edema, no tremors or asterixis, no clubbing
SKIN: No rashes or skin breakdown
NEURO: CNII-XII nonfocal, strength 5/5 of the upper and lower
extremities, reflexes 2+ of the upper and lower extremities,
toes down bilaterally
Pertinent Results:
Admission Labs:
[**2162-9-21**] 01:05AM BLOOD WBC-33.2*# RBC-2.57* Hgb-7.3* Hct-22.9*
MCV-89 MCH-28.4 MCHC-31.9 RDW-17.2* Plt Ct-330
[**2162-9-21**] 01:05AM BLOOD PT-13.8* PTT-40.6* INR(PT)-1.2*
[**2162-9-21**] 01:05AM BLOOD Glucose-89 UreaN-34* Creat-0.8 Na-146*
K-3.8 Cl-105 HCO3-30 AnGap-15
[**2162-9-21**] 01:05AM BLOOD ALT-75* AST-133* LD(LDH)-354*
AlkPhos-913* TotBili-0.6
[**2162-9-21**] 01:05AM BLOOD Albumin-2.7* Calcium-9.2 Phos-3.4 Mg-1.7
[**2162-9-21**] 01:25AM BLOOD Type-[**Last Name (un) **] pO2-98 pCO2-39 pH-7.49*
calTCO2-31* Base XS-5 Comment-GREEN TOP
Discharge Labs:
[**2162-9-30**] 04:30AM BLOOD WBC-12.2* RBC-2.59* Hgb-7.3* Hct-23.3*
MCV-90 MCH-28.1 MCHC-31.2 RDW-18.5* Plt Ct-470*
[**2162-9-30**] 04:30AM BLOOD Glucose-99 UreaN-31* Creat-0.6 Na-139
K-4.1 Cl-102 HCO3-27 AnGap-14
[**2162-9-30**] 04:30AM BLOOD ALT-164* AST-151* AlkPhos-1069*
TotBili-0.4
[**2162-9-30**] 04:30AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.0
Imaging:
[**9-21**] CXR: Slight interval worsening of left upper lobe and
retrocardiac
opacity concerning for persistent infectious process. Given
history of immuno suppression, chest CT could be performed for
further evaluation.
[**9-23**] CXR: Interval improvement in left upper lobe and
retrocardiac
opacities. Attention on follow up radiographs of subtle right
upper lobe
opacity. Small left pleural effusion.
Micro:
Bcx: Neg
Sputum Cx: >25 PMN, Sparse resp flora
ucx: neg
Brief Hospital Course:
#PNA: Pt with history of psuedomonal pna. On admission pt had
leukocytosis (33.2), increased sputum production, and new
infiltrate on CXR concerning for pna. On admission pt was on
colistin (inhaled and IV), micafungin, voriconazole, and
doxycycline. Vancomycin was added on admission for greater g+
coverage. ID was consulted who recommended stoping micafungin
and doxycycline, and adding doripenem. Vanco was eventually
stopped per ID recs, and ID recommended stopping inhaled
colistin. His leukocytosis eventually improved to 12.2 by
dischage and he clinically improved with less sputum production
and improved exam, as well as improved CXR. Blood, sputum, and
urine Cx were negative. ID recomended a total of 5 weeks of
doripenem (last day [**2162-10-26**]), in addistion to IV colistin,
voriconazole and LFTs should be monitored.
.
#Elevated LFTs: Patient??????s LFTs chronically elevated, but became
acutely elevated during admission. Source was unclear, but
thought that it may be secondary to GVHD vs doripenem as
potential etiology as this can cause transaminitis (however ID
felt that doripenem should be continued). Thought was also given
to his TPN formulation as a cause of of his LFTs, and nutrition
changed formulation on [**9-24**] to improve this. His LFTs were
stabily elevated by d/c. No liver imaging was obtained given
clinical stability and eventual stabilization of LFTs. Howerver
it should be noted that he has not had any lung or abdominal
imaging in 3 months so this may be warranted non-emergently,
especially if LFTs continue to rise, and to monitor his BOOP
.
#resp failure: pt remained on assist control through his
tracheostomy throughout admission. Pt's respiratory status was
stable
.
#Tachycardia: likely [**1-26**] dehydration. Responded well to IV
fluids, which the patient received prn.
.
#NHL s/p allogenic SCT, s/p GVHD. His prophylactic acyclovir and
bactrim were continued. [**Month/Day (2) 3242**] was c/s and recommended holding off
on cellcept. and on [**9-29**] he received 20g IVIg per [**Month/Day (4) 3242**] recs.
.
#BOOP: continued combivent nebs, prednisone, guaifenesin,
bactrim. Repeat lung imaging should be considered since it has
been 3 months since his last.
.
#Malnutrition and cachexia: Pt was continued on TF and TPN
Medications on Admission:
Acyclovir 400 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO Q12H (every 12
hours): per NGT.
Acetaminophen 650 mg/20.3 mL Solution [**Month/Day (4) **]: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for fever or pain.
Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Age over 90 **]: Six
(6) Puff Inhalation Q6H (every 6 hours) as needed for SOB.
Ascorbic Acid 500 mg/5 mL Syrup [**Age over 90 **]: Five (5) ML PO once a
day.
Colistin 125 mg IV Q12H
d1 [**8-17**]
Colistin Sulfate (Bulk) 1,000,000,000 unit Powder [**Month/Year (2) **]:
Seventy Five (75) MG Miscellaneous [**Hospital1 **] (2 times a day): INHALED
to be administered over 10 minutes.
Cyanocobalamin (Vitamin B-12) 1,000 mcg/15 mL Suspension [**Hospital1 **]:
Two [**Age over 90 1230**]y (250) MCG PO once a day.
Docusate Sodium 50 mg/5 mL Liquid [**Age over 90 **]: One Hundred (100) MG
PO BID (2 times a day).
DiphenhydrAMINE 12.5 mg IV Q6H:PRN itching
Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Age over 90 **]: Three
Hundred (300) MG PO once a day.
Guaifenesin 100 mg/5 mL Syrup [**Age over 90 **]: Ten (10) ML PO Q6H (every
6 hours).
Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Levothyroxine 125 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Daily
[**Last Name (STitle) 766**] through Saturday.
Humalog 100 unit/mL Solution [**Last Name (STitle) **]: 2-10 units Subcutaneous
every six (6) hours: As directed according to sliding scale. .
Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime) as needed for insomnia: Per NGT. .
Lorazepam 1 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q4H (every 4
hours) as needed for anxiety: Per NGT.
Micafungin 100 mg IV Q24H
Zofran 4 mg/5 mL Solution [**Last Name (STitle) **]: 4-8 MG PO every eight (8)
hours as needed for nausea.
Prednisone 5 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO DAILY
(Daily): Per NGT.
Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation: Per NGT.
Sulfamethoxazole-Trimethoprim 200-40 mg/5 mL Suspension [**Last Name (STitle) **]:
Twenty (20) ML PO M/W/F ().
Zinc Sulfate 220 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY
Daily).
Doxycyline 100mg [**Hospital1 **]
Fondaparinux SOdium 2.5 SQ daily
Voriconazole 200mg q12h
Discharge Medications:
1. lorazepam 0.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
2. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. sucralfate 1 gram Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day) as needed for nausea.
4. acyclovir 400 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every 12
hours).
5. ascorbic acid 500 mg/5 mL Syrup [**Hospital1 **]: One (1) PO DAILY
(Daily).
6. cyanocobalamin (vitamin B-12) 250 mcg Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
7. ferrous sulfate 300 mg (60 mg Iron) Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
8. fondaparinux 2.5 mg/0.5 mL Syringe [**Hospital1 **]: One (1) Subcutaneous
DAILY (Daily).
9. sulfamethoxazole-trimethoprim 800-160 mg Tablet [**Hospital1 **]: One (1)
Tablet PO QMWF ().
10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
11. guaifenesin 100 mg/5 mL Syrup [**Hospital1 **]: Ten (10) ML PO Q6H (every
6 hours) as needed for cough.
12. ergocalciferol (vitamin D2) 50,000 unit Capsule [**Hospital1 **]: [**12-26**]
Capsules PO QSUN (every Sunday).
13. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler
[**Month/Day (2) **]: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
sob wheezing.
14. acetaminophen 325 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
15. levothyroxine 125 mcg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
EXCEPT SUNDAY ().
16. voriconazole 200 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q12H
(every 12 hours).
17. prednisone 10 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily).
18. diphenhydramine HCl 25 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO
ONCE (Once) as needed for 30 min prior to IVIG for 1 doses.
19. lorazepam 2 mg/mL Syringe [**Month/Day (2) **]: One (1) Injection Q4H (every
4 hours) as needed for anxiety.
20. ondansetron HCl (PF) 4 mg/2 mL Solution [**Month/Day (2) **]: One (1)
Injection Q4H (every 4 hours) as needed for nausea.
21. doripenem 500 mg Recon Soln [**Month/Day (2) **]: Two (2) Recon Soln
Intravenous Q8H (every 8 hours) as needed for hospital aquired
pneumonia for 26 days.
22. Colistin 125 mg IV Q12H
23. Pantoprazole 40 mg IV Q24H
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
Pneumonia
BOOP
Non hodgkins lymphoma
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 38598**],
You were admitted to the hospital with pneumonia. While you
were in the hospital you were followed closely by the infectious
diseases and Bone Transplant team who helped to manage your
antibiotics. You improved throughout the hospitalization and
are stable enough to return to rehab.
We have made the following changes to your medications:
-Added Doripenem 1g every 8 hours for total course of 5 weeks
(last dose on [**2162-10-26**])
-Stopped inhaled colistin
-Stopped micfungin
-stopped doxycicline
-Changed lansoprazole to pantoprazole
you should continue your other medications
Followup Instructions:
You should make an appointment to follow up with Dr. [**Last Name (STitle) 724**] in
Infectious diseases.
|
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6765, 7321
|
15555, 15692
|
5263, 5821
|
5837, 6163
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,908
| 170,506
|
14016
|
Discharge summary
|
report
|
Admission Date: [**2167-12-28**] Discharge Date: [**2168-1-5**]
Date of Birth: [**2121-7-14**] Sex: M
Service: TRANSPLANT SURGERY
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 4318**] is a 46 year old
male with end stage liver disease, secondary to hepatitis C
and alcohol, who presented to the [**Hospital1 190**] on [**2167-12-28**], for a liver transplant.
PAST MEDICAL HISTORY:
1. Hepatitis C.
2. Cirrhosis.
3. Hepatocellular carcinoma, question of.
4. Varices.
5. Cholelithiasis.
6. Urinary tract infection.
7. Renal insufficiency.
8. Hypertension.
9. VRE.
10. Encephalopathy.
MEDICATIONS ON ADMISSION:
1. Ursodiol 300 mg po twice a day.
2. Nadolol 20 mg po once daily.
3. Protonix 40 mg po once daily.
4. Ciprofloxacin 500 mg po twice a day.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Temperature 98.9, blood pressure
102/60, heart rate 71, respiratory 20, oxygen 100% on room
air. General: Patient was somewhat mildly confused, but
otherwise appropriate, attentive to the examiner, in no acute
distress. Head, eyes, ears, nose and throat: Normocephalic,
atraumatic, extraocular movements intact, oropharynx clear.
Chest clear to auscultation bilaterally. Heart was regular
rate and rhythm. Abdomen was soft, nontender, distended,
ascites present. Extremities were well perfused without
clubbing or cyanosis.
LABORATORY ON ADMISSION: White blood cell count 3.9,
hematocrit 23, platelets 35. Sodium 130, potassium 5.2,
chloride 107, bicarbonate 27, BUN 32, creatinine 1.0, glucose
140. AST 144, ALT 67, alkaline phosphatase 163, total
bilirubin 6.8, PT 16.3, PTT 36.2, INR 1.7, fibrinogen 270.
BRIEF SUMMARY OF HOSPITAL COURSE: Mr. [**Known lastname 4318**] is a 46 year
old gentleman with end stage liver disease, secondary to
hepatitis C and a question of hepatocellular carcinoma, who
presented to [**Hospital1 69**] on [**2167-12-28**], for an orthotopic liver transplant. The patient
was transferred from the Post Anesthesia Care Unit in stable
condition, intubated and sedated, to the Intensive Care Unit
for closer monitoring in the initial postoperative period.
He received several blood products initially in the Intensive
Care Unit including 14 units of packed red blood cells, 19
units of fresh frozen plasma, 15 units of platelets, and 5
units of cryo.
Patient was eventually extubated without any difficulty. He
received a short course of Unasyn postoperatively. His
prophylactic antibiotics included Acyclovir, Bactrim, and
Fluconazole. He started on the usual immunosuppressant
therapy which included CellCept [**Pager number **] mg intravenous twice a
day as well as a Solu-Medrol taper. He was started on
Cyclosporin on postoperative day one and levels were checked
on a daily basis and adjusted accordingly. He received a
total of 2 doses of Simulect. A postoperative ultrasound of
the transplanted liver was normal. The surgical specimen to
Pathology revealed stage 4 cirrhosis without any evidence of
hepatocellular carcinoma.
For additional nutritional support, patient was on a very
brief course of TPN. Patient was eventually transferred to
the floor on postoperative day four wherein his diet was
slowly advanced which he tolerated. Pain was well controlled
with po medications. His liver function tests all trended
downward. There was just a slight bump in his alkaline
phosphatase and total bilirubin on the day of discharge. The
patient is to have his laboratories done three days
post-discharge to follow these labs. Otherwise, his
discharge immunosuppressants should include CellCept 1 gram
po twice a day, Cyclosporin 175 po twice a day, as well as 20
mg of Prednisone once daily. Patient was stable for discharge
on postoperative day eight. He is to follow-up with Dr.
[**Last Name (STitle) **] at the Transplant Center.
DISCHARGE STATUS: Home with [**Hospital6 407**]
services.
DISCHARGE STATUS: Stable.
DISCHARGE DIAGNOSIS:
1. End stage liver disease secondary to hepatitis C.
2. No evidence of hepatocellular carcinoma by pathologic
specimen.
3. Hypertension.
4. Patient is status post orthotopic liver transplant on
[**2167-12-28**].
DISCHARGE MEDICATIONS:
1. Fluconazole 400 mg 1 tablet po once daily.
2. Insulin sliding scale as well as six doses. He is to
follow this scale which will be provided for the patient.
3. CellCept [**Pager number **] mg po twice a day.
4. Bactrim SS 1 tablet po once daily.
5. Cyclosporin 175 mg po twice a day.
6. Percocet 1 to 2 tablets po q4-6 hours as needed for pain.
7. Colace 100 mg 1 tablet po twice a day.
8. Pantoprazole 40 mg po once daily.
9. Prednisone 20 mg 1 tablet po once daily.
10. Valcyte 450 mg 1 tablet po once daily.
FOLLOW-UP PLAN: Patient is to follow-up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] at the Transplant Center on [**2168-1-18**] at 2:50
p.m. He additionally has an appointment on [**2168-1-21**],
at 2:00 p.m. at the Transplant Center. He was additionally
to follow-up with Dr. [**Last Name (STitle) **] at the [**Hospital Unit Name **] at the
Liver Center ([**Telephone/Fax (1) 1582**] on [**2168-1-19**] at 10:00 a.m.
DISCHARGE STATUS: To home with [**Hospital6 407**]
services for wound care as well as medication review and
compliance. He is to have [**Hospital1 **]-weekly laboratories drawn which
include complete blood count, Chem 10, LFTs, amylase, lipase,
albumin, and a Cyclosporin level to be drawn before the
morning dose is given. These are to be sent to the
Transplant Center. Additionally, [**Hospital6 407**]
services are to review insulin teaching and monitor blood
sugars.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,PH.D.[**MD Number(3) 12276**]
Dictated By:[**Last Name (NamePattern1) 12360**]
MEDQUIST36
D: [**2168-1-5**] 19:01
T: [**2168-1-11**] 12:21
JOB#: [**Job Number 41845**]
|
[
"303.93",
"155.2",
"570",
"789.5",
"286.7",
"070.54",
"789.2",
"571.2",
"572.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.59",
"99.04",
"99.15",
"99.05",
"99.00",
"99.07",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
4193, 5929
|
3953, 4170
|
641, 824
|
1702, 3932
|
847, 1390
|
176, 383
|
1405, 1673
|
405, 615
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,758
| 155,030
|
8603
|
Discharge summary
|
report
|
Admission Date: [**2177-8-27**] Discharge Date: [**2177-9-8**]
Date of Birth: [**2122-6-13**] Sex: M
Service: MEDICINE
Allergies:
Nafcillin
Attending:[**First Name3 (LF) 6378**]
Chief Complaint:
Right shoulder pain with associated fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
55 year-old gentleman with h/o cervical spondylosis who presents
with fevers and right shoulder pain. First noticed right
shoulder pain and swelling Monday afternoon. He felt it was
likely [**1-28**] "irritating it" while sailing on Sunday although no
specific injury. No other recent trauma. Fevers began shortly
thereafter and have been intermittent up to 103 at home. No
chills. No cough, abdominal pain, nausea/vomiting, diarrhea or
dysuria. Went to PCP who sent patient to ED with concern for
infected shoulder.
.
On arrival in ED initial VS were 98.3 hr 100 bp 138/73 rr 16 sat
97%/ra. Patient was unable to lift his right arm due to pain.
Evaluated by orthopedics, attempted to tap shoulder twice but
unable to collect fluid. While in ED O2 sats dropped to 88%/ra.
CXR showed bilateral consolidations. CBC showed WBC of 10.9 with
32% bands. Lactate 2.0.
.
Upon further review patient now feels that he has been slightly
more short of breath across the past 4-5 days although at the
time he thought this was just due to his being in poorer shape
than previously.
.
No rashes. No known recent infectious exposures. No prior
history of septic arthritis.
Past Medical History:
-cervical spine pain: cervical spondylosis, cervical
degenerative disc disease, cervical facet arthropathy, with:
- h/o C6-C7 anterior cervical fusion [**2167**]
- h/o anterior decompression and fusion at C6-7 in [**2168**]
- hemilaminectomy at C5-6 in [**2168**]
-depression
Social History:
married father or two, biotech sales representative, never
smoker, [**3-31**] etoh beverages per week
Family History:
NC
Physical Exam:
VS: 101.5 116/72 86 16 98/2L pain [**4-5**] (mostly shoulder)
Gen: NAD
HEENT: MMM
Neck: supple, no JVD
CV: RRR no murmor
Pulm: bibasilar crackles, R>L, no wheeze
Abd: soft, nontender, nondistended, normoactive bowel sounds
Ext: no edema, pulses 2+ bilaterally
Shoulders: right shoulder warm to touch, erythematous, swollen,
+TTP posteriorly, limited ROM (abduction to ~90') [**1-28**] pain
Neuro: CNII-XII intact, moving all extremities
On Discharge
Vitals: Afebrile BP:135/60 P:88 RR:18 O2:98 on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, S1S2, S4.
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. Shoulder ROM limited by pain. Moves passively to 90
degress with pain.
Skin: Erythema and warmth over right shoulder.
Neuro: CN II-XII intact, strength 5/5.
Pertinent Results:
TTE [**8-28**]: The left atrium is normal in size. The estimated right
atrial pressure is 10-15mmHg. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is moderate pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Normal biventricular systolic function. Estimated
moderate pulmonary artery systolic hypertension.
Chest X-Ray [**8-29**]: Multifocal opacities have been significantly
increased in the interim involving the entire lungs and
demonstrating progression of the infection or potentially
combination of infection and ARDS. Hemorrhage would be another
possibility. Small bilateral pleural effusions are noted.
MR [**Name13 (STitle) 30171**] [**8-31**]: 1. Findings in keeping with fasciitis and
myositis, however, nonspecific in appearance.
2. Acromioclavicular joint changes,likely severe DJD, however
with the above
findings, infection cannot be excluded.
3. Glenoid labral tears, as above.
4. Small partial undersurface tear of the distal supraspinatus
tendon.
MR [**Name13 (STitle) 30171**] [**9-6**]: 1. No significant change in appearance of
nonspecific myositis about the right shoulder.
2. Bone marrow edema and enhancement in the acromion and distal
clavicle is
little changed in distribution over short interval.
Osteomyelitis cannot be
excluded.
Brief Hospital Course:
Mr [**Known lastname **] [**Last Name (Titles) **] a 55 male with a hx of cervial spondylosis who
presented with fevers and right shoulder pain concerning for
septic arthritis. He was noted to have desatruations to the mid
80's on the floor.
.
# Respiratory Distress: While in ED O2 sats dropped to 88%/ra.
CXR showed bilateral consolidations. CBC showed WBC of 10.9 with
32% bands. Lactate 2.0. The patient was admitted to the medicine
service and treated with Vanc/ctx/azithro. Over the next 24
hours, the patient has continued to be febrile, and
intermittently required a nonrebreather to maintain O2
saturation in the 90s. A blood gas drawn the morning of [**8-28**] on
NRB showed: 7.43/35/65/24. He was felt to possibly have a
component of CHF from 4 L fluid resuscitation overnight, and
given furosemide 10 IV, then 20 IV with 2L fluid output over the
course of the day. The next morening, the patient was febrile
to 103.9; he was sent for CXR on 6L nc and became hypoxic to
75%; he was replaced on NRB and SaO2 improved to 99%. CXR showed
worsening of bilateral consolidations concerning for multifocal
infection versus ARDS and he was transferred to the MICU for
closer monitoring. In the MICU he was initially on a NRB, he
has [**3-30**] blood culture bottles from [**8-27**] growing GPCs that were
speciated to MSSA. His antibiotics were narrowed to nafcillin.
He had a TTE that did not show endocarditis. Over the course of
24 hours his respiratory status improved and he was down to 5LNC
and his CXR showed improving infiltrates.
.
#Shoulder Pain: Patient with MSSA growing in blood, likely MSSA
pneumonia and shoulder pain concerning for infected joint.
Ortho was unable to get fluid on the Glenohumoral joint, and the
patient's ROM and pain were more consistent with a AC joint
infection. Patient was taken to IR for guided taps which did
not reveal organisms. All surveillance cultures were negative
and the patient was narrowed to Nafcillin and followed by the
infectious disease service. However, MRI on [**8-31**] of shoulder
revealed edema in soft tissues and along fascial planes of
muscle concerning for potential abscess or possibly necrotising
fasciitis. He subsequently developed a rash on nafcillin and he
was placed back on Vancomycin. Infectious disease recommended a
total of 6 weeks for treatment with an end date of [**10-11**].
.
Transaminititis: He was noted to have rising LFTs during his
admission. At first it was thought that it was secondary to
sepsis and shock liver however they continued to trend upward.
He subsequenlty developed a rash and the nafcillin was sitched
to Vancomycin. After he was switched to Vancomycin his LFTs
began to trend downward to the normal range.
Medications on Admission:
gabapentin 900mg TID
percocet 5/325 TID prn
venlaxafine 75mg daily
Discharge Medications:
1. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
2. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO three times a day
as needed for pain.
4. Outpatient Lab Work
Please draw CBC with diff, BUN, Cr, LFTs, ESR, and CRP weekly
starting on the [**9-11**]; fax results to the [**Hospital **] clinic at
[**Telephone/Fax (1) 1419**].
5. Outpatient Lab Work
Please check Vanc trough prior to AM Vanc dose on [**9-11**]
6. Vancomycin 1,000 mg Recon Soln Sig: 1.25 Intravenous twice a
day for 35 days.
Disp:*70 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Home solutions
Discharge Diagnosis:
Acromioclavicular joint infection
Hypoxic respiratory failure due to pneumonia, acute respiratory
distress syndrome
MSSA bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital for fever and shoulder pain and were
found to have low levels of oxygen. Your chest x-rays were
concerning for developing pneumonia, fluid overload, and/or
acute respiratory distress syndrome. You were treated with
antibiotics for both a shoulder joint infection, pneumonia, and
methicillin-sensitive Staph aureus (MSSA) infection in your
blood. Your hospital course was complicated by the need for ICU
transfer given worsening oxygen level but this gradually
improved. You will need to complete at least a 6-week course of
vancomycin with routine lab checks and will need to follow up
with the infectious disease specialists.
The following changes were made to your medication list:
- Vancomycin x 5 more weeks
Followup Instructions:
Department: INTERNAL MEDICINE
When: WEDNESDAY [**2177-9-10**] at 10:00 AM
With: [**Last Name (NamePattern5) 6666**], MD, MPH [**Telephone/Fax (1) 4775**]
Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**]
Department: INFECTIOUS DISEASE
When: FRIDAY [**2177-9-19**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 27625**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: FRIDAY [**2177-10-10**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 27625**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Someone will contact you regarding orthopedics follw up
appointmenr.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6384**] MD, [**MD Number(3) 6385**]
|
[
"518.81",
"570",
"787.91",
"E849.7",
"790.4",
"E930.0",
"693.0",
"486",
"711.91",
"721.0",
"276.1",
"038.11",
"995.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.91",
"38.93",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
8289, 8334
|
4779, 7501
|
312, 318
|
8510, 8510
|
3058, 4756
|
9427, 10562
|
1940, 1944
|
7618, 8266
|
8355, 8489
|
7527, 7595
|
8661, 9404
|
1959, 3039
|
230, 274
|
346, 1506
|
8525, 8637
|
1528, 1805
|
1821, 1924
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
948
| 142,734
|
3330
|
Discharge summary
|
report
|
Admission Date: [**2107-11-18**] Discharge Date: [**2107-11-24**]
Date of Birth: [**2078-11-9**] Sex: F
Service: Transplant Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 29 year old
female with a history of end-stage renal disease, status post
living related kidney transplant in [**2107-8-27**], who had a
preoperative complication course of a fungal line infection
of a Perm-A-Cath. That was the patient's second kidney
transplant, the first of which was in [**2098-5-26**] and had
failed secondary to preeclampsia during pregnancy.
The patient presents for this admission with 48 hours of a
sore throat, body aches, chills, fatigue and some weakness.
She went to an outside hospital, where her temperature was
found to be 103.8 and her creatinine was 2. She was
transferred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for
definitive care.
On coming to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **], the
patient denied nausea, vomiting, had fevers and chills, no
dysuria, no hematuria, no cough.
PAST MEDICAL HISTORY: 1. End-stage renal disease. 2.
Preeclampsia during pregnancy.
PAST SURGICAL HISTORY: Living related kidney transplant in
[**2098-5-26**] and [**2107-9-7**].
MEDICATIONS ON ADMISSION: Rapamycin 8 mg p.o.q.d., Prograf 2
mg p.o.b.i.d., Prednisone 10 mg p.o.q.d., Epogen 4,000 units
q. [**Year (4 digits) 766**], Wednesday and Friday, Lopressor 75 mg p.o.b.i.d.,
Dilantin 400 mg p.o.q.d., ganciclovir 500 mg p.o.t.i.d.,
Bactrim one p.o.q.d.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient is married and lives with her
husband and child.
PHYSICAL EXAMINATION: On physical examination, the patient
had a temperature of 101.7, heart rate 109, blood pressure
159/87, respiratory rate 20 and oxygen saturation 100% in
room air. General: Ill appearing. Chest: Clear to
auscultation bilaterally. Cardiovascular: Tachycardiac,
regular rhythm. Abdomen: Soft, nontender with no tenderness
over graft. Extremities: No peripheral edema. Rectal:
Guaiac negative.
LABORATORY DATA: Admission white blood cell count was 2,
hematocrit 25.9, platelet count 121,000, sodium 133,
potassium 3.4, chloride 92, bicarbonate 29, BUN 41,
creatinine 2, glucose 124, liver function tests within normal
limits, and amylase 80. Urinalysis was significant for 0 to
2 red blood cells, and protein 30. Chest x-ray showed no
consolidation, no infiltrate.
HOSPITAL COURSE: The patient was admitted, placed on
intravenous fluids and was started on ceftriaxone, ampicillin
and Flagyl. Upon arriving to the floor, the patient's
temperature spiked to 105. The patient became tachycardiac
to the 130s and was quite ill appearing. She was placed on a
cooling blanket, her axillae were iced and she was
pancultured for blood for both bacteria and fungal cultures
and urine. Several serologies were sent and she was sent to
the Intensive Care Unit for close monitoring.
Overnight, the patient continued to have elevated
temperatures up to 105 despite care, but she remained
hemodynamically stable. In the morning, the patient
defervesced, with a temperature of 98.3. The patient was
feeling much better. Her heart rate had come down to 84 with
a blood pressure of 108/55.
After monitoring further, on hospital day number two the
patient was transferred to the floor, where she remained for
the remainder of her recovery.
The patient continued to be hemodynamically stable on the
floor, but continued to have fever spikes up to 105 on
hospital day number three. On hospital day four, her
examination was remarkable for decreased breath sounds in the
right lung with bilateral rales. Her oxygen saturation
remained 95% in room air. A chest x-ray was obtained, which
showed a focal density in the right mid-chest with a right
pleural effusion.
With the continued fevers, the patient was also sent for an
abdominal CT scan to rule out for any intra-abdominal process
causing her illness. This was significant for right lower
lobe air space disease and a small fluid collection around
the transplanted kidney, which had been present on the prior
study and had been unchanged.
The patient was changed, per infectious disease
recommendation, to intravenous ceftazidime 2 grams every 24
hours and intravenous vancomycin 1 gram daily. In addition,
to cover for fungal infections, she was started on
intravenous ampicillin 250 mg daily and intravenous
ganciclovir 125 mg daily to cover for cytomegalovirus
dissemination.
Upon starting the new regimen, the patient began to improve.
She began afebrile and her vital signs remained stable. Her
ceftazidime was discontinued and changed to Levaquin. Her
Ambisome was discontinued once the fungal cultures were
negative. She continued to improve and has been afebrile for
the last 72 hours. She is tolerating a regular diet and is
ambulating.
In regard to culture studies, the following have been sent
and have resulted: Blood cultures, no growth to date; fungal
cultures, no growth to date; urine significant for 10,000 to
100,000 colonies of alpha streptococci; cytomegalovirus titer
was IgG positive, IgM negative and PCR was negative; HSV 1
and 2 were negative; varicella zoster virus was negative.
Stool was sent for various pathogens, which were all
negative, including Clostridium difficile. Sputum was sent
for viral detection and was negative for adenovirus,
parainfluenzae 1, 2, 3, influenza AB and respiratory
syncytial virus. Urine was sent for Legionella antibody,
which was negative. The sputum Gram stain did show 3+ gram
positive cocci and 2+ gram negative rods, but was a poor
sample with greater than 10 epithelial cells and was thought
to be oropharyngeal contamination.
The patient continued to clinically improve. Her lung
examination, on the day of discharge, is clear bilaterally
with no wheezes, rales or rhonchi. The patient's vancomycin
was discontinued on hospital day number seven and she has
continued to remain afebrile.
In regard to the patient's hematologic status, her hematocrit
has remained stable at around 20 to 22. Her white blood cell
count has come down from 3.3 to a low of 1.1 but has now
started to increase and is 1.9 on discharge without any
G-CSF. She will receive one dose prior to discharge to
augment her white blood cell count. Her platelet count has
remained stable. Her creatinine has come down to 1.1 and
chemistries are all within normal limits.
The patient's Dilantin level was high on admission at 27.8.
Her Dilantin was held and her last level was 9.4. She was
restarted on 100 mg three times a day. Her FK-506 level was
2.9, below the therapeutic value. Her dose was increased to
3 mg twice a day. A level is pending today and will be
adjusted accordingly prior to discharge.
The patient continues to remain stable and is ready for
discharge, with follow-up in the clinic.
DISCHARGE DIAGNOSES:
Suspected viral cytomegalovirus dissemination.
Status post living related kidney transplant.
End-stage renal disease.
History of preeclampsia during pregnancy.
DISCHARGE MEDICATIONS:
Rapamycin 8 mg p.o.q.d.
Prograf 3 mg p.o.b.i.d.
Prednisone 10 mg p.o.q.d.
Epogen 4,000 units q. [**Year (4 digits) 766**], Wednesday and Friday.
Lopressor 75 mg p.o.b.i.d.
Dilantin 100 mg p.o.t.i.d.
.................... 900 mg p.o.q.d.
Bactrim one p.o.q.d.
Levaquin 500 mg p.o.q.d. times ten days.
CONDITION ON DISCHARGE: Stable.
FOLLOW-UP: The patient was instructed to follow up in the
transplant clinic as scheduled and we will check Prograf
levels and white blood cell count levels while she is getting
cytomegalovirus therapy. Any pending cultures will be
checked and followed on an outpatient basis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15475**], M.D. [**MD Number(1) 15476**]
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2107-11-24**] 10:59
T: [**2107-11-28**] 08:42
JOB#: [**Job Number 15479**]
|
[
"078.5",
"584.9",
"996.81",
"401.9",
"284.8",
"528.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7054, 7215
|
7238, 7537
|
1399, 1708
|
2606, 7033
|
1299, 1372
|
1810, 2588
|
178, 1187
|
1210, 1275
|
1725, 1787
|
7562, 8132
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,898
| 170,625
|
271
|
Discharge summary
|
report
|
Admission Date: [**2123-2-25**] Discharge Date: [**2123-4-23**]
Date of Birth: [**2040-1-17**] Sex: M
Service: EMERGENCY
Allergies:
Aspirin / Codeine / Penicillins / Bactrim / Heparin Agents /
Tetanus
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
R hip pain
Major Surgical or Invasive Procedure:
Closed reduction of right hip
Tracheostomy
Placement of gastric tube
Intubations
History of Present Illness:
83yo Arabic speaking male with multiple medical problems
including dementia, HTN, COPD, GERD, BPH, osteoporosis, CKD,
prior GI bleed secondary to ulcer [**1-/2120**] and hx of hip
replacement presenting with right hip pain. Hip pain started
after bumpy car ride on [**2-19**]. At baselin,e patient is in
wheelchair and can ambulate with assistance. Since car ride, son
has noticed that patient can no longer stand up straight or go
up stairs. Has tried tylenol with little relief for hip pain. No
fever/chest pain/SOB/abd pain/new focal neurologic changes.
Currenly on lovenox for PE diagnosed in [**Month (only) 205**], also getting
dressing changes for bilateral shin ulcers and a coccyx ulcer.
The patient's mental status is at baseline per son.
In the ED, initial vs were: T 99 P 93 BP 131/79 R 20 O2 sat 98%
on RA. The patient was given acetaminophen for pain Patient was
evaluated by ortho trauma, who are planning to attempted a
closed reduction tomorrow AM for a displaced acetabular ring
seen by Xray.
Past Medical History:
1. Hypertension.
2. Renal artery stenosis.
3. Chronic obstructive pulmonary disease.
4. Gastroesophageal reflux disease.
5. Chronic constipation.
6. Benign prostatic hypertrophy.
7. Peptic ulcer disease.
8. Insulin resistance.
9. Memory loss.
10. Osteoporosis.
11. Gait instability with history of falls.
12. History of GI bleed secondary to ulcer 01/[**2120**].
13. Weight loss.
14. Left lower extremity DVT.
15. Status post hip fracture [**2120**].
16. Chronic kidney disease.
17. History of aspiration.
18. Nondisplaced pelvic fracture 05/[**2120**].
19. Peripheral vascular disease with lower extremity ulcers.
20. Renal lesion.
21. Pancreatic cystic lesion.
22. Pneumonia 01/[**2122**].
23. PE in [**7-/2122**], on lovenox
.
PAST SURGICAL HISTORY:
1. Right cataract removal.
2. Right total hip arthroplasty 01/[**2120**].
3. Inguinal hernia repair.
Social History:
Smoked for 30 years (heavily). Rare ETOH now. The patient lives
with his son who is the only caretaker; is completely dependent
on him for ADLs, IADLs. Remaining family in [**Country 1684**]. The son
continues to express the urgency with which he needs to have the
extra help to assist his father. This has been a very complex
social issue given the patient's current status as a non US
citizen and his inability to have adequate health insurance.
Family History:
Not contributory to patient's acute presentation
Physical Exam:
On Admission:
Vitals: T:96.6 BP: 134/58 P: 87 R: 21 O2: 95% on RA
General: Alert, oriented to person and place, not date, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: fine crackles throughout lungs
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
Skin: ulcer
Neuro: pt was not cooperative with exam, moving all
extremities, with draws to pain in all extremities
Discharge:
General: Not responsive, no spontanoues movement except
lipsmacking
HEENT: Pupils responsive 6-->4mm bilaterally, lip smacking, left
eye with lateral subconjunctival hemorrhage, erythema under
trach site but with cushion
CV: S1, S2, no murmurs auscultated
Lungs: Clear to anterior auscultation bilaterally
Abdomen: Soft, non-tender, BS present, PEG in place
Extremities: Edematous in dorsal hands, but not in feet, distal
pulses 2+
Neurology: not responsive, no spontaneous movement except
lipsmacking, tone is flaccid in all extremities
Pertinent Results:
On Admission:
[**2123-2-25**] 11:00AM BLOOD WBC-5.8 RBC-3.99* Hgb-12.3* Hct-37.0*
MCV-93 MCH-30.9 MCHC-33.3 RDW-14.3 Plt Ct-170
[**2123-2-25**] 11:00AM BLOOD WBC-5.8 RBC-3.99* Hgb-12.3* Hct-37.0*
MCV-93 MCH-30.9 MCHC-33.3 RDW-14.3 Plt Ct-170
[**2123-2-25**] 11:00AM BLOOD Neuts-77.4* Lymphs-10.8* Monos-4.7
Eos-6.2* Baso-0.7
[**2123-2-25**] 11:00AM BLOOD PT-11.4 PTT-37.1* INR(PT)-1.1
[**2123-2-25**] 11:00AM BLOOD Glucose-114* UreaN-21* Creat-1.4* Na-141
K-4.3 Cl-102 HCO3-30 AnGap-13
.
Discharge Labs:
[**2123-4-22**]:
WBC 6.6 Hbg 7.1 Hct 23.3 Plt 137
PT 10.9 PTT 26.2 INR 1.0
Na 140 K 4.6 Cl 97 HCO3 39 BUN 36 Cr 0.5 Glucose 114
Ca 8.3 Phos 3.4 Mg 2.3
.
Microbiology:
Urine Culture [**2123-3-10**]
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
.
Sputum Culture [**2123-3-22**]
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 4 S
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 4 S
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ =>16 R
.
Sputum Culture [**2123-4-6**]
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 8 S
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 8 I
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ =>16 R
.
RESPIRATORY CULTURE (Final [**2123-4-20**]):
Commensal Respiratory Flora Absent.
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| PSEUDOMONAS AERUGINOSA
| |
AMIKACIN-------------- 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S 16 I
CEFTAZIDIME----------- <=1 S 16 I
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S =>4 R
GENTAMICIN------------ <=1 S =>16 R
MEROPENEM-------------<=0.25 S 4 S
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ <=1 S =>16 R
TRIMETHOPRIM/SULFA---- <=1 S
.
Studies:
CT Head [**2123-3-7**]
Large intraventricular hemorrhage with interval worsening and
greater mass effect on third ventricle. CTA of the head appears
unremarkable.
.
CT head [**2123-3-9**]
Extensive left-sided intraventricular hemorrhage with a small
amount of hemorrhage in the right lateral ventricle, similar in
distribution to the prior examination. There may be slight
interval increase in surrounding edema with 5-mm rightward shift
of midline structures, previously measured as 4 mm. Pl. see
prior CTA study for vascular details.
.
LENIs [**2123-3-19**]:
IMPRESSION: No evidence of deep venous thrombosis in either
lower extremity.
.
IVC filter [**2123-3-19**]:
1. Placement of an Option IVC filter, just below the level of
the lowermost right renal vein.
2. The filter is retrievable, and removal should be considered
when the
patient's contraindication to anticoagulation is no longer
present.
.
[**2123-4-6**] Portable abdomen:
IMPRESSION: IVC filter in the expected infrarenal location. No
evidence of
bowel obstruction.
.
Patient has had more than 30 chest X-rays, below is most recent
([**2122-4-20**]):
FINDINGS: The right PICC terminates in the mid SVC. Tracheostomy
is noted.
There is minimal if any change from [**4-18**]. There is
persistent
cardiomegaly, bilateral pleural effusions and pulmonary vascular
congestion, greater on the left. No focal consolidation is seen,
though an underlying pneumonia cannot be excluded.
Brief Hospital Course:
This is an 83 year old Arabic speaking male with multiple
medical problems including dementia, HTN, COPD, GERD, BPH,
osteoporosis, CKD, prior GI bleed secondary to ulcer [**1-/2120**] and
prior right total hip replacement who presented with a right hip
dislocation s/p closed reduction and postoperatively developed a
left sided intracranial hemorrhage and now has been left with
only residual brain stem function and s/p trach, PEG, and IVC
filter who has bounced between MICU and medicine floor for
respiratory distress and recurrent [**Company 191**]-Pneumonias, hypoxia and
mucous plugging. Extensive discussion regarding goals of care
indicate duty to prolong patient's life as long as possible
regardless of quality of life.
# Goals of care: [**Name (NI) **] son [**Name (NI) **] is the healthcare proxy.
After extensive discussion the family clearly states that
withdrawl of care is firmly against both patient and HCP
personal, ethical and religious beliefs. Additionally, the
patient had requested all treatment measures regardless of
outcomes 3 months ago prior to this acute presentation. Goals of
care at this point are to prolong patient's life regardless of
quality, meaningful prognosis and regardless of mental status.
Given goals of care to prolong life at all costs, medical
management was continued in prevention of cardiac arrest. CPR
was discussed with Dr. [**Last Name (STitle) **] and HCP at length, decision that
CPR is not indicated was made and patient's son/HCP was
agreeable to this. HCP continued to push for aggressive care
though realizes futility of some measures. Frequent revisiting
of goals of care continued to confirm goal to prolong life.
Social work, ethics, legal and Geriatrics have all been involved
in this patient's care. Neurology re-consulted and re-evaluated
patient on [**4-9**], documenting no significant improvement in
neurological status, had lengthy discussion with family
discussing that prognosis for a meaningful recovery is
unfavorable and he is at a risk for both neurological and
systemic complications. Geriatrics chief spoke with patient's
son and daughter extensively, indicating that patient should as
much as possible stay on the medical floor w/ frequent pulmonary
toilet and care, and try to avoid ICU transfer. Family, while
understanding, continues to push for MICU transfer whenever
hypoxia or labored breathing develops. The patient ended his
[**Hospital1 18**] stay in the ICU secondary to respiratory failure. He will
leave for rehabilitation requiring mechanical ventilation.
#. Vegetative state: Secondary to intracerebral hemorrhage with
midline shift. On [**2123-3-7**] patient was transferred to the
neurosurgical service for lethargy and a right facial droop. CT
head was done and showed a large left IVH. Patient was placed
in the SICU for close neuro monitoring. All anticoagulation was
held. A CTA was performed which ruled out vascular anomaly. On
[**2123-3-8**] patient's neuro exam improved and the decision to hold
off on surgical intervention was made. His blood pressure was
liberalized and the goal was to keep him greater than 160. Later
in the evening he began desatting due to poor pulmonary status
and it was discussed with son that any interventions would be
high risk and that if he was intubated then he most likely would
not be extubated. Social work was consulted for his son who was
having difficulty coping with the situation. On [**3-10**] a family
meeting was held to discuss goals of care which was attended by
the ICU team, stroke team, geriatrics team, ethics, social work,
and his son in addition to neurosurgical team. The son voiced
his wishes that everything possible be done for his father even
if it meant eventual trach and PEG and him never leaving the
hospital. Later on [**3-9**] he was intubated secondary to
paradoxical breathing and required neosynephrine for BP control.
On [**3-10**] his neurologic exam deteriorated and he was transferred
to the MICU given his multiple medical issues and lack of
indication for surgical intervention. A PEG, trach, and IVC
filter was placed in the MICU, and he has had no neurological
recovery since. Neurology re-consulted and re-evalutated patient
on [**4-9**], documenting no significant improvement in
neurological status, had lengthy discussion with family
discussing that prognosis for a meaningful recovery is
unfavorable and he is at a risk for both neurological and
systemic complications.
# Hypoxic respiratory distress: The patient bounced from
Medicine and MICU a few times secondary to respiratory failure.
VAP with MDR pseudomonas and pan-sensitive Klebsiella s/p
Vancomycin/Cefepime and s/p Meropenem last dose 3/10. Sputum
culture from [**4-9**] shows Pseudomonas without clinical s/s
pneumonia so more likely colonizer. During his last stay in the
IVU, the patient was in distress again, likely due to another
pneumonia, this time his sputum culture grew Klebsiella and
Pseudomonas, both of which were susceptible to meropenem. He was
treated for ventilator-associated pneumonia, with the last day
of therapy intended to be [**2123-4-24**]. The patient will be
discharged still requiring mechanical ventilation, on CPAP with
50% FiO2, pressure supprt of 12, and PEEP 5.
# Tachycardia, ectopy / non-sustained v-tach: Episodes of A.Fib
with RVR to 150s occasionally. Generally in Sinus rhythm with
rate in 80s otherwise. Occasional episodes of NSVT on floor.
Sinus tachycardia and ectopy likely related to intracranial
process / myocardial irritation. Patient on admission to ICU was
in atrial fibrillatoin with RVR; upon the time of his transfer
to the floor, he was maintained in NSR with rates in the 80s on
both metoprolol and diltiazem PO. Addiionally, he began to alarm
on telemetry for ST elevations in V3 greater than 2 mm; EKG did
not show any obvious distributions of cardiac territory to
suggest MI, and tropinins checked x 2 were stable. In addition,
the family was notified that even if an MI were present, the
risks of heparinization and Plavix loading given his ICH were
too great, and he would not undergo these therapies. The
patient's atrial fibrillation was controlled in the ICU via oral
metoprolol and diltiazem.
.
#. Right hip dislocation- The patient presented with a
dislocated right hip with neurovasular compromise. On HD#1, he
underwent a successful closed reduction - right dislocated total
hip arthroplasty with constrained component that appears to have
no function with [**Last Name (un) 2637**] on [**2123-2-26**]. The patient was on bedrest
until a brace was fit, which occurred on HD#2. The patient was
restarted on lovenox 90mg SC q12 hours for DVT ppx and due to
lifelong need give prior PEs. The patient was placed on
subcutaneous heparin on prophylaxis doses in the ICU. His
rehabilitation facility can determine which prophylactic form of
heparin works best for them.
.
# Acute on chronic renal insufficiency- On HD#2 the patient
developed acute on chronic renal insufficiency likely secondary
to poor PO intake following the closed reduction. The patient
was given IVF, nephrotoxins were avoided, and all medications
were renally dosed. The patient returned to baseline (1.0-1.2)
shortly therafter.
.
#. Dementia- The patient was noted to have progressing dementia
and was bowel and bladder incontinent at baseline. He was
having difficulty swallowing solids and was started on
pureed/dysphagic diet on thin liquids. He was also supplemented
ensure for each meal given poor nutrition status. He currently
has a PEG tube and is receiving tube feeds.
.
#. Pulmonary Embolus: The patient was diagnosed with his second
PE in [**2122-7-24**] and was on lifelong anticoagulation with
Lovenox. Lovenox was held the night before the closed reduction
and restarted after the procedure (Lovenox 90 mg SC Q12H).
Unfortunately, he developed a left sided intracranial hemorrhage
and it was stopped. An IVC filter was placed and he is
currently on heparin SC at prophylaxis dosing.
# DVT/PE: H/o DVT in [**2120**], underwent treatment with 4 months of
lovenox. PE in [**7-/2122**] retreated with lovenox 80 mg [**Hospital1 **]. IVC
filter placed on [**3-19**]. Patient is at risk of pulmonary embolus
given history and persistant vegetative state though systemic
anticoagulation is contraindicated given recent ICH. Continuing
prophylactic heaprin.
.
#. COPD: Kept on a regimen of fluticasone, albuterol, and
ipratropium.
.
#. GERD: Kept on lansoprazole.
.
#. BPH: Holding home tamsulosin, finasteride. The patient has a
Foley catheter in place and is passing urine.
.
#. Code Status/[**Name (NI) 2638**] With son/HCP, [**Name (NI) **], who is
constantly present at bedside. Extensive goals of care
discussions were held with [**Doctor First Name **] and he elected to proceed with
PEG, trach, and IVC filter. His father's poor prognosis has
been communicated with him, but he continues to hope for a
miraculous recovery. His code status is DNR, but its ok to
place him back on ventilatory support since he has a trach.
Medications on Admission:
1. acetaminophen 325 mg Tablet [**Doctor First Name **]: [**1-25**] Tablet PO TID prn pain
2. docusate sodium 100 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO BID
3. senna 8.6 mg Tablet [**Month/Day (2) **]: 1 tablet [**Hospital1 **].
4. cholecalciferol (vitamin D3) 400 unit daily
5. calcium 600 mg calcium (500 mg) [**Hospital1 **]
6. multivitamin One (1) Tablet PO DAILY (Daily).
7. carvedilol 18.75 mg Tablet [**Hospital1 **]: PO BID (2 times a day).
8. enoxaparin 80 mg/0.8 mL Syringe [**Hospital1 **]: One (1) Subcutaneous
Q12H (every 12 hours).
9. finasteride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
10. furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
11. furosemide 20 mg Tablet [**Hospital1 **]: 1.5 Tablets PO EVERY OTHER DAY
(Every Other Day).
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: 1
Capsule, Delayed Release(E.C.) PO BID
13. tamsulosin 0.4 mg Capsule, Ext Release 24 hr [**Hospital1 **]: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
14. tiotropium bromide 18 mcg Capsule, w/Inhalation Device [**Hospital1 **]:
One (1) Cap Inhalation DAILY (Daily).
15. lactulose 10 gram/15 mL Solution [**Hospital1 **]: One (1) PO once a
day prn constipation
16. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
One (1) Inhalation every four (4) hours as needed for shortness
of breath or wheezing.
17. alendronate 70 mg Tablet [**Hospital1 **]: One (1) Tablet PO qwednesday
18. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]: Two
(2) Inhalation twice a day.
19. Ensure Liquid [**Hospital1 **]: One (1) PO TID.
20. Miralax 17g PO daily prn constipation
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
2. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
3. multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
4. polyethylene glycol 3350 17 gram/dose Powder [**Hospital1 **]: One (1) PO
DAILY (Daily) as needed for constipation.
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation Q4H (every 4 hours) as
needed for SOB.
6. acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO TID (3 times
a day) as needed for pain.
7. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
injection Injection TID (3 times a day).
8. polyvinyl alcohol-povidon(PF) 1.4-0.6 % Dropperette [**Hospital1 **]: [**1-25**]
Drops Ophthalmic [**Hospital1 **] (2 times a day).
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. chlorhexidine gluconate 0.12 % Mouthwash [**Hospital1 **]: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
11. diltiazem HCl 30 mg Tablet [**Hospital1 **]: One (1) Tablet PO QID (4
times a day).
12. fluticasone 110 mcg/actuation Aerosol [**Hospital1 **]: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
13. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler
[**Hospital1 **]: Six (6) Puff Inhalation QID (4 times a day).
14. levetiracetam 250 mg Tablet [**Hospital1 **]: Three (3) Tablet PO BID (2
times a day).
15. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
16. metoprolol tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID
(4 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Dislocation of right hip
Left intracranial/intraventricular hemorrhage
Respirator failure requiring ventilation
Pneumonia
[**Doctor Last Name 780**] terminal ulcer
Atrial fibrillation
Chronic obstructive pulmonary disorder
Benign prostatic hyperplasia
Discharge Condition:
Mental Status: Nonresponsive.
Activity Status: Bedbound.
Level of Consciousness: Lethargic and not arousable.
Discharge Instructions:
For the caretakers of Mr. [**Known lastname 2639**],
Following hip surgery, Mr. [**Known lastname 2639**] suffered an intracranial
hemorrhage, which has left him in a persistent vegetative state.
His prognosis is grim, and multiple neurological specialists
believe that he will not recover substantial function. His
family believes that he would want as much time as possible and
still hope for a miraculous recovery. The patient has multiple
medical problems, which have continued to be treated.
.
Mr. [**Name14 (STitle) 2640**] will go to rehabilitation with an entirely new
regimen of medications:
Albuterol, ipratropium for COPD
Keppra for prevention of seizure
Lansoprazole for GERD
Metoprolol and diltiazem for control of atrial fibrillation and
for hypertension
Heparin for prevention of DVT
Acetaminophen for pain
Artifical tears for comfort of his eyes
Bisacodyl, docusate, polyethylene glycol, and senna for
constipation
Followup Instructions:
None
Completed by:[**2123-4-24**]
|
[
"428.0",
"507.0",
"997.31",
"428.30",
"707.19",
"277.39",
"585.9",
"V58.61",
"518.83",
"112.0",
"041.3",
"403.90",
"584.9",
"041.7",
"707.8",
"996.42",
"276.2",
"437.9",
"780.03",
"331.4",
"496",
"427.31",
"997.02",
"E934.2",
"V43.64",
"V12.51",
"431",
"V12.55"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"79.75",
"38.7",
"33.24",
"31.1",
"96.72",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
20609, 20675
|
7952, 16987
|
341, 424
|
20971, 20971
|
4065, 4065
|
22063, 22099
|
2826, 2876
|
18764, 20586
|
20696, 20950
|
17013, 18741
|
21107, 22040
|
4569, 7929
|
2242, 2345
|
2891, 2891
|
291, 303
|
452, 1467
|
4079, 4553
|
20986, 21083
|
1489, 2219
|
2361, 2810
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,150
| 164,465
|
29812
|
Discharge summary
|
report
|
Admission Date: [**2114-6-11**] Discharge Date: [**2114-6-26**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Aspirin / Levofloxacin /
NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
Left great toe gangrene
Major Surgical or Invasive Procedure:
- Amputation of the left hallux ([**2114-6-14**]), without immediate post
procedure complication
History of Present Illness:
88 yo male w/ h/o IDDM, CKD, HTN, who presented to OSH with
worsening left foot pain, swelling erythema (started around
[**6-4**]). The patient's son notes that 1 day prior to onset of
symptoms he was grinding down his father's toenails with a file,
slipped and accidentally broke the skin around the left great
toe. As per report from OSH, "his left LE extremity has evidence
of extensive cellulitis over the dorsum of the foot. There is
ulceration of the left great toe with an eschar formation".
Pt. was treated with vancomycin ([**Date range (1) 26246**]), ancef ([**6-6**]) and
zosyn ([**Date range (1) 71315**]). His cellulitis reportedly improved, but the
eschar increased in size. He was evaluated by the infectous
disease and vascular surgery teams. They felt that there was
evidence of gangrene in his left great toe and it would likely
need to be amputated. As per report, there was also concern
concern for osteomyelitis on plain films.
Family requested transfer to [**Hospital1 18**] for second opinion with
regards to surgical management. Pt. currently reports little
pain, and denies fevers/chills. He has significant diabetic
neuropathy and little sensation in b/l lower extremities.
ROS:
per HPI, denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain. He does endorse occasional diffuse
abdominal pain with bloating which radiates to left groin area.
Past Medical History:
Diabetes Mellitus Type 2 - insulin dependent - ? secondary to
prednisone (per pt. son)
CAD s/p stent
Congestive Heart Failure
Polymyalgia rheumatica - on chronic prednisone
Essential Tremor - manifest as frequent spasm-like activity
? Factor 11 and 13 deficiency
Hyperlipidemia
h/o rheumatic fever
HTN
Diabetic Neuropathy
Diverticulosis
BPH s/p TURP
PUD s/p partial gastrectomy
s/p hiatal hernia repair
s/p appendectomy
s/p cholecystectomy
s/p rectal surgery - secondary to bleeding
Social History:
He completed high school and worked as an electronics technician
as well as a meat cutter. He is married, lives with his wife. [**Name (NI) **]
never smoked and denied any alcohol or drug use. He lives in a 2
family house with his son, dtr in law and 4 children above him.
WWII veteran medic who saw active combat in [**Country 6171**] and [**Country 2784**].
Never smoked. Rare ETOH. Caregiver of his wife who has dementia
and recently fell and admitted to the hospital. Son does
shopping. He does the bills, meds, cleaning, cooking. Has VNA.
Family History:
Mother- [**Name (NI) 5895**] disease. Sister - bilateral hand tremor.
Physical Exam:
Admission:
VS - T97.5 BP 110/70 HR 90 RR 20 96% on RA
GENERAL - Well-appearing elderly M who appears comfortable,
appropriate and in NAD
HEENT - NC/AT, PERRL, eyes do not face midline together, but
movements intact, MMM, OP clear
NECK - supple, no JVD,
LUNGS - Lungs are clear to ausculatation bilaterally, moving air
well and symmetrically, resp unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, S1-S2 clear and of good quality
without murmurs, rubs or gallops
ABDOMEN - NABS, soft/NT/ND, regional areas of firmness in
abdomen, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 1+ equal peripheral pulses
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-14**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric
Discharge:
VS - T98.2 BP 135/80 HR 64 RR 20 99% on RA
GENERAL - Well-appearing elderly M who appears comfortable,
appropriate and in NAD
HEENT - NC/AT, PERRL, eyes do not face midline together, but
movements intact, MMM, OP clear
NECK - supple, no JVD,
LUNGS - fine b/l basilar rales, moving air well and
symmetrically, resp unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, S1-S2 clear and of good quality
without murmurs, rubs or gallops
ABDOMEN - NABS, soft, mild umbilical tenderness, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 1+ equal peripheral pulses
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-14**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric
Pertinent Results:
Admission:
[**2114-6-11**] 09:52PM BLOOD WBC-11.0# RBC-3.39* Hgb-11.0* Hct-32.5*
MCV-96 MCH-32.4* MCHC-33.8 RDW-14.4 Plt Ct-233#
[**2114-6-11**] 09:52PM BLOOD PT-12.9* PTT-26.6 INR(PT)-1.2*
[**2114-6-14**] 11:10AM BLOOD Fact [**Doctor First Name 81**]-147 Fac XII-114 FacXIII-PND
[**2114-6-11**] 09:52PM BLOOD Glucose-139* UreaN-34* Creat-1.6* Na-140
K-4.7 Cl-105 HCO3-25 AnGap-15
[**2114-6-11**] 09:52PM BLOOD Calcium-9.4 Phos-2.4* Mg-1.9
[**2114-6-11**] 09:52PM BLOOD CRP-15.7*
Discharge:
[**2114-6-15**] 08:10AM BLOOD CK-MB-2 cTropnT-0.08*
Cath report [**6-20**]
PTCA COMMENTS: Initial angiography revealed a totally
occluded mid
LAD at the proximal portion of the mid LAD stent as well as an
80%
osital D1 lesion which originated just before the CTO in the mid
LAD. We
initially planned to treat the LAD and then D1 eith PTCA and
stenting.
Bivalirudin was started prophylactically. A 6 French XBLAD 3.5
guiding
catheter provided good support for the procedure. The CTO was
initially
engaged with a [**Month/Year (2) 71316**] wire and was unable to be crossed.
Multiple
wires were attempted ([**Name (NI) 71316**], CHOICE PT ES, PILOT 200 and
CONFIANZA).
The CONFIENZA appeared to cross the CTO, but a balloon could not
be
passed through the lesion, and the wire was never able to move
very far
into the distal vessel. At this point we chose to not go further
in
trying to open the CTO of the mid LAD and instead turned our
attention
to D1. A [**Name (NI) 71316**] wire crossed the lesion with minimal
difficulty. The
lesion was dilated with a 2.0x12mm SPRINTER balloon. A 2.5x8mm
INTEGRITY
RX stent was deployed in the ostium of the D1 at 14 ATMs. The
stent was
postdilated with a 2.5x6mm NC QUANTUM APEX MR balloon at 18
ATMs. Final
angiography revealed no residual stenosis at the ostium of the
D1, no
angiographically apparent dissection and TIMI III flow.
Agniography of
the right femoral arteriotomy site showed a site compatible with
percutaneous closure. The patient left the lab free of angina
and in
stable condition.
Micro: UC pending
Path:
I. Big toe, left foot, amputation (A-D):
a. Gangrene, focally involving skin and soft tissue margins.
b. Underlying acute osteomyelitis.
II. Proximal margin (E):
Bone with foci of reparative change and intra medullary fibrosis
with no significant acute inflammation; multiple levels are
examined.
Studies:
ABIs ([**2114-6-12**]):
INDICATIONS: 89-year-old male with dry gangrene of left hallux.
FINDINGS: Bilateral lower extremity ABIs, Doppler waveforms,
and PVRs were
performed at rest. All of the lower extremity vessels are
noncompressible.
On the right, the femoral, popliteal, posterior tibial, and
dorsalis pedis
waveforms are all [**Hospital1 **]/triphasic. Right-sided PVRs are mildly
diminished in the amplitude but at the metatarsal level suggest
potential for healing minor tissue loss.
The right femoral, popliteal, and posterior tibial waveforms are
all biphasic. The dorsalis pedis waveform is monophasic.
Left-sided PVRs are essentially within normal limits.
IMPRESSION: Noncompressible vessels. Strong Doppler waveforms
with PVRs
suggest mild tibial disease on the right and mild, non-occlusive
tibial
disease on the left.
Heme:
FACTOR ASSAYS Fact [**Doctor First Name 81**] FacXII FacXIII
[**2114-6-14**] 11:10AM 147 114 NORMAL
Brief Hospital Course:
89 yo male with history of CAD s/p LAD stent, IDDM2, and PAD,
admitted for gangrenous L foot s/p left hallux amputation
complicated by post-op NSTEMI, now s/p cardiac catheterization
with BMS to Diag1 transferred to the MICU for hypotension with
concern for sepsis.
# Hypotension: On the 10th day of his hospital stay, he
triggered for hypotension with SBP to 70, fever to 102 and a
lactate of 2.9. Most likely septic in origin given fever,
leukocytosis, hypotension with elevated lactate. Potential
sources include GU tract, toe, and scrotum however no clear
evidence of disease. Also risk for hypotension with blood loss,
Hct trending down. He was started on vancomycin and meropenem.
CT abdomen did not reveal any evidence of acute infection. He
was given stress dose steroids which were tapered quickly. A
source of infection was never identified and the patient s bp
remained stable following transfer from MICU. With no source of
infection, normal WBC, and no fevers, abx were discontinued on
[**6-25**].
# Scrotal pain: He reports month long duration of pain, with
acute exacerbation. No torsion, abcess, or epididymitis on
ultrasound. Urology was consulted who recommended ice and
elevation of scrotum. He was continued on his home MS contin at
30mg [**Hospital1 **] with oxycodone and morphine for breakthrough pain.
# NSTEMI: The patient has known CAD, and is s/p PCI ~7 years
prior. He and his family are not entirely sure of the dates or
details of his cardiac history. The morning following his
amputation ([**6-15**]), the patient reported significant nausea and
chest tightness. EKG at the time was reassuring with sinus
tachycardia with nonspecific and stable lateral ST segment
changes. Cardiac enzymes were monitored and were slightly
elevated (peak troponin 0.21, peak CK-MB 5). He was evaluated by
the cardiology team who did not feel he required acute
intervention, but recommended close follow up with his
PCP/cardiologist. He was given a low dose of aspirin and started
on a statin to increase his medical management. CP resolved w/
antiemetics. Had another episode on [**6-16**], relieved by SL NG. On
[**6-17**] continued to c/o CP, partially relieved by nitropaste, and
on [**6-18**] it was decided to send pt for cardiac catheterization to
relieve sxs. Unstable angina s/p cardiac catheterization with
BMS placement to diag1. Currently on aspirin/plavix and chest
pain free. Cath complicated by groin ecchymosis without
palpable hematoma. He was continued on aspirin and plavix daily
and will need to continue these medications without exception
until [**2114-7-21**]. He was continued on simvastatin and started on
metoprolol. His hematocrit was maintained at 30.
# Diarrhea: Has loose stool at home, now with continued diarrhea
in the setting of multiple abx. Uncertain etiology but most
likely [**1-11**] abx has pt has no WBC or temp. C diff PCR negative.
Patient believes its improving.
# Dysuria: Patient complaining of dysuria and increasing
frequency following removal of foley on [**6-23**]. Previous UC showed
yeast. UA on [**6-25**] showed pyuria with some bacteria. Will follow
up culture.
# Gangrene/osteomyelitis of left hallux s/p L hallux amputation:
He was treated with zosyn x7d upon transfer (he also received
doses of vanco and ancef). His toe worsened and appeared
gangrenous upon transfer to [**Hospital1 18**]. Plain films at the OSH
revealed evidence of likely osteo and vascular surgery at the
OSH felt that it was going to require amputation. Patient and
family requested transfer to [**Hospital1 18**]. Vascular surgery was
consulted who recommended ABIs to ensure appropriate blood flow
for future wound healing. Given the reassuring results, he
underwent an amputation of his left hallux on [**2114-6-14**]. Final
result of bone biopsy showed clean tibial margin with gram
positive cocci in amputated toe. Pt was on Vanc/Zosyn for 10+
days. The abx were discontinued in setting of clean margins.
Surgical site looks well on exam. He will need to follow up
with podiatry as an outpatient.
# Peripheral vascular disease: Extensive bilateral tibial
disease found on noninvasives. He will need to follow up with
vascular surgery as an outpatient.
# [**Last Name (un) **] on CKD: Baseline creatinine 1.2, peaked at 1.8. FeNa c/w
prerenal etiology and improved with IVF. Lisinopril, lasix were
held.
# Abdominal masses: Patient with firmness with abdominal
palpation and recent PE. New inderminate enhancing soft tissue
mass encasing the left renal artery noted on Abd CT on [**2114-4-19**].
Head CT without evidence of mets. As per OMR, during his last
hospitalization the family and patient reported that they would
not like to persue further investigations/treatment of this,
however, son also mentioned that they had missed an appointment
with an oncologist. The family does not wish to further work up
these findings.
# INCORRECT Report of Factor [**Doctor First Name 81**] and XII deficiency: Seen by
heme/onc, who confirmed pt all factors were normal. He does NOT
have these factor deficiencies.
# DM2: He was continued on his home NPH with a humalog sliding
scale.
# PMR: On home prednisone 20mg daily. He was given stress dose
steroids during his hypotension. This was rapidly tapered and
he was restarted on 20mg of prednisone three days later. He was
also started on Dapsone 100mg daily for PCP [**Name Initial (PRE) **].
# HTN: Currently normotensive. He was started on metoprolol and
nitrates. His lisinopril, metoprolol, and nitrates were
intermittently held given his blood pressure.
# Presumed diastolic CHF: Patient appears relatively euvolemic.
He was started on metoprolol and nitrates. His lisinopril,
metoprolol, and nitrates were intermittently held given his
blood pressure.
# Anemia: Patient is within baseline anemia (low 30s) with
normo-macrocytic MCV. Likely due to anemia of chronic disease,
given CKD. B12 was normal.
# Gout: Continued renally dosed allopurinol.
# GERD: Continue home pantoprazole.
# Med rec: Continue home vitamin D.
TRANSITIONAL ISSUES:
-Code status: Full Code, no prolonged measures, would never want
to be ventilated
-Follow up: With primary cardiologist Dr. [**Last Name (STitle) 1693**]
[**Name (STitle) 71317**] appointment next week for follow up and removal of
sutures.
-Patient given instructions for following up with hospice
-Follow up urine culture.
-Please CONTINUE PLAVIX.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. PredniSONE 20 mg PO DAILY
2. Vitamin D 800 UNIT PO BID
3. Furosemide 20 mg PO DAILY
4. Lisinopril 5 mg PO DAILY
5. Allopurinol 100 mg PO DAILY
6. Potassium Chloride 20 mEq PO TID
7. Pantoprazole 40 mg PO Q12H
8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
9. Nitroglycerin SL 0.4 mg SL PRN chest pain
Call 911 if medication fails to reduce chest pain after 2 doses
10. magnesium chloride *NF* 64 mg Oral [**Hospital1 **]
11. Morphine SR (MS Contin) 30 mg PO Q12H
12. Nitroglycerin Patch 0.4 mg/hr TD Q24H
12h on/12h off
13. HumuLIN N *NF* (NPH insulin human recomb) 100 unit/mL
Subcutaneous [**Hospital1 **]
24 UNITS QAM and 6 UNITS QPM
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *Adult Low Dose Aspirin 81 mg 1 tablet(s) by mouth daily Disp
#*20 Tablet Refills:*0
2. Clopidogrel 75 mg PO DAILY
3. Metoprolol Tartrate 25 mg PO TID
HOLD for SBP < 100, HR < 60
4. Simvastatin 40 mg PO DAILY
5. Pantoprazole 40 mg PO Q12H
6. Furosemide 20 mg PO DAILY
7. Allopurinol 100 mg PO DAILY
8. NPH 18 Units Breakfast
NPH 9 Units Bedtime
9. Lisinopril 5 mg PO DAILY
10. PredniSONE 20 mg PO DAILY
11. Vitamin D 400 UNIT PO DAILY
12. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
13. Dapsone 100 mg PO DAILY
14. Nitroglycerin SL 0.3 mg SL PRN chest pain
Call 911 if medication fails to reduce chest pain after 2 doses
15. Morphine SR (MS Contin) 30 mg PO Q12H
16. Nitroglycerin Patch 0.4 mg/hr TD Q24H
12h on/12h off
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Nursing Care - [**Location (un) 6981**]
Discharge Diagnosis:
Primary:
- Gangrene of the left hallux
- osteomyelitis
- NSTEMI
Secondary:
- Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking part in your care during this
hospitalization. You were transferred to [**Hospital1 18**] for evaluation
of the infection in your left toe that required amputation. You
were evaluated by the vascular surgery team, who found that
while you continue to have good blood flow to your feet, it is
diminished. Because the infection was also in your bone, you
required antibiotics in addition to your amputation.
You also reported that you were having chest pains. We
performed several blood tests and found that you were having a
mild heart attack. The interventional cardiologist interserted a
stent into your heart to open up a blockage.
Following the procedure, you had a low blood pressure and
temperature and were transferred to the medical ICU. Your
recovered quickly and were stable the rest of the admission.
We hope you continue to feel well.
Please continue to take all other home medications as directed.
Followup Instructions:
Department: PODIATRY
When: FRIDAY [**2114-7-6**] at 3:30 PM
With: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Name: [**Last Name (LF) **],[**First Name3 (LF) 275**] E.
When: Wednesday [**7-12**] at 11:15pm
Location: [**Hospital **] MEDICAL
Address: 237A [**Street Address(1) **], [**Location **],[**Numeric Identifier 21478**]
Phone: [**Telephone/Fax (1) 9674**]
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71,558
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40039
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Discharge summary
|
report
|
Admission Date: [**2157-11-28**] Discharge Date: [**2157-12-20**]
Date of Birth: [**2127-12-1**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
S/P jump from moving train
intubated
Major Surgical or Invasive Procedure:
[**2157-11-27**]
Placement of right frontal intracranial pressure
monitor.
[**2157-12-1**]
1. Percutaneous tracheostomy.
2. Percutaneous endoscopic gastrostomy.
3. Inferior vena cava filter via the right femoral route.
[**2157-12-1**]
Pressure monitor removed
History of Present Illness:
33 year old male who jumped or fell from a train, moving at
approximately 40 mph. He was found reportedly with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**]
Coma Scale of 3 on the scene, taken to an outside hospital where
he was intubated and sent to [**Hospital1 18**] by helicopter.
Past Medical History:
none
Social History:
Works as a chef for a local church. Currently in college.
Married
with a child, wife currently pregnant with second child.
Nonsmoker, occasional ETOH, no recreational drug use. Wife,
brothers and [**Name2 (NI) **] at bedside.
Family History:
nc
Physical Exam:
T: 97 BP: 126/98 HR: 110 R 23 O2Sats 98% ETT
Gen: Intubated, extensor posturing x4
HEENT: Head laceration
Neck: Cspine hard collar
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft
Neuro post fentanyl:
Post-fentanyl: NO EO, Pupils 2 and nonreactive, extensor
posturing to all 4 extremities. No corneals. Biting down on ETT.
Later exam: R pupil reactive 5 to 2, left remains nonreactive.
Post-mannitol: Pupils 2.5-2 bilaterally
Pertinent Results:
MICRO:
[**11-28**] MRSA: neg
[**11-28**] BCx x 2: NG
[**11-28**]: UCx: NEG
[**11-29**]: BCx: NG
[**11-29**]: Urine Cx: NEG
[**11-29**]: Sputum Cx: Bad Sample
[**11-29**]: Hep C: VL not detected
[**11-30**]: UCx: NG
[**11-30**]: BCx: NG
[**11-30**]: Sputum: Bad Sample
Multiple cultures of blood, urine and sputum taken thru [**2157-12-15**]
are all negative including c&s of spinal fluid
IMAGING:
[**11-27**] CT Head: 1. Small focal hyperdensities in the bifrontal
region (near the vertex), and left basal ganglia, compatible
with small hemorrhagic contusion. No intraventricular
hemorrhagic extension. 2. Tiny SAH near the vertex contusion
site. Cannot exclude a small SDH. 3. Large subgaleal hematoma
at/near the vertex. 4. No evidence of bony fracture.
[**11-27**] CT C-spine: No acute cervical fx or malalignment. Patchy
opacity in the R lung apex, could represent contusion vs
aspiration.
[**11-27**] CT Thorax/Pelvis: 1. Bilateral patchy opacities in the
lungs, compatible with aspiration, contusion or atelectasis. No
PTX. 2. No intra-abdominal solid organ injury. 3. No spinal fx
or malalignment. Bony pelvis intact.
12/5 L Wrist Xrays: minimally displaced distal radius fracure,
ulnar styloid fx
[**11-28**] CT Head: Tiny intraventricular hemorrhagic extension into
the left occipital [**Doctor Last Name 534**]. Small amount of subarachnoid hemorrhage
in the vertex, unchanged. No developing hydrocephalus.
[**11-29**]: EEG: P
[**11-29**]: Head CTA: 1. Unchanged hemorrhagic contusions, diffuse
axonal injury, subarachnoid and subdural hemorrhage. 2.
Unchanged diffuse cerebral swelling. 3. Unremarkable head CTA.
[**11-29**]: CTA Chest: 1. No evidence of pulmonary embolism. 2. Marked
worsening of lower lobe consolidation, concerning for infection,
and possibly aspiration. 3. Mildly displaced T3 vertebral body
fracture.
4. Endotracheal tube tip at the thoracic inlet, and should be
advanced.
[**12-1**] CT Head: Subdural and intraparenchymal hemorrhage again
identified with no evidence of new bleeding. No evidence of
infarction or mass effect
[**2157-12-14**] EEG :This telemetry over four hours showed an
encephalopathic
background with prominent generalized slowing suggestive of
deeper
structure dysfunction. There were no prominently lateralized
features.
There were no epileptiform abnormalities, including at the time
of the
pushbutton activation.
[**2157-12-14**] MRI T spine : 1. Likely Chance-type fracture of the T12
vertebral body, which may be an unstable fracture (if two or
more "columns" are involved). If confirmation is necessary, a
focused MDCT, targeting the thoracolumbar junction can be
obtained.
There is no retropulsion or spinal canal compromise.
2. T3 vertebral body anteroinferior compression fracture.
3. Normal signal intensity of the thoracic spinal cord on all
pulse sequences including STIR).
[**2157-12-15**] EEG : This monitoring on the morning of [**12-15**]
showed the
same continued encephalopathic background. There were eye
movement
artifacts, as well. There were no epileptiform features. The
pushbutton activations showed no change in the background.
[**2157-12-15**] CT T-L spine : 1. No evidence for T12 bony injury to
correlate with the MR findings.
2. Posterior inferior vertebral body fracture of T3 without bony
retropulsion and without involvement of the posterior elements.
Brief Hospital Course:
Mr. [**Known lastname 19704**] was evaluated by the Trauma team in the Emergency
Room and his scans were reviewed. He was admitted to the trauma
ICU on the neurosurgery service for his head bleed. A bolt was
placed and ICP's were monitored. Mannitol and normal saline
were started. The patient was transferred to the trauma surgery
service for concern of pulm contusions. Tube feeds were started
on [**11-28**]. On [**11-29**] a neo gtt was utilized to maintain the CPP.
On [**11-29**] a CTA chest was performed as pt was hypoxic and this
revealed no pulmonary embolism. On [**11-30**] and [**12-1**] he had fevers
a CXR revealed worsening PNA (aspiration likely). On [**12-1**] the
bolt was removed after a CT head revealed no change or
worsening. He also underwent trach/PEG/IVC filter on [**12-1**].
From a neurologic standpoint his mental status remained the same
for weeks...not responsive and not tracking. There was no change
in his head CT. He moved his extremities randomly, arms >>
legs. His cervical collar remained on as we were unable to clear
his neck due to his depressed mental status. The Neurosurgery
service followed him closely and want to re image in a few more
weeks. Following transfer to the Trauma floor it became more
apparent that he had minimal movement of his lower extremities
and he also had nystagmus. The Neurology service was consulted
and multiple EEG's were done and ruled out seizure activity. He
also had an LP done due to persistent fevers and that was
negative including the culture. His nystagmus was simply from
encephalopathy. An MRI of his T spine was also recommended due
to his decreased movement of his lower extremities. A T 12
Chance fracture was noted with ligamentous injury along with a T
3 vertebral body compression fracture. There was no evidence of
cord compression. The Ortho Spine surgeons reviewed the films
and recommended treatment with a TLSO brace and re imaging in
[**1-26**] weeks to check alignment. He became much more alert on
[**2157-12-19**] and was able to recognize his family and speak.
Currently he responds to questions with short answers, tracks
appropriately but is not always consistent. The Neurosurgery
service is still unable to clear his C spine as he does not
consistently answer questions clearly.
During his ICU stay he required mechanical ventilation and early
tracheostomy due to his mental status and the necessity of
protecting his airway. He also had Chest CT findings of
bilateral lower lobe opacities, possibly due to aspiration
associated with hypoxia. He was cultured on multiple occasions
as he was febrile on a daily basis. He was treated for
ventilator acquired pneumonia but other than for admission had a
minimally elevated WBC. Sputum cultures were all negative and
eventually he was slowly able to be weaned from the respirator
and maintained adequate oxygenation on a Trach collar.
His recurrent fevers prompted more than pan culturing. He had a
duplex scan of his lower extremities which ruled out DVT and a
liver ultrasound which ruled out cholecystitis. He was
empirically treated with Zosyn and Vancomycin and both of these
drugs were stopped on [**2157-12-13**]. Since that time he has had low
grade fevers intermittently and a normal WBC. The Neurology
service thinks that the fevers are coming from his brain injury.
In order to keep him nutritionally fit a PEG tube was placed for
tube feedings. Recently he has been switched from continuous
feedings to bolus feedings and he is tolerating them well. He
has not been consistently alert enough to undergo a swallowing
study but if he continues to improve as he is doing now, he
should be able to participate in a week or so. He has become
hypernatremic to 155 since changing feeding methods and his free
water flushes have just been increased along with IV D5W until
his sodium returns to normal. Today his sodium is 149 and his
IV D5W has stopped. He will continue to get an extra 600cc
water daily with tube feedings.
The Orthopedic service evaluated him on admission and felt that
his left arm may require surgical repair but during this acute
phase the radial and ulnar fractures were stabilized with a
short arm cast. He will be re imaged in a few weeks and further
recommendations will come at that time. For now, he is non
weight bearing with his left arm.
Due to the mechanism of his injury and the thought that it was a
suicide attempt, he was evaluated by the Psychiatry service.
Most of their assessment was done with the help of his family as
he was unable to participate in answering questions. He
evidently had no history of depression or suicide attempts in
the past and what actually happened may never come to light
however, once stable and communicative, he should be
reevaluated.
The Physical Therapy and Occupational Therapy service have been
involved with [**Doctor First Name **] during his ICU stay and while on the floor. He
is able to transfer out of bed with his TLSO brace on and will
hopefully increase the amount of time out of bed and eventually
begin balance and gait training. His brain injury will require
intense rehab including both the patient and his family.
Hopefully in time he will be able to return home with his wife
and children.
Medications on Admission:
none
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. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
3. Senna Lax 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. ibuprofen 100 mg/5 mL Suspension Sig: Twenty (20) mL PO Q8H
(every 8 hours) as needed for fever.
5. bacitracin zinc 500 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day).
6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
7. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
S/P fall from train
1. L occipital laceration
2. Bifrontal contusions
3. Left basal ganglia contusion
4. IPH
5. SAH at vertex
6. Diffuse cerebral edema
7. Subgaleal hematoma at vertex
8. Bilateralpatchy lung opacities
9. Left distal radius fx
10.Left ulnar styloid fx
11.Moderately displaced T3 vert body fx
12.T 12 chance fx
13.TBI
14.Aspiration pneumonia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair with TLSO brace on.
Discharge Instructions:
You were admitted to the hospital after falling from a train,
sustaining severe injuries. You ultimately required a breathing
tube in your neck and a feeding tube in your stomach to maintain
your nutrition.
You have made remarkable improvements over the last week and
hopefully will continue to do so at rehab. As you make progress
you will eventually be able to have your trach tube and feeding
tube removed.
You also had multiple broken bones including a left arm fracture
which will remain in a cast for at least 6 weeks. Do NOT bear
any weight on that arm. A decision will be made at your follow
up appointment regarding the need for surgical repair.
You have a thoracic spine fracture and will need to wear the
TLSO brace for 3 months. Put the brace on before you get out of
bed.
You will have to work hard with Occupational Therapy and
Physical Therapy. Many things that came easy to you before the
accident will need to be relearned now. This takes alot of time
and patience on your part.
You will have doctors that take [**Name5 (PTitle) **] of you at rehab but you
will still need to return to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] for follow up with some
of your specialists here.
Followup Instructions:
Call the Ortho Spine Clinic at [**Telephone/Fax (1) 3573**] for a follow up
appointment in [**1-26**] weeks with Dr. [**Last Name (STitle) 363**]. You will need Xrays
done at that time to check the alignment of your spine. You will
also have your left arm checked at the same time.
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in 4 weeks.
Call the [**Hospital 4695**] Clinic at [**Telephone/Fax (1) 1669**] for a follow up
appointment with Dr. [**First Name (STitle) **] in 3 weeks. You will need a non
contrast head CT prior to that appointment. The secretary will
arrange that for you.
Completed by:[**2157-12-20**]
|
[
"348.30",
"851.85",
"507.0",
"805.2",
"V49.87",
"E804.1",
"861.21",
"873.0",
"780.61",
"348.5",
"813.44",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"43.11",
"03.31",
"33.24",
"38.7",
"96.72",
"31.1",
"01.10"
] |
icd9pcs
|
[
[
[]
]
] |
11207, 11277
|
5152, 10421
|
342, 606
|
11680, 11680
|
1784, 2195
|
13135, 13801
|
1230, 1234
|
10476, 11184
|
11298, 11659
|
10447, 10453
|
11877, 13112
|
1249, 1765
|
266, 304
|
634, 941
|
3712, 5129
|
11695, 11853
|
963, 970
|
986, 1214
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
425
| 118,058
|
30273
|
Discharge summary
|
report
|
Admission Date: [**2149-5-13**] Discharge Date: [**2149-5-26**]
Date of Birth: [**2091-10-9**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins / Erythromycin Base / Codeine /
Nsaids / Aspirin / Sulfa (Sulfonamides) / Vancomycin / Levaquin
/ Clindamycin / Sensipar
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
s/p VT/VF arrest
Major Surgical or Invasive Procedure:
parathyroidectomy
ET during surgery
Right A line
Right Femoral line
History of Present Illness:
57 yo female with PMH ESRD, Afib (on sotalol), baseline QTc
prolongation, Lupus, diverticulitis (s/p resection and
ileostomy) had elective parathyroidectomy today c/b VT arrest.
Pt has a baseline PTH of 2500 with bony pain and difficulty
walking which prompted this surgery. She took sotolol this AM.
During the procedure, pt developed ventricular bigeminy. She
then developed a prolonged episode of VT/VF which lasted for
minutes. She became pulseless and CPR was initiated. The VT
spontaneously terminated. Pt was given amio 150mg bolus. She had
recurrent episode of sustained VT which terminated and was given
another amio 150mg and started on amio gtt at 1mg/min. Also
started on proporol gtt. Of note, the parathyroidectomy was
completed with removal of left upper/lower gland, right
upper/lower gland (total 3.5 glands) and thyroid. [**Name (NI) 4452**] PTH was
[**2111**]; no repeat performed in setting of acute event outlined
above.
.
On arrival to [**Name (NI) 153**], pt was hemodynamically stable. Started on
magnesium.
Past Medical History:
Hyperparathyroidism (baseline PTH >2500; severe bone pain and
inability to walk)
Lupus (diagnosed [**2128**])
ESRD ([**2-21**] lupus; HD MWF)
Afib (on sotalol and coumadin)
Diverticulitis (s/p resection-ileostomy)
L knee surgery ([**2-21**] septic knee in [**2140**] c/b mult re-do
surgeries. Unable to bend knee at baseline)
Benign cyst removal from right knee ([**2144**])
Benign tongue growth removal ([**2145**])
Burst left arm aneurysm
HTN
multiple AVF surgeries
Hx of multiple Cdiff infections
MR
Social History:
Functional capacity limited [**2-21**] pain, wheelchair-bound.
Family History:
NC
Physical Exam:
VS: 98.2, p55, 107/49, rr18, 99% on AC 400 (spont 424)/16/5/.60
Gen: intubated and sedated
HEENT: PERRL, clear OP, ET tube in place
CVS: RRR, nl s1 s2, holosystolic murmur at base
Lungs: coarse BS bilaterally anteriorly
Abd: soft, ND, decr BS
Ext: no edema
MSK: deformed right elbow with effusion and no warmth or
redness, bilateral ankle joint swelling w/o evidence of
infection
Pertinent Results:
EKG: NSR@59, leftward axis, QTc prolongation of 497, slight STD
lead 2 (new), LVH by voltage criteria.
.
Rhythm strips: Unable to obtain strip of sustained VT. Strip of
episode of NSVT reveals short runs of polymorphic VT preceded by
long pauses with significantly increased RR intervals.
.
Echo: [**2148-11-21**] ([**Hospital3 **])
Normal LV size and function. EF 65%. Mild concentric LVH. No
regional wall motion abnl. 2+ MR. [**Name14 (STitle) **] TR. biatrial
enlargement.
.
[**2149-5-13**] ECHO: The left atrium is mildly dilated. The estimated
right atrial pressure is 11-15mmHg.. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets are moderately thickened. There is a
minimally increased gradient consistent with minimal aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Mild aortic valve stenosis. Moderate mitral
regurgitation. Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Pulmonary artery systolic hypertension.
CLINICAL IMPLICATIONS:
Based on [**2149**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
[**2149-5-14**] CXR: Change in lung opacities.
There has been interval extubation and removal of a nasogastric
tube. Cardiac silhouette remains enlarged with vascular
engorgement and perihilar haziness, which may be due to CHF or
volume overload. Homogeneous opacity in left retrocardiac region
and adjacent left pleural effusion are again demonstrated with
interval increase in size of left effusion. Air space opacity in
right lower lobe is difficult to compare due to positional
differences but may be slightly worse, and there is also
apparent slight increase in adjacent right pleural effusion.
Bones are heterogeneous in appearance with a lucent lesion of
the left humeral head as described on the recent study.
.
[**2149-5-14**] ECG: Technically difficult study
Sinus rhythm with PVCs with PACs
QT interval prolonged for rate
Extensive ST-T changes are nonspecific
Since previous tracing of the same date, premature beats are
new, precordial voltage lower
.
[**2149-5-15**] ECG: Sinus rhythm
Long QTc interval
Inferior/lateral ST-T changes are nonspecific
Low limb lead voltage
Since previous tracing of [**2149-5-14**], premature beats not seen,
precordial voltage higher
.
[**2149-5-16**] CXR: Probably no change in the left pleural effusion and
underlying opacity in the left retrocardiac region. Slight
decrease in the right pleural effusion, as well as airspace
opacity in the right lower lobe. Slightly improved degree of
vascular engorgement and perihilar haziness.
.
[**2149-5-16**] ECG: Sinus rhythm, rate 70. Since the previous tracing
of [**2149-5-15**] minimal shortening of the Q-T interval is present,
though it remains prolonged. Technical artifacts are noted over
the lateral precordium.
.
[**2149-5-17**] ECG: Sinus rhythm. Left atrial abnormality. Prolonged
QTc interval. Clinical correlation is suggested. compared to the
previous tracing of [**2149-5-16**] no significant change.
.
[**2149-5-18**] CXR: Worsening fluid status with features of CHF and
larger effusions. New right airspace disease which is
nonspecific in nature requiring clinical correlation and
additional imaging followup.
.
[**2149-5-18**] ECG: Atrial flutter with rapid ventricular response.
Since the previous tracing of [**2149-5-17**] atrial flutter is now
present.
.
[**2149-5-19**] ECG: Sinus rhythm
Left atrial abnormality
Possible left ventricular hypertrophy
Since previous tracing of [**2149-5-19**], sinus rhythm restored
.
[**2149-5-21**] ECG: Atrial fibrillation with a rapid ventricular
response. Low limb lead voltage. Compared to the previous
tracing of [**2149-5-19**] atrial fibrillation with a rapid ventricular
response has appeared.
.
[**2149-5-23**] ECG: Sinus rhythm. Non-specific T wave inversion in lead
III. Baseline artifact in leads V5-V6 makes interpretation
difficult. Compared to the previous tracing of [**2149-5-21**] sinus
rhythm is now present.
.
Brief Hospital Course:
57 yo female with PMH AF (on sotalol), baseline prolonged QTc,
ESRD on HD, lupus (on chronic steroids), now s/p
parathyroidectomy c/b VT/VF arrest.
.
1. VT/VF arrest: Most likely secondary to torsade de pointes in
setting of alkalemia and hypocalcemia in this patient with
baseline prolonged QTc [**2-21**] Sotalol. Pt had ventricular bigeminy
preceding event, and PVC with post-PVC compensatory pause likely
initiated torsades. We discontinued amio, sotalol(esp since
it's renally cleared) and plaquenil, all of them prolonged QT;
continued her tele and repeat EKG qAM; monitored and repleted
lytes aggressively. No further events in house.
.
2. Hyperparathyroidism (s/p parathyroidectomy): Likely secondary
hyperparathyroidism [**2-21**] ESRD vs. tertiary hyperpara. PTH 58
post surgery. Received hydrocortisone 100mg x 1 in OR.
Developed subsequent hungry bone syndrome requiring a calcium
drip, calcitriol, and po calcium supplement. She was weaned off
the drip but is still requiring large amounts of po calcium to
maintain her levels. Renal and endocrine were consulted and
assisted with her management. She will have calcium checked
with hemodialysis to follow for weaning of her po supplement.
.
3. Abnl CXR: RLL opacity, LLL collapse vs. atelectasis. Patient
received 7 days of antibiotics for treatment.
.
4. Afib: Patient was in sinus prior to surgery. Her sotalol had
to be discontinued. Cardiology recommended starting lopressor
for rate control. Her rate has been well controlled on this
medication. She is on coumadin for anticoagulation. She will
have her INR checked with hemodialysis until it is stable.
.
5 ESRD: renal was consulted, she was to continue on HD on MWF.
Continue nephrocaps.
.
6. Lupus: No evidence of acute infection/inflammation. continued
her prednisone 6mg daily (home dose), but stopped her plaquenil
as plaquenil prolongs QT and discussed with her outpt
rheumatologist (Dr. [**First Name (STitle) 6164**], [**Location (un) 3307**]) who agreed with stopping
her plaquenil and continuing the prednisone.
7. Hypertension: Normotensive. Hold captopril and stopped
sotalol given prolongation of QT. Currently on lopressor.
.
8. Drug rash: Thought possible due to ceftriaxone for pneumonia
so this was stopped after 6 days. She received a 7th day of
antibiotics, with doxycycline.
.
9. Full code
.
10. Comm: [**Name (NI) 4906**] [**Telephone/Fax (1) 72070**]
Medications on Admission:
Hydroxychloroquine 200mg qhd
prednisone 6mg qd
nephrocaps qd
captopril 12.5 mg qd
sotolol ? dose ([**1-21**] tab qd)
protonix 40mg qd
coumadin 1 mg daily qd
tylenol prn
Discharge Medications:
1. PredniSONE 1 mg Tablet Sig: Six (6) Tablet PO DAILY (Daily).
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Calcium Citrate 950 mg Tablet Sig: Six (6) Tablet PO qid ():
YOU MUST HAVE YOUR CALCIUM CLOSELY FOLLOWED WHEN TAKING THIS.
Disp:*336 Tablet(s)* Refills:*0*
6. Calcitriol 0.5 mcg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
Disp:*84 Capsule(s)* Refills:*0*
7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO Q MON ().
Disp:*4 Capsule(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
9. Outpatient Lab Work
PLEASE DRAW CALCIUM AND INR WITH EVERY HEMODIALYSIS, UNTIL
STABLE. PLEASE CONTACT DR. [**Last Name (STitle) **] WITH THE RESULTS, PHONE:
[**Telephone/Fax (1) 39393**]
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
primary:
cardiac arrest secondary to ventricular fibrillation
ventricular tachycardia
hypocalcemia
atrial fibrillation
hyperparathyroidism s/p parathyroidectomy
community acquired pneumonia
secondary:
systemic lupus erythematous
end stage renal disease
Discharge Condition:
good: calcium stable, no significant arrhythmias
Discharge Instructions:
Please call your doctor or go to the emergency room if you
experience chest pain, palpitations, shortness of breath,
cramping in your muscles or abdominal area, or other concerning
symptoms.
Please note that your sotalol and hydrochloroquine have been
discontinued due to a life-threatening heart rhythm. Please do
not take this medication anymore.
You have been started on 3 new medications, please take them as
prescribed.
You must have your calcium and coumadin level checked with every
hemodialysis until it is stable.
Followup Instructions:
1. You have an appointment scheduled with your primary care
doctor, Dr. [**Last Name (STitle) **], on Friday [**2149-5-30**] at 12:30. [**Telephone/Fax (1) 39393**]
2. You have a follow-up appointment scheduled with Dr.
[**Last Name (STitle) **] on Thursday [**2149-6-12**] at 12:45. [**Telephone/Fax (1) 9**]
3. You have a follow-up appointment scheduled in the endocrine
clinic at [**Hospital1 18**] with Dr. [**First Name (STitle) **] [**Name (STitle) 9835**] on [**Last Name (LF) 766**], [**6-2**] at
8:20 am. [**Telephone/Fax (1) 1803**]
4. You have an appointment scheduled in the cardiology clinic
at [**Hospital1 18**]. Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D.
Phone:[**Telephone/Fax (1) 902**]. Date/Time:[**2149-6-10**] 9:00. Location: [**Hospital Ward Name **], [**Hospital Ward Name 23**] building, [**Location (un) 436**].
5. Please call to schedule a follow-up appointment with your ENT
doctor within 1-2 weeks.
|
[
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"275.2",
"427.31",
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"426.82",
"276.2",
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"427.41",
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"518.5",
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"710.0",
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icd9cm
|
[
[
[]
]
] |
[
"99.60",
"39.95",
"38.93",
"06.89",
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] |
icd9pcs
|
[
[
[]
]
] |
10914, 10989
|
7237, 9645
|
427, 496
|
11287, 11338
|
2601, 4074
|
11913, 12877
|
2181, 2185
|
9865, 10891
|
11010, 11266
|
9671, 9842
|
11362, 11890
|
2200, 2582
|
4097, 7214
|
371, 389
|
524, 1558
|
1580, 2085
|
2101, 2165
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,853
| 109,025
|
2689
|
Discharge summary
|
report
|
Admission Date: [**2182-4-23**] Discharge Date: [**2182-5-1**]
Date of Birth: [**2123-10-15**] Sex: F
Service: NEUROLOGY
Allergies:
Fosphenytoin / Codeine / Morphine
Attending:[**First Name3 (LF) 8850**]
Chief Complaint:
Witnessed seizure.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
[**Known firstname **] [**Known lastname **] is a 58-year-old right-handed woman with
metastatic breast cancer to the brain and ribs currently on
HK1-272 04-266 trial, now with chief complaint of witnessed,
grand mal seizure. She initially presented to [**Hospital3 3765**]
earlier today after generalized seizure witnessed by her
husband. [**Name (NI) **] is a very poor historian, but reports going to
her usual, psychotherapy appointment this a.m., in her usual
state of health. Afterwards, she walked out of the hospital with
her husband and then her story becomes a bit unclear. By report,
her husband witnessed a seizure lasting 2-3 minutes, involving
her arms and legs. She was observed to be snoring loudly after
seizure. Patient reports waking up in the ambulance on her way
to [**Hospital **] Hosp. At [**Hospital1 **], patient given fosphenytoin with
subsequent allergic reaction halfway through infusion with
pruritis, urticaria, erythema to abdomen. Infusion stopped and
she was treated with Benadryl 50 mg x 1, prednisone 40 mg x 1,
ativan 1 mg. Labs at [**Hospital1 **] with WBC 5.8, Hct 33.6 (MCV 83.6),
Plts 278, and CK 215. In our emergency room, her vital signs
were stable. She did not have further seizure activity, and she
was given 1,000 mg [**Hospital1 13401**] x 1 and admitted to OMED service. Head
CT was negative for acute process.
Past Medical History:
Oncology History: Somewhat unclear as patient longtime patient
of [**Hospital1 18**] and no recent synopsis of treatments:
-patient with breast cancer with stable mets to brain, ribs
-initially diagnosed with right breast cancer in [**2162**]. Biopsy at
that time revealed an infiltrating ductal carcinoma and the
patient underwent a mastectomy (tumor size was 4.5 cm, ER
positive, and Her2neu positive).
-approximately 14 months after mastectomy, underwent six cycles
of CMF therapy.
-[**2174**]: left hip met
-initiated care w/ Dr. [**Last Name (STitle) **] in [**2175**]; XRT and herceptin
-Navelbine and Herceptin
-Herceptin and carboplatin [**1-27**]
-now with brain and rib mets
-has been on multiple protocols
-currently on HK1-272 04-266 trial with several recent dose
reductions, Zometa last received on [**2182-4-16**]
-seen in ED on [**2182-3-21**] with rib pain, ruled out for PE, thought
to be due to known metastases.
OTHER PMH:
Asthma and elevated cholesterol.
Social History:
She lives w/ her husband, and she has 4 grown children. She is
a lifetime non- smoker and rare alcohol use.
Family History:
Non-contributory.
Physical Exam:
Vital Signs: Temperature 98.1 F, Blood Pressure 128/80, Pulse
117, Respiration 20, Oxygen Saturation 97% in Room Air.
General: Restless, moving all extremities all about,
alert/oriented, scattered; She is inattentive, and keep needing
to re-focus her for history
HEENT: MM dry, OP clear but dry; EOMI
NECK: supple, no lymphadenopathy, no rigidity
BREAST: mastectomy on right; port a cath c/d/i
CHEST: CTA; pruritic-uriticarial rash on anterior chest; patient
scratching actively
CV: RRR, no m/r/g; patient kept talking through exam even when I
asked her to be quiet for auscultation
ABD: soft non tender,nabs, no masses
EXTRM: swaying them around, decreased tone but normal strength
NEURO: alert and oriented x 3 but a few seconds later she said "
i am going to be transferred to [**Hospital3 **]." Appropriate but
needs constant re-focusing for questions. Scattered. Normal
speech. Moving all extremities about with ease. Spelled WORLD
foreward but not backward. Serial sevens with ease. Cerebellar
examination intact. did not ambulate patient.
Pertinent Results:
[**2182-4-23**] 06:00PM GLUCOSE-101 UREA N-12 CREAT-0.6 SODIUM-142
POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-26 ANION GAP-16
[**2182-4-23**] 06:00PM NEUTS-80.5* BANDS-0 LYMPHS-14.1* MONOS-2.9
EOS-2.5 BASOS-0.1
[**2182-4-23**] 06:00PM PT-12.1 PTT-21.6* INR(PT)-1.0
MRI Head [**2182-4-24**]:
FINDINGS: All of the sequences with the exception of the axial
FLAIR sequence are so severely limited by patient motion as to
be practically diagnostically useless. On the FLAIR sequence,
the extensive white matter edema in the periventricular regions
and the left temporal lobe are identified and are similar to the
previous examination. On the postcontrast sequence in today's
examination, the previously noted temporal lobe enhancing
lesions can be discerned. It cannot be compared adequately.
IMPRESSION: Markedly limited study due to patient motion.
Persistent white matter abnormal signal and enhancing focus in
the left temporal lobe.
MRI Head [**2182-4-26**]:
FINDINGS: Again, two small enhancing lesions are seen in the
left frontal cortical and subcortical region with mild
surrounding edema. Additionally, there is an approximately 15 mm
enhancing lesion seen in the left temporal lobe with a small
adjacent enhancing nodule. This lesion on axial images appears
slightly larger compared to the prior study. However, compared
on the sagittal and coronal images it remains unchanged.
Therefore, the differences on the axial images could be due to
slice selection. An additional small focus of enhancement is
seen adjacent to the occipital [**Doctor Last Name 534**] of the right lateral
ventricle. Diffuse periventricular and subcortical
hyperintensities are seen on the FLAIR and T2-weighted images
which could be related to small vessel disease and/or radiation
therapy. There is no mass effect or midline shift seen. There is
moderate ventriculomegaly which could be related to atrophy.
There are no other definite areas of abnormal parenchymal or
meningeal enhancement seen.
IMPRESSION: Overall, no significant interval change compared to
the previous MRI of [**2182-3-27**]. The left frontal and temporal
enhancing lesions are again seen with surrounding edema. A small
focus of enhancement is again seen adjacent to the occipital
[**Doctor Last Name 534**] of the right lateral ventricle. Diffuse hyperintensities in
the white matter are again noted which could be related to small
vessel disease or radiation therapy.
EEG [**2182-4-25**]:
IMPRESSION: Normal portable EEG. There were no areas of
persistant focal slowing, no epileptiform feature. Tachycardia
was noted.
Brief Hospital Course:
This is a 58-year-old right-handed woman with metastatic breast
cancer to [**Last Name (LF) 500**], [**First Name3 (LF) **], here with new seizures, presumably from
disease progression. She was transferred to [**Hospital1 18**] for further
care given that her oncology care is here. She was intially
confused on [**2182-4-23**] overnight and was less so during [**2182-4-24**].
She continued to recieve Benadryl prn and in addition received
ranitidine, Zyrtec, and Ativan. On the evening of [**2182-4-24**], she
became increasingly confused and agitated requiring restraints
and a sitter and she was then no longer able to be managed on
the floor. She denied dysuria, cough, subj fever, pain. She was
noted to have some phlebitis on her left arm at the site of a
prior IV and her husband noted an increase in her urinary
urgency. She had no chest pain, shortness of breath, N/V/D. Her
agitation was possibly due to Benadryl given that she had a
similar reaction in the past to phenobarbitol. Most likely
etiology was polypharmacy - she has had steroids, multiple
anticholinergics (Benadryl, ranitidine, Zyrtec), and Ativan.
Also on ddx was non-convulsive status, infection (? UTI, ?
cellulitis at old IV site), primary effect of metastases. Her
Zyrtec and Benadryl were discontinued. She was monitored in the
ICU over the next 48 hrs and was transferred back to the floor
after her mental status had drastically improved with the d/c of
anticholinergics.
(1) Seizure/Mental Status Changes: Her grand mal seizure was
intially felt to be most likely from progression of disease.
She had an allergic reaction to fosphenytoin at the outside
hospital, so she was loaded with [**Date Range 13401**] on admission here. Her
electrolytes were within normal limits. She was afebriile. She
had no recent alcohol use or evidence of withdrawal from her
benzodiazepines. Head CT was negative for acute change. As per
above, she was very disoriented on admission and was transferred
to the ICU. She recovered from this event with lucid periods,
but was sundowning while in the ICU. The ddx for these MS
changes was long. The most likely was felt to be polypharmacy -
she has had steroids, multiple anticholinergics (Benadryl,
ranitidine, Zyrtec), and ativan. Also on ddx were non-convulsive
status, infection (? UTI, ? cellulitis at old IV site), primary
effect of mets. MRI of brain on admission was poor due to
patient movement but white matter edema in periventricular and
left temporal lobe regions seemed similar to one month ago. EEG
was negative for epileptiform features. LP was negative for any
cells and culture was negative. Repeat MRI [**2182-4-26**] showed left
frontal cortical and subcortical enhancing lesions with mild
surrounding edema unchanged from prior, 15 mm lesions left
temporal lobe unchanged, and lesion adjacent to occipital [**Doctor Last Name 534**]
of right ventricle unchanged. Following transfer back to the
floor from the ICU, she was continued on her [**Doctor Last Name 13401**]. On the
first 2 nights back on the floor she became very agitated,
requiring IV ativan. She was noted by nursing to have multiple
attempts to get out of bed when she was instructed not to. She
seemed very sleepy, barely able to sit upright. It was felt
these symptoms could be a side effect of [**Last Name (LF) 13401**], [**First Name3 (LF) **] her [**First Name3 (LF) 13401**]
was weaned to 250 mg po bid from 500 mg po bid and she was
started on lamictal 25 mg po bid. The following day, she was
much more alert and less agitated. She continued on Lamictal
and [**First Name3 (LF) 13401**], with the intention of discontinuing [**First Name3 (LF) 13401**] in [**5-30**]
weeks after the patient's Lamictal levels become therapeutic.
Her Lamictal is to be increased to 50 mg po bid on [**2182-5-11**].
She resumed her HKI-272 protocol drug on [**2182-4-29**].
(2) Metastatic Breast Cancer: The pt is currently on protocol
drug HKI-272. She has stable brain mets per MRI and a long
history of breast cancer, since [**2163**].
(3) Allergic Reaction: Given her allergic reaction to Dilantin
at OSH, she was started on Bendaryl, ranitidine and Zyrtec for
her hives. These medications were discontinued after she was
found to have an altered mental status.
(4) UTI: The patient was treated with a 7 day of Keflex.
(5) ? cellulitis: Patient had a very subtle area of likely
phelbitis over L wrist at site of old IV and restraints. She has
had cellulitis in past. She was treated with a 7 day course of
Keflex.
(6) Asthma: Continued outpatient advair/albuterol/flovent prn.
(7) Tachycardia: She had sinus tachycardia likely due to
dehydration and agitation. Her initial TSH level was elevated,
but on repeat her TSH and free T4 were within normal limits.
She states she has always had a fast heart rate.
(8) Agitation/Restlessness: This was likely initially secondary
to her altered mental status and then [**Year (4 digits) 13401**] side effect, as per
above. This was resolved by the time of discharge.
(9) Hyperlipidemia: Continued Lipitor per outpatient regimen.
Medications on Admission:
Zometa (last given [**4-16**]); oxybutynin qhs (she doesn't know dose)
Aleve two pills twice daily, Zyrtec, Nexium, Flonase, Advair,
vitamin B1, oxybutynin, 1 mg of warfarin for Port-A-Cath
patency, Singulair, magnesium and glucosamine chondroitin.
Although she has used Lomotil regularly in the past she is using
it only on a p.r.n. basis now as her stools have essentially
normalized.
Discharge Medications:
1. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2)
Spray Nasal DAILY (Daily).
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
7. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 2 days.
Disp:*8 Capsule(s)* Refills:*0*
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
9. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*0*
11. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed.
13. Chlorpheniramine-Hydrocodone 8-10 mg/5 mL Suspension, Sust.
Release 12HR Sig: Five (5) ML PO Q12H (every 12 hours) as
needed.
14. HKI Sig: One [**Age over 90 881**]y (160) mg DAILY (Daily): HKI
272.
15. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for sleep.
Disp:*30 Tablet(s)* Refills:*1*
16. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal twice a
day as needed for itching: around port site.
Disp:*1 tube* Refills:*0*
17. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 3765**] Program
Discharge Diagnosis:
Grand mal seizure.
Confusion/delerium related to polypharmacy.
Discharge Condition:
Stable, alert and oriented.
Discharge Instructions:
Please take all medications as prescribed. Please follow up with
Dr. [**Last Name (STitle) 724**]. Return to the ER if you experience a recurrent
seizure or change in mental status (ie confusion). Do not take
benadryl.
Followup Instructions:
1 Provider: [**Name10 (NameIs) 26**] [**Name8 (MD) 28**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2182-5-13**]
8:00
2. Please call Dr. [**Last Name (STitle) 724**] to schedule follow up for prior to [**5-11**].
He will discuss adjustment of your lamictal dose. Please call
Dr.[**Name (NI) 6767**] office tomorrow. [**Telephone/Fax (1) 1844**]
|
[
"198.5",
"298.9",
"E936.1",
"285.9",
"999.2",
"276.51",
"708.0",
"799.2",
"E936.3",
"451.84",
"198.3",
"785.0",
"307.9",
"292.81",
"493.90",
"V10.3",
"780.39",
"599.0",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
13693, 13752
|
6561, 11645
|
314, 321
|
13859, 13889
|
3956, 6538
|
14158, 14515
|
2853, 2872
|
12083, 13670
|
13773, 13838
|
11671, 12060
|
13913, 14135
|
2887, 3937
|
256, 276
|
349, 1711
|
1733, 2711
|
2727, 2837
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,044
| 104,324
|
19626
|
Discharge summary
|
report
|
Admission Date: [**2175-2-16**] Discharge Date: [**2175-2-22**]
Date of Birth: [**2106-10-15**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
IVC filter placement
History of Present Illness:
Ms. [**Known lastname 1356**] is a 68 yo F with recent history of L humerus fracture
[**2-6**] (nonoperative) who developed SOB & LH the day of admission.
C/o near syncopal event while walking to the bathroom. Father
and son called ambulance. Presented to OSH with these
complaints, hypotensive (60/p --> 76/51 --> 102/63) s/p fluid
resuscitation. Guaiac negative, CT with saddle emboli. Given
4000u heparin bolus and transferred to [**Hospital1 18**] for further
management. In our ED intial VS 132, 113/60, 22, 97/3L. Did
bedside cariac ultrasound, which was poor quality but did not
reveal RV strain. Lowest SBP 104/69 in ED. Able to answer all
questions. On heparin gtt from OSH to here. She is currently
getting IVF and has recieved approximately 200cc while in the
ED.
.
On arrival to the ICU, patient is conversant and mild tremulous
[**12-26**] 'nerves'. Relays history as above & denies any sense of
palpitations, chest pain or difficulty breathing. States her
left arm, which is significantly swollen, has actually improved
since the fracture. She also has some swelling / bruising of her
left breast s/p fall. She is right-handed. C/o of being
dehydrated and very thirsty. Denies any current pain.
.
Review of sytems:
(+) Per HPI; lost 9lbs approximately 3 months prior with
increased walking
(-) Denies fever, chills, night sweats, recent or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denied
cough. Denied chest pain or tightness, palpitations. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denied
myalgias.
Past Medical History:
Left humerus fracture - [**2-6**] nonoperative care using [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8688**]
brace
HTN
Bipolar disorder
Anxiety
Social History:
Patient lives with her husband, 2 sons, and a daughter-in-law.
[**Name (NI) **] reports remote use of tobacco (but denies inhaling). She
denies alcohol or other recreational drug use.
Family History:
Patient denies FH of coagulopathy. Mother had [**Name2 (NI) 499**] cancer and
died at age 76. Father died at 79 during terrible accident when
her mother [**Name (NI) 53185**] ran over him with their car while backing
out of the garage.
Physical Exam:
Vitals: T: 97.1 BP: 116/66 P: 142 R: 22 O2: 100/2L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, ronchi; L breast ecchymoses
CV: Regular rhythm, tachycardia, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: LUE with swelling, mild yellow appearance of skin, fingers
are warm and well perfused, brace on upper arm only, 2+ pitting
edema; RUE, LLE and RLE without erythema, edema or clubbing
.
Pertinent Results:
Admission Labs:
[**2175-2-16**] 04:00AM WBC-14.6* RBC-3.47* HGB-9.8* HCT-31.0* MCV-90
MCH-28.3 MCHC-31.6 RDW-13.3
[**2175-2-16**] 04:00AM NEUTS-90.7* LYMPHS-6.4* MONOS-1.4* EOS-1.4
BASOS-0.1
[**2175-2-16**] 04:00AM PLT COUNT-335
[**2175-2-16**] 04:00AM PT-14.8* PTT-150* INR(PT)-1.3*
[**2175-2-16**] 04:00AM CK-MB-NotDone cTropnT-0.06*
[**2175-2-16**] 04:00AM CK(CPK)-48
[**2175-2-16**] 04:00AM GLUCOSE-191* UREA N-18 CREAT-1.0 SODIUM-141
POTASSIUM-4.3 CHLORIDE-112* TOTAL CO2-20* ANION GAP-13
[**2175-2-16**] 04:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2175-2-16**] 08:36AM CK-MB-NotDone cTropnT-0.04*
.
ECHO - [**2-16**] - The left atrium is normal in size. The estimated
right atrial pressure is 10-20mmHg. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal(LVEF 70%). The right ventricular cavity is moderately
dilated with focal basal free wall hypokinesis. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. No mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: Dilated right ventricle with severe hypokinesis and
relative preservation of apical function c/w large pulmonary
embolism ([**Last Name (un) 13367**] sign). Mild to moderate tricuspid
regurgitation. There is mild to moderate pulmonary hypertension
(UNDERestimated based on TR jet velocity as RA pressures are
likely greater than 15-20 mm Hg). Normal regional and global
left ventricular systolic function.
.
LENI Bilateral LEs [**2-16**] -
1. Deep vein thrombosis: Occlusive thrombus demonstrated in the
left
popliteal vein extending to the left calf veins.
2. Occlusive thrombus in the left greater saphenous vein
extending to its'
junction with the common femoral vein.
3. Left [**Hospital Ward Name 4675**] cyst.
No DVT of the left upper extremity.
.
LENI LUE [**2-16**] -
No DVT of the left upper extremity.
Brief Hospital Course:
68 yo woman wtih bipolar disorder, hypertension, and recent
humeral fracture who presented with shortness of breath to
outside hospital, found to have saddle pulmonary embolus on CTA,
now s/p IVC filter placement and discharged on coumadin.
.
Hospital course by problem:
.
# Pulmonary embolism: The etiology of the patient's PE is
unclear though it is expected to be partially due to recent
fracture and possible decreased mobility. Source was a large
left lower extremity DVT. Hemodynamic instability at the
outside hospital that resolved with fluids was presumably due to
preload dependency due to right heart strain. This was further
reenforced by formal echocardiogam here that showed severe right
ventricle hypokinesis. Nevertheless, the patient remained
hemodynamically stable after transfer to [**Hospital1 18**]. She had an IVC
filter placed given concern for further embolic events. She was
maintained on heparin and transitioned to coumadin on the night
of [**2175-2-17**]. She became therapeutic on coumadin and was
discharged with VNA follow up of INR.
.
# Left humerus fracture: This was sustained on [**2-6**]. She was
maintained in her previously placed brace and followed by
orthopedics. She was discharged with follow up appointments with
orthopedic surgery.
.
# Leukocytosis: This was noted upon admission to ED and the
patient had a left shift. Nevertheless, she was afebrile with
a negative UA and this was considered possibly just due to
stress in context of large PE. She ws monitored and her
leukocytosis resolved. She then developed a new leukocytosis and
was noted to have a UTI on UA and was discharged on antibiotics
for the UTI.
.
# Anemia: Patient had normocytic anemia, newly developed since
last admission. HCT 32 at OSH ED. Could possibly be marrow
suppression due to inflammatory state s/p fracture, but also on
heparin gtt. No h/o GIB. Guaiac negative at OSH prior to Heparin
gtt start. The pt was discharged with plans for outpatient
follow up of her anemia.
.
# Nongap metabolic acidosis: Present on presentation probably
due to compensatory tachypnea and respiratory acidosis. No
history of diarrhea or other increased bicarbonate losses. This
resolved over the course of her hospitalization.
.
# Bipolar disorder / Anxiety: The patient was stable on her home
psychiatric meds (lithium and trifluoperazine. )
.
# Hypertension: The patient was initially hypotensive on her
presentation to the outside hospital. Nevertheless she became
hypertensive here and was eventually started back on her home
anti-hypertensive regimen.
.
Medications on Admission:
Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Lithium Carbonate 150 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Trifluoperazine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Diovan 160 mg Tablet Sig: One (1) Tablet PO once a day - states
stopped 2-3 days prior for low blood pressure
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or fever > 101.
2. Lithium Carbonate 150 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
3. Trifluoperazine 2 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
Disp:*3 Tablet(s)* Refills:*0*
6. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
Disp:*60 Tablet(s)* Refills:*2*
7. Outpatient Lab Work
Please draw INR on [**2175-2-23**] and fax to [**Telephone/Fax (1) 41861**] [**First Name9 (NamePattern2) 5035**]
[**Last Name (LF) **],[**First Name3 (LF) **] L.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis;
Pulmonary Embolism
Deep Vein thrombosis
Secondary Diagnoses:
Hypertension
Bipolar affective disorder
Discharge Condition:
Good, breathing comfortably on room air, able to ambulate with
some assistance.
Discharge Instructions:
Ms [**Known lastname 1356**]: You were admitted due to a large blood clot in your
lung. We monitored you and gave you blood thinners to keep this
clot from getting bigger. We eventually transitioned you to an
oral blood thinner. You are being discharged to complete your
therapy.
.
Your home medications remain the same. You have been STARTED on
short course of Cipro for a urinary tract infection. You have
also been STARTED on Warfarin for your pulmonary embolus. You
will need close follow up of your INR (a blood test) to follow
the levels of your warfarin.
.
Please return to the hospital or call your doctor if you have
fevers or chills, worsening chest pain or shortness of breath,
or any other concerning changes to your health.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2175-2-28**] 2:15
.
MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP
Specialty: Primary Care
Date and time: [**3-2**] at 10:30am
Location: [**Street Address(2) 53186**], [**Location (un) 620**]
Phone number: [**Telephone/Fax (1) 5294**]
Special instructions if applicable: Patient is followed by above
NP
|
[
"599.0",
"300.00",
"812.21",
"285.9",
"296.80",
"727.51",
"401.9",
"E888.9",
"424.2",
"444.22",
"276.2",
"416.8",
"415.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.51",
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
9345, 9403
|
5623, 5866
|
335, 357
|
9568, 9650
|
3349, 3349
|
10439, 10906
|
2410, 2647
|
8588, 9322
|
9424, 9484
|
8224, 8565
|
9674, 10416
|
2662, 3330
|
9505, 9547
|
276, 297
|
1614, 2009
|
5894, 8198
|
385, 1596
|
3366, 5600
|
2031, 2193
|
2209, 2394
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,544
| 185,976
|
38429
|
Discharge summary
|
report
|
Admission Date: [**2167-6-6**] Discharge Date: [**2167-6-17**]
Date of Birth: [**2135-2-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
hemoptysis, dyspnea, chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a 32yo man with a h/o IVDU who went to
[**Hospital1 **] ED for evaluation of hemoptysis, dyspnea, and
chest pain. The pt has had 3 days of cough with hemoptysis and
dyspnea, which has limited him substantially. He coughs up
"globs" of bright red blood, but denies any clots. He has had an
associated wheeze, and acknowledges bilateral sharp pleuritic
8/10 chest pain with coughing. He did have a fever as well, a
few days prior to the onset of these symptoms, but has continued
to have chills and sweats since then. He does acknowlege most
recent IVDU 10 days ago.
.
He went to OSH ED for evaluation, where he was noted to be
febrile to 104, diaphoretic, and hypoxic to 88% on RA. He was
given Tylenol, and blood Cx were drawn x3. CXR showed multiple
bilateral nonspecific rounded lung opacities, and CTA showed no
PE, but revealed patchy bilateral parenchymal opacities
throughout both lungs with suggestion of cavitation, most likely
due to septic emboli, with extensive mediastinal
lymphadenopathy. ECG was unremarkable. Labs revealed WBC 12.9
with neutrophilic predominance, and Na 123. He was given Zosyn
3.375mg IV, Vancomycin 1g IV, and 2L NS IVF, and transferred to
[**Hospital1 18**] ED. On arrival to the ED, VS - Temp 99.8F, BP 132/76, HR
98, R 18, SaO2 99% 4L NC. Blood Cx sent x2, Fungal Cx also sent.
UA negative. SBP decreased to 80s, so he received an additional
3L IVF, and a RIJ CVL sepsis line was placed. Labs were sent and
he is admitted to the MICU for further care.
.
On the floor, the pt also notes mild upper abdominal pain,
epigastric, without nausea, or vomiting. He does acknowledge
diarrhea, but denies any melena, hematochezia, or BRBPR. He also
has a right wrist fracture that he sustained after a fall [**2-12**]
days ago, which is currently casted.
Past Medical History:
Poly-substance abuse
Social History:
- Lives with wife; works as electrician.
- Tobacco: 1.5 PPD x 15 years
- Alcohol: Denies
- Illicits: (+) IVDU with heroin, occasional cocaine. Last use
~10 days ago. (+) h/o marijuana, oxycodone, percocet, vicodin
abuse. Denies skin-popping, denies sharing needles. Reports
previously checked for hepatitis and HIV, last 4-6 months ago.
Family History:
Non-contributory
Physical Exam:
VS: Temp 98.3F, HR 78, BP 122/89, R 18, SaO2 95% 2L NC
General: alert and oriented x 3, no acute distress
HEENT: NC/AT, PERRL/EOMI, sclera anicteric, moist mucous
membranes, oropharynx clear
Neck: supple, no JVD, no LAD
Lungs: diffuse bronchial breath sounds, no
wheezes/crackles/rhonchi
Heart: RRR, nl S1-S2, II-III/VI systolic murmur at LLSB
Abdomen: +BS, soft, nondistended, nontender, no masses or HSM,
no rebound/guarding
Extrem: warm, distal pulses intact
Skin: track marks noted on pt's right AC fossa and back of left
hand
Pertinent Results:
On admission:
[**2167-6-6**] 08:30PM BLOOD WBC-8.7 RBC-3.07* Hgb-8.7* Hct-28.3*
MCV-92 MCH-28.3 MCHC-30.7* RDW-13.7 Plt Ct-118*
[**2167-6-6**] 08:30PM BLOOD Neuts-89* Bands-4 Lymphs-4* Monos-2 Eos-0
Baso-0 Atyps-1* Metas-0 Myelos-0
[**2167-6-6**] 08:30PM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-OCCASIONAL Microcy-NORMAL Polychr-NORMAL
[**2167-6-6**] 08:30PM BLOOD PT-17.6* PTT-42.3* INR(PT)-1.6*
[**2167-6-6**] 08:30PM BLOOD Glucose-830* UreaN-10 Creat-0.8 Na-107*
K-2.9* Cl-77* HCO3-22 AnGap-11
[**2167-6-6**] 11:32PM BLOOD ALT-48* AST-52* CK(CPK)-24* AlkPhos-162*
Amylase-28 TotBili-1.1
[**2167-6-6**] 11:32PM BLOOD Lipase-18
[**2167-6-6**] 08:30PM BLOOD cTropnT-<0.01
[**2167-6-6**] 11:32PM BLOOD CK-MB-<1 cTropnT-<0.01
[**2167-6-6**] 08:30PM BLOOD Calcium-5.9* Phos-2.6* Mg-1.7
[**2167-6-10**] 03:15AM BLOOD Cortsol-5.6
[**2167-6-7**] 05:02AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2167-6-7**] 06:31AM BLOOD HIV Ab-NEGATIVE
[**2167-6-7**] 05:02AM BLOOD HCV Ab-NEGATIVE
[**2167-6-7**] 05:47AM BLOOD Type-MIX pO2-37* pCO2-43 pH-7.42
calTCO2-29 Base XS-2 Intubat-NOT INTUBA
[**2167-6-6**] 07:45PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.013
[**2167-6-6**] 07:45PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-6.5 Leuks-NEG
[**2167-6-6**] 07:45PM URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0-2
[**2167-6-12**] 04:45PM PLEURAL WBC-2444* RBC-[**Numeric Identifier 82586**]* Polys-89*
Lymphs-1* Monos-9* Meso-1*
[**2167-6-12**] 04:45PM PLEURAL TotProt-2.4 Glucose-101 LD(LDH)-458
Amylase-46 Albumin-1.0
[**2167-6-6**] Blood Culture, Routine (Final [**2167-6-12**]): NO
GROWTH.
[**2167-6-6**] BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS
ISOLATED.
[**2167-6-6**] BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA
ISOLATED.
[**2167-6-7**] GRAM STAIN (Final [**2167-6-7**]):
>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.
.
On discharge:
[**2167-6-12**] Fluid Culture (CSF) in Bottles (Preliminary): NO
GROWTH.
[**2167-6-12**] Blood Culture, Routine: PENDING
[**2167-6-16**] 03:22PM BLOOD WBC-9.6 RBC-3.04* Hgb-8.1* Hct-25.5*
MCV-84 MCH-26.8* MCHC-31.9 RDW-17.4* Plt Ct-666*
[**2167-6-16**] 03:22PM BLOOD Glucose-100 UreaN-6 Creat-0.7 Na-141
K-3.7 Cl-105 HCO3-28 AnGap-12
[**2167-6-15**] 06:50AM BLOOD ALT-18 AST-19
[**2167-6-16**] 03:22PM BLOOD Calcium-8.3* Phos-4.5 Mg-1.9
HCT [**2167-6-17**] HCT 24.4, plt 650, creatinine 0.8
.
OSH CTA CHEST: FINDINGS: No evidence of PE. Multiple bilateral
rounded opacities throughout both lungs, soome of which appear
slightly cavitary, could represent septic emboli. Neoplastic
process difficult to exclude. Right lung base infiltrate. Trace
right pleural effusion. Heart and great vessels normal.
Extensive mediastinal adenopathy. Visualized abdomen normal.
Soft tissues and bones are normal. IMPRESSION: No evidence of
PE. Patchy bilateral parenchymal opacities throughout both lungs
with suggestion of cavitation. Most likely due to septic emboli.
Extensive mediastinal lymphadenopathy.
.
OSH CXR: FINDINGS: Multiple bilateral rounded opacities.
Nonspecific, could relate to infectious, inflammatory, or
neoplastic process. No cardiomegaly. Mediastinal silhouette
normal. No fractures. IMPRESSION: Multiple bilateral nonspecific
rounded lung opacities.
.
TEE [**2167-6-10**]:
The esophagus was intubated on the third attempt due to a
prominent gag reflex. The patient was dry retching during the
majority of the procedure. The TEE was performed and five
minutes after the procedure ended the cardiology fellow and MICU
team noticed that he was hypoxic with O2 sats between 80-90,
tachycardiac, hypertensive and wheezing on examination. He
responded to 100% O2 face mask. Methemoglobinemia was ruled out
on the basis of an ABG with birght red blood and a METHgb level
of 0. He responded to the oxygen, IV morphine, and 10 mg IV
lasix. We felt that he most likely had an aspiration event given
prominent gagging during the procedure.
.
Overall left ventricular systolic function is normal (LVEF>55%).
The right ventricular cavity is moderately dilated with normal
free wall contractility. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No masses or
vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. No mass or vegetation is seen on the mitral
valve. No mitral regurgitation is seen. Trivial mitral
regurgitation is seen. There is a large, multilobulated
vegetation on the tricuspid valve (measuring 0.6 x 2.9 cm in
largest dimensions) with associated flail tricuspid valve
leaflet and torn chordae. No definite tricuspid valve abcess is
seen (can not be fully exlcuded). Severe [4+] tricuspid
regurgitation is seen. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion. A TEE
procedure related complication occurred (see comments for
details).
.
IMPRESSION: Large tricuspid valve vegetation with associated
anterior leaflet flail and severe tricuspid valve regurgitation.
No definite tricuspid valve abcess.
.
CXR (portable) [**2167-6-14**]:
FINDINGS: In comparison with the study of [**6-13**], there is little
interval
change. Right IJ line again extends to the region of the
cavoatrial junction. Retrocardiac opacification persists,
consistent with volume loss and bilateral pleural effusions.
There again are vague areas of patchy opacification throughout
both lungs.
.
MRI Spine [**2167-6-12**]:
FINDINGS: In the cervical region, no evidence of epidural
abscess seen or
evidence of fluid collection seen within the spinal canal.
Vertebral
alignment is normal. The spinal cord shows normal signal
intensities.
.
In the thoracic region, there is no evidence of abnormal signal
seen within the spinal cord or evidence of fluid collection
seen. There is no epidural abscess. The areas of low signal in
the posterior portion of the spinal cord in the thoracic region
are due to pulsation artifacts, a normal finding.
.
In the lumbar region, there is no evidence of epidural abscess
identified. There is no evidence of fluid collection seen.
Degenerative disc disease and bulging seen at L5-S1 level. There
is mild increased signal identified in the posterior soft
tissues in the lumbar region which could be secondary to edema.
.
The paraspinal soft tissues are unremarkable otherwise without
fluid
collection or abscess.
.
Note is made of diffuse low signal in the visualized bony
structures which could be secondary to marrow hyperplasia or
given patient's young age could be secondary to persistent red
marrow.
.
IMPRESSION: No evidence of epidural abscess seen. No evidence of
intraspinal fluid collection or spinal cord compression
identified.
.
COMMENT: There are bilateral large pleural effusions identified.
Correlation with patient's chest film and chest CT recommended.
.
Right Wrist 3 View [**2167-6-11**];
IMPRESSION: No radiographic evidence of fracture. Given the
close interval followup, a repeat film in one week can be
performed if there is continued clinical concern for scaphoid
fracture.
.
Abdominal Ultrasound [**2167-6-8**]:
FINDINGS: Bilateral pleural effusions and a small amount of
ascites are
present. The liver echotexture is normal. There is no focal
intrahepatic
lesion or intrahepatic biliary ductal dilatation. The
gallbladder is
unremarkable. The CBD is not dilated, measuring 4 mm. The right
kidney
measures 13.8 cm and the left kidney measures 10.0 cm, with no
evidence of stones or hydronephrosis. Included views of the
pancreas are unremarkable. The aorta is normal. The spleen
measures 11.8 cm.
.
IMPRESSION: 1) Small amount of ascites. 2) No hepatic or splenic
abscesses or lesions detected.
.
ECG [**2167-6-6**]:
Sinus rhythm. Non-specific ST-T wave changes, probably normal
variant.
No previous tracing available for comparison.
Brief Hospital Course:
32-year-old male with recent hx of IV drug use who presented
with hemoptysis, dyspnea, and pleuritic chest pain and was found
to have bacterial endocarditis (tricuspid vegetation) with
septic emboli to lungs.
.
#. Hypotension - The patient's hypotension was likely secondary
to sepsis and insensible fluid losses. The pt presented w/
septic emboli on chest CP and insensible fluid losses from
fevers/ chills/ sweats over the last several days. The patient
was treated with aggressive fluid hydration for length of stay
in ICU w/ intermittant levophed drip to keep MAP above 65. The
CVP is likely difficult to interpret in setting of tricuspid
endocarditis and regurgitant valvular disease with significant
preload requirement given right-sided valvular disease. As the
patient was having difficulty maintaining pressures and was
becoming significantly volume overloaded, a TTE and TEE were
ordered demonstrating 4+ TR, a flail tricuspid valve with
ruptured chordae, and 2.9 cm in diameter vegetation on the TV.
On [**6-10**] after the TEE the patient became tachypneic,
hypertensive, hypoxic, rigoring (ABG 7.43/37/57). The patient
was given NRB, morphine, and lasix, and the episode resolved. A
CXR at the time was negative for flash pulmonary edema. Etiology
of episode unclear, it may be bacteremia because of vegetation
spray during the TEE or aspiration. He had repeated episodes
like this one until 2 days prior to transfer, usually in the
morning, all treated successfully with Lasix, Morphine, NRB, and
bair hugger. At the time of discharge, he had sbp's of 110-130s
and had no further episodes of hypotension.
.
#. Endocarditis and Septic emboli to lung- The patient had
pulmonary septic emboli identified on OSH CT from right-sided
endocarditis in setting of IVDA. Trans-thoracic echos on [**6-8**]
and [**6-7**] revealed moderate to severe tricuspid regurgitation
with mild pulmonary artery hypertension. A TEE on [**6-10**]
demonstrated a large tricuspid vegetation and could not rule out
a valvular abscess although one was not visualized. The patient
was initiated on Vancomycin q8hrs and Zosyn and switched to
Vancomycin on [**6-8**] after blood cx from an outside hospital grew
GPC. The patient was switched to Nafcillin on [**6-9**] after
confirmation from outside hospital of MSSA infection. Daily
blood cultures from the MICU have been negative to date, but
several were still pending on discharge. ID has recommended a
6-wk course of nafcillin, due to end on [**2167-7-22**]. The patient
needs weekly Chem 10, LFTS and CBC for surveillance which should
be faxed to the Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**]. He
has follow up with ID Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2167-7-1**] at 10:30am.
Spine MRI was negative for septic emboli and abscesses.
Abdominal ultrasound was also negative for abscesses in liver
and spleen. CT surgery said that the patient is not a surgical
candidate at this time since he is relatively stable and still
infected. He will have follow-up with CT surgery Dr. [**Last Name (STitle) **] on
[**2167-7-1**] at 01:00p at [**Hospital1 **] Cardiac Surgery.
.
#. Volume overload - Pt initially became volume overloaded due
to aggressive rehydration for hypotension and chest x-rays have
shown bilateral pulmonary edema. Pt also has some splinting due
to pleuritic chest pain upon deep inspiration, probably from the
peripheral septic emboli in the lungs. He has had a
supplementary O2 requirement ranging from 2-6 L nasal cannula
with good saturations at time of discharge. By time of
discharge, he had oxygen saturations in the mid 90s on 2-3L
oxygen by nasal cannula.
.
#. Elevated LFTs - On admission, patient was noted to have
elevated transaminases and epigastric pain, which were thought
to be likely [**1-13**] hepatic congestion from R heart dysfunction.
Hepatitis and HIV serologies were negative, and liver ultrasound
was negative for abscess. His LFTs trended to normal and were
ALT/AST 18/19 at discharge.
.
#. Right wrist fracture - The patient was casted for a suspected
right wrist fracture at an outside hospital. Communication with
the OSH revealed final radiologic read of no acute fx, but need
for repeat imaging. The cast was removed in the MICU and repeat
xrays demonstrated no apparent fracture. A repeat xray with
scaphoid view confirmed that there was no scaphoid fx under the
soft tissue swelling. By discharge, patient no longer complained
of wrist pain or swelling. He was advised to follow up with a
repeat xray in 1 week if he began to experience discomfort in
that wrist again.
.
#. Nutrition: The patient's albumin has been low since
admission, probably due to his decreased PO intake. His diet
was supplemented with Ensure shakes.
#. IVDU: Patient has history of heroin use and had been on
suboxone until his recent relapse. He reported that his most
recent abuse occurred 10 days prior to presentation at OSH. His
home dose suboxone was continued throughout his hospital stay
without problems.
#. Pain control: Patient has had abdominal and pleuritic chest
pain during this admission. In the setting of opioid abuse, pain
management was more difficult and the pain Team was consulted.
He received a 3-day course of Ketorolac with tizanidine. By
discharge, he was no longer complaining of pain and was
discharged on tizanidine, ibuprofen, and acetaminophen as needed
for pain.
.
Medications on Admission:
Suboxone 8mg PO BID
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
3. Buprenorphine-Naloxone 8-2 mg Tablet, Sublingual Sig: One (1)
Tablet Sublingual [**Hospital1 **] (2 times a day).
4. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily): Please remove patch if you start
smoking again.
5. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day) as needed for pain.
6. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1)
Intravenous Q4H (every 4 hours) for 6 weeks: Continue for 6
weeks total ([**2167-6-9**] to [**2167-7-22**]).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 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 for Wheezing.
13. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
14. Surveillance labs
Chem 10, LFTS, and CBC weekly
15. Labs and abx questions
All Surveillance laboratory results should be faxed to
Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
All questions regarding outpatient antibiotics should be
directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**]
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
Bacterial endocarditis
Septic emboli to lungs
.
Secondary:
Polysubstance abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at the hospital. You were
admitted for fever, coughing up blood, and chest pain when
breathing. You underwent several lab tests and imaging tests
both at [**Hospital1 **] and at an outside hospital that
showed that you have an infection of one of the heart valves.
This occurs due to infection secondary to IV drug use. The
bacteria on your heart valve also occasionally get released to
your lungs, which likely caused your symptoms of shortness of
breath and coughing up blood. We started you on antibiotics for
this infection and you will need to continue this antibiotic
through your PICC line for a total of 6 weeks (from [**2167-6-9**] to
[**2167-7-22**]).
.
You were given a nicotine patch during your hospital stay. It
is dangerous for you to smoke cigarettes while you on the
nicotine patch. If you do decide to smoke again, please remove
the patch. We strongly encourage you to no longer smoke.
.
The following medications were added:
1) Nafcillin IV 2g every 4 hours for a total of 6 weeks
2) Ibuprofen 600mg every 8hours as needed for pain pls take
with food
3) acetaminophen 500mg; 1-2 tablets every 6 hrs as needed for
fever and pain. Do not take more than 4 grams in 24 hrs or it
can be toxic to your liver.
4) nicotine patch daily
5) docusate sodium 100mg twice a day
6) senna 8.6 mg tablets twice a day as needed for constipation
7) tizanidine 4mg three times a day as needed for pain
8) bisacodyl 10mg as needed for constipation
9) Heparin shots while at the [**Hospital1 **]
10) Albuterol as needed for shortness of breath or wheeze
.
The following medications were continued:
1) suboxone (buprenophine-naloxone 8-2mg); one tablet sublingual
twice a day
All Surveillance laboratory results should be faxed to
Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**] All questions
regarding outpatient antibiotics should be directed to the
when clinic is closed
Followup Instructions:
-You need to follow up with infectious disease and cardivascular
surgery as below. However, it is VERY IMPORTANT THAT YOU FIND A
PCP.
[**Name10 (NameIs) 21421**] register insurance if you have any. Otherwise your
appointments will be self-pay. IT IS ESSENTIAL THAT YOU FOLLOW
UP WITH ID.
.
Department: CARDIAC SURGERY
When: WEDNESDAY [**2167-7-1**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 551**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2167-7-1**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: INFECTIOUS DISEASE
When: THURSDAY [**2167-7-30**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10000**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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"415.12",
"416.8",
"421.0",
"304.01",
"305.1",
"785.52",
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"038.10",
"573.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"38.93",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
18689, 18704
|
11351, 16779
|
347, 353
|
18836, 18836
|
3177, 3177
|
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|
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|
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18725, 18815
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2625, 3158
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275, 309
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381, 2175
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3191, 4876
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|
2236, 2575
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,524
| 142,960
|
53045
|
Discharge summary
|
report
|
Admission Date: [**2143-10-31**] [**Month/Day/Year **] Date: [**2143-11-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2356**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
88F with CAD, chronic diastolic CHF, Afib on coumadin,
cardioembolic CVA, DM admitted with respiratory distress. Felt
well until the day of admission when she began to feel
progressive generalized weakness. She awoke in the middle of the
night to use the bathroom and suddenly felt weak, "hot" and
short of breath. No increase in dietary salt or water intake, no
recent med changes. Denies fever, chills, headache, sore throat,
chest pain, palpitations, cough, orthopnea, abdominal pain,
nausea, vomiting, diarrhea, edema, or dysuria. Home health aide
reportedly noted patient to appear in some distress, short of
breath, and diaphoretic and EMS was called to transport patient
to ED.
In the ED, initial V/S 105 irreg 153/111 32 94%NRB. EKGs showed
AFib/flutter at 74-100 bpm without ischemic changes. CXR showed
mild CHF. Placed on BiPAP 8/8 FiO2 0.5 and given lasix 40 mg IV
with improvement (700 cc UOP). Nitro gtt d/c'd due to
hypotension 85/59 (recovered to 109/49 after stopping nitro).
Blood and urine cultures sent. Given vanc & ceftriaxone,
albuterol nebs. Levofloxacin started but discontinued due to
concerns re INR elevation. ABG 7.33/43/155/24 on BiPAP 8/8 FiO2
0.5. BNP 1440. Vital signs prior to transfer 82 119/52 24 99%
BiPAP 8/8 FiO2 0.4.
Past Medical History:
CAD s/p MI & PCI [**1-15**]
Chronic diastolic CHF
DM
Right-sided cardioembolic CVA [**5-17**]
Hypertension
Hypercholesterolemia
Spinal stenosis
s/p ERCP with biliary stent placement for choledocholithiasis
s/p ventral hernia repair
s/p appendectomy
s/p cataract surgery
Social History:
Lives alone with 24[**Hospital 109318**] home health aides. Daughter lives nearby.
Former light smoker, quit in her 20s. No ETOH.
Family History:
Noncontributory.
Physical Exam:
Vitals - T 96.2 BP 127/60 HR 90 RR 19 02sat 98% on 40% FiO2
GENERAL: Well-appearing, resp non-labored, speaks in full
sentences
HEENT: PERRL OP clear dry MM
NECK: JVD difficult to appreciate due to habitus
CARDIAC: irreg irreg no m/r/g
LUNGS: diminished at bases no w/r/r
ABDOMEN: soft obese NTND normoactive BS
EXT: tr pitting edema to ankles bilat
NEURO: awake, alert, conversing appropriately oriented to
person, place, month/year
Pertinent Results:
Admission labs:
[**2143-10-31**] 03:20AM WBC-20.8*# RBC-4.68 HGB-14.3 HCT-42.3 MCV-91
MCH-30.7 MCHC-33.9 RDW-14.0
[**2143-10-31**] 03:20AM NEUTS-66.7 LYMPHS-28.5 MONOS-3.2 EOS-0.9
BASOS-0.6
[**2143-10-31**] 03:20AM PLT COUNT-295
[**2143-10-31**] 03:20AM GLUCOSE-242* UREA N-25* CREAT-1.0 SODIUM-138
POTASSIUM-6.0* CHLORIDE-106 TOTAL CO2-19* ANION GAP-19
[**2143-10-31**] 03:20AM CK(CPK)-144*
[**2143-10-31**] 03:20AM CK-MB-5 proBNP-1440*
[**2143-10-31**] 03:20AM cTropnT-<0.01
[**2143-10-31**] 03:20AM PT-29.5* PTT-26.3 INR(PT)-2.9*
[**Month/Day/Year **] Labs:
[**2143-11-3**] 06:25AM BLOOD WBC-10.9 RBC-4.40 Hgb-13.3 Hct-39.3
MCV-89 MCH-30.3 MCHC-33.8 RDW-14.0 Plt Ct-212
[**2143-11-3**] 06:25AM BLOOD Neuts-58.7 Lymphs-34.6 Monos-3.7 Eos-2.4
Baso-0.5
[**2143-11-3**] 06:25AM BLOOD Plt Ct-212
[**2143-11-3**] 06:25AM BLOOD Glucose-163* UreaN-35* Creat-1.0 Na-139
K-4.0 Cl-102 HCO3-30 AnGap-11
[**2143-11-2**] 06:00AM BLOOD proBNP-811*
[**2143-11-3**] 06:25AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.1
Brief Hospital Course:
Patient presented with exacerbation of her CHF. A brief
description of her hospital course according to system is
described below:
#Acute diastolic CHF - Attributed to acute hypertension with an
unclear precipitant given that prior TTE showed evidence of LVH,
grade II diastolic dysfunction, hyperdynamic LV and elevated
PCWP. No evidence of acute ischemia or rapid atrial arrhythmia
on EKG. Cardiac biomarkers cycled with 3 negative sets. Treated
with BiPAP initially then weaned to nasal cannula and then room
air. Diuresed with lasix boluses. Repeat TTE [**11-1**] without
changes.
.
#Atrial fibrillation - Continued metoprolol and coumadin while
in the hospital.
.
#HTN - Continued her home medications which included an ACEi, BB
and CCB.
.
#DM - Held her oral hypoglycemic and covered her with sliding
scale insulin.
.
#Hyperlipidemia - Continued zetia.
.
#Code status - Patient is DNR/DNI per discussion with her
daughter on [**2143-10-31**].
.
#Dispo- Patient felt much improved at time of [**Date Range **]. She
was no longer feeling short of breath or light headed. Her
vitals signs were within normal range. She was tolerating oral
medications and a normal diet.
Medications on Admission:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Amlodipine 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for LBP.
8. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
9. Citalopram 20 mg Tablet Sig: 0.25 Tablet PO DAILY (Daily).
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
[**Date Range **] Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Amlodipine 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for LBP.
8. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
9. Citalopram 20 mg Tablet Sig: 0.25 Tablet PO DAILY (Daily).
10. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
13. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
[**Date Range **] Disposition:
Home
[**Date Range **] Diagnosis:
Primary diagnosis:
- Acute diastolic heart failure
Secondary diagnoses:
- Community acquired pneumonia
- Hypertension
- Coronary artery disease
- Atrial fibrillation
- Diabetes Mellitus
[**Date Range **] Condition:
Stable, ambulating without assistance, oxygen saturation 93% on
room air.
[**Date Range **] Instructions:
Ms. [**Known lastname **],
You were admitted for shortness of breath. It was felt that this
was related to worsening heart failure, and possibly a pneumonia
as well. You were given medications to help remove fluid and
antibiotics, and improved.
Please note the following changes to your medications:
- Lasix 40 mg daily was STARTED
- Cefpodoxime 200 mg twice a day was STARTED, please take this
for 5 more days to treat a possible pneumonia
- Azithromycin 250 mg daily was STARTED, please take this for 3
more days to treat a possible pneumonia
No other medication changes were made.
Please contact your primary care physician or go to the
emergency room if you experience any difficulty breathing, chest
pain, fevers, cough, or other concerning symptoms.
Followup Instructions:
Please follow up with your primary care provider, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 1270**], within the next 1-2 weeks after [**Last Name (STitle) **] and
discuss with him whether you need to stay on lasix.
[**First Name4 (NamePattern1) 1730**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 2362**]
Completed by:[**2143-11-26**]
|
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
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3570, 4750
|
296, 303
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2534, 2534
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7976, 8362
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
426
| 163,706
|
2952+2953
|
Discharge summary
|
report+report
|
Admission Date: [**2198-12-24**] Discharge Date: [**2199-1-2**]
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old male with
known coronary artery disease presenting with chest and
abdominal pressure. He has had several month history of
exertional angina that was relieved with rest. He did not
take anything for it. Last night pain occurred with minimal
exertion and kept him from sleeping. He has mild shortness
of breath. No nausea, vomiting, diaphoresis or palpations.
No radiation. He had been feeling well prior to the onset of
this pressure.
The patient call EMS. Pain relieved with aspirin and
Nitroglycerin. Pain entirely relieved in the emergency room
after two sublingual Nitroglycerin. Due to diffuse
precordial ST depressions, the patient was started on
heparin.
PERTINENT LABORATORY: Patient's admission creatinine was
1.7, troponin I was 3.3, CK MB was 11.
EKG showed ST depressions in V2 through V6 (3 to 5 mm) and T
wave inversion in I and aVL.
HOSPITAL COURSE: Patient was admitted on [**2198-12-24**] with
complaints of chest pain and SOB. In the emergency room, the
patient was started on heparin drip for ST elevations noted on
EKG and elevated troponin I and CK MB. Patient also received
a Cardiology consult at which time it was decided to continue
with the heparin drip and add on aspirin once a day. To
start catheterization.
Subsequent cardiac catheterization showed severe left main
and three vessel disease. The LMCA was 80% stenosed
proximally and 60% distally. LAD diffuse disease with 60%
stenosis. Left circumflex 70% proximal and total occlusion
after the OM2. The distal LCX fills via right to leg
collaterals. RCA of 50% stenosis and osteal; 90% in mid.
At that time, it was advised because of the patient's three
vessel and left main disease to proceed with a coronary
artery bypass graft. Cardiothoracic Surgery was called and
the risk and benefits of coronary artery bypass graft were
discussed with the patient.
An IABP was placed in the cath lab because of increased pain.
He underwent successful underwent CABG x 3 on [**2198-12-26**]. The
LIMA was placed to the LAD, veins were placed to the Diagonal
branch and the PL branch of the RCA. The circumflex could not
branch and the PL branch of the RCA. The circumflex could not
be grafted. Intraop TEE showed pre CPB ef of 30% with 2+ MR.
[**First Name (Titles) **] [**Last Name (Titles) **] function was slightly improved. Post operatively he
did well. He was extubated and the IABP was removed. He
progressed slowly but well on the floor. The patient in being
transferred to rehab in good condition, tolerating a diet well
and ambulating with a walker.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 14176**]
MEDQUIST36
D: [**2199-1-2**] 10:23
T: [**2199-1-2**] 10:40
JOB#: [**Job Number 14177**]
Admission Date: [**2198-12-24**] Discharge Date: [**2199-1-4**]
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old male with
no known coronary artery disease who presented with chest
pressure and abdominal pressure who has reportedly had a
several month history of exertional angina relieved with
rest.
On the evening prior to admission, this anginal occurred with
minimal exertion and prevented him from sleeping. He also
had mild shortness of breath with this pain. He contact[**Name (NI) **]
Emergency Medical Service who administered aspirin and
nitroglycerin with good relief.
PAST MEDICAL HISTORY: (This is a [**Age over 90 **]-year-old male with a
past medical history significant for)
1. Atrial flutter (status post ablation of [**2192-6-16**]).
2. Gastroesophageal reflux disease.
3. Spinal stenosis.
4. Status post prostatectomy.
5. Status post herniorrhaphy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Medications on admission were
Colace, Celebrex, Tylenol, and FiberCon.
SOCIAL HISTORY: The patient has a known history of tobacco
use with rare alcohol use.
HOSPITAL COURSE: The patient underwent cardiac
catheterization on [**2198-12-24**] which revealed severe
left main and 3-vessel disease with 80% proximal and 60%
distal stenosis of the left main coronary artery, diffusely
diseased proximally, and with 60% stenosis of the left
anterior descending artery, and 70% proximal, and total
occlusion after second obtuse marginal of the left
circumflex, and 50% ostial and 90% medial stenosis of the
right coronary artery. Left ventriculography revealed 1+
mitral regurgitation, and anterolateral and inferoapical
hypokinesis, with an ejection fraction of 40%.
The patient underwent coronary artery bypass graft times
three on [**2198-12-26**] with an intra-aortic balloon pump
placed preoperatively. The patient had left internal mammary
artery to the left anterior descending artery, saphenous vein
graft to the diagonal, and saphenous vein graft to the right
posterolateral. The total cardiopulmonary bypass was 50
minutes. Total cross-clamp time was 40 minutes. The
patient was transferred in stable condition, in a normal
sinus rhythm at 80 beats per minute, to the Coronary Recovery
Unit on propofol 30 mcg/kg per minute, and Milrinone 0.25
mg/kg per minute, and nitroglycerin at 0.5 mcg/kg per minute.
On postoperative day one, 24-hour events included the patient
receiving another Swan-Ganz catheter as well as extubated.
The patient was in atrial fibrillation at 99 beats per minute
with a low-grade temperature (with a temperature maximum of
100.8, peak temperature current of 99).
On physical examination, the patient had decreased breath
sounds at the bilateral bases. Otherwise unremarkable. The
plan was to wean the patient's dobutamine, and to discontinue
the intra-aortic balloon pump if stable, and to continue with
the amiodarone.
The Renal Service came by to see the patient on postoperative
day one for complaints of labored breathing; at which time
they recommended checking Chemistry-7, magnesium,
phosphorous, and calcium levels, and to continue gentle
diuresis if the patient continued to be dyspneic and
requiring increased oxygen. They also suggested using Lasix
as needed for his clinical condition.
On postoperative day two, the patient was still a temperature
maximum with a low-grade temperature of 100.6. The patient
was still in atrial fibrillation; rate controlled.
Twenty-four events included the intra-aortic balloon pump
being discontinued, and administration of Lasix overnight
with good effect.
On physical examination, the patient still had coarse breath
sounds with expiratory wheezing. The plan was to administer
heparin for the atrial fibrillation, to discontinue the
amiodarone, and to administer oral Lopressor, and to transfer
the patient to the floor.
The Renal Service came by to see the patient again on
postoperative day two; at which time they recommended to
avoid the Lasix for the rest of the day, and his oxygen
saturation was fine with good urine output, and to continue
the Lasix as needed for dyspnea. They also recommended that
we could packed red blood cells. They also recommended to
follow up on sodium for worsening hyponatremia, but they felt
that this hyponatremia would improve as his diet was
advanced.
On postoperative day three, the patient was afebrile. Vital
signs were stable, with no events acutely over the last 24
hours.
On postoperative day four, the patient was still in atrial
fibrillation, rate controlled. On physical examination, he
had improved coarse breath sounds bilaterally, and the plan
was to increase the patient's Lopressor dose.
Electrophysiology Service came by and saw the patient; at
which time they recommended proceeding with anticoagulation
and rate control. They also stated that they would
cardiovert if the patient became hemodynamically intolerant.
Later on that day, on postoperative day four, the patient was
noted to have a distended abdomen with a decreased urine
output of about 20 cc to 30 cc that evening. A Foley
catheter was placed with 600 cc of urine drained, with relief
of the patient's abdominal discomfort.
On postoperative day five, the patient was afebrile, still in
atrial fibrillation at 105 beats per minute. On physical
examination, the patient still had decreased breath sounds at
both bases which were coarse. His abdomen was still somewhat
distended without tympany with decreased breath sounds. The
plan was to continue the heparin for the patient's atrial
fibrillation, and to start the Coumadin, and to continue the
Lopressor.
Cardiology Service came by to see the patient on
postoperative day five at which time they agreed with the
anticoagulation, and the Coumadin administration, as well as
the beta blockers.
On postoperative day six, the patient with no acute events
overnight. The patient was still in atrial fibrillation at
70 beats per minute and still with coarse breath sounds
bilaterally. The plans were to get the patient ready for
rehabilitation.
On postoperative day seven, the patient was still in atrial
fibrillation at 60 beats per minute. Otherwise,
hemodynamically stable, saturating at 95% on room air. The
patient's preoperative weight was 77 kg; currently at 83.3
kg, with 2+ pitting edema bilaterally of the lower
extremities. The plan was to continue the Lasix for the
patient's edema and coarse breath sounds.
DISCHARGE DISPOSITION: The patient's expected day of
discharge was [**2199-1-3**].
MEDICATIONS ON DISCHARGE: (The patient to be sent home on
the following medications)
1. Coumadin.
2. Flomax 0.4 mg p.o. q.h.s.
3. Percocet one to two tablets p.o. q.4h. as needed (for
pain).
4. Metoprolol 12.5 mg p.o. b.i.d.
5. Lasix 20 mg p.o. q.12h (for two weeks).
6. Potassium chloride 20 mEq p.o. q.12h. (for two weeks).
7. Colace 100 mg p.o. b.i.d. as needed (for constipation).
8. Aspirin 325 mg p.o. q.d.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. To follow up with his primary care physician in two to
four weeks.
2. To follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in four weeks.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Status post coronary artery bypass grafting times three.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Doctor Last Name 182**]
MEDQUIST36
D: [**2199-1-2**] 16:32
T: [**2199-1-6**] 14:34
JOB#: [**Job Number 5331**]
|
[
"426.7",
"997.1",
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"530.81",
"424.0",
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] |
icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
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9536, 9597
|
10253, 10611
|
9624, 10020
|
4006, 4078
|
4184, 9512
|
10053, 10232
|
3134, 3643
|
3667, 3978
|
4095, 4166
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,080
| 168,428
|
45718
|
Discharge summary
|
report
|
Admission Date: [**2169-5-8**] Discharge Date: [**2169-5-21**]
Date of Birth: [**2110-6-19**] Sex: M
Service: VSURG
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
AAA
Major Surgical or Invasive Procedure:
AAA resection with aortobi-iliac BPG [**2169-5-15**]
History of Present Illness:
....58 y/o nondiabetic [**Male First Name (un) 4746**] with CAD, h/o TIA, s/p Left CEA [**12-28**],
HTN, gout, chronic, severe low back pain fell down 10 steps at
home without loss of cons-
ciousness around 5pm on [**2169-5-7**]. Pt was seen at [**Hospital3 **]. Imaging
studies showed fracture posterior left 9th rib with tiny
pneumothorax on CT.
Incidental finding was 9cm AAA.
....Pt denied abdominal pain or new back pain different from his
chronic back
pain. He was transferred to [**Hospital1 18**] ER for further evaluation.
Past Medical History:
PMH:
1.CAD:silent IMI, PTCA LAD and PTCA/stent OM2 [**2162**]; EF=32%
2.TIA, carotid stenosis
3.Hypertension
4.Hypercholesterolemia
5.Gout
6.L5-S1 radiculopathy
7.Hiatal hernia
8.Depression/ anxiety
9.Emphysema
PSH:
1.Left CEA [**12-28**]
2.Arthroscopy right knee
3.Circumcision [**2167-11-25**]
4.Tonsillectomy
Social History:
Pte lives with his wife. [**Name (NI) **] is on disability secondary to back
pain. He quit smoking cigarettes 15 years ago after smoking up
to 5ppd for 13 years. He stop-
ped drinking alcohol 15 years ago. He ambulates independently.
Family History:
CAD
Physical Exam:
VS: P 92 R 16 B/P [**8-/2161**] O2 sat=95% on 2L via N/C WT=113.8 kg
HT=6'2"
General: Alert, cooperative [**Male First Name (un) 4746**] in NAD
Chest: Tenderness left side. Cor-RRR. Lungs clear.
Abdomen: Obese. Soft. Nontender/nondistended. No pulsatile mass
palpated.
Extremities: Feet warm. DP pulses palpable bilaterally.
Neurological exam nonfocal; equal grip strength; alert and
oriented x3.
Pertinent Results:
[**2169-5-7**] 11:20PM BLOOD WBC-13.7*# RBC-5.36 Hgb-15.6 Hct-43.0
MCV-80* MCH-29.2 MCHC-36.4* RDW-14.9 Plt Ct-229
[**2169-5-18**] 03:44AM BLOOD WBC-10.9 RBC-3.72* Hgb-10.6* Hct-31.4*
MCV-85 MCH-28.4 MCHC-33.6 RDW-15.0 Plt Ct-216
[**2169-5-19**] 05:20AM BLOOD WBC-10.2 Hct-31.3* Plt Ct-223
[**2169-5-7**] 11:20PM BLOOD PT-13.6* PTT-27.9 INR(PT)-1.2
[**2169-5-7**] 11:20PM BLOOD Glucose-109* UreaN-18 Creat-0.9 Na-137
K-4.1 Cl-104 HCO3-22 AnGap-15
[**2169-5-21**] 05:12AM BLOOD Glucose-98 UreaN-22* Creat-1.0 Na-137
K-3.5 Cl-101 HCO3-26 AnGap-14
[**2169-5-8**] 05:01PM URINE RBC-[**5-4**]* WBC-0 BACTERIA-FEW YEAST-NONE
EPI-0
[**2169-5-8**] 05:01PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.5
LEUK-NEG
[**2169-5-8**] 05:01PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
EKG [**2169-5-8**] NSR at 86. LBBB. Sinus bradycardia on [**2168-12-28**] EKG
resolved.
CXR [**2169-5-10**] No pneumothorax seen, Left posterior 9th rib fx not
visualized.
Brief Hospital Course:
....Pt was admitted to the hospital from [**Hospital1 18**] ER on [**2169-5-8**].
Repeat CT showed 7.9
x 7.5cm infrarenal AAA, diffuse emphysema, and RML/RUL pulmonary
nodules up to 7mm.
The CXR did not visualize the left rib fx or any pneumothorax.
Pt denied new abdominal pain but c/o increased low back pain.
....Cardiology was consulted for pre-operative cardiac
clearance. Persantine MIBI
study done [**1-26**] showed EF of 32%, inferior fixed defect which
was unchanged from
[**1-24**]. Cardiac cath from [**10/2164**] was reviewed, found to be stable
and pt was cleared for surgery. Cardiology recommended
increasing beta blocker to attain HR of 50-60.
However pt became bradycardic to HR~35 so dose changed back to
at home dose.
....Since admission pt's O2 saturation hovered at ~90%. Pt was
followed by his PCP,
[**Last Name (NamePattern4) **].[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**], who thought this was due to splinting from rib
fracture pain and low
back pain. The Acute Pain Service was consulted regarding pt's
back pain which had
unsuccessfully treated with morphine PCA. Pt's AAA resection was
rescheduled in
order to address respiratory and pain issues adequately.
....On [**2169-5-15**] pt underwent an uneventful AAA resection with an
aortobi-iliac BPG.
At the end of surgery pt had equally warm feet with palpable
femoral and dopplerable
pedal pulses. Ancef was given peri-operatively. One unit of PRBC
was transfused on
POD#2. Post-op pain was managed with hydromorphone epidural
until POD#2 and then
pain was controlled with morphine PCA and finally Percocet prn.
....Pt started on sips on POD#3 and diet was advanced as
tolerated. Physical therapy
cleared pt for discharge home. At time of discharge pt's
abdominal incision was
clean, dry, and intact. He will f/u with Dr.[**Last Name (STitle) 1391**] in th
office in one week
for staple removal.
Medications on Admission:
1.Imdur 40mg po qd
2.Lopressor 50mg po tid
3.Lisinopril 10mg po qd
4.Lipitor 40mg po qd
5.Zantac 150mg po bid
6.Probenecid 500mg po bid
7.Indocin 50mg po qd
8.Zoloft 200mg po qd
9.Ativan prn
10. Nitro sl prn
Discharge Medications:
1.Metoprolol 50mg po tid
2.Atorvastatin 40mg po qd
3.Ranitidine 150mg po bid
4.Probenecid 500mg po bid
5.Sertraline 200mg po qd
6.Percocet 5-325mg 1-2 tabs po q 4-6hrprn pain
Discharge Disposition:
Home
Discharge Diagnosis:
Asymptomatic 7.5cm AAA
Secondary DX:
1.Left posterior 9th rib fx secondary to fall on [**2169-5-7**]
2.Blood loss anemia; s/p transfusion
3.Bradycardia resolved after adjustment of beta blocker dose.
4.Emphysema:O2 desaturation requiring O2 via nasal cannula
5.Chronic severe low back pain
6.CAD: s/p MI'[**56**],PTCA'[**58**],PTCA/stent [**2163-1-23**]
7.TIA,s/p left CEA [**12-28**]
8.Hypertension
9.Hypercholesterolemia
10.Gout
11.Depression/anxiety
12.RML/RLL pulmonary nodules to 7mm seen on CT [**2169-5-8**]; F/U
chest CT in 3months
recommended.
Discharge Condition:
Satisfactory.
Followup Instructions:
Follow with Dr.[**Last Name (STitle) 1391**] in the office in one week: call for
appt. [**Telephone/Fax (1) 1393**]
Completed by:[**2169-6-16**]
|
[
"413.9",
"401.9",
"807.01",
"V45.81",
"860.0",
"E880.9",
"496",
"412",
"441.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.44"
] |
icd9pcs
|
[
[
[]
]
] |
5383, 5389
|
3024, 4926
|
315, 369
|
5988, 6003
|
1974, 3001
|
6026, 6172
|
1533, 1538
|
5184, 5360
|
5410, 5967
|
4952, 5161
|
1553, 1955
|
272, 277
|
397, 930
|
952, 1266
|
1282, 1517
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,556
| 128,443
|
8105
|
Discharge summary
|
report
|
Admission Date: [**2153-5-1**] Discharge Date: [**2153-5-12**]
Date of Birth: [**2074-11-7**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
weakness/malaise, hypotensive
Major Surgical or Invasive Procedure:
a-line placement
History of Present Illness:
Mr. [**Known lastname 4460**] is a 78 yo male with multiple myeloma who presented
with worsening weakness and malaise. He endorses lower extremity
weakness for an extended period of time, however, it became
acutely worsened prior to admission, prompting his wife to call
his Oncologist on [**Name (NI) 1017**] to request a prescription for a
wheelchair. The patient's wife reports that he fell to his knees
three times on [**Name (NI) 1017**] but that he did not hit his head. She
states that "his knees just seem to give out." The patient
states that this happens when he is flexing his knees to bend
over for something. Based upon this history, he was told to come
to the ED for elective admission.
.
He was admitted to the Medicine service on [**5-1**] for work-up of
his weakness. He spiked fevers as high as 100.7 on the evening
of [**5-1**] and to 101.2 on [**5-2**]. Blood cultures x 2 were performed
on both days. On [**5-3**] blood cultures from [**5-2**] were reported to
be growing gram-negative rods in [**3-16**] bottles and he was started
on ciprofloxacin & metronidazole.
.
On the morning of [**5-4**], he became hypotensive to 90/doppler with
HR 102-104 (previously SBP's 100-120, HR 60-80), and was
transferred to the MICU for management of GNR sepsis.
.
ROS at time of transfer is significant for fatigue and
generalized malaise that coincides with the intitiation of
radiation and velcade. He reports decreased appetite for several
months and recent "projectile" diarrhea from his ostomy which he
attributes to a recent dose of magnesium citrate. He endorses
recent indigestion but denies nausea or vomiting. He states that
his LLE edema is chronic since a LN dissection at age 28.
Past Medical History:
PAST MEDICAL HISTORY:
Multiple myeloma
Hyperlipidema
Paroxysmal atrial fibrillation
Chronic renal insufficiency
Compression fractures
Osteonecrosis of the jaw, [**1-13**] Zomeda
Peripheral neuropathy
Stoma prolapse
Melanoma of left thigh s/p resection and LN dissection at age 28
h/o superior mesenteric vein thrombosis
h/o cervical radiculopathy
h/o hypercalcemia
Insomnia
Chronic infected rectosigmoid mesh, s/p removal
.
ONCOLOGIC HISTORY:
Multiple myeloma, diagnosed in [**2143**], initially presented with a
superior mesenteric vein thrombosis as well as a T12 cord
compression fracture, acute renal failure, and hypercalcemia. He
was treated with 6 cycles of VAD, then started on Thalidomide in
[**12-12**]. He received monthly Pamidronate from the time of diagnosis
to [**8-/2147**] when he was switched to Zometa. He continued
thalidomide until [**10/2148**] when it was stopped due to
debilitating symptoms of ataxia and peripheral neuropathy. He
continued monthly Zometa until [**12/2150**], when he was switched to
every other month. In [**4-/2151**], the Zometa was stopped for
concern of right lower jaw osteonecrosis. Mr. [**Known lastname 4460**] was off all
therapy for his myeloma since that time. Bone marrow biopsy done
on [**2152-10-30**] was notable for a marrow cellularity of 28-30%,
interstitial infiltrate of plasma cells occurring singly and in
clusters. By CD138 immunohistochemical staining, plasma cells
were 5-10% of marrow cellularity. Kappa restricted. He started a
Decadron burst on [**2152-11-15**]. After this first cycle of Decadron
he developed an infection in his mouth and lower extremity
weakness so he did not start his second cycle until after our
last visit. He started cycle 1 Velcade on [**2153-1-30**]. He is
currently s/p cycle 3 with last dose [**2153-4-24**].
Social History:
Married, non-smoker, no alcohol, retired. Previously worked as a
printer.
Family History:
Brother died of a metastatic poorly differentiated
neuroendocrine tumor of unknown primary. Mother died of an MI at
age 62. Father died of old age at 98.
Physical Exam:
Vitals: 99.1 104/80 72 18 95% RA
Gen: NAD, alert and conversant
HEENT: NC, ST, MMM
RESP: CTAB, moving air well
CV: RRR, II/VI blowing systolic murmur
ABDOMEN: colostomy in RUQ, soft, non-tender, no
rebound/guarding, negative [**Doctor Last Name 515**] sign
EXT: 1+ edema LLE, WWP
NEURO: CN II-XII grossly intact, muscle strength: straight leg
raise R 5-/5, L [**4-16**], otherwise symmetric and [**4-16**], minimally
decreased sensation to touch bilat lower extremities R>L, toes
down going, proprioception intact
Pertinent Results:
[**2153-5-1**] 12:00PM GLUCOSE-93
[**2153-5-1**] 12:00PM GLUCOSE-95 UREA N-20 CREAT-1.3* SODIUM-132*
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-22 ANION GAP-14
[**2153-5-1**] 12:00PM estGFR-Using this
[**2153-5-1**] 12:00PM ALT(SGPT)-42* AST(SGOT)-42* LD(LDH)-216 ALK
PHOS-88 TOT BILI-1.2
[**2153-5-1**] 12:00PM ALBUMIN-3.7 CALCIUM-8.4 PHOSPHATE-2.9
MAGNESIUM-2.5
[**2153-5-1**] 12:00PM WBC-12.1*# RBC-4.43* HGB-14.0 HCT-41.2 MCV-93
MCH-31.5 MCHC-33.9 RDW-14.2
[**2153-5-1**] 12:00PM PLT COUNT-127*#
[**2153-5-1**] 12:00PM PT-24.2* PTT-36.5* INR(PT)-2.4*
[**2153-5-1**] 12:00PM GRAN CT-9670*
.
MRI SPINE [**2153-5-2**]:
1. There is discrepancy in vertebral body numbering when
counting from above versus counting from below. For the purposes
of this study, c-spine counting was performed from above, and
counting for the t- and l-spine was done from below.
2. Abnormal signal and enhancement of the L2 vertebral body is
unchanged and again may represent a focus of myelomatous
involvement. Enhancing epidural tissue is again suggested
posterior to the L2 vertebral body with extension into the right
lateral recess but without apparent involvement of the neural
foramina. Multilevel degenerative changes are stable compared to
the studies performed earlier this year. In essence, no definite
cause for recent right
lower extremity weakness is seen.
.
MRI Head [**5-2**]:
IMPRESSION: No evidence of acute intracranial process,
intracranial mass or obvious osseous destruction in the
visualized calvarium.
.
CT abd/pelvis [**5-4**]: IMPRESSION:
1. Cholelithiasis with gallbladder distention and edema.
Findings are concerning for cholecystitis.
2. Right lower lobe atelectasis. Calcified right-sided pleural
plaques.
3. Mottled appearance of the bones, compatible with known
multiple myeloma. Numerous compression fractures.
.
[**5-4**] U/S abd:IMPRESSION:
1. Cholelithiasis with associated mild gallbladder wall edema,
which could suggest acute cholecystitis. Consideration should be
given to a HIDA scan.
2. Discrepant renal size with the right kidney measuring smaller
than the left.
.
CXR [**5-4**]:
IMPRESSION: Retrocardiac opacity may represent atelectasis. If
persistent clinical concern for pneumonia persists, then a
followup PA and lateral radiograph if permissible by patient's
clinical status may be considered.
Brief Hospital Course:
Mr. [**Known lastname 4460**] is a 78 yo male with multiple myeloma who presented
with generalized malaise and lower extremity weakness, requiring
MICU transfer for E.coli septicemia.
.
1) E.coli septicemia: Differential for potential sources
included GI/diarrheal illness vs. cholecystitis vs.
intrabdominal abscess (patient has h/o chronically infected
mesh) vs. GU vs. port infection. A RUQ u/s showed gallbladder
wall edema, cholelithiasis, CT abdomen showed gallbladder edema,
suggestive of cholecystitis. No intrabdominal abscess. HIDA
scan subsequently performed, showing evidence of chronic
cholecystitis (wall thickening and delayed emptying). Surgery
was consulted and felt he did not warrant immediate
cholecystectomy (+/- need for this in the future). He required
MICU transfer due to hypotension/shock. This improved with IV
fluids in the intensive care unit. He was double covered for
gram negatives (plus additional gram positive and anaerobic
coverage) initially; this was narrowed to cipro/flagyl once
speciation completed. Vanco again briefly added back when he
was hypotensive once back on the medicine/BMT floor; this
responded to fluids without new positive culture data. FLagyl
stopped at discharge given lack of evidence for its use. He
also received IVIG on [**5-4**]. Surveillance cultures remained
negative (last positive culture [**5-2**]). Stool culture negative.
.
2) Weakness: Patient does have past radiographic evidence of
spinous involvement of his disease. Concern now that weakness
could be secondary to CNS involvement of his disease. MRI spine
as above. Neurosurgery and Neurology were both consulted prior
to transfer to the MICU. Per Neurology consult, his tendency to
fall may be due to weakness combined with instability from his
severe distal neuropathy +/- radiculopathies from his fractures.
His motor symptoms raise possibility of [**Known lastname **] anterior spinal
infact. Neurosurgery felt no intervention felt to be warranted
at this time. He was planning for LP; these plans were held due
to emergent need for MICU transfer. After back on the BMT
floors, this was readdressed. He had EMG showing complex
abnormalities including moderate, chronic, generalized,
sensorimotor polyneuropathy that is predominantly axonal with
evidence for a superimposed moderate, chronic and ongoing, L2-4
polyradiculopathy on the right. Both neurology and oncology
teams felt that patient needs LP to evaluate for malignant cells
in the CSF. This was discussed with patient and family. Given
need for IR guidance (history of lumbar compression fractures)
and need for reversal of anticoagulation, this was not able to
be arranged prior to weekend. Patient preferred discharge home
with return within one week for LP under fluoroscopy.
.
3) Multiple Myeloma: Last dose of Velcade [**4-24**], Cycle 3. Further
treatment deferred in the setting of acute illness. He will
followup with his primary oncology team as an outpatient.
.
4) Diarrhea: Patient reports that he historically suffers from
constipation and was recenlty started on colace and maalox.
Since beginning this new regimen, he has developed projectile
diarrhea from his ostomy. Stool cultures and C.diff were
negative. Potential source of E.coli bacteremia as above.
.
5) Atrial fibrillation. Initially supratherapeutic in setting
of illness and antibiotic use. At discharge, coumadin held in
preparation for upcoming LP.
.
6) Hyperlipidemia: continued statin.
.
Code status: Full code, confirmed with patient and family during
admission
Medications on Admission:
HOME MEDICATIONS:
Velcade
Lipitor 20mg qhs
Coumadin 5mg qhs
Centrum
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO twice a
day for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
4. Outpatient Lab Work
LAB WORK: please check PT/INR on [**Last Name (LF) 766**], [**5-14**]. Please fax
results to Dr. [**First Name8 (NamePattern2) 7306**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 28907**] and Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 28908**]. Dx atrial fibrillation 427.31, long
term use of anticoagulants V58.61
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] VNA
Discharge Diagnosis:
E.coli septicemia
Gait instability
.
Chronic cholecystitis
Atrial fibrillation
Multiple myeloma
Discharge Condition:
Stable, afebrile, on PO antibiotics
Discharge Instructions:
You were admitted with weakness. We found that you have a
bacterial infection of the blood and treated you with
antibiotics. You briefly required a stay in the intensive care
unit. We also did further workup of your weakness.
.
Please return to the hospital or call your doctor if you have
temperature greater than 100.3, lightheadedness, headache,
shortness of breath, abdominal pain, diarrhea, nausea, or any
new symptom that you are concerned about.
.
Please note the following medication changes since you were
admitted:
* Please stop COUMADIN until further instructed by your doctors.
* Please take CIPROFLOXACIN twice daily until all pills are
completed.
Followup Instructions:
Please return to 7 [**Hospital Ward Name 1826**] outpatient center on Thursday, [**5-17**] at 11:00 am for a check.
.
We are planning for you to have a lumbar puncture by our
radiologists on Wednesday or Thursday ([**5-16**] or 5th).
Someone will be in contact with you about when your appointment
will be.
.
Please have your INR checked on [**Month (only) 766**].
.
You also have the following upcoming appointment at [**Hospital1 18**]:
[**Doctor First Name 5005**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2153-6-8**]
2:00
|
[
"995.92",
"V17.3",
"038.42",
"203.00",
"785.52",
"787.91",
"427.31",
"V44.3",
"V16.9",
"575.11",
"782.3",
"272.4",
"733.13",
"719.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.14"
] |
icd9pcs
|
[
[
[]
]
] |
11400, 11458
|
7063, 10618
|
309, 327
|
11598, 11636
|
4704, 7040
|
12348, 12949
|
3999, 4154
|
10737, 11377
|
11479, 11577
|
10644, 10644
|
11660, 12325
|
4169, 4685
|
10662, 10714
|
240, 271
|
355, 2058
|
2102, 3892
|
3908, 3983
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,906
| 128,544
|
47429+47430
|
Discharge summary
|
report+report
|
Admission Date: [**2186-10-20**] Discharge Date: [**2186-11-4**]
Date of Birth: [**2110-3-27**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Hydrochlorothiazide / Ibuprofen / Zosyn
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
acute onset of difficulty speaking and not moving her right side
Major Surgical or Invasive Procedure:
IV/IA tPA (penumbra)
PEG
History of Present Illness:
Ms. [**Known lastname 23638**] is a 76-year-old right-handed woman with a history
of DM, CAD, and PVD who presents with acute onset of difficulty
speaking and not moving her right side. Her daughter saw her
normal at 6 am and exchanged conversation with her. Ten minutes
later after doing chores in the kitchen, her daughter
called for her but she did not answer. She found her in bed,
unable to get up at all. She called EMS. She had some
improvement 10 minutes later but again worsened 30 minutes after
that. There was some improvement in her symptoms during
transport, but worsened again on arrival to [**Hospital1 18**].
CODE STROKE was called at 7:33 am. Neurology resident at bedside
by 7:39 am.
Initial NIH Stroke Scale score was 17:
1a. Level of Consciousness: 0
1b. LOC Question: 2
1c. LOC Commands: 0
2. Best gaze: 1
3. Visual fields: 0
4. Facial palsy: 3
5a. Motor arm, left: 0
5b. Motor arm, right: 4
6a. Motor leg, left: 0
6b. Motor leg, right: 4
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 3 (mute)
10. Dysarthria: UN
11. Extinction and Neglect: 0
She was taken to CT/CTA/CTP by 7:50 am, which showed occlusion
of left MCA at bifurcation with open anterior temporal artery
providing collateral flow. On return from CT, she demonstrated
signficant improvement.
NIH Stroke Scale score at 8 am was 7:
1a. Level of Consciousness: 0
1b. LOC Question: 1
1c. LOC Commands: 0
2. Best gaze: 1
3. Visual fields: 0
4. Facial palsy: 1
5a. Motor arm, left: 0
5b. Motor arm, right: 1
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 1
10. Dysarthria: 2
11. Extinction and Neglect: 0
Her daughter denied prior ICH, any surgery, prior stroke, recent
GI or other bleeding, use of anticoagulation, and any history of
malignancy.
She was given 50% IV tPA at 8:50 am (2h50) = 82kg * 0.9 * 50% =
36 mg; 10% (3.6 mg) given as bolus, 32.4 mg given over next
hour. She was taken up to the angio suite for IA tPA at 9:10 am.
Complete ROS is not possible at this time.
Past Medical History:
1)DMII (A1C 8.1 on [**11-10**])
2)CAD: +MIBI [**12-11**] with reversible defects in inferior and
lateral walls. Cath [**12-11**]: LMCA: 30-40%, LAD: 50-60%, LCx: 50%,
with OM1 T.O, 99% OM2; RCA: diffuse disease. No percutaneous
intervention done. [**12-11**] TTE: EF 70%, moderate symmetric LVH
3)PVD
4)DVT in [**2157**]
5)hyperlipidemia - last LDL 64 on lipitor 80mg PO qD
6)pancreatitis [**2181**], idiopathic
7) HTN
Social History:
Lives in [**Location 686**] with daughter. Widowed. [**Name2 (NI) 1403**] 20 hrs weekly
at Human services company. Former smoker (quit 20 yrs ago, 40
pack yr hx). Denies EtOH and illicit drugs
Family History:
Mother had CAD (unknown age), parents both had HTN, Denies fmhx
of dm and cancers.
Physical Exam:
NEUROLOGICAL EXAMINATION [**2186-10-20**]
Physical Exam: (After CT, with some improvement)
Vitals: T: 97.6 P: 47 R: 16 BP: 175/59 SaO2: 100%RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, 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: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, Alert, oriented x 2 (age 30). Unable to
relate history fluently. Attentive. Language is mildly
non-fluent with intact repetition and comprehension. Pt. was
able to name both high and low frequency objects though had
several errors. Able to read without difficulty. Speech was
severely dysarthric. Able to follow both midline and
appendicular
commands. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 5 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: Partial gaze deviation to the left, can be
overcome. EOMI
without nystagmus.
V: Facial sensation intact to light touch.
VII: Partial right facial paresis.
VIII: Hearing intact to voice.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, increased tone B LE. Drift R UE. Head
tremor noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 4+ 5 5 5 5 5 5
R 4- 5 4+ 5 4+ 4 4+ 5 4+ 5 5 5 5
-Sensory: No deficits to light touch, pinprick throughout. No
extinction to DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 1 2 0 2
R 2 1 2 2 2
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS (some difficulty due to weakness)
bilaterally.
-Gait: Unable.
[**11-4**]
Changes from the exam on [**10-20**]
Right hemiparesis, mute
PEG in situ (normal bowel sounds)
Pertinent Results:
[**2186-10-21**] MRI of the brain
FINDINGS, BRAIN MRI:
There are multiple areas of slow diffusion identified involving
the head of the left caudate nucleus, left basal ganglia,
insular cortex and patchy areas are seen involving the
periventricular and subcortical white matter of left frontal
lobe as well as involvement of the cortex. Findings are
indicative of acute left-sided middle cerebral artery
territorial infarct. There are areas of low signal on
susceptibility images in the left basal ganglia indicating small
areas of hemorrhages. There is mild mass effect on the left
lateral ventricle. There is no midline shift. There is
mild-to-moderate brain atrophy without midline shift. The
suprasellar and craniocervical regions are normal on the
sagittal images. Mucosal thickening is seen in both maxillary
sinuses with soft tissue changes and fluid level in sphenoid
sinus.
IMPRESSION: Acute left-sided MCA infarct with small areas of
hemorrhage in
the basal ganglia region seen on susceptibility images. Mild
mass effect on the left lateral ventricle.
MRA OF THE HEAD:
The head MRA demonstrates diminished flow signal in number of
branches in the left sylvian region and in the left middle
cerebral artery. However, this demonstrates some improvement of
the flow since the previous CTA examination. The left vertebral
artery ends in posterior-inferior cerebellar artery, a normal
variation. No other abnormalities on MRA.
IMPRESSION: Slightly improved flow signal within the left middle
cerebral
artery compared to the previous CTA examination. However, there
remains
diminished number of branches within the left sylvian region. No
other
significant abnormalities on MRA of the head.
[**10-21**] CT chest
1. Negative examination for pulmonary embolism.
2. Unchanged cardiomegaly.
3. Atelectatic changes in the left lower lobe.
4. Small amount of pleural effusions bilaterally, more prominent
on the left.
5. 12 x 8 mm lung consolidation in left upper lobe.
[**2186-10-24**] TTE
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect or patent foramen ovale is seen by 2D, color Doppler or
saline contrast with maneuvers. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are complex
(>4mm) atheroma in the ascending aorta. There are complex (>4mm)
atheroma in the aortic arch. There are complex (>4mm) atheroma
in the descending thoracic aorta down to 40cm from the incisors.
None of the atheroma are mobile. The aortic valve leaflets (3)
are mildly thickened. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**12-7**]+) mitral regurgitation is seen. There is at least moderate
pulmonary artery systolic hypertension (the pulmonary artery
systolic pressure was at least 39mmHg). The pulmonic valve
leaflets are thickened. The main pulmonary artery is dilated.
There is no pericardial effusion.
Impression: Diffuse, complex, non-mobile aortic atheroma at the
ascending aorta, aortic arch, and the descending aorta. Normal
biventricular function. Mild to moderate mitral regurgitation.
Moderate pulmonary hypertension with dilated pulmonary artery.
[**2186-10-25**] CT [**Last Name (un) 103**]/pelvis
1. No retroperitoneal bleeding.
2. New 11x9 mm hypodense lesion of mid pole of the left kidney
which was not present on CT of [**2182-11-6**]. Further evaluation
by MR urography is
recommended.
3. There is soft tissue density in the bladder near the right
ureterovesical junction which either represents a blood clot or
bladder mucosal lesion. Further evaluation by direct cystoscopy
is recommended.
4. 14-mm hypodense lesion of the segment III of the liver which
most likely represents simple cyst.
5. Small left subpulmonic effusion and left basilar atelectasis.
6. Stable 16 x 24 mm left adnexal cystic structure since [**2181**].
Pelvic US can be obtained for further evaluation.
[**2186-10-26**] Urine cytology - a few atypical cells
[**2186-11-3**] Repeat Swallow Evaluation
The patient demonstrates the ability to trigger a swallow.
However, there was significant residue in her oral cavity and
pharynx following just one trial of solids, and it was not
possible to rule out aspiration based on this limited exam. It
does not appear that she will be able to maintain nutrition and
hydration with POs at this time. She should continue with
alternate means of nutrition, and supervised PO trials as
appropriate.
This swallowing pattern correlates to a Dysphagia Outcome
Severity Scale (DOSS) rating of 2, partial POs only.
RECOMMENDATIONS:
1. Continue with alternate means of nutrition, hydrations, and
medication, including consideration of PEG tube placement.
2. Continue with supervised PO trials as outlined:
Twice daily, pt may have therapeutic swallowing trial with
RN with the following guidelines:
a) Sit FULLY upright for all PO trials.
b) perform oral care prior to PO trial to prevent aspiration
of oral bacteria
c) offer purees and nectar thick liquid by spoon only
d) alternate between spoonful of puree and spoon of nectar
e) palpate pharynx to feel when swallow occurs
f) after swallow, check oral cavity for residue and provide
Yankauer suctioning to lateral sulci as needed
g) monitor closely for s/sx of aspiration including throat
clear, coughing, or O2 desaturation during trial. If
these occur, please cease trial and await speech + swallow
re-eval before further trials.
h) maximum volume of oral trial should be 2 ounces each of
puree and juice.
3. We will reevaluate her early next week as appropriate.
4. If patient's voice does not return, please consider ENT
consult to assess vocal fold mobility.
5. The patient will likely benefit from speech/language therapy
in a rehab setting.
These recommendations were shared with the patient, nurse and
medical team.
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2186-11-3**] 07:00AM 10.3 3.97* 12.2 35.4* 89 30.8 34.5 15.3
442*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2186-11-2**] 06:15AM 229* 29* 0.9 137 4.3 105 24 12
Brief Hospital Course:
[**10-20**]: Admitted as a code stroke to ICU. She went to the Angio
Suite, there were difficulties getting femoral access in
beginning ,following Lt ICA catherization A clot found in Left
M1 segment proximal to the left MCA bifurcation. The left MCA
was opened up by penumbra around 10:35 however
another occlusion seen in one of MCA superior division branches
that could not be opened up with penumbra or IA tPA (3 mg ).
patient had very good collaterals , procedure tolerated well.
There was some blood loss from site of groin puncture. Patient
remained hemodynamically stable and transferred to TICU.
[**10-21**]: Her hematocrit dropped and she received 2U PRBC
[**10-22**]: CHF (transfused, no diuresis, elevated BP), required
transfer to ICU and intubation.
[**10-24**]: Extubated. Patient was placed on Coumadin for secondary
stroke prevention due to her atrial fibrillation.
[**10-26**]: Hematuria investigated by CT abdomen and pelvis which
showed a bladder lesion.
[**10-30**]: transferred to [**Hospital Ward Name 121**] 11. Oral intake was poor, therefore a
PEG was inserted to increase the calorie count. Her hematuria
resolved.
Due to her hematuria, the patient's coumadin was stopped.
Medications on Admission:
ASA 325 mg po daily
Enalapril 20 mg po bid
Fish oil
Lasix 40 mg qam and 20 mg qpm
Imdur 90 mg po daily
Lipitor 80 mg po daily
Metformin 500 mg po tid
MVI
NTG SL 0.4 prn
Norvasc 2.5 mg po daily
Plavix 75 mg po daily
Toprol XL 50 mg po daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for temp > 100.4 or pain.
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
3. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
4. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
8. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
14. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal PRN (as needed) as needed for hemorrhoidal pain.
15. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
17. Isosorbide Mononitrate 10 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
18. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN
(as needed).
19. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
20. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
21. Insulin sliding scale
Insulin SC (per Insulin Flowsheet)
Sliding Scale
Fingerstick QACHSInsulin SC Sliding Scale
Q6H
Regular
Glucose Insulin Dose
0-60 mg/dL [**12-7**] amp D50
61-120 mg/dL 0 Units
121-140 mg/dL 4 Units
141-160 mg/dL 6 Units
161-180 mg/dL 8 Units
181-200 mg/dL 10 Units
201-220 mg/dL 12 Units
221-240 mg/dL 14 Units
241-260 mg/dL 16 Units
261-280 mg/dL 18 Units
281-300 mg/dL 20 Units
> 300 mg/dL Notify M.D.
Instructons for NPO Patients: 1/2 dose when NPO
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Stroke
AF
secondary diagnosis:diastolic heart failure
Type 2 Diabetes
Discharge Condition:
Mute, right hemiparesis, can understand and follow commands
Discharge Instructions:
Neurology: You have had a stroke, if you experience sudden onset
weakness, or any alteration of consciousness. Coumadin has been
stopped because you had blood in your urine.
Cardiac:You need to get weighed on a daily basis, [**Name8 (MD) 138**] MD if
weight > 3 lbs. Adhere to 2 gm sodium diet
Urology: You need to be followed up by Urology due to the blood
in your urine, and an abnormality in your bladder seen in your
CT scan of the pelvis.
Followup Instructions:
[ ] Stroke: Please contact Dr. [**Last Name (STitle) **]. E. Searls' office in [**5-14**] weeks
time to get a date for an appointment: ([**Telephone/Fax (1) 41723**]
[] Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2186-11-9**] 3:00
[] Provider: [**Name10 (NameIs) 7158**] [**Last Name (NamePattern4) 7159**], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2186-12-5**] 10:10
[] UROLOGY Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2187-4-11**] 3:00
Completed by:[**2186-11-4**] Admission Date: [**2186-11-4**] Discharge Date: [**2186-11-16**]
Date of Birth: [**2110-3-27**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Hydrochlorothiazide / Ibuprofen / Zosyn
Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
Hematemesis and hematochezia.
Major Surgical or Invasive Procedure:
Endotracheal intubation
Right subclavian central line
G-J tube change
History of Present Illness:
Ms. [**Known lastname 23638**] is a 76 year old female with DM, HTN, CAD, PVD who
was discharged today from neurology following a hospitalization
for a large L MCA infarct. Of note, patient received IV, IA tpA
(penumbra device) [**10-20**] for this infarct. Within 30 minutes of
patient's arrival to rehab today (16:30), the patient was noted
to be pale, minimally responsive and then started vomiting
blood.
ED course: In ED at [**Hospital1 18**] initial vitals: temp 104.2 hr 86 bp
203/79 rr 20 O2 sat 98% on non rebreather. Hypertension rapidly
resolved and was attributed to the patient's acute distress.
Lung clear, tachycardic on exam, hypoactive bowel sounds, frank
bright red blood from rectum with an apparent mass, and vomiting
blood. Mouth 150 ml of blood. Patient was intubated for airway
protection. NG tube was placed with 200 ml of blood returned. In
setting of propofol, for intubation patient became
hemodynamically unstable with SBPs into 80s for less than 10
minutes. Patient recovered blood pressure with cessation of
propofol. Patient sedated with fentanyl and versed for sedation.
CT head no interval change. CT Torso bilateral bronchopneumonia
consistent with either pneumonia or pneumonitis from aspirating
blood. Patient received vancomycin and zosyn for presumed
hospital acquired pneumonia.
Patient had G-tube placement yesterday due to dyphagea from
recent stroke. CT torso on admission did not indicate
complication from G-tube placement, but did show impacted stool.
EKG: sinus, NEW [**Street Address(2) 1766**] depressions in V3-V6 and TWI II, III and
aVF. Enzymes are pending.
Patient received vitamin K for presumed coagulopathy, zofran for
vomiting, tylenol for fever, and protonix 40 mg.
Neurology were consulted. Per Neurology's report "She was an in
patient in [**Hospital Ward Name 121**] 11, and before she left for [**Hospital1 1319**], no
bleeding was noted, her vitals had been stable, she had no
residuals from her tube feeds, and she had normal bowel sounds."
On exam in ED neurology notes the patient had no new
neurological deficits.
GI was also consulted. Repeat NG lavage by GI prior to MICU
transfer was negative. Most recent vitals from ED: HR 89, BP
140/88, 100% RA, RR 16 with vent at CMV Tv 500, rate 14.
On arrival to MICU, patient was noted to be intubated, sedated
with no active bleeding from her mouth or NG tube. Patient also
has no active rectal bleeding.
Past Medical History:
- Stroke L MCA infarct [**10-20**] s/p IV tPA, IA tPA+penumbra and s/p
PEG placement
- Hemorrhoids
- Bladder lesion under investigation: soft tissue density seen
on CT pelvis in bladder [**2186-10-25**]
- DMII (A1C 8.1 on [**11-10**])
- CAD: +MIBI [**12-11**] with reversible defects in inferior and
lateral walls. Cath [**12-11**]: LMCA: 30-40%, LAD: 50-60%, LCx: 50%,
with OM1 T.O, 99% OM2; RCA: diffuse disease. No percutaneous
intervention done. [**12-11**] TTE: EF 70%, moderate symmetric LVH
- PVD
- DVT in [**2157**]
- Hyperlipidemia - last LDL 64 on lipitor 80mg PO qD
- HTN
- Pancreatitis [**2181**], idiopathic
Social History:
Lived in [**Location 686**] with daughter. Widowed. Former smoker (quit
20 yrs ago, 40 pack yr hx). Denies EtOH and illicit drugs.
Family History:
Mother had CAD (unknown age), parents both had HTN, Denies fmhx
of dm and cancers.
Physical Exam:
104.2 P: 78 R: 16 BP: 90/81
Vent settings: 0.5/14/5 (100%)
General: Intubated, ventilated, on 10 mcg of propofol. NG tube
has coffee grounds, hematuria, vaginal bleeding, petechiae on
the
abdomen
HEENT: intubated
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: tense, distended, bruised, bowel sound hypoactive
Neurologic:
-Mental Status: could not be assessed
-Cranial Nerves: known to be mute at baseline with an obvious
right facial droop, PERRL 4----> 2 mm b/l, fundi difficult to
visualize as her eyes are very watery, corneals present
bilaterally, normal dolls head reflex, nasal tickle present, gag
present.
-Motor: Right hemiparesis, with no movement, spontaneous
movement
on the left side.
-Sensory: moves left arm and leg away from noxious stimuli
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 1 2 0 2
R 2 1 2 2 2
Plantar response was flexor bilaterally (at baseline).
-Coordination & Gait could not be assessed.
Pertinent Results:
EKG ([**2186-11-5**]): Sinus rhythm at a rate of 92. Normal axis. 1-2mm
ST depressions in V2-6. ST depressions are less pronounced than
prior study dated [**2186-11-4**] and new from study dated [**2186-10-27**].
.
(11.29.08-12.02.08): WBC 8.2->9.3 (85% N, 11%L), Hct
35.2->27.8->31.4, Platelets 455->456, INR 1.2->1.3, Fibrinogen
548, d-dimer 1633.
.
(11.29.08-12.02.08): Na 141->146, K 4.0->3.3, Cl 107->114,
Bicarb 23->19, BUN/Cr 30/1.3->22/0.9, Ca 8.6, Phos 2.1, Mg 1.8.
.
ALT 34, AST 61, LD 561, Alk Phos 102, T Bili 0.5, Alb 3.2.
.
Lactate ([**2186-11-4**]) 2.7
.
CK 2890->290->378
CK-MB 2->6->6->8
Trop T <0.01->0.12->0.15->0.13
.
Micro:
Sputum ([**2186-11-5**]): Gram negative rods
Blood ([**2186-11-5**]): No growth to date.
.
Imaging:
CT Torso ([**2186-11-4**]): 1. Peribronchovascular right upper lobe
opacities concerning for infection, aspiration, or possibly
pulmonary hemorrhage. 2. Bibasilar pulmonary consolidation
likely atelectasis +/- aspiration. 3. Gastrostomy tube in place
with large amount of subcutaneous gas along the entry site in
the intra-abdominal wall and gas in the left rectus sheath.
Findings may reflect postoperative changes though clinical
correlation is advised. 4. Marked fecal impaction of the rectum.
Clinical correlation is advised. Given the clinical history of
rectal bleeding, the possibility of superimposed
hemorrhoids cannot be excluded. 5. Diverticulosis without
evidence of diverticulitis. 6. Bilateral renal cortical
irregularity which may reflect chronic infarctions. Given
atherosclerotic changes at the level of the renal artery
origins, the possibility of renal artery stenosis cannot be
excluded. Recommend clinical correlation. 7. Cardiomegaly with
atherosclerotic changes of the coronary arteries.
.
Head CT, noncontrast ([**2186-11-4**]): 1. No evidence of new
hemorrhage. Continued evolution of left putamen and globus
pallidus, hemorrhage, and edema. Continued evolution of left
middle cerebral artery territory infarct. 2. No shift of
normally midline structures.
.
CXR ([**2186-11-5**]): Right subclavian catheter has been placed. The
tip terminates in the superior vena cava. Nasogastric tube
courses below the diaphragm, but the tip is not seen. Heart is
mildly enlarged. Again noted is a small left pleural effusion
with left lower lobe atelectasis. The remainder of the lungs are
clear.
.
RUE U/S ([**2186-11-8**]): No DVT.
.
Portable abdominal X-Ray ([**2186-11-9**]): A J-tube is seen in place,
unchanged
from scout images taken on [**2186-11-4**]. Also seen is a
nasogastric tube in good position projecting over the stomach.
The bowel gas pattern is nonspecific and there is no free air or
pneumatosis. Degenerative changes are seen in the thoracic
spine.
.
Perc G-J tube check ([**2186-11-10**]): Prelim report, replacement of
the existing 14 French [**Doctor Last Name 9835**] GJ catheter for a 16 French
gastric-jejunal feeding catheter with the jejunal port ready to
use for feeding.
.
Renal ultrasound ([**2186-11-13**]): Asymmetric kidneys which is noted
on the ultrasound of [**2183-12-7**] otherwise unremarkable renal
ultrasound with no hydronephrosis seen.
.
U/S GJ-tube site ([**2186-11-15**]): No abscess.
Brief Hospital Course:
.
A/P: 76 yo F with DM, HTN, CAD, PVD recently admitted for large
L MCA infarct admitted with hematemesis and hematochezia, found
to have an NSTEMI, aspiration pneumonia and episodic complete
heart block.
.
The patient was recently admitted from 11.14-28.08 with a large
territory left MCA CVA. She received tPA and did develop Hct
loss of unknown source during that hospitalization for which she
received 2U pRBCs. Within 24 hours of discharge to rehab the
patient had G-J tube placement for feeding.
.
Soon after admission to rehab, the patient was found to be pale,
minimally responsive and then developed bloody emesis. She was
transferred to the [**Hospital1 18**] ED where she was noted to be febrile to
104.2. Exam was remarkable at that time for bloody emesis and
bright red blood per rectum. She was intubated for airway
protection with complications of propofol associated
hypotension. Post-intubation CT torso revealed bilateral
pneumonia vs. pneumonitis likely consistent with aspiration of
blood. She was admitted to the ICU and received vitamin K, PPI
and was started on vancomycin and cefepime (initially zosyn but
changed out of concern for rash and history of penicillin
allergy) with culture data remarkable for blood cultures without
growth to date and sputum with eventual growth of pan-sensitive
klebsiella oxytoca. She was evaluated by the surgical consult
service regarding her GI bleeding. They felt there was no
indication for surgical intervention. She was evaluated by the
GI consult service who recorded a negative NG lavage and
external, thrombosed hemorrhoids with some mucosal oozing as
likely source of lower GI blood loss. They recommended elective
endoscopy and colonoscopy in the future unless recurrence of
bleeding dictates more urgent intervention. GI consult felt that
the patient was at high risk for complications from endoscopy
with conscious sedation due to recent respiratory complications
and known CAD with NSTEMI (see below) and therefore did not
pursue more urgent endoscopy. Due to declining Hct from 36 to
27, she received 1U of pRBC's with improvement to mid-30's. For
the remainder of her hospitalization, she had no signs of
ongoing active blood loss with stable hematocrit and
hemodynamics. Initially aspirin and plavix were held due to
active bleeding. Low-dose aspirin was restarted for secondary
prophylaxis for both prior MI and CVA (see below). She continues
off of plavix and warfarin. Email discusssion was held with both
the patient's primary cardiologist and outpatient neurologist
and the decision was made for single antiplatelet therapy with
aspirin and no plavix or warfarin. There is likely only limited
benefit with increased risk of bleeding from either the addition
of plavix (in this patient without coronary stents) or warfarin
(in the setting of known complex aortic atheroma as likely
source of CVA).
.
She was incidentally noted to have new [**Street Address(2) 1766**] depressions in
V3-V6 and TWI II, III and aVF, negative CK-MB with trop T
elevation to peak of 0.15 up from a baseline of <0.01. She was
restarted on aspirin and beta-blocker approximately 24 hours
after admission after a brief hiatus in the setting of acute
bleeding. Beta-blocker was subsequently discontinued due to
heart block (see below) in favor or lisinopril for blood
pressure and heart failure. Plavix was discontinued as above.
She continued on statin therapy. Long-acting nitrate and
maintenance lasix (given known history of diastolic CHF) were
transiently held but restarted prior to discharge. Due to acute
renal failure and hypernatremia, lasix was then discontinued
later in her hospitalization. The patient appeared euvolemic
throughout. She was counselled to discuss restarting furosemide
at her outpatient cardiology appointment. The patient has known
non-operable 3 vessel disease on past cardiac cath and is not a
candidate for intervention. She will have further outpatient
cardiology follow-up as scheduled. Communication was had with
patient' primary cardiologist by email regarding antiplatelet
therapy and decision was made to discharge on aspirin
monotherapy.
.
While being monitored on telemetry after likely NSTEMI, the
patient was noted to have episodes of asymptomatic, wide-complex
bradycardia to the high 30's usually precipitated by vagal
maneuvers. The patient was evaluated by the EP consult service
who felt this was most consistent with AV dissociation with
associated His-Purkinje conduction disease. They noted that this
is an indication for pacemaker placement after confirmation by
EP study. This was discussed, including risks and benefits
ranging from asymptomatic state to death, with both the patient
and her daughter both of whom agreed that the patient would not
want to pursue these invasive diagnostic and therapeutic
procedures at the current time. Her beta-blocker was held and
she was continuously monitored on telemetry with episodic, brief
and asymptomatic complete heart block. The patient will further
discuss at outpatient cardiology follow-up.
.
With respect to her recent CVA, the patient was evaluated by
neurology consult service who felt she had no new neurologic
deficits. Head CT was unchanged from prior. After discussion
with both the patient's primary cardiologist, neurologist and
primary care physician, [**Name10 (NameIs) **] decision was made to discharge on
aspirin monotherapy off of plavix and coumadin as described
above.
.
IR evaluated the patient and the G-J tube site and recommended
ongoing nursing care of the site and NG decompression due to
leakage. Due to persistent drainage from around the G-J tube
site and findings of subcutaneous air tracking to the rectus
sheath, likely originating from the G-J tube entry site, the
patient underwent IR procedure for G-J tube change to a larger
caliber tube. The subcutaneous air was re-evaluated with an
abdominal plain film that was of uninterpretable, poor quality.
The patient's G-J tube site developed erythema, induration and
pus drainage. She was started on initially ciprofloxacin then
was transitioned to ancef and then cefpodoxime for oral
antibiotic therapy. IR removed the tube due to persistent pus
drainage on the day prior to discharge. The patient will
complete 7 days of keflex therapy. The site needs to be closely
monitored at rehab and for worsening appearance or failure to
respond to therapy, antibiotics can be changed to cefpodoxime,
doxycycline for broader coverage. She will return on [**2186-11-24**]
for placement of a new tube by IR. In the interim, the patient
had NG tube placement for ongoing tubefeeds, free water flushes
and medication administration.
.
On admission, the patient reportedly had significant stool
impaction on CT. She recieved an aggressive bowel regimen with
nursing report of copious stool output. Adbominal plain film
revealed no signs of dilated loops of bowel. During her
hospitalization, the patient had a right subclavian central line
in place. She developed RUE swelling. RUE ultrasound revealed no
DVT. She continues on tubefeeds for nutrition and heparin subq
for DVT prophylaxis. The central line was removed prior to
discharge.
.
The patient was placed on a sliding scale insulin regimen on
admission. She developed profound hyperglycemia to >400 in the
setting of known type II DM and ongoing tubefeeds. She was
started on long-acting standing insulin with humalog sliding
scale with improvement in her blood sugar control. As an
outpatient, consideration can be made to restarting the
patient's metformin and transitioning off of subq insulin.
.
Around [**2186-11-12**] the patient developed several laboratory
abnormalities, including hypernatremia to 152, acute renal
failure to 2.0 (from baseline Cr 1.0) and leukocytosis to 17.
The patient's renal failure may have been due to fungal
infection (>100,000 fungal forms on urine culture), post-renal
cause (with >1L output on straight cath and incontinence) and/or
pre-renal etiology. She received fluconazole for treatment of
fungal UTI and must complete a 7 day total course. She also
received volume rescucitation and a foley catheter was left in
place. The patient should have a voiding trial at rehab and then
can discuss this further with urology at her scheduled
outpatient appointment. Renal ultrasound was negative for
hydronephrosis. Less likely but possible is an allergic reaction
to one of the antibiotics causing AIN. Urine eos were ordered
but never sent prior to resolution of the problem.
.
The patient's hypernatremia corrected with free water flushes
via G-J tube and additional free water by vein. She must
continue to receive 250cc free water flushes through the NG (and
then G-J tube once this is placed) every 6 hours to prevent
recurrence of this problem. [**Name (NI) **] leukocytosis was most likely due
to cellulitis at the site of G-J tube entry site or fungal UTI,
both of which she received treatment for with improvement of the
WBC.
.
The patient has a bladder lesion concerning for tumor seen on
previous hospitalization. She was rescheduled for outpatient
urology follow-up on this issue. At this follow-up appointment,
the patient should also discuss possible urinary retention if
she fails a voiding trial as described above.
.
The patient is full code, confirmed by discussion with the
patient's daughter. This must be re-addressed in the future as
this seems to be dependent on her likelihood of regaining
neurologic function. The patient herself seemed very reluctant
to undergo any invasive procedures and therefore these were
avoided. The patient seemed depressed and endorsed feeling
overwhelmed and anxious. She refused antidepressant therapy or
evaluation by our psychiatry team.
.
Contact: [**Name (NI) 73298**] (daughter) [**Telephone/Fax (1) 100332**]
Medications on Admission:
- Acetaminophen 325-650 mg every 6 hours as needed
- Senna 8.6-17.2 mg 2 times a day as needed
- Omega-3 Fatty Acids 2 times a day
- Atorvastatin 80 mg Daily
- Heparin subq 3 times a day
- Famotidine 20 mg every 12 hours
- Docusate liquid 2 times a day
- Chlorhexidine Gluconate 0.12 % Mouthwash 1 ML 2 times a day
- Clopidogrel 75 mg Daily
- Aspirin 325 mg Daily
- Bisacodyl 10 mg Daily as needed
- Furosemide 20 mg Daily in the evening
- Furosemide 40 mg Daily in the morning
- Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Rectal as needed
- Metformin 1000 mg 2 times a day
- Metoprolol Tartrate 12.5 mg 2 times a day
- Isosorbide Mononitrate 10 mg 2 times a day
- Lidocaine HCl 2 % Gel as needed
- Magnesium Hydroxide 400 mg/5 mL Suspension 30 ML every 6 hours
as needed
- Oxycodone-Acetaminophen 5-325 mg every 4 hours as needed for
pain
- Insulin sliding scale
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Hydrocortisone Acetate 1 % Ointment Sig: One (1) Appl Rectal
DAILY (Daily).
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Lidocaine HCl 2 % Gel Sig: One (1) Appl Urethral DAILY
(Daily) as needed.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Isosorbide Mononitrate 10 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Insulin
Lantus 35 units at bedtime. Humalog sliding scale four times
daily as follows: Start at glucose 150 with 2U, increase by 2U
for every increase in glucose of 50. Half-dose when NPO.
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. Lansoprazole (Bulk) 100 % Powder Sig: One (1) Miscellaneous
once a day.
12. Fluconazole 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 4 days.
13. Keflex 500 mg Capsule Sig: One (1) Capsule PO every six (6)
hours for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
14. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO once a day.
15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day:
Before restarting this medication, discuss this further with
your cardiologist.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
- Gastrointestinal bleeding
- Acute blood loss anemia
- Aspiration pneumonia
- Non-ST elevation MI
- Infranodal heart block
- Acute renal failure
- Cellulitis at PEG site
- Possible urinary retention
Secondary:
- Left atheroembolic MCA stroke
- Aphasia, right hemiparesis
- Dysphagia s/p J-tube c/b rectus sheath emphysema
- 3-vessel coronary disease (not amenable to PCI or CABG)
- Left kidney and bladder neoplasm NOS
- Diastolic heart failure
- Peripheral vascular disease
- Diabetes mellitus type II
- Hypertension
- Hyperlipidemia
- Pancreatitis NOS
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with blood in the stool and vomit. The cause
of blood in the stool was thought to be hemorrhoids. The cause
of blood in the vomit is not known and may have been due to
gastritis or inflammation of the stomach lining. The bleeding
was likely precipitated in part by multiple blood thinning
medications. The bleeding has now seemed to stop. Continue to
take aspirin as prescribed. You should no longer take plavix or
coumadin. In addition you should take lansoprazole twice daily
to help prevent future bleeding.
While in the hospital you were found to have a likely small
heart attack. Continue your cardiac medications as prescribed to
help prevent further injury or complications. You were also
found to have periods of poor electrical conduction within the
heart, called AV dissociation or complete heart block. We
discussed pacemaker placement and you were not interested for
the time being. You should no longer take metoprolol as this can
worsen the electrical conduction in the heart. Instead take
lisinopril as prescribed. Discuss both of these issues as well
as restarting lasix with your cardiologist, Dr. [**Last Name (STitle) **].
You have an infection of the skin at the site of your G-J tube.
Please continue to take antibiotics, Keflex for 7 days. You were
also found to have a fungal infection in your urine. Please
complete a course of antifungal therapy, fluconazole for 7 total
days.
You still must follow-up in the urology clinics for further
evaluation of a bladder mass that was found on your recent
hospitalzation. In addition, please discuss possible urinary
retention with the urologist. You should have a voiding trial at
rehab prior to this appointment. This appointment was
rescheduled for [**11-28**].
You require physical and speech therapy to treat the effects of
your recent stroke. You will receive these services at your
rehab facility.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere
to 2 gm sodium diet.
Call your doctor or return to the hospital for any new or
worsening fevers, chills, nausea, vomiting, blood in the stool
or vomit or any other concerning symptoms.
Followup Instructions:
Cardiology: Dr. [**Last Name (STitle) **] [**2186-11-20**] 4:40PM
G-J tube placement: [**2186-11-24**] 10:30AM [**Location (un) 470**]
radiology
Urology: Dr. [**Last Name (STitle) 3748**] [**2186-11-28**] 10:30AM
Primary Care: Dr. [**Last Name (STitle) **] [**2186-12-5**] 10:10 AM
Neurology (Stroke): Dr. [**Last Name (STitle) **]. E. Searls' office ([**Telephone/Fax (1) **])
[**2185-12-17**] 2:00 [**Last Name (un) 469**] [**Location (un) **].
[**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]
|
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"428.0",
"342.00",
"351.8",
"440.0",
"599.70",
"428.30",
"455.6",
"596.9",
"518.81",
"784.5",
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] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"96.04",
"96.6",
"99.10",
"88.72",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
37293, 37363
|
25155, 34939
|
17423, 17495
|
37972, 37981
|
21942, 25132
|
40188, 40753
|
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|
35855, 37270
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37384, 37951
|
34965, 35832
|
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21349, 21923
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17354, 17385
|
17523, 19950
|
15788, 15830
|
6650, 11851
|
21309, 21332
|
19972, 20594
|
20610, 20742
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,042
| 126,841
|
6651
|
Discharge summary
|
report
|
Admission Date: [**2199-6-4**] Discharge Date: [**2199-6-13**]
Date of Birth: [**2122-9-19**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
Hypotension/cellulitis
Major Surgical or Invasive Procedure:
Left internal jugular line placement
History of Present Illness:
76 yo F with AF, CAD s/p CABG, h/o cellultis, who presents from
home with worsening R leg infection. On [**Name (NI) 2974**], pt noticed a
swelling on her right lateral leg with redness. this progressed
over the next few days followed by pain in the last two days.
Denies fevers, but has some chills. No N/V, few loose BM's/day
over last few days. No cough/SOB. Also noted [**Month (only) **] UOP with ok
fluid intake but poor appetite.
.
Seen at OSH today where she was noted to have a large
cellulitis. Her BP was 80's without sxs. She was started on
levofed after being given 2.5 L IVF. A CVL was placed. She was
given clinda/vanc and a surgery consult was called which r/o
necrotizing fascitis. She was sent to [**Hospital1 **] for further care.
.
In the ED, VS 97.3, 80, 80/42, 16, 98%. Exam with 10-20 cm right
erythema to thigh, no skin breakdown. Vascular consult who
reccomended f/u cultures and monitoring exam of leg. Given add'l
clinda/vancomycin in the ED. UO notd to be poor--20 cc total. On
50 mcg of levofed on transfer.
.
Admitted to the ICU for sepsis.
.
In the MICU, surgery consult ruled out necr. fascitis. In the
unit required levophed for hypotension, echo with preserved EF
and severe TR. Mildly elevated LFTs, and CT abdomen with 4X 4 cm
AAA. (per PCP 3.5 cm AAA 3 yeras ago in '[**96**]). Vascular
following. Leg improved. Lateral leg ruptured bullae so Derm
followed. Initially on vanc/clinda for 3 days with some
improvement but due to leucocytosis so started unasysn. failed
[**Last Name (un) 104**] stiim got steroids for 5 days. This AM went into rapid a.
fib (given 5 mg iv lopressor). Started on metoprolol 25 (outpt
dose 75).
Past Medical History:
HTN
CAD
PVD
Afib
diverticulosis
h/o ARF
h/o coagulopathy
CHF
h/o cellulitis/sepsis- at BIDN on [**11-19**]; wound grew coag-neg
staph, txt w/ vanco
Social History:
lives in [**Location 620**] with husband, former [**Name2 (NI) 1818**] (quite 25 years
ago), occ ETOH, no drugs
Family History:
NC
Physical Exam:
Tm 96.8 Tc 95.6 BP 104/58 (95-130/60-70)--off levophed since [**04**]
AM [**1-9**].
HR 76 (76-138) RR 20 O2 98% RA
I/O 1212/900
well, lying comfortablly in bed, NAD, o x 3
EOMI, PEERLA, anicteric, mouth-dry
L IJ in place
RRR, nl s1, nl s2, mild holosystolic murmur
CTA anteriorly
soft NT/D BS, no R/G, nl liver span, mid line surgical scar
LLE: some distal LE brany erythema and discoloation, +2+ edmea
RLE: large confluent areas of red macular ertyhema and warmth
with swelling, outlined, some areas around knee and medial thigh
spared, small areas of skin breakdown on buttock, areas extend
to buttock and over to right flank
Pertinent Results:
Admission Labs:
[**2199-6-4**] 11:12PM LACTATE-1.6
[**2199-6-4**] 10:16PM WBC-13.1* RBC-3.01* HGB-10.6* HCT-31.4*
MCV-104* MCH-35.2* MCHC-33.7 RDW-17.5*
[**2199-6-4**] 08:20PM GLUCOSE-101 UREA N-67* CREAT-2.7* SODIUM-131*
POTASSIUM-3.3 CHLORIDE-94* TOTAL CO2-24 ANION GAP-16
[**2199-6-4**] 08:20PM CALCIUM-8.2* PHOSPHATE-4.9* MAGNESIUM-2.4
[**2199-6-4**] 04:20PM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.015
[**2199-6-4**] 04:20PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2199-6-4**] 04:20PM URINE RBC-[**3-18**]* WBC-[**6-23**]* BACTERIA-MOD
YEAST-NONE EPI-0-2
[**2199-6-4**] 04:15PM CK(CPK)-25*
[**2199-6-4**] 04:15PM cTropnT-<0.01
[**2199-6-4**] 04:15PM CK-MB-NotDone
.
IMAGING:
CXR: FINDINGS: Consistent with the given history, a left
internal jugular approach central line has been placed. The
distal tip lies in the brachiocephalic vein proximal to the
junction with the superior vena cava. There is evidence of prior
median sternotomy and CABG. Consistent with the prior report,
there is massive cardiomegaly and chamber enlargement. A double
density is noted with splaying of the carina consistent with
left atrial enlargement in particular. There is no focal
consolidation. No significant cephalization is evident although
there is interlobular septal thickening noted in the periphery.
No pleural effusion or pneumothorax is evident.
IMPRESSION: Left internal jugular approach central line as above
with no pneumothorax. Massive cardiomegaly. Interlobular septal
thickening of indeterminate acuity. Regardless, there is no
evidence to suggest significant volume overload.
.
LENIs: FINDINGS: Ultrasound evaluation of the right and left
lower extremity deep venous system using grayscale, color, and
pulse wave Doppler demonstrates the veins to be fully
compressible with normal Doppler waveforms, augmentation, and
respiratory variation in flow.
IMPRESSION: No evidence of DVT involving the right or left lower
extremities.
.
ECHO: Conclusions:
The left atrium is dilated. The right atrium is markedly
dilated. 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
appears dilated. Right ventricular systolic function is normal.
[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) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve leaflets are mildly
thickened. There is moderate/severe mitral valve prolapse.
Moderate (2+) mitral regurgitation is seen. The mitral
regurgitation jet is eccentric. 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.
.
Abdominal Ultrasound: FINDINGS: The liver is normal in
echotexture without evidence of focal lesion. There is a
questionable tiny hyperechogenic focus in the gallbladder neck
that could represent a small gallstone vs. polyp. No evidence of
cholecystitis. No evidence of intra or extrahepatic biliary
ductal dilatation and the common duct measures 5 mm. Main portal
vein is patent with antegrade flow. The pancreas appears normal.
The aorta demonstrates a fusiform aneurysm on its mid portion
measuring 4.2 x 3.9 cm. The right kidney measures 10.8 cm and
the left 11.8 cm. The renal parenchymal thickness is normal.
There is a 9 mm non-obstructive stone in the left kidney. No
evidence of hydronephrosis. No evidence of free fluid.
IMPRESSION:
1) 4.2 cm infrarenal aortic aneurysm.
2) 9 mm non-obstructive left renal stone.
3) Small hyperechogenic focus within the gallbladder neck could
represent a small stone vs. a polyp. No evidence of
cholecystitis
.
MICRO:
URINE CULTURE: NEGATIVE
.
BLOOD CULTURE: NGTD
Brief Hospital Course:
ICU course: Patient was admitted to the ICU for pressor support
from her persistent hypotension. She was given Levophed
successfully through her left IJ CVL which was placed in the ED.
She was initially treated with empiric Vancomycin/Clindamycin.
Vascular surgery was consulted and followed the patient in
house. She did respond to these antibiotics, but her
Clindamycin was stopped in favor of Unasyn for better GNR
coverage. Her urine culture was negative, and her blood
cultures were NGTD on transfer from the MICU. Moreover, given
the extensive nature of her cellulitis, dermatology was
consulted. They felt her primary insult was likely a stasis
dermatitis. She was thus treated with clobetasol cream and
bactroban. LENIs was also performed and was negative for DVT.
Throughout her ICU course her cellulitis continued to improve.
Moreover, she was successfully weaned off Levophed on [**6-9**]. Her
steroids (which were started for possible adrenal insufficiency)
were quickly weaned and discontinued.
Regarding her mild transaminitis, abdominal ultrasound was
performed which showed a polyp vs. gallstone without evidence of
cholecystitis or ductal dilatation. She remained asymptomatic
and her LFTs remained stable.
Ultrasound did show an infrarenal aortic aneurysm which will
need follow up.
With regards to her afib, she was initially supratherapeutic on
her anticoagulation and her coumadin was held. There was no
evidence of bleeding. Her beta blocker was held due to her
hypotension. She did have [**2-16**] brief episodes of RVR requiring
IV metoprolol which she responded well to. On the day of her
transfer out of the ICU, her beta blocker was re-started at a
lower dosage to be uptitrated as tolerated by the floor team.
While on the floor, the hypotension and sepsis were resolved and
BP was stable. She was given hydrocortisone in the ICU but did
not require further steroids on the floor. Antbiotics were
continued with Day 1 [**6-4**] of IV Vancomycin, but unasyn started
[**6-7**]. Will continue for full 14 day course of Unasyn to finish
[**6-20**].
- Statis dermatitis/ cellulitis- Evaluated by dermatology and
recommended to apply clobetasol ointment to erythematous areas
on thighs/legs. Bactroban to open erosions. The cellulitis
appears to be in the distribution of her previous herpes zoster
and is likely the nidus for the infection. She will have to
have a completion of antibiotics as above and follow up with
dermatology if the areas do not heal.
- Infrarenal aortic aneurysm - Noted on CT and per outpatient
PCP this is old and given lack of positive blood cultures, doubt
this is a mycotic aneurysm.
- Renal failure: Given lytes likely ATN [**2-15**] hypotension.
Currently improving, with Cr of 1.1 Haved dosed meds for CrCl
of 55.
- Atrial Fibrillation: rate controlled on admission. has had
brief episodes of RVR. As outpt on BB and coumadin. She was
restarted on metoprolol 25 [**Hospital1 **] on [**6-9**] (outpt dose 75),
increased to TID on [**6-11**] and 50 mg TID on [**6-12**]
Initially held coumadin with elevated INR, but restarted at home
dose of 2.5mg on [**6-10**] (received 5 mg on [**6-12**] to increase
INR). This should be rechecked at least q week with the first
check occurring 2-3 days after discharge.
- CHF: slightly volume overloaded on admission, but currently
euvolemic. EF 55-60% on echo here. Restarted benicar 20 mg qday
on [**6-13**]. Her outpatient diuretics were not restarted as the
patient was autodiuresing after ATN, but it should be restarted
as an outpatient as the BP allows (lasix, hctz).
- Early decub ulcers: bactroban to erosions as well as zinc
oxide paste to erythematous areas. wound care consult for skin
breakdown on buttocks. Started on zinc, vitamin C. As well the
patient should have movement to prevent further stasis.
- Elevated LFTs/pancreatic enzymes: unclear if there is a
clinical significance. But may be secondary to hypotensive and
inadequate perfusion during septic phase. Will no longer trend
as no clinical correlation
- Elevated finger sticks: no known diagnosis of DM. Was recently
on steroids. Should be followed as an outpatient.
- Hx of loose stool: f/u c. diff cultures negative. Symptoms
improved.
Medications on Admission:
Benicar 20, Lopressor 75'', Crestor 30', Coumadin 2.5', HCTZ
25', Lasix 120', MVI, vit E, zetia
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: per ss
Injection ASDIR (AS DIRECTED).
2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
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 for constipation.
6. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day): until wounds heal.
7. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day): until wounds heal.
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
10. Olmesartan 20 mg Tablet Sig: One (1) Tablet PO Qday ().
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Please check INR weekly and adjust dose appropriately.
13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. Vancomycin 1000 mg IV Q 24H
D#1 [**6-4**] FINISHES approx [**2107-6-20**]. Ampicillin-Sulbactam 3 gm IV Q8H FINISHES [**2108-6-20**]. 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.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
sepsis secodary to cellulitis
hypertension, CAD, PVD, atrial fibrillation, diverticulosis,
history of acute renal failure, CHF
Discharge Condition:
Improved infection, stable vitals
Discharge Instructions:
You were admitted for a severe infection. You were treated with
antibiotics and improved.
Please follow up with your PCP upon discharge from rehab.
Followup Instructions:
Please follow up with your PCP upon discharge from Rehab by
calling: [**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 17753**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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28,528
| 132,626
|
34219
|
Discharge summary
|
report
|
Admission Date: [**2195-4-7**] Discharge Date: [**2195-4-24**]
Date of Birth: [**2148-11-2**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Rollover motor vehicle crash with multiple trauma
Major Surgical or Invasive Procedure:
[**2195-4-7**]
Exploratory laparotomy, left chest tube.
[**2195-4-7**]
1. Closed reduction, left elbow, with manipulation.
2. Debridement of open wound down to muscle.
[**2195-4-9**]
1. IVC filter
2. Fluoroscopy for IVC filter
3. Left chest superior chest tube for residual
pneumothorax.
[**2195-4-9**]
Sacroiliac screw fixation of left hemipelvis and
cyst. Examination under anesthesia left elbow. Irrigation and
debridement left elbow laceration down to fascia.
[**2195-4-17**]
1. Thoracic endograft repair of transected aorta with a
[**Doctor Last Name 4726**] TAG endograft, 280 x 10 mm (reference number
[**Serial Number 78811**], lot or batch number [**Serial Number 78812**]).
2. Thoracic aortography.
History of Present Illness:
46 yo male unrestrained driver s/p multiple rollover motor
vehicle crash; was reportedly awake at the scene. He was taken
to an area hospital where he was found to be hypotensive and was
intubated on arrival. he was then transferred via [**Location (un) 7622**] to
[**Hospital1 18**] for further care. A chest tube was placed, his blood
pressure varied between 80 and 115 systolic and was dependent
upon transfusion of blood and blood products. FAST examination
which suggested a hematoma in the right kidney. The CXR and
Pelvic AP films showed no bleeding site. He was taken to the
operating room for exploration of his abdomen.
Past Medical History:
Depression/Anxiety
Social History:
Noncontributory
Family History:
Noncontributory
Physical Exam:
Upon arrival:
BP 128/111 HR 81 vented O2 sats 100%
Pupile 2 mm and reactive
BS CTA bilat; + crepitus left chest
open fracture left elbow; abrasion left hip
Rectal tone normal
Pertinent Results:
[**2195-4-7**] 06:05PM GLUCOSE-132* UREA N-12 CREAT-1.0 SODIUM-143
POTASSIUM-4.4 CHLORIDE-112* TOTAL CO2-26 ANION GAP-9
[**2195-4-7**] 06:05PM ALT(SGPT)-38 AST(SGOT)-85* CK(CPK)-2765* ALK
PHOS-38* AMYLASE-37 TOT BILI-0.8
[**2195-4-7**] 06:05PM ALBUMIN-3.0* CALCIUM-8.6 PHOSPHATE-2.5*
MAGNESIUM-1.9
[**2195-4-7**] 06:05PM WBC-6.3 RBC-3.99* HGB-11.9* HCT-33.3* MCV-84
MCH-29.8 MCHC-35.6* RDW-15.6*
[**2195-4-7**] 06:05PM PLT COUNT-162
[**2195-4-7**] 06:05PM PT-13.7* PTT-29.3 INR(PT)-1.2*
CT HEAD W/O CONTRAST [**2195-4-7**] 9:23 AM
CT HEAD W/O CONTRAST
Reason: eval ICH
[**Hospital 93**] MEDICAL CONDITION:
47M rollover mvc
REASON FOR THIS EXAMINATION:
eval ICH
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 47-year-old with rollover motor vehicle collision.
Evaluate for intracranial hemorrhage.
COMPARISON: None.
TECHNIQUE: Non-contrast head CT.
FINDINGS: No intra- or extra-axial bleed, masses, mass effect,
or shift of normally midline structures is noted. The ventricles
and sulci are normal in size and configuration. The [**Doctor Last Name 352**] and
white matter differentiation is well preserved. No acute major
vascular territorial infarcts are evident.
No acute fractures. Mild mucosal thickening in left maxillary
sinus and moderate opacification of bilateral anterior and
posterior ethmoid air cells, likely secondary to patient's
intubation is noted. The mastoid air cells are well pneumatized.
The remainder of the soft tissue structures are unremarkable.
IMPRESSION: No acute intracranial process or hemorrhage.
CT C-SPINE W/O CONTRAST [**2195-4-7**] 9:23 AM
FINDINGS: A focus of ovoid hyperdense material is noted in the
posterior nasopharynx. This could represent a foriegn body,
possibly post-intubation chipped dental enamel. There are no
acute fractures or alignment abnormalities of the cervical
spine. The atlanto- occipital atlanto- axial articulations are
preserved. The facet joints well aligned. The paravertebral soft
tissues are unremarkable. Endotracheal tube is present in
standard location with balloon inflated 1.6 mm below the vocal
cord. Right posterior first and second rib and left posterior
first rib fractures are evident. There is soft tissue emphysema
coursing along the left posterior intramuscular planes. Apical
chest tube with a left apical pneumothorax is also noted. There
is opacification of bilateral ethmoid air cells, likely due to
intubation. Multiple prominent lymph nodes measuring up to 8 mm
in short axis not enlarged by CT criteria.
IMPRESSION:
1. No acute fractures or alignment abnormalities of the cervical
spine.
2. Right first rib and bilateral second rib fractures.
3. Left apical pneumothorax and soft tissue emphysema.
4. Layering hyperdense material in the posterior nasopharyngeal
wall of uncertain etiology, may represent chipped dental enamel,
post intubation, clinical correlation is recommended.
RADIOLOGY Final Report
ELBOW, AP & LAT VIEWS LEFT PORT [**2195-4-7**] 4:30 PM
FINDINGS: Subluxation at the left elbow is noted. The olecranon
is posteriorly subluxed with respect to the humerus, and the
trochlea appears to be perched on the coronoid process of the
proximal ulna. Widening of the radiocapitellar joint is noted
along the radial aspect of the elbow joint. No definite
underlying fracture is seen. Diffuse soft tissue swelling is
noted.
IMPRESSION:
Subluxation at the left elbow joint including subluxation of the
olecranon with respect to the distal humerus.
Cardiology Report ECG Study Date of [**2195-4-7**] 9:28:44 AM
Baseline artifact. Sinus tachycardia. Left axis deviation.
Persistent
S waves to lead V6 may be related to axis. ST-T wave
abnormalities.
Clinical correlation is suggested. No previous tracing available
for
comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
152 0 [**Telephone/Fax (3) 78813**] 0 111 -84
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 78814**] (Complete)
Done [**2195-4-20**] at 2:17:45 PM FINAL
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. A patent foramen ovale is present.
2. Overall left ventricular systolic function is normal
(LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the descending thoracic aorta.
5. The aortic wall is thickened consistent with an intramural
hematoma.
6. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. 7. There is
no pericardial effusion.
Post-stent deployment.
1. There is a enhancement at the junction of the aortic arch and
descendiong thoracic aortic consistent with a stent.
Brief Hospital Course:
He was admitted to the Trauma Service. Vascular and Orthopedics
Surgery were also consulted because of his injuries. His
vascular injury - aortic tear with
associated para-aortic hematoma at thoracic T4-5 level was not
repaired initially as he was deemed stable and required repair
of his other multiple injuries more urgently. He was taken to
the operating room for exploratory laparotomy and placement of
his left chest tube by Trauma Surgery. Orthopedics also
performed irrigation and debridement of the open left elbow
wound and closed reduction of the fracture same site. There were
no intraoperative complications; postoperatively he was taken to
the Trauma ICU. Two days later he was taken back to the
operating room for placement of IVC filter and insertion of
superior left chest tube; also underwent by Orthopedic surgery
sacroiliac screw fixation of left hemipelvis and examination
under anesthesia left elbow with irrigation and debridement left
elbow laceration down to fascia. A left elbow external fixator
remains in place; he will follow up in [**Hospital 5498**] clinic 2
weeks after discharge. He remained in the ICU for approximately
2 weeks and was then transferred to the regular nursing unit.
During this time it became apparent that his blood loss was into
the left buttock where he had a Morel-[**Last Name (un) 66188**] type degloving.
This remained stable and did not require I&D.
He was later taken to the operating room on [**4-20**] by Vascular for
stent graft repair of aortic injury. There were no
intraoperative complications. He will follow uo in [**Hospital **]
clinic in about 6 months for repeat CT angiogram.
He was evaluated by Speech Language Pathology for evaluation of
his oral and pharyngeal swallow function. He was recommended for
a video swallow which showed mild oral residue and residue seen
in the valleculae and piriform sinuses without any evidence of
aspiration. He is on a soft solid diet and can have thin
liquids.
Because of his extensive injuries Physical and Occupational
therapy were consulted early and have continued to work with
him. He has made slow gains and is being recommended for rehab
post acute hospitalization.
Social work has followed patient and his family closely
throughout his stay; several family/team meetings were held to
keep family informed of patient's status given his multiple
injuries.
Medications on Admission:
Adderal
Lexapro 10'
Klonopin 1'''
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day): hold for HR<60; SBP<110.
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed
for constipation.
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
7. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
9. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day): hold for increased sedation.
11. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime):
hold for loose stools.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
s/p Rollover motor vehicle crash
Injuries:
*Left flail chest (s/p chest tube)
*Rib fractures: L 1, [**2-8**]; R [**12-3**]
*Left L1, L2 and Right Transverse Process fractures
*Dislocated left elbow
*Pelvic hematoma
*Hemoperitoneum
*Inf/sup pubic rami fractures
*Grade 2 splenic lac
*Left renal lac
*Morel Lavalee injury
Discharge Condition:
Good
Followup Instructions:
Follow up in 1 - 2 weeks with Dr. [**Last Name (STitle) 914**], Cardiac Surgery, call
[**Telephone/Fax (1) 170**] for an appointment.
Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Trauma Surgery, call
[**Telephone/Fax (1) 6429**] for an appointment.
Follow up in [**Hospital 5498**] clinic in 2 weeks with Dr. [**Last Name (STitle) 1005**]
call [**Telephone/Fax (1) 1228**] for an appointment.
Follow up with Dr. [**Last Name (STitle) **], Vascular Surgery. You should
see him in 6 months. You will have a CT Angiogram at the time so
please inform the office of this when you call to schedule your
appointment; tel number [**Telephone/Fax (1) 2625**].
Completed by:[**2195-4-24**]
|
[
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"812.50",
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"482.83",
"807.4",
"287.5",
"401.9",
"861.21",
"866.02",
"300.4",
"805.6",
"482.82",
"441.2",
"458.29",
"458.9",
"805.4",
"997.4",
"560.1",
"865.03",
"482.49",
"868.04",
"808.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"54.11",
"96.05",
"79.01",
"88.42",
"38.7",
"78.12",
"79.61",
"38.93",
"39.73",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
10674, 10744
|
7117, 9491
|
367, 1094
|
11108, 11115
|
2073, 2659
|
11138, 11835
|
1845, 1862
|
9575, 10651
|
2696, 2713
|
10765, 11087
|
9517, 9552
|
1877, 2054
|
274, 329
|
2742, 7094
|
1122, 1753
|
1775, 1796
|
1812, 1829
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,679
| 175,371
|
13720
|
Discharge summary
|
report
|
Admission Date: [**2150-6-23**] Discharge Date: [**2150-6-30**]
Date of Birth: [**2081-1-9**] Sex: F
Service: SURGERY
Allergies:
Percocet / Aspirin / Tylenol / Morphine
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
end stage renal disease admitted for kidney transplantation
Major Surgical or Invasive Procedure:
[**2150-6-23**] - deceased donor renal transplant
[**2150-6-26**] - cardioversion
History of Present Illness:
Patient is a 69 year old female with ESRD [**12-22**] HTN maintained on
peritoneal dialysis for the past 3 years. Her last hemodialysis
was the night prior to presenting for transplant operation. At
the time of admission patient had no active issues, she was
afebrile, had no nausea or vomiting. Patient had no recent
hospitalizations.
Past Medical History:
- ESRD [**12-22**] HTN
- partial colectomy for colonic polyps
- thyroid resection for benign disease
- ventral hernia repair
- ichemic left leg s/p common femoral and profunda
endarterectomy, SFA embolectomy, four compartment
fasciotomies
Social History:
- married, lives at a farm house with her husband
- has 2 daughters and 1 son (one daughter and a son lives within
a block of the patient)
Family History:
Noncontributory
Physical Exam:
gen: WD/WA, NAD, AOOX3
CV: RRR, nl S1, S2, no murmur appreciated
pulm: CTAB
abdomen: Soft/NT/ND, well healed midline scar, PD site c/d/i,
post-tranplant incision is c/d/i, there is no edema, no
erythema, no drainage
extremities: no c/c, 1+ pitting edema left LE, 4 incision
fasciotomy scars
well healed on left foot
Pulses: 2+ femoral b/l, 1+ Right DP/PT, 2+ left DP/PT
neuro: CN II - XII intact
Pertinent Results:
admission [**2150-6-23**]:
[**2150-6-23**] 10:32AM GLUCOSE-135* UREA N-52* CREAT-8.2* SODIUM-141
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-28 ANION GAP-15
[**2150-6-23**] 10:32AM CALCIUM-8.5 PHOSPHATE-3.0 MAGNESIUM-1.4*
[**2150-6-23**] 10:32AM WBC-4.8 RBC-3.25* HGB-10.5* HCT-32.7*
MCV-101* MCH-32.2* MCHC-32.1 RDW-16.3*
[**2150-6-23**] 10:32AM PLT COUNT-286
[**2150-6-23**] 09:57AM TYPE-ART PO2-209* PCO2-40 PH-7.42 TOTAL
CO2-27 BASE XS-1 INTUBATED-INTUBATED VENT-CONTROLLED COMMENTS-OR
16
[**2150-6-23**] 09:57AM GLUCOSE-102 LACTATE-1.7 NA+-136 K+-3.7
CL--99*
[**2150-6-23**] 09:57AM HGB-9.8* calcHCT-29
[**2150-6-23**] 09:57AM freeCa-1.09*
[**2150-6-23**] 09:00AM TYPE-ART PO2-170* PCO2-35 PH-7.50* TOTAL
CO2-28 BASE XS-4 INTUBATED-INTUBATED VENT-CONTROLLED
[**2150-6-23**] 09:00AM GLUCOSE-95 LACTATE-1.8 NA+-135 K+-3.4*
CL--99*
[**2150-6-23**] 09:00AM HGB-9.3* calcHCT-28
[**2150-6-23**] 09:00AM freeCa-0.89*
[**2150-6-23**] 03:16AM UREA N-55* CREAT-9.1* SODIUM-140
POTASSIUM-5.6* CHLORIDE-98 TOTAL CO2-28 ANION GAP-20
[**2150-6-23**] 03:16AM estGFR-Using this
[**2150-6-23**] 03:16AM ALT(SGPT)-18 AST(SGOT)-54*
[**2150-6-23**] 03:16AM ALBUMIN-3.5 CALCIUM-7.8* PHOSPHATE-3.3
MAGNESIUM-1.7
[**2150-6-23**] 03:16AM WBC-8.1 RBC-3.56* HGB-11.1* HCT-35.9*#
MCV-101* MCH-31.0 MCHC-30.8* RDW-15.4
[**2150-6-23**] 03:16AM PLT COUNT-354
[**2150-6-23**] 03:16AM PLT COUNT-354
discharge:
[**2150-6-30**] 05:20AM BLOOD WBC-6.1 RBC-3.20* Hgb-9.9* Hct-31.6*
MCV-99* MCH-31.0 MCHC-31.4 RDW-15.9* Plt Ct-315
[**2150-6-30**] 05:20AM BLOOD PT-14.9* PTT-25.9 INR(PT)-1.3*
[**2150-6-30**] 05:20AM BLOOD Glucose-95 UreaN-21* Creat-1.6* Na-136
K-4.4 Cl-105 HCO3-22 AnGap-13
[**2150-6-28**] 03:41PM BLOOD CK(CPK)-27
[**2150-6-28**] 05:44AM BLOOD ALT-5 AST-14 CK(CPK)-23* AlkPhos-116
TotBili-0.6
[**2150-6-30**] 05:20AM BLOOD Calcium-9.6 Phos-2.4* Mg-1.4*
[**2150-6-26**] 06:01AM BLOOD TSH-0.52
[**2150-6-30**] 05:20AM BLOOD tacroFK-10.5
imaging:
ECG [**2150-6-25**]
Sinus rhythm. First degree A-V block. Premature atrial
contractions.
Non-specific ST-T wave changes. Compared to the previous tracing
of [**2150-6-23**]
QRS changes in leads V2-V3 could be due to lead placement.
ECG [**2150-6-26**]
Narrow complex tachycardia is sprobably due to sinus tachycardia
with a
long P-R interval. Diffuse ST-T wave changes are likely due to
the rate.
Compared to the previous tracing of [**2150-6-25**] atrial premature
beats are not seen. the overall rate has increased. The ST-T
wave changes are now more prominent, though they likely reflect
repolarization abnormalities from a fast heart rate.
CXR [**2150-6-27**]
IMPRESSION: No evidence of failure. No cardiomegaly.
Portable TTE [**2150-6-29**]
IMPRESSION: Normal regional and global biventricular systolic
function. Mild mitral regurgitation.
Brief Hospital Course:
HD1 [**2150-6-23**] Patient presented to the hospital and had a kideny
transplant done on the day of admission. She tolerated surgery
well, her post-operative course in the PACU was uneventful and
she was transferred to the floor in stable condition. Her pain
was controlled with PCA dilaudid.
HD2 [**2150-6-24**] Patient was stable. Her urine output increased very
shortly after the operation; she made about 400mL of urine in
the initial 12 hours post-op and her creatinine decreased from
8.2 to 6.8. Her JP output was replaced with 1cc per 1cc
replacement. She also recieved maintainence IV fluids. She was
started on the sips of clears and continued to have PCA in
place, yet had a minimal pain requirement. Her anticoagulation
was resumed, she received coumadin 2mg. There were no
cardiovascular or pulmonary issues.
HD3 [**2150-6-25**] Patient's creatinine decreased further to 3.7. Her
urine output increased to over 2200mL in 24 hours. Her JP output
was now replaced with 1/2cc per 1cc, the maintaince IV fluids
continued. Patient developed chest pain and shortness of breath.
The work up was done, she had chest x-ray, EKG and cardiac
enzymes sent out, which were all negative for any sign of
cardiac ischemia. Her blood pressure increased a little but
during the episode and she was tachycardic to 100, yet never
experienced any oxygen desaturation. In the afternoon, patient
developed cardiac arrythmia, atrial flutter. She recieved
metoprolol IV pushes, to which she did not respond. Her blood
pressure and heart rate remained elevated, her oxygen saturation
was close tp 100% on room air, she was tachypnic. Cardiology was
consulted. The recommendation was to increase metoprolol to 50mg
[**Hospital1 **], TTE was ordered for next day and the plan was to cardiovert
the patient the next morning.
She was started on Wellbutrin 75 mg [**Hospital1 **]. She recieved coumadin
2mg.
HD4 [**2150-6-26**] Her urine output was over 2L with still
downtreanding creatinine level. Her cardiovascular status has
not changed and the cardioversion was attempted unsuccesfully.
Her medical managment was changed to metoprolol 75mg tid after
cardioversion. Her tachypnea in 100s and hypertension in
150s/90s continued. Her Wellbutrin was increased to her home
dose of 150mg [**Hospital1 **]. She did not recieve her coumadin as she was
supratherapeutic. She tolerated regular diet. The foley was
removed.
HD5 [**2150-6-27**] Patient's creatinine decreased further, her urine
output was over 2L for the past 24 hours. She continued to be
tachycardic now in 120- 150s and hypertensive. The change was
made by cardiology and she was started on metoprolol 100mg tid
and sotalol 40mg once daily. Later in the afternoon,
electrophysiology fellow recommended that we stop the sotalol
and start digoxin. She recieved one dose of digoxin that day. In
the late evening patient was unchanged and develop shortness of
breath, her heart rate was in 130-150s, bp was 160-170s/90-100s.
She was transferred to ICU and started on amiodarone taper, her
metoprolol was increased to 150mg tid. Her coumadin was held.
Patient tolerated regular diet.
HD6 [**2150-6-28**] Patient's urine output has dropped, but she was
still making urine and her creatinine was downward trending. Her
arrythmia resolved in the afternoon, yet she remained
tachycardic and hypertensive. She recieved 24 hour IV amiodarone
taper and was subsequently switched to an oral amiodarone. Her
chest pain has resolved, all the workup was negative for an
ischemic event. She continued to tolerate regular diet.
HD7 [**2150-6-29**] Patient's urine output increased again and her
creatinine was down to 1.6. Norvasc and hydralazine were added
and adequate blood pressure control was achieved. Patient had no
chest pain and continued to be in sinus rythm. She was
transferred from the ICU to the floor. She tolerated regular
diet. She recieved 0.5mg of coumadin.
HD8 [**2150-6-30**] Patient's creatinine is still improving with good
urine output. There were no cardiac issues at this time. The
blood pressure was controlled in 140-150s/80-90s range. She
tolerated regular diet.
Throughout her hospitalization patient was afebrile. She did not
have any infections and recieved no antibiotics. She denied any
nausea, vomiting, diarrhea, constipation, chest pain, shortness
of breath or pain at the time of dicharge. She was discharged
with the JP drain in place.
Medications on Admission:
Alendronate 35 qmonth, Amlodipine 10', atenolol 25',
nephrocaps 1', bupropion 150", calcium acetate 1334 QIDWMHS,
sensipar 30', EPO, nexium 40', lactulose 30", lisinopril 10',
KCL
20', simvastatin 20', renagel 800'''', sucralfate 2''', coumadin
2' on Mon and Fri, 1' TWThSSun
Discharge Medications:
1. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO every eight
(8) hours.
Disp:*30 Tablet(s)* Refills:*1*
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
Disp:*60 Capsule(s)* Refills:*2*
4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
6. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
7. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. 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*
9. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
10. Bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
11. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
12. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 2 weeks: take 400mg twice daily for 2 weeks, then
take 200mg twice daily for 4 weeks .
Disp:*56 Tablet(s)* Refills:*0*
15. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 4 weeks.
Disp:*56 Tablet(s)* Refills:*0*
16. Alendronate 35 mg Tablet Sig: One (1) Tablet PO once a
month.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
end stage renal disease s/p deceased donor renal transplant
new onset cardiac arrythmia/ atrial flutter
Discharge Condition:
stable
Discharge Instructions:
You are going home with your immunosupression medications.
Please call transplant coordinator with any questions you may
have regarding the medications or any other concerns/questions.
The JP drain has not yet been removed, as it continues to drain
fair amount of fluid. The VNA services will visit you at home
and help with the JP drain managment. Dr. [**Last Name (STitle) **] will see you
in clinic and will determine when the JP will come out. It will
be removed at the clinic. You may shower with the drain in
place.
You may eat regular diet, but ideally low in sodium and
potassium to protect your new kidney. You may resume your
previous activities as tolerated, however no heavy lifting for
at least a month. You may keep the incision uncovered. You may
shower with the staples in place. Staples will be removed at the
clinic in a few weeks.
Please monitor your output. If it drops significantly, please
call the transplant coordinator or come to the emergency room.
Also, if you develop any drainage from your incision, fever,
nausea, vomiting or significant pain, shortness of breath, chest
pain or palpitations please call the coordinator or go to
emergency room.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2150-7-2**] 1:40
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK
Date/Time:[**2150-7-2**] 3:00
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2150-7-9**] 3:20
Provider: [**Name10 (NameIs) **], [**Name11 (NameIs) **], MD Phone: [**Telephone/Fax (1) 32935**]
Date/Time:[**2150-7-13**] 10:30
Completed by:[**2150-6-30**]
|
[
"585.6",
"403.91",
"427.32",
"427.31",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.69",
"99.61",
"00.93"
] |
icd9pcs
|
[
[
[]
]
] |
10962, 11013
|
4528, 8944
|
357, 441
|
11161, 11170
|
1692, 4505
|
12396, 12970
|
1243, 1260
|
9271, 10939
|
11034, 11140
|
8970, 9248
|
11194, 12373
|
1275, 1673
|
258, 319
|
469, 808
|
830, 1071
|
1087, 1227
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
703
| 124,912
|
46151
|
Discharge summary
|
report
|
Admission Date: [**2106-8-6**] Discharge Date: [**2106-8-8**]
Date of Birth: [**2032-3-8**] Sex: M
Service: MEDICINE
Allergies:
Phenergan
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Confusion, Rigors
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
74yo M with h/o CAD s/p CABG, DMII, HTN and CRI who underwent
elective ERCP today for intrahepatic duct stone seen on MRI
evaluation for renal cysts. ERCP was complicated in that
multiple attempts were made for gallstone extraction in the CBD
and intrahepatic ducts. The patient went to recovery area where
he did well for approx 2 hrs post procedure. He rec'd 25mg
phenergan at 4pm for nausea. 45 minutes later, the patient was
found in the bathroom, confused with peripheral IV pulled out.
He was not oriented to place or time. He was also noted to be
rigoring. His slightly hypotn, tachycardic and hypoxic at this
time, SBP 80-90s, HR 90's, SaO2 80s. He remained afebrile (98.3)
despite rigors. He was given 25mg of demerol for rigors. He was
placed on NRB, given add'l NS bolus x 1 L, and EKG obtained.
Labs, Blood Cx x 2, UA, UCx sent, patient given levofloxacin
500mg x 1 and flagyl 500mg x 1. Sent to [**Hospital Unit Name 153**] for further care.
In the [**Hospital Unit Name 153**] he has had a short stay; he was treated with unasyn
and agressive IV fluids to maintain pressure, but he required no
pressors. He returned quickly to baseline and is sent to the
floor and accepted by us on the next day.
Past Medical History:
1. CAD, status post CABG in [**2104-6-5**].
2. Hypertension.
3. Hypercholesterolemia.
4. Gastroesophageal reflux disease.
5. Benign prostatic hypertrophy.
6. Cholelithiasis, status post ERCP in [**2104-5-6**].
7. Cholelithiasis, status post laparoscopic to open
cholecystectomy, cholangiogram, resection of hepatic rim on
gallbladder on [**2105-3-15**].
8. basal cell ca.
Social History:
Married, lives with wife, Significant for moderate ETOH, remote
history of tobacco. The patient quit 15 years ago, about 35 pack
year.
Family History:
non contributory
Physical Exam:
PHYSICAL EXAMINATION (on admission to floor):
VITAL SIGNS: T 98 BP 123/53 HR 78 RR 16 100% NRB
GENERAL: Elderly man, confused, somnolent but arousable
HEENT: PERRL, anicteric, EOMI, sl dry MM
LUNGS: Clear to auscultation bilaterally.
CARDIOVASCULAR: S1, S2. RRR, no MRG.
ABDOMEN: Mildly obese, soft, nontender, nondistended, + BS.
Midline scar (CABG), oblique scar (cholecystectomy in the past)
EXTREMITIES: Without edema, warm, [**2-7**]+ DPs
Neuro: Alert and oriented x 3
Pertinent Results:
[**2106-8-7**] 05:15AM BLOOD WBC-10.3# RBC-3.67* Hgb-11.6* Hct-34.0*
MCV-93 MCH-31.7 MCHC-34.2 RDW-13.2 Plt Ct-119*
[**2106-8-7**] 05:15AM BLOOD Neuts-85.8* Bands-0 Lymphs-8.7* Monos-3.8
Eos-1.2 Baso-0.5
[**2106-8-7**] 05:15AM BLOOD Plt Ct-119*
[**2106-8-7**] 05:15AM BLOOD PT-13.3 PTT-27.0 INR(PT)-1.1
[**2106-8-7**] 05:15AM BLOOD Glucose-110* UreaN-16 Creat-0.9 Na-140
K-3.4 Cl-112* HCO3-20* AnGap-11
[**2106-8-7**] 05:15AM BLOOD ALT-33 AST-26 LD(LDH)-162 CK(CPK)-82
AlkPhos-43 Amylase-63 TotBili-0.9
[**2106-8-7**] 12:26AM BLOOD CK(CPK)-75
[**2106-8-7**] 05:15AM BLOOD Lipase-29
[**2106-8-7**] 05:15AM BLOOD CK-MB-2 cTropnT-<0.01
[**2106-8-7**] 05:15AM BLOOD Albumin-2.9* Mg-1.4*
Brief Hospital Course:
74yo M with CAD, DMII, HTN, CRI s/p ERCP presented with hypoxia,
hypotension, tachycardia and MS changes. He was admitted to the
ICU.
1. Shock: likely related to bacteremia/sepsis from ERCP and
stone extraction. He was initially treated presumtively for
bacteremia with Unasyn for possible GI flora from translocation
from ERCP vs. cholangitis. Blood and Urine cultures were sent.
His MAP was maintained >60 with IVF NS boluses. His O2
saturation was maintained >92% on 2L NC. The patient in a few
hours became stable, afebrile, saturation 98% on room air. He is
kept on levofloxacin and flagyl x 7-10 days. We will follow up
on culture results.
2. Choledolitiasis: the patient is discharged on ursodiol tid as
per GI recs.
2. CAD: h/o CABG, event post-procedure. There was no evidence
of ischemia on EKG, cardiac enzymes negative. He is continued
on ASA and atorvastatin. His antihypertensive medications were
held but he was given prescriptions to re-start his usual
regimen upon discharge, as his BP was becoming elevated on no
meds one hour prior to discharge.
3. DMII: Blood sugars were monitored q4. He was on sliding
scale insulin, and able to eat a normal diet.
4. CRI: Last creatinine 0.9. No edema. Good urine output.
5. FEN: Diabetic Diet
6. PPI: PPI, TEDs if needed. Patient is ambulatory.
7. Code: Full
Medications on Admission:
MEDICATIONS:
Prilosec 20 once daily
Lipitor 40 once daily
Lopressor 100 b.i.d.
Enalapril 10 once daily,
Hydrochlorothiazide 25 once daily
Aspirin 325 once daily
Multivitamin one a day.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin Calcium 40 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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
6. Multi-Vitamin Oral
7. Lopressor 100 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
1. Choledocholithiasis
2. Septic Shock
SECONDARY DIAGNOSIS
1. Coronary Artery Disease
2. Hypertension
3. Benign Prostatic Hyperplasia
4. GERD
5. DM type II
Discharge Condition:
Able to ambulate without assistanceBreathes well on room airEats
a normal diet without nausea or vomitingFeels very well
Discharge Instructions:
Call your PCP or go to the ED for any concerning symptoms, such
as fever, dizziness, abdominal pain, chest pain or shortness of
breath
Take your medications as prescribed
Followup Instructions:
Follow up with Dr [**Last Name (STitle) 98167**] [**Name (STitle) **] Phone number [**Telephone/Fax (1) 1247**]
within two to three weeks after discharge.
You need to have an abdominal MRI in [**4-11**] months to follow up on
your hepatic lesion and renal cyst.
|
[
"272.0",
"250.00",
"600.00",
"530.81",
"785.52",
"V45.81",
"995.94",
"574.50",
"998.59",
"038.9",
"401.9",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.88"
] |
icd9pcs
|
[
[
[]
]
] |
5794, 5800
|
3344, 4676
|
283, 289
|
6021, 6143
|
2637, 3321
|
6363, 6628
|
2096, 2114
|
4911, 5771
|
5821, 6000
|
4702, 4888
|
6167, 6340
|
2129, 2618
|
226, 245
|
317, 1531
|
1553, 1927
|
1943, 2080
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,915
| 121,756
|
30043
|
Discharge summary
|
report
|
Admission Date: [**2137-3-13**] Discharge Date: [**2137-3-29**]
Date of Birth: [**2061-5-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Esophageal cancer
Major Surgical or Invasive Procedure:
Transhiatal esophagectomy, partial pancreatic resection,
splenectomy, J-tube placement
Picc line placement
History of Present Illness:
75-year-old male with recently diagnosed cancer of distal
esophagus (adenocarcinoma). Cancer is of unclear depth with 1
FDG-avid paraesophageal node on PET that was FNA-negative. He
denies any dysphagia and has no pain.
Past Medical History:
GERD, HTN, hyperlipidemia, distal esophageal adenoCA
Social History:
Tobacco: 7-pack-year smoking history, quit 35 years ago.
EtOH: one to two alcoholic beverages a day.
Has 3 adult children, healthy.
He works as a clothing presser
Family History:
HTN, hypercholesterol. His mother lived to age [**Age over 90 **]. His father
died in a
drowning accident, and his children remain healthy.
Physical Exam:
T: 98.5 HR: 93 BP: 144/50 RR: 22 O2Sat: 94%
Gen: AAOx3, NAD
Heart: RRR, no murmur
Lungs: CTAB
Abd: +BS, soft, NT, ND
Incision: Neck and abdominal incisions C/D/I
Extr: 1+ edema
Pertinent Results:
[**2137-3-15**] ABD DRAIN FLUID Amylase 3721 IU/L
[**2137-3-20**] Amylase (Abd drain) 6600 IU/L
.
PATHOLOGY:
PLEURAL FLUID: NEGATIVE FOR MALIGNANT CELLS
OR SPECIMEN:
SPECIMEN SUBMITTED: PORTA HEPATIS LYMPH NODE FS, ESOPHAGUS AND
PROXIMAL STOMACH, LEFT GASTRIC LYMPH NODES, SPLEEN, TAIL OF
PANCREAS, OMENTUM DEPOSIT (6).
Procedure date [**2137-3-13**]
DIAGNOSIS:
I. Porta hepatitis lymph node (A-B):
1. Hyperplasia and lipogranulomas.
2. No neoplasm.
II. Left gastric lymph node (C-L):
Three lymph nodes: No malignancy identified.
III. Omental deposit (M):
1. Organizing hematoma and fat necrosis.
2. No carcinoma.
IV. Tail of pancreas (N-P):
1. Focus of fresh hemorrhage.
2. Microscopic foci of pancreatic intraepithelial neoplasm with
low grade dysplasia (PanIN 1)
3. The margin is free of dysplasia, and there is no carcinoma.
V. Spleen (Q-T):
1. Focus of fresh hemorrhage.
2. No carcinoma.
VI. Esophagus and proximal stomach (U-AK):
1. Adenocarcinoma of the distal esophagus, arising in glandular
dysplasia; see synoptic report.
2. Glandular metaplasia of the esophagus, consistent with
Barrett's esophagus.
3. Segment of stomach, within normal limits.
4. Squamous epithelium at the proximal margin, and gastric
corpus mucosa at the distal margin.
Esophagus: Resection Synopsis
MACROSCOPIC
Specimen Type: Esophagogastrectomy.
Tumor site: Distal esophagus.
Tumor Size
Greatest dimension: Dysplasia and carcinoma involving
distal 4 cm.
MICROSCOPIC
Histologic Type: Adenocarcinoma.
Histologic Grade: G1: Well differentiated.
EXTENT OF INVASION
Primary Tumor: pT1a: Tumor invades lamina propria.
Regional Lymph Nodes: pN0: No regional lymph node metastasis.
Lymph Nodes
Number examined: 4.
Number involved: 0.
Distant metastasis: pMX: Cannot be assessed.
Margins
Proximal margin: Uninvolved by invasive carcinoma.
Distal margin: Uninvolved by invasive carcinoma.
Circumferential (adventitial) margin: Uninvolved by
invasive carcinoma.
Distance of invasive carcinoma from closest margin: 8 mm.
Specified margin: Adventitial.
Lymphatic (Small Vessel) Invasion: Absent.
Venous (Large vessel) invasion: Absent.
Clinical: Esophageal cancer.
IMAGING:
CHEST (PORTABLE AP) [**2137-3-15**] - Small bilateral pleural
effusions and retrocardiac atelectasis versus air space
consolidation
CHEST (PORTABLE AP) [**2137-3-16**] - Increased pulmonary parenchymal
density which may represent developing edema.
CHEST (PORTABLE AP) [**2137-3-17**] - Clearing of pulmonary vascular
congestion. No other significant interval change
CHEST (PORTABLE AP) [**2137-3-20**] - Stable moderate bilateral
pleural effusions with increasing left basilar atelectasis or,
less likely, consolidation
ESOPHAGUS [**2137-3-20**] - Normal esophagogastric anastomosis without
evidence of leak or stricture
CHEST (PA & LAT) [**2137-3-21**] - no pneumomediastinum or
pneumothorax
Chest CT : [**2137-3-24**]:
IMPRESSION:
1. Segmental right upper and right middle lobe pulmonary emboli.
2. Small mediastinal lymph nodes and a tiny 3-mm pleural-based
left upper lobe pulmonary nodule. In a patient with a known
malignancy, followup CT scan in [**2-5**] months is recommended.
3. Small bilateral pleural effusions with adjacent lower lobe
atelectasis.
4. Status post left splenectomy. There is a simple fluid
collection anterior to the pancreatic head which probably
represents a seroma.
5. Small 9-mm pancreatic head cyst. Interval 3- to 6-month CT
followup is recommended for this finding as well.
6. Diffuse pancolonic diverticula.
7. Adrenal hyperplasia
8. Solitary sub-cm. gallbladder polyp.
[**2137-3-25**]
CT guided needle aspirate of abd collection:
IMPRESSION: Successful CT-guided aspiration of a peripancreatic
fluid collection anterior to the head of the pancreas. 30 mL of
nonpurulent, brownish, non-foul smelling fluid was aspirated and
sent for microbiology, amylase, lipase, and bilirubin, which are
currently pending.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted and underwent his operation on [**2137-3-13**].
His operative course was complicated by splenectomy and distal
pancreatectomy. He otherwise tolerated the procedures well and
was transferred to the SICU post-op. He was eventually
transferred to the floor [**3-17**] where he did well.
His pain was controlled with an epidural and PCA. The acute
pain service was following closely. His epidural was removed on
[**3-17**]. His PCA was continued and he was eventually transitioned
over to dilaudid po, which controlled his pain well.
CV: Patient developed A. Fib on POD#1 and was started on an
amiodarone drip. He was hemodynamically stable without
requiring pressors/inotropes. He was eventually transitioned to
PO amiodarone taper and he converted back to and remained in
sinus rhythm since [**3-16**].
Respiratory: He arrived in SICU intubated and was extubated on
[**3-15**]. His follow-up CXRs revealed a left pleural effusion that
was tapped by IP on [**3-19**] that resulted in 500cc of
serosanguinous fluid. His pleural fluid had inflammatory cells
but was negative for malignant cells. Subsequent CXRs showed
stable bilateral pleural effusions. He responded well to
diuresis. His oxygen requirement remained high despite diuresis
and a Ct scan was done and subsegmenatl PE's were discovered.
Anticoagulation was started with a heparin drip and then
transitioned to lovenox. Coumadin was not started as of date of
discharge. LE duplex US were negative for DVT. He was
comfortable on supplemental oxygen via nasal canula and was
eventually discharged with oxygen.
GI: NPO with NGT until bowel function returned, NGT was removed
on [**3-19**] and was started on clears [**3-20**] and advanced to full
liquids. TF were started @30cc/hr [**3-15**] and was advanced to goal
of 70cc/hr.
GU: His UOP was stable throughout and the Foley catheter was
removed after the epidural was discontinued. A Foley had to be
replaced after failure to void on [**3-19**]. His Foley was then
removed on [**3-21**] and he voided afterwards.
Heme: His HCT decreased to 22.6 on [**3-15**]. This was most likely
secondary to mediastinal oozing post-op and he was transfused 2
units of blood followed by lasix. His HCT rose to 25.5 and
stablized there.
ID: spiked temp 101.4 w/ elevated WBC to 22K [**3-15**]. His blood
and urine were cultured and were negative for infection. His
WBC eventually returned to [**Location 213**] but on discharge was slightly
elevated to 13.9. However, he was afebrile and did not appear
toxic. A CT scan of the abd was done on [**2137-3-25**] and an abdomen
fluid collection at the head of the pancreas was seen and
subsequently tapped by IR and was non-infectious.
T/L/D: Post-op, he had an NGT, neck JP drain along with an
abdominal JP, a J-tube to gravity and a Foley catheter. The
neck JP and Foley catheter were eventually removed ([**3-20**] and
[**3-21**], respectively), the NGT was removed [**3-19**]. The abdominal
JP, which had an amylase level of 6600 ([**3-20**]) and the J-tube,
which was used for tubefeeds, remained after discharge. His
abdominal JP was placed to gravity bag prior to discharge.
Dispo: Physical therapy was consulted and had been working with
patient. He did well overall except for decreases in oxygen sat
with ambulation. Therefore, he was recommended to a [**Hospital1 1501**] with
supplemental oxygen after discharge.
Medications on Admission:
lansoprazole 30", atenolol 25', atorvastatin 10', HCTZ 12.5'
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed for
SOB/wheeze.
Disp:*1 * Refills:*1*
3. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO q3hrs prn.
Disp:*80 Tablet(s)* Refills:*0*
4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
5. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO twice a day.
6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for SOB/wheeze.
Disp:*1 * Refills:*1*
7. oxygen
2-3liters/min continous via nasal cannula. conserving device for
portability
8. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
10. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
[**Hospital1 **] (2 times a day): DO NOT START COUMADIN.
11. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 392**] Rehabilitation & Nursing Center - [**Hospital1 392**]
Discharge Diagnosis:
GERD, HTN, hyperlipidemia, distal esophageal adenoCA,
Esophageal adenocarcinoma
subsegmental pulmonary emboli
Discharge Condition:
deconditioned
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if you experience chest
pain, shortness of breath, fever, chills, nausea, vomiting,
diarrhea, or abd pain.
If your feeding tube sutures become loose or break, please tape
tube securely and call the office [**Telephone/Fax (1) 170**]. If your feeding
tube falls out, save the tube, call the office immediately
[**Telephone/Fax (1) 170**]. The tube needs to be replaced in a timely manner
because the tract will close within a few hours.
Do not put any medication down the tube unless they are in
liquid form.
Flush your feeding tube with 50cc every 8 hours if not in use
and before and after every feeding.
Please empty the abd drain daily and record the ouput. Bring a
record of the drainage to your clinic appointment. Any questions
reguarding the drain, please call [**Telephone/Fax (1) 170**].
Take your lovenox as instructed. you will NOT start coumadin( a
blood thinner ) until you have been instructed to do so by Dr.
[**Last Name (STitle) **].
Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) **] on thursday
[**2137-4-4**] at 11am in the [**Hospital Ward Name 23**] clinical center [**Location (un) **] . Please
arrive 45 minutes prior to your appointment and report to the
[**Hospital Ward Name 23**] clinical center [**Location (un) **] radiology for a CXR.
Completed by:[**2137-4-8**]
|
[
"998.2",
"V15.82",
"401.9",
"997.3",
"272.4",
"415.19",
"998.11",
"427.31",
"997.1",
"150.5",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"34.91",
"96.6",
"44.29",
"38.93",
"42.42",
"54.91",
"52.52",
"41.5",
"46.39"
] |
icd9pcs
|
[
[
[]
]
] |
10160, 10259
|
5347, 8787
|
339, 448
|
10414, 10430
|
1333, 5324
|
11502, 11864
|
973, 1116
|
8898, 10137
|
10280, 10393
|
8813, 8875
|
10454, 11479
|
1131, 1314
|
282, 301
|
476, 700
|
722, 777
|
793, 957
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,643
| 118,478
|
4431
|
Discharge summary
|
report
|
Admission Date: [**2107-9-27**] Discharge Date: [**2107-9-30**]
Date of Birth: [**2039-3-10**] Sex: M
Service: MEDICINE
Allergies:
Levaquin
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Respiratory Distress
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 68 year old male with history of severe COPD on 4L
home O2, CAD, HTN, Hyperlipidemia, and GERD who called EMS this
evening for worsening shortnesss of [**First Name3 (LF) 1440**]. Per the patient he
had increased frequency of urination throughout the day
yesterday. This was without any burning with urination or
malodorous, cloudy, or bloody urine. He denied any inability to
completely void or obstructive symptoms and reported that his
increased urination had resolved as of yesterday morning. Then,
later in the evening of [**9-27**] he had increased shortness of
[**Date Range 1440**] so he called EMS. He denies any chest pain, fevers,
chills, or night sweats. No hemoptysis. He reports continued
baseline thick sputums but doesn't think this was worse over the
last few days. He denies any leg swelling, orthopnea, or PND. He
reports no chest pain associated with this.
In the ED the patient was alert and oriented *3 at presentation
and was quite interacting laughing and joking with the staff
despite an O2 sat in the 80's on room air. He was also noted at
that time to by hypotensive to SBP's in the 70's-80s. After 2
liters of fluid his SBP's improved to the 100's and his
respiratory status improved dramatically after receiving
supplementary O2, inhalers, and one dose of azithromycin.
Currently, he reports his breathing status is coming back to his
baseline.
REVIEW OF SYSTEMS: Notable for left sided groin pain that he
reports has been going on for the last couple of days. Denies
fevers, chills, weight loss, chest pain, shortness of [**Date Range 1440**].
Denies cough. No [**Date Range **], hematochezia, hematemesis, or abdominal
pain. No dysuria or hematuria. No weakness or dizziness though
patient is not particularly physical active at baseline.
Past Medical History:
1. Severe COPD on 4 L O2 at home
2. History of VRE UTI
3. History of MRSA
4. CAD w/ NSTEMI ([**2101**]) (last cath in [**4-/2103**] w/o abnormalities.
5. Steroid induced hyperglycemia
6. Hypertension
7. Hyperlipidemia
8. Chronic low back pain after L1-2 laminectomy
9. Left shoulder pain for several months
10. Cataracts bilaterally - s/p surgery for both
11. GERD
12. BPH
13. History of resistant Pseduomonas PNA
Social History:
He is retired from working as a mechanic for [**Company **], where he
was frequently expposed to spray paint. He lives with his wife
in [**Location (un) 686**] with several children and grandchildren nearby. He
has not smoked tobaccos in 25 years and has not smoked marijuana
in 3 years. Very occasional EtOH.
Family History:
Mother w/ asthma, Alzheimer's disease. Father w/ [**Name2 (NI) 499**] cancer.
Physical Exam:
Vitals: Afebrile BP 115/80 HR 80 O2 100% on 2L
Gnl: NAD, Alert and oriented x 3
HEENT: Anicteric, MMM
CV: RRR, Normal S1 + S2, No murmurs, rubs or gallops
Resp: Clear to auscultation bilaterally, No wheezes or crackles
Abd: +Distention, no appreciable fluid wave, +TTP, no guarding,
no rebound, no discernable HSM
Extremities: No cyanosis, clubbing or edema
Neuro: AAOx3. Strength grossly intact throughout. No sensory
deficits to light touch appreciated.
Rectal (by ED resident): guaiac pos x2, dark red clot
Pertinent Results:
Labs on admission:
[**2107-9-27**] 10:33PM TYPE-ART TEMP-36.4 RATES-/18 O2 FLOW-2
PO2-79* PCO2-85* PH-7.28* TOTAL CO2-42* BASE XS-9 INTUBATED-NOT
INTUBA COMMENTS-NASAL [**Last Name (un) 154**]
[**2107-9-27**] 10:33PM LACTATE-2.6* K+-5.2
[**2107-9-27**] 10:30PM GLUCOSE-128* UREA N-31* CREAT-2.0*#
SODIUM-134 POTASSIUM-5.8* CHLORIDE-91* TOTAL CO2-35* ANION
GAP-14
[**2107-9-27**] 10:30PM CK-MB-NotDone proBNP-247*
[**2107-9-27**] 10:30PM cTropnT-0.03*
[**2107-9-27**] 10:30PM CK(CPK)-79
[**2107-9-27**] 10:30PM CALCIUM-9.9 PHOSPHATE-5.7*# MAGNESIUM-2.4
[**2107-9-27**] 10:30PM WBC-15.2* RBC-3.90* HGB-9.7* HCT-33.8* MCV-87
MCH-24.9* MCHC-28.7* RDW-15.9*
[**2107-9-27**] 10:30PM NEUTS-82.5* LYMPHS-10.0* MONOS-4.8 EOS-2.3
BASOS-0.4
[**2107-9-27**] 10:30PM PLT COUNT-398
[**2107-9-27**] 10:30PM PT-11.3 PTT-26.5 INR(PT)-0.9
Imaging:
CXR: CHEST, PORTABLE UPRIGHT FRONTAL VIEW: The lungs are
hyperinflated and lucent consistent with COPD. There is no focal
airspace consolidation or effusion. A horizontally oriented
linear lucent band across the inferior mediastinum corresponds
with the [**Month/Day/Year 499**] when compared to the previous chest CTA. The
aorta is markedly tortuous with vascular calcifications. Heart
size is normal. Hilar and mediastinal contours are stable.
IMPRESSION: COPD. No pneumonia.
Brief Hospital Course:
68 y.o. male with COPD, CAD, Hypertension, and Hyperlipidemia
presenting with increased shortness of [**Month/Day/Year 1440**] at home and found
to be hypoxic.
#) Respiratory Distress/ COPD Exacerbation: Unclear precipitant,
but he does report that his granddaughter who lives with himself
and his wife had a cold last week and does have a dry cough.
Likely viral illness precipitating exacerbation of RAD/asthma
component. No pneumonia on CXR. No swelling, JVD, or signs of
heart failure. Given dramatic improvement on measures
implemented so far will continue to treat for COPD exacerbation
and monitor. Given lack of headache/fever/myalgias or any active
viral prodrome did not feel inclined to test for flu at this
time as minimal presentation in MA so far and very unlikely to
be consistent with this. Continued on azithromycin 500 mg daily
and home inhalers. Patient switched from methylpred to 40 mg PO
prednisone daily starting on [**2107-9-28**]. Continued on albuterol
and albuterol/ipratroprium short acting nebs PRN, as well as
montleukast, fluticasone-salmeterol, and tiotroprium. After
transfer out of the MICU, his steroid taper was increased to
prednisone 60mg daily, with planes for a slow taper down to 20mg
daily, which he will continue. Additionally, he was continued
on azithromycin to complete a 5 day course. After two days on
the floor of continued nebulizer treatments, steroids and
antibiotics he felt that his breathing had returned to his
baseline and he felt that he was ready for discharge.
#) Hypotension: Patient had brisk response to fluids and
appeared dry on presentation. After fluid resuscitation his
blood pressure stabilized and after transfer to the floor he had
no further episodes of hypotension. At the time of discharge,
his blood pressure had increased and he was instructed to
restart his lisinopril when he returned home.
#)Acute renal failure: Patient's Cr on admission was 2 from
baseline of 0.6-0.7. Given dehydration and hypotension, it was
thought that there was a component of pre-renal but also concern
for hypoperfusion due to the hypotension. Urine studies and a
renal ultrasound were performed but his renal function rapidly
returned to his baseline with fluid resuscitation.
#) History of CAD: No signs of active ischemia on admission, but
did have slight increase in troponins with normal CK's, likely
due to strain in the setting of hypotension and decreased
clearance with his acute renal failure. Continued his
outpatient CAD medications, while in the hospital.
#) Chronic Pain: Remained stable, continued home regimen of
oxycodone/APAP and fentanyl patch.
#) Code Status: DNR/DNI
Medications on Admission:
1. Fentanyl 50 mcg/hr TD Q72hrs
2. Finasteride 5 mg daily
3. Alendronate 70 mg PO QMON
4. Fluticasone-Salmeterol 250-50, one inhalation twice a day.
5. Lactulose 20 gm Q8hr: PRN
6. Lorazepam 0.5 mg PO HS
7. Omeprazole 20 mg PO daily
9. Sertraline 50 mg PO once a day.
10. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet One Tablet
PO QMOWEFR
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
12. Calcium Carbonate 500 mg PO TID
13. Senna 8.6 mg 1-2 Tablets PO at bedtime as needed
14. Cholecalciferol 800 mg PO daily
15. Tiotropium Bromide 18 mcg once a day.
16. Lisinopril 5 mg PO DAILY.
17. Albuterol
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
1. COPD Exacerbation
2. Acute Kidney Injury
3. Hypotension
Secondary:
-History of Hypertension
-CAD
-Chronic Low Back Pain
Discharge Condition:
At the time of discharge patient felt he was breathing at his
baseline on 4LNC, afebrile, hypotension had resolved and he was
considered medically stable for discharge.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with shortness of [**Hospital1 1440**], due to an
exacerbation (worsening of your COPD). When you were admitted
you we also found that your kidneys were not working as well as
they had before and your blood pressure was low. You were given
IV fluids that helped your blood pressure and kidney function,
because we thought you were dehydrated. You were initially
admitted to the MICU because we were concerned about your
breathing. We treated your shortness of [**Hospital1 1440**] with steriods,
nebulizer treatments and azithromycin. After one night in the
ICU, your breathing and blood pressure had improved and you were
transferred to a medicine floor. We think that your breathing
worsened because you likely got a mild viral infection, which
caused you not to eat and drink much which made your blood
pressure lower and kidney function worsen. The viral infection
seems to have resolved.
.
After transfer out of ICU, your kidney function returned to
[**Location 213**] and you felt like your breathing was back to baseline.
We continued your nebulizer treatments, prednisone taper, and
azithromycin. After a few days in the hospital you felt like
your breathing had returned to your baseline, and you were ready
to go home. Physical therapy also worked with you, and felt
like you were safe to go home.
.
Changes made to your medication regimen:
1. Started Azithromycin 500mg daily to complete a 5 day course,
which will finish on
2. Started a prednisone taper: take 60mg for one more day, then
50mg for three days, then 40mg for three days, then 30mg for
three days, then take 20mg-you will continue to take 20mg unless
otherwise directed by Dr. [**Last Name (STitle) 575**]
3. Restart your lisinopril when you get home
***Continue to take all other medications as previously
directed***
.
Please call your doctor or return to the hospital if you have
more trouble breathing, chest pain, fever/chills, are unable to
eat or drink, have difficulty taking your medications or any
other concerning symptoms.
.
It was a pleasure taking care of you and we wish you the best!
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 8499**] your primary care doctor,
we made an appointment for you on [**10-17**] at 6:15pm.
.
You should also make an appointment to follow up with Dr.
[**Last Name (STitle) 575**], since you missed your last appointment, please call
the office to make an appointment.
|
[
"530.81",
"272.4",
"401.9",
"276.51",
"458.9",
"276.7",
"079.99",
"414.01",
"518.81",
"584.9",
"412",
"600.00",
"V13.02",
"724.2",
"493.92"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8242, 8300
|
4873, 7533
|
290, 296
|
8476, 8647
|
3515, 3520
|
10820, 11139
|
2888, 2967
|
8321, 8455
|
7559, 8219
|
8671, 10797
|
2982, 3496
|
1727, 2106
|
230, 252
|
324, 1708
|
3535, 4850
|
2128, 2545
|
2561, 2872
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,785
| 175,344
|
14751
|
Discharge summary
|
report
|
Admission Date: [**2188-2-22**] Discharge Date: [**2188-3-7**]
Date of Birth: [**2113-1-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain/Jaw pain/shortness of breath
Major Surgical or Invasive Procedure:
[**2188-2-29**] Redo sternotomy, Redo [**Month/Day/Year 8813**] valve replacement with a
size 23-mm [**Last Name (un) 3843**]-[**Doctor Last Name **] Magna pericardial valve
[**2188-2-29**] Exploration for postoperative hemorrhage following a
redo [**Month/Day/Year 8813**] valve replacement
History of Present Illness:
75 year old male who complains of Chest pain. He is s/p cardiac
cath [**1-28**] with 1 stent placed. Presented to OSH with sudden
onset of bilateral back pain and left jaw pain last night.
Symtpoms resolved in terms of pain after 2 hours but the he then
noted Shortness of breath on ambulation to the mailbox today. He
was seen at OSH and referred back to [**Hospital1 18**] given recent cardiac
stent. He is now being referred to cardiac surgery for
redo-[**Hospital1 8813**] valve replacement.
Past Medical History:
Dyslipidemia
Hypertension
Diabetes Mellitus
Congestive Heart Failure
Peripheral artery disease
Past Surgical History:
s/p CABG x2(LIMA to LAD, SVG to OM)/AVR (porcine [**Hospital1 43404**])
in [**2179**]
s/p Left Fem-[**Doctor Last Name **] bypass [**2176**]
s/p [**2188-1-30**] with drug-eluting stent deployment to RCA
Social History:
Race:Caucasian
Last Dental Exam:[**2187-11-9**]
Lives with:wife
Occupation:retired
Tobacco:smoked 1.5PPD for 30 years though quit 15 yrs ago
ETOH:2 vodka/night
Family History:
Father died of MI at age 71
Physical Exam:
Pulse:63 Resp:18 O2 sat: 97/Ra
B/P 121/54
Height:5'[**87**]" Weight:94.9 kgs
General:
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: systolic ejection murmur
with radiation to both left and right carotids; healed median
sternotomy incision
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: - Left: -
PT [**Name (NI) 167**]: - Left: -
Radial Right: + Left: +
Carotid Bruit
Right: referred murmur Left: referred murmur
Pertinent Results:
[**2188-2-26**] CT Chest: Status post [**Month/Day/Year 8813**] valve replacement and
sternotomy, status post CABG. Extensive coronary and
moderate-to-severe [**Month/Day/Year 8813**] calcifications. Mild centrilobular
emphysema, no evidence of pulmonary edema. Mild pleural
calcifications, several subpleural granulomas, none of which
requires followup. Small hiatal hernia.
[**2188-2-27**] Carotid U/S: Right ICA stenosis <40%. Left ICA stenosis
60-69%.
[**2188-2-29**] 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 moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Right ventricular chamber
size and free wall motion are normal. There are simple atheroma
in the ascending aorta. There are complex (mobile) atheroma in
the [**Month/Day/Year 8813**] arch. There are complex (mobile) atheroma in the
descending aorta. The transaortic gradient is higher than
expected for this type of prosthesis. The mitral valve leaflets
are mildly thickened. Mild (1+) mitral regurgitation is seen.
There is a very small pericardial effusion. Dr. [**First Name (STitle) **] was
notified in person of the results on Mrs. [**Known lastname 43400**] before
surgical incision. POST-BYPASS: Overall LVEF 45%. Normal RV
systolic function. Mild MR. [**First Name (Titles) **] [**Last Name (Titles) 43404**] is in place,
stable and functioning well with a mean gradient of 11 mm of HG.
Intact thoracic aorta.
[**2188-3-3**] CXR: In comparison with study of [**2-29**], the Swan-Ganz
catheter and nasogastric tubes have been removed. The patient
has taken a somewhat better degree of inspiration. Continued
enlargement of the cardiac silhouette with probable small
effusions and bibasilar atelectatic change. Coarse interstitial
markings persist.
[**2188-2-22**] 11:10AM BLOOD WBC-9.3 RBC-4.50* Hgb-13.1* Hct-37.1*
MCV-82 MCH-29.1 MCHC-35.3* RDW-14.1 Plt Ct-175
[**2188-2-29**] 06:46PM BLOOD WBC-13.7* RBC-2.94* Hgb-8.2* Hct-24.3*
MCV-83 MCH-28.0 MCHC-33.9 RDW-14.2 Plt Ct-204
[**2188-3-5**] 04:55AM BLOOD WBC-9.6 RBC-2.78* Hgb-8.2* Hct-23.4*
MCV-84 MCH-29.6 MCHC-35.2* RDW-14.7 Plt Ct-182
[**2188-2-22**] 11:10AM BLOOD PT-13.2 PTT-26.1 INR(PT)-1.1
[**2188-3-1**] 02:38AM BLOOD PT-13.8* PTT-29.6 INR(PT)-1.2*
[**2188-2-22**] 11:10AM BLOOD Glucose-125* UreaN-16 Creat-0.9 Na-142
K-4.0 Cl-107 HCO3-24 AnGap-15
[**2188-3-5**] 04:55AM BLOOD Glucose-83 UreaN-21* Creat-0.8 Na-132*
K-4.7 Cl-99 HCO3-28 AnGap-10
[**2188-3-1**] 02:38AM BLOOD ALT-23 AST-53* AlkPhos-36* TotBili-1.6*
[**2188-2-22**] 11:10AM BLOOD Calcium-8.9 Phos-3.2 Mg-2.1
[**2188-3-5**] 04:55AM BLOOD Calcium-7.7* Phos-3.6 Mg-2.3
Brief Hospital Course:
This 73-year-old patient who had a prior [**Month/Day/Year 8813**] valve
replacement and coronary artery bypass graft x2 with left
internal mammary artery to left anterior descending artery and a
saphenous vein graft to obtuse marginal, presented with
increasing cardiac symptoms and was investigated and was found
to have critical [**Month/Day/Year 8813**] stenosis which has been worsening with a
valve area down to 0.6. Coronary angiogram showed the grafts to
be patent, and he had disease in the right coronary artery which
was stented, and he was put on Plavix for that. He was referred
for redo [**Month/Day/Year 8813**] valve replacement. His left ventricular ejection
fraction was about 40%, and his previous surgery was about 9
years ago.The patient was admitted to the hospital and brought
to the operating room on [**2188-2-29**] where the patient underwent
redo sternotomy and redo [**Date Range 8813**] valve replacement with a size
23-mm [**Last Name (un) 3843**]-[**Doctor Last Name **] Magna pericardial valve. Post
operatively the patient had high volume of bloody drainage from
the chest tubes and the decision was made to return to the
operating room for reexploration. He was hemodynamically stable
upon return to the operating room. Intraoperatively there was a
significant amount of clot and blood in the mediastinum which
was evacuated. The surgical sites were explored and no bleeding
from the aortotomy or the cannulation sites was found. The only
possible bleeder was on the right chest wall, probably from the
sternal wire or needle hole, and no other significant bleeder
was found. Hemostasis was achieved and he was again transferred
to the CVICU in stable condition. He was weaned from all
vasoactive medications and extubated on POD #1 without incident.
Beta blockers were not started due to bradycardia with heart
rate in the 50-60's. Lisinopril was started for blood pressure
control. He was started on Lasix for gentle diuresis which was
increased to 40 mg IV BID with patient complaining of shortness
of breath on 3 L nasal cannula. He was transferred to the step
down unit POD #2 in stable condition. Chest tubes and pacing
wires were discontinued without complication. Oral diabetic
medication was added back for better blood sugar control. The
patient was evaluated by the physical therapy service for
assistance with strength and mobility. His hematocrit trended
down over several days and required multiple blood transfusions.
Hematocrit at time of discharge was 25.8. In addition he
underwent an echo on [**3-6**] which revealed no pericardial
effusion/tamponade. Post-op he also required a free water
restriction for hyponatremia. By the time of discharge on POD
seven the patient was ambulating freely, the wound was healing
well and pain was controlled with oral analgesics. The patient
was discharged to [**Male First Name (un) 4542**] [**Hospital3 **] rehab in good condition with
appropriate follow up instructions.
Medications on Admission:
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 10 mg
Tablet - one Tablet(s) by mouth daily
CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg
Tablet - one Tablet(s) by mouth daily
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet -
one Tablet(s) by mouth daily
GLIMEPIRIDE - (Prescribed by Other Provider) - 4 mg Tablet -
one Tablet(s) by mouth daily
NIFEDIPINE - (Prescribed by Other Provider) - 30 mg Tablet
Extended Rel 24 hr - one Tablet(s) by mouth daily
POTASSIUM CHLORIDE - (Prescribed by Other Provider) - 20 mEq
Tab Sust.Rel. Particle/Crystal - one Tab(s) by mouth daily
Medications - OTC
ACETYLCYSTEINE [NAC] - (Prescribed by Other Provider) - 600 mg
Capsule - one Capsule(s) by mouth twice a day
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - one
Tablet(s) by mouth daily
DOCUSATE SODIUM [COLACE] - (Prescribed by Other Provider) - 100
mg Capsule - one Capsule(s) by mouth 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 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once a
day as needed for constipation.
5. furosemide 40 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours: Please take 40 mg twice daily x 1 week. Then reduce
to 40 mg daily.
6. potassium chloride 10 mEq Capsule, Sustained Release Sig: One
(1) Capsule, Sustained Release PO once a day.
7. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
Cape Code Nursing & Rehabilitation Center - [**Location (un) 10072**]
Discharge Diagnosis:
Bioprosthetic [**Location (un) **] valve stenosis s/p Redo-sternotomy, [**Location (un) **]
Valve Replacement
Past medical history:
Dyslipidemia
Hypertension
Diabetes Mellitus
Congestive Heart Failure
Peripheral artery disease
Past Surgical History:
s/p CABG x2(LIMA to LAD, SVG to OM)/AVR (porcine [**Location (un) 43404**])
in [**2179**]
s/p Left Fem-[**Doctor Last Name **] bypass [**2176**]
s/p [**2188-1-30**] with drug-eluting stent deployment to RCA
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
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. [**First Name (STitle) **] on [**3-24**] at 1:45PM
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**3-12**] at 11:30AM
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5311**] in [**5-13**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2188-3-7**]
|
[
"401.9",
"411.1",
"250.00",
"996.71",
"433.30",
"E878.1",
"440.20",
"285.9",
"V45.81",
"276.1",
"433.10",
"272.4",
"428.0",
"V45.82",
"410.72",
"424.1",
"998.11",
"428.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61",
"34.03"
] |
icd9pcs
|
[
[
[]
]
] |
10147, 10243
|
5453, 8417
|
348, 641
|
10743, 10916
|
2498, 5430
|
11755, 12415
|
1703, 1732
|
9409, 10124
|
10264, 10374
|
8443, 9386
|
10940, 11732
|
10514, 10722
|
1747, 2479
|
269, 310
|
669, 1166
|
10396, 10491
|
1526, 1687
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,352
| 139,319
|
9822
|
Discharge summary
|
report
|
Admission Date: [**2129-11-17**] Discharge Date: [**2129-11-21**]
Date of Birth: [**2098-1-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Boric Acid ingestion
Major Surgical or Invasive Procedure:
Gastric lavage
Administration of activated charcoal
History of Present Illness:
31 year old man with h/o depression who was feeling upset at
home after dispute with ex-girlfriend about visitation of his
children and took [**12-23**] of a bottle of boric acid (Zap-a-Roach)
and 6 beers as a suicide attempt. Patient had acute onset of
abdominal pain and presented to [**Hospital1 18**] ED 45 minutes later. He
received charcoal and gastric lavage and was sent to the ICU for
close monitoring.
Past Medical History:
Depression - seen by Dr [**Last Name (STitle) **] @ [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9464**]
H/o suicide attempt x 2
Disk Herniation
Social History:
Patient lives with his girlfriend and her 2 children. He has 6
children, 3 of whom he does not see regularly due to poor
relations with aforementioned ex-girlfriend. [**Name (NI) **] has had two
previous suicide attempts in the past, both times with ingestion
of pills.
EtOH: States that he does not drink EtOH regularly, just drank
EtOH yesterday because feeling depressed. Per psychiatry, he
admitted to one 12-pack of beer per week. No h/o of withdrawal
seizures or DT. Patient denies any tobacco use.
Family History:
depression in mother
Physical Exam:
PE: T 97.6 HR 112 BP 100/70 RR 16 O2Sat 99% RA
Gen: Patient lying flat in bed in discomfort [**12-22**] to back pain
Heent: PERRLA, EOMI, OP clear, no angioedema, MMM
Lungs: CTA B/L
Cardiac: RRR S1/S2 no murmurs
Abdomen: Soft NTND NABS
Ext: no edema, DP +2
Brief Hospital Course:
31yo man w/ PMH significant for depression admitted after
ingesting approximately 100gms of borate in Zap-a-Roach, with
EtOH level in 200s. For his boric acid ingestion, the patient
was treated in the ED with 6L NS, NG lavage, and activated
charcoal. Toxicology was consulted. The patient spent one
night in the ICU for monitoring. The next day he was transfered
to the floor. He remained stable without signs of
cardiovascular collapse, renal failure (which can be delayed up
to 4 days), or seizures. The patient had TID electrolytes
checked, then [**Hospital1 **], and then daily once he was out of the window
for renal failure. His lytes were aggressively repleted. His
Creatinine remained at baseline. The patient was hypernatremic
on [**11-17**], which was thought to be due to decreased fluid intake.
Urine lytes showed FENa of 2.9%. He was given 1L of IVF on
[**11-18**] and his sodium level returned to [**Location 213**].
.
2. Psych: The patient was evaluated by Psychiatry the morning
after admission. They recommended 1:1 sitter, suicide
precautions, restarting celexa at 20 mg Qam, and evaluation for
inpatient psychiatric hospitalization. The patient denied
suicidal ideation but showed little insight into the reason for
his hospitalization. Social work was consulted to help with his
concerns over not seeing his children. On morning of discharge
psychiatry evaluated the patient and felt that he needed
inpatient psychiatric hospitalization.
.
3. EtOH ingestion: Pt does not have a history of heavy EtOH use,
withdrawal seizures, or DTs. The patient was ordered for
diazepam per CIWA scale but did not require doses on the floor.
.
4. Lower back pain: The patient has chronic pain and is seen by
the [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Clinic. He was given IV morphine for pain in
the ICU and transitioned to his home dose of percocets (2 tabs
Q4-6H) on the floor. NSAIDs were held given risk for renal
failure and possible esophageal irritation. They may be
restarted as an outpatient.
.
5. Anemia - The patient was found to have a microcytic anemia.
Fe studies and retic ct unremarkable. HIs Hct remained stable
while in-house. The patient will need outpatient work-up of
this anemia (ex Hb electrophoresis).
Medications on Admission:
Celexa
Seroquel
Percocet
Motrin
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
4. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1680**] Hospital - [**Location (un) 538**]
Discharge Diagnosis:
Suicide Attempt
Boric Acid Ingestion
...
Depression
chronic low back pain
Discharge Condition:
stable. normal renal function. denying suicidal ideation.
Discharge Instructions:
Please return if you experience thoughts to hurt yourself or
other people, racing thoughts, chest pain, shortness of breath,
or any other worrisome symptoms.
.
Please take all medications as directed.
.
You will need follow-up with a psychiatrist. This should be
arranged by the psychiatric care facility.
Followup Instructions:
Provider: [**Name10 (NameIs) **] GATES, RNC MSN Phone:[**Telephone/Fax (1) 10657**]
Date/Time:[**2129-12-1**] 3:15
.
Provider: [**Name10 (NameIs) 8380**],[**Name11 (NameIs) **](A) PAIN MANAGEMENT CENTER
Date/Time:[**2129-12-12**] 1:30
|
[
"276.0",
"311",
"285.9",
"976.0",
"724.2",
"E950.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.33"
] |
icd9pcs
|
[
[
[]
]
] |
4608, 4689
|
1874, 4163
|
337, 390
|
4807, 4869
|
5224, 5462
|
1556, 1578
|
4246, 4585
|
4710, 4786
|
4189, 4223
|
4893, 5201
|
1593, 1851
|
277, 299
|
418, 832
|
854, 1017
|
1033, 1540
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,241
| 144,172
|
40670
|
Discharge summary
|
report
|
Admission Date: [**2125-1-10**] Discharge Date: [**2125-1-16**]
Date of Birth: [**2061-11-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Erythromycin Base / Nickel
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
aortic stenosis, dilated ascending aorta
Major Surgical or Invasive Procedure:
Aortic valve replacement (23mm ON-X mechanical), 28mm Gelweave
graft ascending aorta, Cor-Matrix pericardial closure [**2125-1-10**]
History of Present Illness:
This 63 year old white female has a known bicuspid aortic valve
and a history of rheumatic fever. Serial echos have
demonstrated progressive stenosis of the valve and now a dilated
ascending aorta. She has had peripheral edema and increasing
dyspnea with exertion. She was admitted now for operation
having a catheterization in [**2124-11-23**] showing no coronary
disease.
Past Medical History:
Aortic stenosis
h/o rheumatic fever
Hypertension
ypercholesterolemia
hypothyroidism
rt foot fracture (s/p ORIF)
s/p appendectomy
s/p ovarian cyst removal
osteoporosis
Social History:
She is a widow, living alone. Looking for part-time work. She
used to manage medical records for [**Hospital1 1501**]. Does not exercise. She
is a widow, living alone. Sister lives nearby. Tobacco: quit
[**2097**] ETOH: [**2-25**] wine/wk.
Family History:
Both parents died early of alcohol abuse. Brother died of
esophageal cancer. She has two sisters living. Paternal uncle
with sudden cardiac death in his 40's.
Physical Exam:
Pulse: 92
B/P: Right 116/65 Left 116/54
Resp: 18
O2 Sat: 99% RA
Temp:98
Height: 4'6" Weight: 140
General: alert short statured female in NAD
Skin: color pink, skin warm and dry. Rash right chest and neck.
Belly button without erythema or drainage. There is a small
lesion with scab noted. The skin is friable.
HEENT: conjunctiva pink, left eye lower lid droop, left eye skin
tag lower lid. Oropharynx moist, dental bridge, good dentition.
Neck:supple, trachea midline. Chest:clear
Heart: RRR, III/VI SEM, holosystolic. Nl S1-S2 No S3 or S4
Abd: soft, nontender, nondistended. (+)bowel sounds
Extremities: No CCE. No varicosities
Neuro: alert and oriented, mildy anxious, gait steady, gross
FROM
Pulses: Right Left
Radial 2 2
femoral 2 2
PT 2 2
DP 2 2
Carotids No bruits, transmitted cardiac Murmur bilaterally
Pertinent Results:
[**2125-1-15**] 02:57AM BLOOD WBC-7.1 RBC-2.93* Hgb-8.9* Hct-27.3*
MCV-93 MCH-30.4 MCHC-32.6 RDW-13.0 Plt Ct-185
[**2125-1-10**] 01:56PM BLOOD WBC-10.1# RBC-2.46*# Hgb-7.6*# Hct-22.7*#
MCV-92 MCH-30.9 MCHC-33.5 RDW-12.9 Plt Ct-151
[**2125-1-15**] 02:57AM BLOOD PT-16.0* PTT-59.7* INR(PT)-1.5*
[**2125-1-14**] 04:53AM BLOOD PT-14.2* PTT-45.0* INR(PT)-1.3*
[**2125-1-13**] 04:30AM BLOOD PT-13.6* PTT-25.7 INR(PT)-1.3*
[**2125-1-12**] 01:16AM BLOOD PT-15.3* PTT-31.8 INR(PT)-1.4*
[**2125-1-15**] 02:57AM BLOOD Glucose-124* UreaN-21* Creat-0.5 Na-136
K-3.5 Cl-98 HCO3-30 AnGap-12
[**2125-1-10**] 03:45PM BLOOD UreaN-11 Creat-0.4 Na-142 K-4.3 Cl-115*
HCO3-21* AnGap-10
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 88965**]Portable TTE
(Complete) Done [**2125-1-11**] at 7:44:37 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2061-11-20**]
Age (years): 63 F Hgt (in): 56
BP (mm Hg): 120/60 Wgt (lb): 140
HR (bpm): 84 BSA (m2): 1.53 m2
Indication: Aortic valve disease. H/O cardiac surgery. Left
ventricular function. Prosthetic valve function.
ICD-9 Codes: V43.3, 424.1, 428.0
Test Information
Date/Time: [**2125-1-11**] at 07:44 Interpret MD: [**First Name8 (NamePattern2) 35980**] [**Name8 (MD) 35981**],
MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West SICU/CTIC/VICU
Contrast: None Tech Quality: Suboptimal
Tape #: 2012AW000-0:00 Machine: vivid q
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 30% to 35% >= 55%
Left Ventricle - Stroke Volume: 51 ml/beat
Left Ventricle - Cardiac Output: 4.29 L/min
Left Ventricle - Cardiac Index: 2.80 >= 2.0 L/min/M2
Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 18
Aortic Valve - LVOT diam: 1.9 cm
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A ratio: 1.25
Mitral Valve - E Wave deceleration time: 147 ms 140-250 ms
TR Gradient (+ RA = PASP): >= 11 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2124-9-4**].
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Moderately depressed LVEF.
RIGHT VENTRICLE: RV not well seen.
AORTIC VALVE: Mechanical aortic valve prosthesis (AVR). AVR well
seated, normal leaflet/disc motion and transvalvular gradients.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. No MR.
TRICUSPID VALVE: Tricuspid valve not well visualized.
Physiologic TR. Normal PA systolic pressure.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
The rhythm appears to be A-V paced. Results were personally
Conclusions
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is moderately depressed (LVEF= 30-35%). A
mechanical aortic valve prosthesis is present. The aortic valve
prosthesis appears well seated, with normal leaflet/disc motion
and transvalvular gradients. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. The right ventricle is not well [**Doctor First Name **] but its
function is probably normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2124-9-4**]
there is now global left ventricular systolic dysfunction which
is new.
Electronically signed by [**First Name8 (NamePattern2) 35980**] [**Name8 (MD) 35981**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2125-1-11**] 18:00
Brief Hospital Course:
As a same day admit she went to the Operating Room where the
aortic valve was replaced and the ascending aorta replaced using
a 23mm ON-X valve and a 28mm gelweave graft. The peicardium was
closed with Cor-matrix as well. She weaned from bypass on Neo
Synephrine in stable condition. She weaned from the ventilator
and pressor support easily. Chest tubes and temporary pacing
wires were removed per protocol. Coumadin was started for the
mechanical valve and Heparin on POD 3.
Heaprain was stopped on POD#6 when her INR was therapeutic at
2.5 and was given 5mg of coumadin.
She developed a junctional rhythm in the 70s postoperatively and
Electrophysiology was consulted. She converted to sinus rhythm
subsequently. She was aggresively diuresed towards her
preoperative weight. Physical Therapy worked with her for
strength and mobility.
On POD #6 she was cleared for discharge to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in
[**Last Name (un) 17679**]. Appropriate follow up instructions, medications and
appointments were given.
Medications on Admission:
EZETIMIBE-SIMVASTATIN [VYTORIN 10-40] 10 mg/40 mg Tablet daily
GENTAMICIN - 0.1 % Cream - apply twice daily
HYDROCHLOROTHIAZIDE 25 mg daily
KETOCONAZOLE - 2 % Cream - apply to rash daily
LEVOTHYROXINE 112 mcg daily
LISINOPRIL 40 mg daily
TRIAMCINOLONE ACETONIDE 0.1 % Cream - apply to ears and neck
daily for 7 to 10 days
TYLENOL EXTRA STRENGTH 1000 mg [**Hospital1 **]
CALCIUM CITRATE-VITAMIN D3 [CALCIUM CITRATE + D] Dosage
uncertain
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] - [**Hospital1 1559**]
Discharge Diagnosis:
aortic stenosis
bicuspid aortic vaslve
dilated ascending aorta
s/p aortic valve replacement and ascending aortic replacement
hypertension
hypercholesterolemia
s/p appendectomy
h/o rheumatic fever
osteoporosis
s/p hysterectomy
s/p ovarian cystectomy
hypothyroidism
s/p open reduction and internal fixation of right foot fracture
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 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Mech AVR (ON-X)/
Ascending aortic replacement (28 gelweave)
Goal INR 2.5-3.0
First draw [**2125-1-17**]
Results to phone - please arrange coumadin follow up on
discharge from rehab
Followup Instructions:
You are scheduled for the following appointments:
Surgeon:Dr.[**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) on [**2125-2-19**] at 1:15pm
Cardiologist:Dr.[**Last Name (STitle) **] on [**2125-2-9**] at 12:OOPM
Please call to schedule appointments with:
Primary Care: Dr.[**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 133**]) in [**3-29**] weeks
Labs: PT/INR for Coumadin ?????? indication Mech AVR (ON-X)/
Ascending aortic replacement (28 gelweave)
Goal INR 2.5-3.0
First draw [**2125-1-17**]
Results to phone - please arraneg coumadin follow up on
discharge from rehab
**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:[**2125-1-16**]
|
[
"395.0",
"V15.82",
"441.2",
"746.4",
"401.9",
"V85.35",
"272.0",
"493.90",
"518.52",
"V70.7",
"V14.0",
"V58.61",
"458.29",
"518.89",
"733.00",
"426.13",
"416.8",
"285.1",
"278.00",
"244.9",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.22",
"38.45",
"37.49",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
8188, 8303
|
6635, 7699
|
348, 483
|
8675, 8851
|
2454, 6612
|
10001, 10822
|
1353, 1513
|
8324, 8654
|
7725, 8165
|
8875, 9978
|
1528, 2435
|
268, 310
|
511, 888
|
910, 1079
|
1095, 1337
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,922
| 185,211
|
40813
|
Discharge summary
|
report
|
Admission Date: [**2197-5-5**] Discharge Date: [**2197-5-22**]
Date of Birth: [**2145-2-16**] 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:
[**2197-5-9**]
1. Coronary bypass grafting x4, with the left internal mammary
artery to left anterior descending artery, and reverse saphenous
vein grafts to the right coronary artery, the first and second
obtuse marginal artery.
2. Patch closure of secundum atrial septal defect with
pericardium.
History of Present Illness:
52 year old male smoker w h/o htn, hyperlipidemia, diabetes and
a long history of chest pain. He reports more severe discomfort
recently with exertion. On the morning of admission, he
developed left sided chest pain associated with SOB and
diaphoresis as well as bilateral arm weakness after taking out
the garbage and climbing a set of stairs. He was admitted to an
OSH on [**5-2**] and ruled in for NSTEMI with a troponin to 95, and
was found to have multi-vessel CAD on cath. He is transferred
for surgical evaluation.
Past Medical History:
Coronary Artery Disease, s/p Coronary Artery Bypass Graft x 4
Atrial Septal Defect s/p closure
Myocardial Infarction
PMH:
Diabetes
Hypertension
Hyperlipidemia
GERD
post op afib
Social History:
Last Dental Exam: 7 months ago
Lives with: wife and son
Occupation: "disabled"
Tobacco: 1 ppd
ETOH: rum, daily
Family History:
father with diabetes and [**Name (NI) 2481**]
mother has hypertension
Physical Exam:
Pulse: 79 Resp: 18 O2 sat: 100%RA
B/P Right: Left: 159/85
Height: 6" Weight: 193lb
General: NAD, WGWN, appears stated age
Skin: Dry [x] intact [x] well-healed lower lumbar scar
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, Varicosities: None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: 1+ Left:1+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 1+ Left:1+
Radial Right: 2+ Left:2+
Carotid Bruit Right: Left:
no bruits
Pertinent Results:
[**2197-5-9**] 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. The right atrium is dilated. A
left-to-right shunt across the interatrial septum is seen at
rest. A large (2 cm) secundum atrial septal defect is present.
The left ventricular cavity size is normal. There is moderate to
severe regional left ventricular systolic dysfunction with
anterior akinesis, severe septal and anterolateral hypokinesis
in the backdrop of moderate global hypokinesis. The base of the
lateral wall functions best. The right ventricular free wall is
hypertrophied. The right ventricular cavity is dilated with
normal free wall contractility. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results in the operating room at the time of the study.
POST BYPASS: The patient is receiving epinephrine by infusion
and is atrially paced. There is normal right ventricular
systolic function. The left ventricle displays both improved
global function as well as improved function of the septum and
anterior walls. The left ventricular ejection fraction is now
40-45%. The interatrial septum is status post placement of a
patch. A very small residual left to right shunt across the
septum remains. The thoracic aorta is intact after
decannulation. No other significant changes from the pre-bypass
findings.
[**2197-5-22**] 05:40AM BLOOD WBC-12.5* RBC-3.85* Hgb-11.6* Hct-34.2*
MCV-89 MCH-30.2 MCHC-34.0 RDW-13.6 Plt Ct-616*
[**2197-5-21**] 05:40AM BLOOD WBC-11.4* RBC-3.35* Hgb-10.4* Hct-29.6*
MCV-88 MCH-30.9 MCHC-35.1* RDW-13.4 Plt Ct-499*
[**2197-5-22**] 05:40AM BLOOD PT-22.2* INR(PT)-2.1*
[**2197-5-21**] 05:40AM BLOOD PT-23.9* INR(PT)-2.2*
[**2197-5-20**] 04:25AM BLOOD PT-25.6* INR(PT)-2.4*
[**2197-5-19**] 04:30AM BLOOD PT-33.9* PTT-35.8* INR(PT)-3.4*
[**2197-5-18**] 04:13PM BLOOD PT-38.2* INR(PT)-3.9*
[**2197-5-18**] 04:30AM BLOOD PT-26.2* PTT-31.6 INR(PT)-2.5*
[**2197-5-17**] 12:20AM BLOOD PT-13.6* PTT-28.5 INR(PT)-1.2*
[**2197-5-16**] 03:30AM BLOOD PT-13.9* PTT-26.9 INR(PT)-1.2*
[**2197-5-15**] 01:07AM BLOOD PT-14.1* PTT-27.5 INR(PT)-1.2*
[**2197-5-14**] 05:18AM BLOOD PT-14.1* PTT-28.1 INR(PT)-1.2*
[**2197-5-22**] 05:40AM BLOOD UreaN-15 Creat-0.8 Na-135 K-4.6 Cl-101
[**2197-5-21**] 05:40AM BLOOD UreaN-17 Creat-0.8 Na-134 K-4.4 Cl-101
[**2197-5-20**] 04:25AM BLOOD Glucose-118* UreaN-17 Creat-0.8 Na-135
K-4.2 Cl-100 HCO3-25 AnGap-14
[**2197-5-19**] 04:30AM BLOOD Glucose-120* UreaN-20 Creat-1.0 Na-133
K-4.0 Cl-96 HCO3-28 AnGap-13
[**2197-5-22**] 05:40AM BLOOD Mg-2.1
[**2197-5-21**] 05:40AM BLOOD Mg-1.7
[**2197-5-19**] 04:30AM BLOOD Mg-2.1
[**2197-5-18**] 04:30AM BLOOD Calcium-8.1* Phos-3.3 Mg-2.2
Brief Hospital Course:
Mr. [**Known lastname **] was admitted for pre-op workup and Plavix washout. He
remained stable, receiving medical management while awaiting
Plavix washout prior to surgery. On [**5-9**] he was brought to the
operating room where he underwent a coronary artery bypass x 4
and atrial septal defect closure. Please see operative note for
surgical details. Following surgery he was transferred to the
CVICU for invasive monitoring in stable condition. Later that
day he was weaned from sedation, awoke neurologically intact and
extubated. On post-op day one he was started on beta-blockers
and diuretics and gently diuresed towards his pre-op weight.
Later this day he was transferred to the step-down floor for
further care. Chest tubes and epicardial pacing wires were
removed per protocol. On the evening of post-operative day
three he developed flash pulmonary edema and was transferred to
the surgical intensive care unit. By the morning he had mental
status changes and his PO2 began to decrease. By late morning
he required intubation with bilateral white-out on his chest
radiograph. He began to spike fevers and was pan cultured. A
chest/abdomen/pelvis CT which revealed lungs with fluid
overload/possible pneumonia. Antibiotics were begun and an
infectious disease consult was requested. After several days of
diuresis and antibiotics his lungs improved and he was
extubated. His mental status changes had resolved. He was
transferred to the step down floor to complete his antibiotics
course. By post-operative day 13 he was ready for discharge to
home. All follow-up appointments were advised.
Medications on Admission:
Medications at home:
Toprol 100mg daily, metformin 500mg [**Hospital1 **], flexeril 10mg TID prn,
HCTZ 25mg daily, ranitidine 150mg [**Hospital1 **], lisinopril 40mg daily
Meds on Transfer:
aspirin 325', famotidine 20mg [**Hospital1 **], folic acid 1mg daily, haldol
prn, HCTZ 25mg, Novolog sliding scale, lisinopril 40mg daily,
ativan prn 0.5 prn, Mag Oxide 400mg daily, Toprol XL 100mg
daily, MVI daily, simvastatin 80mg daily, thiamine hcl 100mg
daily, cyclobenzaprine 10mg TID prn, robitussin dm prn, morphine
prn, NTG prn, zofran prn, (**Plavix on [**5-3**])
Discharge Medications:
1. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for muscle pain.
Disp:*60 Tablet(s)* Refills:*0*
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. warfarin 3 mg Tablet Sig: One (1) Tablet PO ONCE (Once): dose
to change daily for goal INR 2-2.5, managed by Dr. ******.
Disp:*60 Tablet(s)* Refills:*2*
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
11. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 400mg daily x 1 week, then 200mg daily until further
instructed.
Disp:*60 Tablet(s)* Refills:*2*
12. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
13. Outpatient Lab Work
Labs: PT/INR
Coumadin for atrial fibrillation
Goal INR 2-2.5
First draw [**2197-5-23**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 89171**]
Results to phone [**Telephone/Fax (1) 63099**] (**office unavailable on
discharge-- will confirm tomorrow**)
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronary Artery Disease, s/p Coronary Artery Bypass Graft x 4
Atrial Septal Defect s/p closure
Myocardial Infarction
PMH:
Diabetes
Hypertension
Hyperlipidemia
GERD
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Right forearm with phlebitis- will be d/c on Levaquin
Edema none
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 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**] [**5-31**] at 1:15pm
Cardiologist Dr. [**Last Name (STitle) 29070**] [**6-15**] at 12:30pm in the [**Hospital1 3597**] office
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) 23068**] M. [**Telephone/Fax (1) 63099**] in [**4-11**] 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
Coumadin for atrial fibrillation
Goal INR 2-2.5
First draw [**2197-5-23**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 89171**]
Results to phone [**Telephone/Fax (1) 63099**] (**office unavailable on
discharge-- will confirm tomorrow**)
Completed by:[**2197-5-22**]
|
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icd9cm
|
[
[
[]
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[
"36.15",
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"36.13",
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] |
icd9pcs
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[
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320, 619
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,736
| 177,199
|
20894+20895
|
Discharge summary
|
report+report
|
Admission Date: [**2167-7-22**] Discharge Date: [**2167-7-26**]
Date of Birth: [**2115-11-9**] Sex: M
Service: MED
INTERIM SUMMARY
DATE OF DISCHARGE FROM INTENSIVE CARE UNIT: [**2167-7-26**].
CHIEF COMPLAINT: Fever, cellulitis, adenitis and
hypotension.
HISTORY OF PRESENT ILLNESS: A 51-year-old male, without any
significant past medical history, who was transferred from an
outside hospital for cellulitis and adenitis that was not
responsive to antibiotics, resulting in hypotension. The
patient stated that he was in his usual state of health until
Tuesday, [**2167-7-14**] when he first noted some left upper
groin pain. The groin pain became progressively worse over
the next several days, and also he noted an area of erythema.
He developed fevers on [**2167-7-19**]. He went to an outside
hospital Emergency Department the following day. At that
time, he was diagnosed with cellulitis and adenitis, and was
given 2 gm of ceftriaxone, and was discharged to home. He
continued to have persistent fevers to 103 and returned the
following morning to the outside hospital Emergency
Department where he was admitted for cellulitis and adenitis.
He was started on Ancef, but developed a diffuse erythroderma
rash the day after initiation of Ancef therapy, which was
felt to be due to a drug rash. On [**2167-7-22**], the day of
transfer to [**Hospital6 256**], the patient
was still persistently spiking fevers, had an elevated white
blood cell count with a bandemia, and became hypotensive
despite IV antibiotics, including vancomycin, clindamycin and
Levaquin. His blood pressure dropped to 70 systolic, and he
was given IV fluids and started on peripheral dopamine. At
this time, arrangements were made to transfer the patient to
[**Hospital6 256**]. On arrival to [**Hospital6 1760**], the patient was no longer on
the dopamine drip and was normotensive with blood pressure's
in the 100's to 110's/60's to 70's.
The patient reported that 3 to 4 days prior to the onset of
his symptoms on [**7-14**], he had been doing work at a family
member's house and had been trying to close-off openings that
rodents were using to get into a house. He also, at that
time, removed a dead squirrel from the chimney. He noted
that during his work that day there were a lot of bugs and
spiders. He, however, does not remember being bitten by any
insect. The patient lives in a heavily wooded area, has deer
in his backyard, and also has a pet dog. He has not had any
recent travel outside of [**Location (un) 3844**]. He has had no sick
contacts.
PAST MEDICAL HISTORY: History of prior wrist and hand
surgery.
ALLERGIES: Possible allergy to Ancef causing a rash.
MEDICATIONS: None.
MEDICATIONS ON TRANSFER:
1. Vancomycin.
2. Clindamycin.
3. Levaquin.
4. Zofran.
5. Vicodin.
FAMILY HISTORY: No family history of early coronary artery
disease, or diabetes.
SOCIAL HISTORY: The patient has a remote tobacco history.
He quit smoking in the [**2133**]'s. He drinks occasionally only
socially. The patient lives in [**Location (un) 3844**] with his wife
and children. He has a dog and lives in a heavily wooded
area.
PHYSICAL EXAM ON ARRIVAL: Temperature 98.6, heart rate 106,
blood pressure 108/67, respiratory rate 24, oxygen saturation
96 percent on 2 liters.
GENERAL: In no acute distress, alert and oriented x 3.
HEENT: Pupils equal, round and reactive to light. Supple
neck. Clear oropharynx. No cervical lymphadenopathy.
Anicteric sclerae. Extraocular muscles intact. No facial
asymmetry.
LUNGS: Clear to auscultation bilaterally.
CARDIOVASCULAR EXAM: Tachycardic, irregular.
ABDOMEN: Soft, nontender, normoactive bowel sounds, no
hepatosplenomegaly.
EXTREMITIES: No lower extremity edema. 2 plus dorsalis
pedis pulses and posterior tibialis pulses bilaterally.
LEFT GROIN: With several large, palpable subcutaneous
nodules and an erythema over the left upper thigh extending
from several inches above the knee to just below the inguinal
crease. The area of erythema was warm and tender to
palpation. The subcutaneous nodules were nontender to
palpation.
NEUROLOGIC EXAM: Cranial nerves II through XII intact
bilaterally. Strength 5/5 in upper and lower extremities
bilaterally.
LABORATORY DATA: White blood cell count 19.8 with 94 percent
polys, 0 bands, 3 percent lymphs, hematocrit 35.3, platelets
201, INR 1.3, PTT 30.7, ESR 100, reticulocyte count 1.7,
sodium 137, potassium 3.8, chloride 103, bicarbonate 21, BUN
12, creatinine 0.7, ALT 64, AST 27, LDH 81, CK 153, alkaline
phosphatase 127, amylase 12, total bilirubin 1.7, direct
bilirubin 1.0, lipase 12, troponin-T less than 0.01, albumin
3.3, uric acid 3.0, haptoglobin 328, TSH 0.36, Lyme serology
160:[**2167**], negative.
CHEST X-RAY: Showed increased interstitial markings,
possibly suggesting fluid overload.
EKG: Showed sinus tachycardia with first degree AV block
with a PR interval of 0.218.
HOSPITAL COURSE:
1. GROIN ERYTHEMA AND SUBCUTANEOUS NODULES: The patient's
groin erythema was clinically consistent with a
cellulitis. Given the patient's possible allergy to
Ancef, he was continued on IV vancomycin and clindamycin.
Blood cultures were sent which did not reveal any
organism. The patient remained hemodynamically stable and
did not require any further pressors. The subcutaneous
nodules had been previously ultrasounded and sampled with
fine needle aspiration at the outside hospital on the day
of admission. The ultrasound at the outside hospital
revealed only lymphadenopathy. The Gram stain showed 2
plus polys but no organisms.
A repeat ultrasound at [**Hospital6 256**]
showed only left groin enlarged lymph nodes. No evidence of
an abscess or fluid collection. The surgical service was
consulted for biopsy of the left upper thigh lymph nodes, as
the patient continued to spike fevers and had a persistently
elevated white blood cell count despite vancomycin and
clindamycin. An excisional biopsy was attempted; however, no
lymph node was obtained.
After approximately 3 to 4 days, the patient's cellulitis was
clinically improving, he was no longer spiking fevers, and
his white blood cell count was decreasing. Given his
extremely low risk for MRSA, and the fact that his cultures
did not reveal any organisms, the patient's antibiotic
coverage was changed to PO clindamycin.
There was also concern for possible streptococcal infection
with his diffuse erythroderma rash, possibly representing the
rash seen as scarlet fever. The patient never reported any
pharyngitis, but given his complaints of diffuse arthralgias,
myalgias, migrating neuropathic pain, there was some concern
of rheumatic fever, as the patient had 2 ASO screens
performed which were both negative.
1. MYALGIAS, ARTHRALGIAS AND NEUROPATHIC PAIN: The patient
complained of bilateral shooting neuropathic-like pain,
migrating arthralgias, swelling in the fingers and toes,
and pleuritic chest pain. Given the patient's exposure to
multiple insects and animals, there was initially concern
over tick-borne illnesses, including Lyme disease and
tularemia. Tularemia titers were sent to the State Lab
and were pending at the time of transfer out of the
intensive care unit. The patient was started on
doxycycline to cover tularemia and Lyme disease. However,
with the patient's clinical improvement on antibiotics, it
was felt that his clinical course was not consistent with
tularemia. The patient did develop a significant amount
of pleuritic chest pain that was relieved with NSAIDS and
IV Toradol. He also developed a pericardial friction rub.
An echocardiogram revealed a normal ejection fraction and
no pericardial effusion, and Lyme titers were initially
negative. However, given the patient's clinical evidence
of pericarditis, newly prolonged PR interval, and
migratory arthralgias and neuropathic pain, there was a
significant concern for Lyme disease and Lyme carditis
despite lack of serologic evidence. Therefore, the
decision was made to complete a 1 month course of
doxycycline, and to repeat Lyme serologies in [**2-6**] weeks.
On [**2167-7-26**], the patient was transferred out of the
intensive care unit to the general medical floor. The
remainder of this discharge summary will be dictated by the
covering intern on the general medicine floor.
[**First Name11 (Name Pattern1) 122**] [**Last Name (NamePattern4) 24325**], [**MD Number(1) 24326**]
Dictated By:[**Last Name (NamePattern1) 18139**]
MEDQUIST36
D: [**2167-7-27**] 12:52:10
T: [**2167-7-27**] 13:58:13
Job#: [**Job Number 55595**]
Admission Date: [**2167-7-22**] Discharge Date: [**2167-7-27**]
Date of Birth: [**2115-11-9**] Sex: M
Service: MED
HISTORY OF PRESENT ILLNESS: The patient is a 51 year old,
Caucasian male who was admitted to the [**Hospital Unit Name 153**] with fever, rash
and subcutaneous nodules with hypotension from an outside
hospital on [**2167-7-22**]. The patient was at an outside hospital
on [**2167-7-14**], eight days prior to admission with groin pain,
left greater than right, and then presented again on [**7-19**],
which was three days prior to admission, with a rash and
painful subcutaneous nodules in the left inguinal area. The
patient spiked a temperature to 103 degrees and received IV
ceftriaxone 2 gm in the E.D. and sent home. After no
improvement, he presented again and received IV Ancef and
developed a diffuse, macular, nonpustular, nonbullous,
nonpruritic, whole body rash except above his collar, but he
does note that the rash was on his palms, but did not affect
the soles of his feet, that had been attributed to a drug
rash from Ancef. The patient then presented to [**Hospital1 18**], spiked
a fever and dropped systolic to 70, but responded to IV
fluids and dopamine. The patient continued to state groin
pain and rash, macular, blanching, nonpruritic, painful, but
without drainage in the left groin area and medial thigh that
the patient states responded somewhat to the previous
antibiotics at the outside hospital. The patient presented
without any history of sick contacts, travel outside of [**Location (un) **], ingestion of raw or undercooked food, no history of
pharyngitis or any people in his family with pharyngitis, but
did state recent exposure to numerous wildlife including dead
chipmunks, aerosolizer on feces and because of recent work in
the forest, had positive exposure to all the classic vectors
known in [**Location (un) 511**] including ticks, spiders and mosquitos.
The patient also presented with arthralgias in bilateral
shoulders which migrated down his arm into his phalangeal
joints, a dry, hacking, intermittent cough and urge to move
his lower legs, running in place because it tingled. The
patient was also admitted with the diagnosis of sepsis
secondary to hypotension and fever with an unknown source.
PAST MEDICAL HISTORY: None.
ALLERGIES: Presumed rash allergy to Ancef.
MEDICATIONS: Meds at home none. Meds at outside hospital
were vanc, clinda and Levaquin times one day and Zofran.
FAMILY HISTORY: Rheumatoid arthritis in his father.
SOCIAL HISTORY: The patient states he quit tobacco in [**2141**].
Lives in a small, [**Location 55596**]with his wife and kids.
Denies polygamous sexual contacts.
HOSPITAL COURSE: The patient was admitted to the [**Hospital Unit Name 153**] with
the initial diagnoses of fever, rash, subcutaneous nodules.
Lyme titers were sent which were not positive for either IgM
or IgG. The patient's systolic blood pressure dropped to 70,
but he responded to IV fluids and dopamine. The patient
continued to spike fevers. Titers were sent for tularemia as
well as blood cultures being sent for Ehrlichia, Yersinia and
other rickettsial diseases. The patient had significant
leukocytosis upon admission which was as high as 25.2, which
came down to less than 12. He continued to have the
subcutaneous nodule which was firm, moveable, without cystic
palpation and not compressible. It was about 2 to 3 cm. He
denied continued pain at the inguinal rash site or the nodule
site. Once he was hemodynamically stable, the patient was
started on vanc and clinda for questionable staph strep
cellulitis and doxycycline was later added on for rickettsial
coverage.
The patient had improved since admission, although it was not
known if this was from the antibiotics that were started or
from his pathology running its course. The patient also
developed a new complaint of a band of chest tightness across
his chest from left to right in an nondermatomal pattern,
although essentially across the pectorals that was provocated
by deep breaths and palliated by sitting forward. EKG showed
some diffuse ST segment elevations and prolonged PR interval.
Motrin was started for pericarditis. Vanc IV was
discontinued and the patient was put on p.o. clinda.
Throughout the hospital course the rash became smaller and
not painful. The nodule did not change in size, although
when surgery did I&D of the area, they did not find anything
but PMNs, but nothing growing out on culture and no cystic
fluid aspirated. The patient also had throughout his body
questionable remnants of a red, macular, reticular or
streaking rash which he described as the same appearance of
what was throughout his whole body which is still remnant on
his arms and legs toward the anterior sides. Of note, this
is not the same and his current inguinal rash and pertinent
negatives included negative sore throat, facial palsy,
central clearing rash, confusion or lethargy, ulceration or
eschar around the rash or any uncontrolled upper extremity
movements.
Labs upon transfer to the floor were white count 12.2 which
was down from 25.2, hematocrit 34.1, thrombocytosis of 411
which was up from 201 on admission. Differential had 86.7
percent neutrophils which was down from 93.8 percent on
admission, with no bands. Sodium 141, potassium 3.7,
chloride 103, bicarb 27, BUN 10, creatinine 0.5, glucose 155.
CK 30. MRSA swabs were taken of his rectal and
nasopharyngeal areas. ASO was less than 200. Blood cultures
were negative for growth times two. Urine was dark amber in
color with large blood, but only 2 RBC, positive for
urobilinogen and trace protein. Tularemia [**Doctor First Name **] is still
pending, although we expect it to be back on [**2167-7-28**]. Lyme
IgG and IgM antibodies are negative. ESR times two has been
greater than 100. Lower extremity Doppler of the area showed
enlarged lymph nodes in the left groin area that are probably
reactive, but no fluid collections. Chest x-ray showed a
small right pleural effusion, otherwise within normal limits.
EKG on [**7-23**] showed borderline first degree AV block which was
resolved by [**7-26**], but had an increased PR interval and
multiple lead ST changes. Echo also done in-house showed
LVEF greater than 55 percent with no vegetations, no
pericardial effusion.
On physical exam vital signs t-max 98.5, t-current 97.4,
pulse 101 ranging from 77 to 101, blood pressure 126/67 with
systolic ranging from 109 to 126, respirations 24 ranging
from 21 to 34, O2 sat 94 to 99 percent on 2 liters nasal
cannula. In general, this is an alert and oriented times
three patient who is appropriate, in no acute distress,
pleasant. HEENT shows no rashes or lesions on his head or
neck. Moist mucous membranes. White patches without exudate
at the back of his throat. Oropharynx clear. Pupils equally
reactive to light and accommodation. Extraocular muscles
intact. No sensation deficits on his face. No exophthalmos.
No rhinorrhea, nares are clear. Cardiovascular was very
significant for a friction rub, regular rate and rhythm
without murmur, S1, S2, no gallop. Pulmonary clear to
auscultation bilaterally, no wheezes, rales or rhonchi.
Abdomen soft, nondistended, nontender, positive bowel sounds,
no rash, lesions or nodules visualized on his anterior
abdomen or lower back. Extremities left inguinal and medial
macular red rash that is blanching without drainage that has
been marked with a pen. It is warm with a 2 to 3 cm
subcutaneous nodule that is palpated underneath the rash
which is firm, noncystic on palpation. No similar findings
on the right side. Lower extremities without venous stasis
changes, without edema or erythema distal to the site. Lower
leg and distal arm have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], reticular, red rash which is
very faint. The patient attributes this to remnants of his
whole body rash. No other trunk, abdomen, back or extremity
lesions, incisions, punctures, rashes, nodules that are
palpable on inspection. Neurologic exam cranial nerves II-
XII grossly intact. No facial palsy. No focal sensation or
motor deficits in his upper extremities, lower extremities,
head or neck.
[**Hospital **] hospital course, much of which has been covered in the
HPI, 51 year old with multiple infectious exposures with
resolving fever, who was transferred out of the [**Hospital Unit Name 153**] once
hemodynamically stable, who shows a resolving rash and a
stable, palpable nodule in his left inguinal area. Because
of his multiple exposures the differential diagnosis for this
presentation was quite large. Blood cultures were sent
including instructions for growing out rickettsial diseases,
which in this area would include ehrlichiosis, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9880**]
spotted fever and Lyme disease. The patient denied any
recent trauma to the area, denied finding any bites, ticks in
the inguinal area. He stated a very monogamous sexual
history. Denied preceding pharyngitis or sick contacts, no
signs of upper respiratory viral illness, no other nodules
throughout his body, no preceding arthralgias which reduce
the differential diagnosis for the team to Lyme disease,
tularemia staph strep cellulitis or acute rheumatic fever.
Throughout the hospital course the patient was receiving
doxycycline and clindamycin and he did improve clinically.
He did not spike any more fevers, had a very stable white
count and was feeling well by the day before discharge. The
diagnosis of acute rheumatic fever was pursued because of
evolving pericarditis, rash and subcutaneous nodules which
are part of major Jones' criteria as well as this migrating
polyarthritis which was most apparent in his left shoulder,
radiating down his arm. The patient's ASO was negative times
one, he had no signs of chorea and did have significant
exposure to wild animals and vectors as well as apparent
resolution with antibiotics and no aspirin or steroids, it
was assumed that the etiology was more infectious than
rheumatologic.
The patient did well after leaving the [**Hospital Unit Name 153**] and coming to the
floor. He complained of occasional, left, pinpoint shoulder
pain, but did not have reduced range of motion. He did have
multiple EKGs for pericarditis and for any other cardiac
events because of this migrating pain/arthritis that went
down his left arm, all of which were negative. The
questionable first degree AV block on day of discharge was
also not apparent any longer. His signs and symptoms of
pericarditis as well as signs of pericarditis on EKG were
also not present on day of discharge.
The patient's subcutaneous nodule was not significantly
smaller on the day of discharge, but did not bother the
patient. It was not painful, did not have any connection to
the cutaneous tissue, was freely moveable and it was
considered that this was probably a reactive lymph node that
would decrease in size over time. The patient was given very
specific instructions on how to follow up with this
questionable diagnosis of Lyme disease which was most likely
the entity that is being treated, although other rickettsial
diseases also could be treated with doxycycline.
Streptomycin was not started for tularemia as this was lower
on the differential diagnosis, although tularemia does not
necessarily have to be glandular with ulcerations in the
central eschar which, of note, was not present in this
patient. As his ASO was negative, anti-DNase, DNA-SD, anti-
DNase B and antihyaluronidase were also checked before
discharge. A throat culture was done for beta strep and the
primary consulted with the infectious disease team who
believe that aspirin for the initial diagnosis of rheumatic
fever was not necessary as this was more likely an infectious
etiology. Upon discharge the patient's pericarditis was
apparently resolved. Motrin was able to control his left
shoulder arthralgias. He was taking a full diet, had been
afebrile for at least 24 hours, had very stable white count,
showed no other pertinent signs on physical exam except for
an apparently resolving, [**Doctor Last Name **], reticular rash in the same
left inguinal area with a very stable subcutaneous nodule
that is most likely a lymph node.
The patient instructed upon discharge that he will need to
complete 14 days of p.o. clindamycin, 14 days of p.o.
doxycycline and to follow up with his PCP [**Last Name (NamePattern4) **] 14 days. On day
of discharge another Lyme titer, ESR and CRP were drawn and
it was encouraged that the patient's PCP look at the results
of these labs, especially at the titers to make a clinical
decision on whether to complete a full 30 day course of
doxycycline in the case of Lyme serology being positive. The
patient was reminded to keep this appointment as it is very
important to prevent further sequelae including very serious
complications of disseminated Lyme disease by following up
with his PCP [**Name Initial (PRE) **].
DISCHARGE DIAGNOSES: Most likely Lyme disease.
Cellulitis with subcutaneous nodule.
DISCHARGE MEDICATIONS:
1. Doxycycline 100 mg b.i.d. times 30 days with the option to
stop after 14 days after consulting with his PCP.
2. Clindamycin 450 mg four times a day.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home.
FOLLOWUP: The patient was given an appointment with his PCP,
[**Name10 (NameIs) 1023**] is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], in his [**Location 27224**] for [**8-12**] at
10:50 a.m. to discuss appropriateness of continuing
doxycycline for a one month regimen based on Lyme titers, ESR
and CRP which were drawn at [**Hospital1 18**] on the day of discharge.
The patient was also asked that if this time does not work
for him, to reschedule, but to try to keep that followup
appointment within a two week period.
The patient was also asked that if this dictation or the lab
results do not make their way to Dr.[**Name (NI) 55597**] office, that he
does remind Dr. [**Last Name (STitle) **] that these labs were drawn and it is
very important to follow up on the Lyme serology to prevent
future serious sequelae of untreated Lyme disease or
improperly treated Lyme disease.
The patient was also asked to be compliant with antibiotic
regimen until seeing his PCP physician and to see his PCP
physician before two weeks or in an E.D. if the rash is not
resolving, if he experiences high fever, myalgias, chest
pain, palpitations, shortness of breath or any other
condition he believes needs to be seen by a medical
professional.
Upon discharge the patient was understanding of his
diagnosis, discharge condition, discharge medications and
plans for followup and states compliance with these plans.
Please fax this report to the attention of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
MD.
Fax number is [**Telephone/Fax (1) 55598**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 5617**]
Dictated By:[**Doctor First Name 55599**]
MEDQUIST36
D: [**2167-7-27**] 13:42:50
T: [**2167-7-27**] 16:16:16
Job#: [**Job Number 55600**]
cc:[**Numeric Identifier 55601**]
|
[
"995.91",
"038.9",
"423.9",
"289.3",
"682.6",
"088.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.04"
] |
icd9pcs
|
[
[
[]
]
] |
11190, 11227
|
21754, 21819
|
21842, 21999
|
11410, 21732
|
233, 279
|
8857, 10981
|
4137, 4931
|
2745, 2814
|
11004, 11173
|
11244, 11392
|
22024, 23951
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,447
| 119,258
|
54042
|
Discharge summary
|
report
|
Admission Date: [**2153-12-19**] Discharge Date: [**2153-12-21**]
Date of Birth: [**2087-5-20**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
NPH
Major Surgical or Invasive Procedure:
[**2153-12-18**]: Insertion of right VP Shunt(Re-Do)
History of Present Illness:
This is a 66 year old male with NPH. He had a VP shunt placed on
[**2153-2-7**] with Dr. [**Last Name (STitle) 65817**]. This was removed on [**2153-11-20**] for
infection and he was treated with a course of IV antibiotics.
Past Medical History:
1. Parkinson's Disease
2. NPH
3. Diabetes Mellitus
4. Hypertension
5. Hypercholesterolemia
5. CAD - s/p CABG
7. L ulnar nerve surgery
8. Melanoma
9. CVA
[**53**]. Dementia
11. VPS placement [**1-29**]([**Doctor Last Name **])
Social History:
Patient lives at nursing home for the last 3-4 months. His wife
and daughters live in [**State 350**]. He was a tax accountant but
retired ?4 months ago, secondary to difficultly performing his
job. Mr. [**Known lastname **] wife (cell: [**Telephone/Fax (1) 110787**])
Family History:
No history of stroke or heart disease per patient. O/w
NX
Physical Exam:
On discharge: He is awake and oriented but has minimal speech.
His left hemiplegia remains. He follows commands with his right
side. PERRLA, face symmetrical. Incisions clean, dry, intact.
Pertinent Results:
CT Head [**2153-12-19**]:
IMPRESSION:
1. Interval placement of a ventriculostomy catheter with
unchanged
ventriculomegaly, small pneumocephalus.
2. Chronic small vessel ischemic disease and moderate global
atrophy.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] neurosurgery service on
[**2153-12-19**]. He underwent replacement of right VP shunt. Post-op
head CT showed expected post-op changes. He was transferred to
the floor on [**2153-12-20**]. His VP shunt was interrogated at the
bedside. The valve was determined to be at 1.5. He had a mildly
elevated temperature of 100.1 on [**2153-12-20**]. UA was without
bacteria. Urine culture is pending. HE had a slight
nonproductive cough that seemed unrelated to feeding. IS was
recommended. He was medically cleared to return to his NH and
was transferred on [**2152-12-21**].
Medications on Admission:
1.Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2.Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3.Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4.Divalproex 125 mg Capsule, Sprinkle Sig: Three (3) Capsule,
Sprinkle PO BID (2 times a day).
5.Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
6.Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7.Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8.Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
9.Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10.Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
11.Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
12.Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
13.Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
14.Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO once a day.
15.Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
16.Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO twice a day.
17.Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze.
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
10. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Divalproex 125 mg Capsule, Sprinkle Sig: Three (3) Capsule,
Sprinkle PO BID (2 times a day).
12. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
15. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
17. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location (un) 5165**]
Discharge Diagnosis:
Normal Pressure Hydrocephalus
Discharge Condition:
Neurologically Stable
Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE
?????? You or a family member, or nurse [**First Name (Titles) 4801**] [**Last Name (Titles) **] your wound
every day and report any of the following problems to your
physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo 24 hours after your
[**Last Name (Titles) 2729**] are removed.
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
[**Last Name (Titles) **]
Usually no special [**Last Name (Titles) **] is prescribed after a craniotomy. A
normal well balanced [**Last Name (Titles) **] is recommended for recovery, and you
should resume any specially prescribed [**Last Name (Titles) **] you were eating
before your surgery.
MEDICATIONS
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
o Narcotic pain medication such as Dilaudid (hydromorphone).
o An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your surgery, do not
resume use until seen in the clinic.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
ACTIVITY
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour, that you
are awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either partial or
total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or face.
?????? Stiff neck, and/or a fever of 101.5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure from
which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
Follow-Up Appointment Instructions
?????? Please return to the office in [**6-29**] days (from your date of
surgery) for removal of your [**Date Range 2729**] and a wound check. Although
we try to be thorough, we may miss [**First Name (Titles) 2730**] [**Last Name (Titles) 2729**] or staples. Be
sure to point out any incisions, which may be covered by
clothing at the time of suture/staple removal. This appointment
can be made with the Nurse Practitioner. Please make this
appointment by calling [**Telephone/Fax (1) 2731**]. 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 _______weeks.
?????? You will / will not need a CT scan of the brain with / without
contrast.
?????? You will / will not need an MRI of the brain with/ or without
gadolinium contrast.
Followup Instructions:
GENERAL INSTRUCTIONS
WOUND CARE
?????? You or a family member should [**Last Name (STitle) **] your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo 24 hours after your
[**Last Name (STitle) 2729**] are removed.
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
[**Last Name (STitle) **]
Usually no special [**Last Name (STitle) **] is prescribed after a craniotomy. A
normal well balanced [**Last Name (STitle) **] is recommended for recovery, and you
should resume any specially prescribed [**Last Name (STitle) **] you were eating
before your surgery.
MEDICATIONS
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
o Narcotic pain medication such as Dilaudid (hydromorphone).
o An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
ACTIVITY
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour, that you
are awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either partial or
total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or face.
?????? Stiff neck, and/or a fever of 101.5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure from
which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
Follow-Up Appointment Instructions
?????? Please return to the office in [**6-29**] days (from your date of
surgery) for removal of your [**Date Range 2729**] and a wound check. Although
we try to be thorough, we may miss [**First Name (Titles) 2730**] [**Last Name (Titles) 2729**] or staples. Be
sure to point out any incisions, which may be covered by
clothing at the time of suture/staple removal. This appointment
can be made with the Nurse Practitioner. Please make this
appointment by calling [**Telephone/Fax (1) 2731**]. 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 a CT scan of the brain with / without contrast.
Completed by:[**2153-12-21**]
|
[
"332.0",
"331.5",
"V45.81",
"V10.82",
"250.00",
"272.0",
"414.00",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.34"
] |
icd9pcs
|
[
[
[]
]
] |
5201, 5272
|
1709, 2342
|
325, 380
|
5346, 5370
|
1468, 1686
|
11594, 14816
|
1184, 1244
|
3732, 5178
|
5293, 5325
|
2368, 3709
|
5394, 8794
|
1259, 1259
|
1273, 1449
|
14844, 17543
|
282, 287
|
408, 633
|
655, 882
|
898, 1168
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,385
| 119,502
|
50204
|
Discharge summary
|
report
|
Admission Date: [**2179-7-5**] Discharge Date: [**2179-8-25**]
Date of Birth: [**2118-4-7**] Sex: F
Service: MEDICINE
Allergies:
Ampicillin / Amoxicillin / Heparin Agents
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
scheduled admission for autologous stem cell transplant
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
A 61-year-old woman with amyloidosis, being admitted for
autologous stem cell transplant. The patient was in her usual
state of health until [**1-/2179**], then
she developed pneumonia. She responded to antibiotics with
resolution of fever and cough that continued after that point to
have progressive fatigue, weight loss, early satiety, and
constipation. The patient as part of her workup underwent a
24-hour urinalysis, which showed elevated quantitative protein
with the presence of Bence [**Doctor Last Name **] that is representing a minority
of the protein with a presence of albuminuria. She had a
protein to creatinine ratio that was markedly elevated at 12.0.
She underwent a bone marrow biopsy, which revealed 10-20% plasma
cells with some areas of amyloid deposition. A skeletal survey
showed no bony lesions. The patient underwent a renal biopsy,
which confirmed the presence of amyloidosis. She did not need a
primary criteria for diagnosis of multiple myeloma and was felt
that this was a primary amyloidosis in the setting of an
underlying plasma cell dyscrasia. She underwent an extensive
pretransplant evaluation was seen by Cardiology. Her ejection
fraction was intact. She has had some ventricular hypertrophy
on echocardiogram. She underwent a MRI, which did show some
evidence of amyloidosis. She underwent a stress test, which
showed good effort, no evidence of ischemic disease, and
ultimately after extensive discussions with Cardiology, it was
felt that the patient did have increased risk of transplantation
in the setting of amyloidosis, but that this risk was not
prohibitive and the functional impairment of the heart was quite
modest. The patient underwent stem cell mobilization with G-CSF
and collected 8 million CD34 cells per kilo with good viability
and is now being admitted for autologous stem cell transplant.
The patient's primary complaint is continued to be fatigue and
some abdominal discomfort. She has had easy bruisability with a
normal PT and PTT. She has had no evidence of congestive heart
failure. Has had some mild edema in her lower extremities. She
has had no shortness of breath, cough, fevers, sweats, chills,
or other localizing complaints.
Past Medical History:
PAST MEDICAL HISTORY:
1. Amyloidosis: + urine and serum paraprotein with a modest
increase in plasma cells in the bone marrow, suggesting that
amyloidosis is associated with a plasma cell dyscrasia, does not
meed criteria for multiple myeloma. Being prepared for
autotransplant; received GCSF treatment starting [**6-19**] for stem
cell collection.
2. Normal EF, minimal diastolic dysfunction, normal stress test.
3. Asthma
4. Hypertension
5. Hypothyroidism
6. S/P fall at age 21 with resultant LE neuropathy
7. S/p tonsillectomy at age 21
Social History:
She works as a hairdresser. She smoked for 30 years, she stopped
for approximately 9 years but then restarted 7 years ago. Mother
with history of colon cancer.
Family History:
She has a sister with rheumatoid arthritis, mother with history
of colon cancer.
Physical Exam:
Vs:T 98.3, HR 93, BP 110/74, RR 20, O2 Sat 97% RA
GENERAL: NAD, obese
HEENT: PERRLA, MMM, no adenopathy, sclerae anicteric
SKIN: multiple bruises, petechial rash throughout
CV: RRR, S1S2 quiet, no murmurs, no rubs
PULM: CTAB, large dressing around upper thorax (for skin
exfoliations)
ABD: obese, ND, NT, +BS
OB/GYN: patient will be examined today by OB/GYN for vaginal
bleeding
EXTR: 3+ edemas BL
NEURO: AOx3
Pertinent Results:
[**2179-7-5**] 02:44PM PT-12.3 PTT-34.2 INR(PT)-1.1
[**2179-7-5**] 02:44PM PLT COUNT-618*#
[**2179-7-5**] 02:44PM NEUTS-57.6 LYMPHS-34.3 MONOS-5.1 EOS-2.0
BASOS-1.0
[**2179-7-5**] 02:44PM WBC-9.6 RBC-4.64 HGB-13.6 HCT-39.4 MCV-85
MCH-29.3 MCHC-34.5 RDW-17.3*
[**2179-7-5**] 02:44PM ANISOCYT-1+ MICROCYT-1+
[**2179-7-5**] 02:44PM ALT(SGPT)-8 AST(SGOT)-16 LD(LDH)-174 ALK
PHOS-83 TOT BILI-0.2
[**2179-7-5**] 02:44PM ALBUMIN-2.1* CALCIUM-9.0 PHOSPHATE-4.0
MAGNESIUM-1.7 URIC ACID-5.2
[**2179-7-5**] 02:44PM GLUCOSE-116* UREA N-13 CREAT-0.6 SODIUM-137
POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-27 ANION GAP-12
.
CXR [**7-22**]: Right effusion. In order to see any underlying lung
disease on the right, a left decubitus rather than a right
decubitus views would be necessary.
.
CT [**7-24**]: Large right-sided and smaller left-sided pleural
effusions. Moderate gallbladder distension without evidence of
cholecystitis. Apparent wall thickening of the descending colon
is likely secondary to collapse, although an intrinsic process
cannot be excluded on this examination. There is no pericolonic
stranding. Clinical correlation is advised.
.
Chest CT [**7-25**]: 1. 11 mm left apical spiculated mass with
pathologic mediastinal adenopathy is concerning. A PET scan is
recommended for further evaluation. 2. Bilateral pleural
effusions with associated atelectasis (right greater than left).
.
Head CT [**7-25**]: No intracranial hemorrhage.
.
Echo [**7-25**]: There is symmetric left ventricular hypertrophy. Due
to suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Left ventricular systolic function is
hyperdynamic (EF>75%). Right ventricular chamber size and free
wall motion are normal. Trivial mitral regurgitation is seen.
Ventricular cavity sizes appear small suggestive of hypovolemia.
.
CXR [**7-27**]: Moderate right and small left pleural effusion have
progressively enlarged since [**7-22**]. Mild pulmonary edema and
mediastinal venous engorgement indicate biventricular cardiac
decompensation, although heart is not particularly enlarged.
Severe right lower lobe atelectasis is partially obscured by
pleural effusion.
.
[**7-28**] LUE U/S: Limited study, no subclavian, axillary, or
internal jugular thrombus.
.
[**8-4**] CXR: Almost complete resolution of pulmonary edema.
Bilateral pleural effusions improved.
.
[**8-4**] Irregular Antibodies: This patient has a newly acquired
anti-Jka (Kidd) antibody. Kidd antibodies are IgG antibodies
that fix complement. They have the potential to cause delayed
hemolytic transfusion reactions that are intravascular and
severe. The possiblility of delayed hemolytic transfusion
reaction as well as the fact that the Coombs test was negative
was discussed with the clinical team. These reactions typically
occur from 7-10 days post sensitization but may occur later. As
a result, the patient must receive blood products lacking the
Jka antigen should future need for transfusion arise.
.
Lung Scan [**8-5**]: This is a limited examination. Perfusion
abnormalities are
consistent with the patient's known right sided pleural
effusion. There are no other segmental or subsegmental perfusion
defects.
.
Echo [**8-5**]: The left atrium is normal in size. There is symmetric
left ventricular hypertrophy. The left ventricular cavity is
unusually small. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Left
ventricular systolic function is hyperdynamic (EF>75%). The
right ventricular cavity is small. Right ventricular systolic
function is normal. The aortic valve is not well seen. There is
no valvular aortic stenosis. The increased transaortic gradient
is likely related to high cardiac output. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is a
very small pericardial effusion. There are no echocardiographic
signs of tamponade. Compared with the prior study (images
reviewed) of [**2179-7-25**], findings are similar although views are
technically suboptimal for comparison. A very small pericardial
effusion is now detected.
.
CXR [**8-14**]: 1) New small left pleural effusion with underlying
collapse and/or consolidation. Right effusion and underlying
collapse and/or consolidation unchanged. Mild CHF. 2) A
spiculated left apical mass seen on the [**2179-7-25**] CT scan is not
appreciated radiographically. At the time of that CT scan, a PET
scan was recommended for further evaluation. Clinical
correlation is requested.
.
Cytology, sputum [**8-14**]: NEGATIVE FOR MALIGNANT CELLS.
.
CXR [**8-16**]: Stable appearance to the bilateral pleural effusions.
Brief Hospital Course:
The patient is a woman with what appears to be primary
amyloidosis as such we are going forward with autologous
transplant. We have carefully reviewed potential
risks and benefits of autologous transplant and explained that
in phase II data. This has been associated with improvement or
stabilization of symptoms in patients with amyloidosis and
disease free for progression free survival of approximately 4 to
6 years. There has been no randomized phase III studies
comparing this directly to standard chemotherapy, but in case
control, this does appear to be advantageous risks of autologous
transplant and include complications from infection, bleeding,
need for transfusion, risk of end organ damage including
hepatic, renal, pulmonary, and cardiac toxicity, potential risk
for poor engraftment, myelodysplasia, acute leukemia, and
appears transplant mortality of [**4-7**]% that transplant related
morbidity
and mortality is increased in the setting of cardiac amyloid and
as a result the patient underwent an extensive evaluation by
Cardiology and was felt that her degree of involvement is quite
modest and that based on the patient's overall symptoms that
will be reasonable to look forward. This was carefully
discussed with the patient who would like to look forward as
indicated. She went through the eligibility assessment process
and met eligibility criteria as per the treatment plan for
autologous stem cell transplantation and is to be admitted for
this purpose.
______________________
Ms. [**Known lastname 104722**] is a 61yo F w/ amyloidosis. She was admitted on
[**2179-7-5**] and underwent conditioning w/ melphalan. She had a
relatively unremarkable pre-transplant course. She was having
postmenopausal bleeding on admission, for which she was
evaluated by GYN, with the question of ? vaginal amyloid. Has
also had some mild hematuria, emesis x1 w/ blood (not frank
hematemesis) and issues with fluid management, requiring almost
daily lasix doses to keep I/O even (is now up 30# from baseline
weight). After her stem cell infusion, had significant n/v and
was given ativan and compazine but dropped her BP and required
fluid boluses to bring BP back up (on [**2179-7-9**]). Allopurinol was
added on [**7-10**] for elevated LDH and uric acid (for ? tumor lysis
syndrome, with good results). Cardiology was consulted on
[**2179-7-12**] for volume overload and possible diastolic dysfunction,
but recommended diuresis which has been difficult given her
hypotension. She has started to develop mild mucositis and
decreased appetite, requiring TPN to keep her nutritional status
up. Per BMT team, pt was doing well yesterday, afebrile, and
without any complaints.
.
At 4am VS check, patient was noted to be febrile. Shortly
thereafter the moonlighter was called for hypotension and came
to evaluate the patient. The pt told the moonlighter that she
felt "awful", like she was "going to die", worse than she's felt
through the entire transplant. Denied CP or SOB. She was given
250cc NS bolus for SBP in the 80s, with minimal improvement (SBP
to 90s). Moonlighter did not feel comfortable giving more IVF
given her h/o volume overload and instead began to administer
pressors through her IV. She was originally going to receive neo
given her tachycardia (HR was in 130s), but given her CAD, her
pressor was changed to levophed. Her TPN was stopped so as to
free up another port for access. ABG was attempted x4 with no
success. EKG was obtained and showed ST elevations in V1-V2,
somewhat more pronounced than in the past. CXR was performed and
did not show frank pulmonary edema, but did show a new RLL
infiltrate vs. effusion. Once the levophed was able to be
started, the patient was stable for transfer and was brought to
the [**Hospital Unit Name 153**] for further management.
In the [**Hospital Unit Name 153**], no source of sepsis was found. She was started on
steroids for presumed adrenal insufficiency. Her blood pressure
resolved. After transfer back to the floor, on [**7-30**], she remained
stable. She experienced several episodes of shortness of breath,
but V/Q scan, echocardiogram, chest X-ray showed no source of
dyspnea. Her oxygen saturations remained above 88% on room air,
and she was given oxygen via nasal cannula for comfort.
.
She developed acute thrombocytopenia, which was attributable to
a positive anti-platelet antibody. Her platelets had resolved to
~70K at the time of discharge.
.
Throughout her hospital stay, she was followed by the psychiatry
consult service for anxiety and depression. At the time of
discharge, she was stable on doses of ativan (TID), mirtazapine
15mg daily, and Ritalin 15mg [**Hospital1 **]. She was discharged with
Bactrim for prophylaxis.
Medications on Admission:
Lisinopril 10 mg PO DAILY
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
OxycodONE (Immediate Release) 5 mg PO Q4-6H:PRN
Levothyroxine Sodium 125 mcg PO DAILY
Lorazepam 0.5 mg PO ONCE MR1
Hydrochlorothiazide 25 mg PO DAILY
Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
Discharge Medications:
1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Salmeterol 50 mcg/Dose Disk with Device Sig: [**11-30**] Disk with
Devices Inhalation Q12H (every 12 hours). Disk with Device(s)
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Methylphenidate 5 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
13. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO BID MWF:
Please take twice a day on monday, wednesday, and friday.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary amyloidosis s/p autologous stem cell transplant
Discharge Condition:
Stable, good oxygen saturation on room air.
Discharge Instructions:
You were admitted for autologous stem cell transplant. You are
being discharged to a rehabilitation facility. Please take all
of your medications as prescribed. If you experience any
shortness of breath, fevers, chest pain, or other concerning
symptoms, please seek medical attention immediately.
Followup Instructions:
Follow up appointment with Dr. [**Last Name (STitle) **]: Please follow-up with Dr.
[**Last Name (STitle) **] on [**2179-8-26**] at 2:30 PM. It will be important for youto
tell [**Hospital **] rehab to arrange transportation for you to attend
this appointment.
Dentist: Nopsaran Chaimattayompol, DDS. Private practice number:
[**Telephone/Fax (1) 104723**]. Three more follow up appointments for denture
fitting.
|
[
"627.1",
"458.9",
"255.4",
"611.0",
"793.1",
"511.9",
"585.9",
"995.92",
"707.8",
"284.8",
"276.7",
"414.01",
"038.9",
"999.8",
"425.7",
"401.9",
"528.0",
"428.32",
"356.9",
"599.7",
"054.9",
"493.90",
"583.81",
"682.3",
"277.3",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"38.93",
"00.17",
"99.04",
"99.05",
"99.15",
"41.04",
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
15027, 15106
|
8689, 13414
|
356, 381
|
15206, 15252
|
3910, 8666
|
15597, 16014
|
3383, 3465
|
13735, 15004
|
15127, 15185
|
13440, 13712
|
15276, 15574
|
3480, 3891
|
261, 318
|
409, 2624
|
2668, 3190
|
3206, 3367
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,788
| 107,191
|
19676
|
Discharge summary
|
report
|
Admission Date: [**2199-9-17**] Discharge Date: [**2199-9-20**]
Date of Birth: [**2124-12-7**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Thoracic aortic aneurysm
Major Surgical or Invasive Procedure:
[**2199-9-17**]: Stent graft repair of thoracic aortic aneurysm
History of Present Illness:
Mr. [**Known lastname 18995**] is a 74-year-old gentleman with a large descending
thoracic aortic aneurysm, who presented for elective
endovascular repair.
Past Medical History:
PMH: HTN, focal type A dissection, type B aortic dissection,
AAA, seizure d/o, SAH 98 s/p craniotomy/aneurysm repair, PUD,
retinal detachment, Raynauds, GIB
PSH: craniotomy/aneurysm repair, hernia repair
Social History:
Alcohol - none; tobacco - 1ppd x many years
Family History:
noncontributory
Physical Exam:
PE on admission:
Gen: AAOx4, cachectic, NAD
CVS: RRR, no M/R/G
Pulm: Coarse b/l. Chronic cough.
Abd: Scaphoid. Nontender, nondistended.
Ext: no clubbing, cyanosis, or edema
Pulses: DP and PT dopplerable bilaterally
Neuro: CN II-XII grossly intact
PE on discharge:
Gen: AAOx4, cachectic, pleasant and conversant, NAD
CVS: Regular, no M/R/G
Pulm: Course, stable, chronic cough.
Abd: Nontender, nondistended, +BS
Ext: Warm, no clubbing, cyanosis, or edema. Bilateral groin
puncture sites clean, dry, and intact. Soft, without erythema
or evidence of hematoma.
Pulses: DP and PT dopplerable bilaterally
Neuro: CN II-XII grossly intact
Brief Hospital Course:
Mr. [**Known lastname 18995**] was admitted on [**2199-9-17**] for planned repair of his
thoracic aortic aneurysm. After appropriate preparation and
informed consent, he underwent endovascular stent graft repair
of his thoracic aortic aneurysm. He tolerated the procedure
well, and after initial recovery in the PACU, he was admitted to
the cardiovascular ICU for post-operative monitoring, management
of his blood pressure and ICP, and frequent neurologic exams.
Through POD#1, Mr. [**Known lastname 18995**] remained hemodynamically stable and
his neurologic exam continued to be intact. His lumbar drain
was removed on [**9-18**] without complication. His diet was
advanced, and he was able to be out of bed to a chair. His
blood pressure was closely monitored, and kept within the target
range. He was transferred to the vascular surgery floor in good
condition.
On [**9-19**], he was able to ambulate and his arterial line and foley
catheter was removed. He voided without difficulty. His home
medications were resumed, and his fluids heplocked.
On [**9-20**], Mr. [**Known lastname 18995**] was evaluated by the physical therapy team,
who cleared him for home with home physical therapy and a
walker. He was found to be ambulating at baseline, tolerating a
regular diet, taking oral pain medication, and with a stable
neurovascular exam. He was instructed to undergo an abdominal
CT scan and follow up in clinic with Dr. [**Last Name (STitle) 1391**] in one month.
He will receive daily home physical therapy, and will follow up
with his PCP for blood pressure management. He was started on
aspirin, and given prescriptions for oral pain medication. Mr.
[**Known lastname 18995**] and his wife understood and agreed with the plan. He
was discharged home with a walker and home PT in good condition
on [**2199-9-20**].
Medications on Admission:
simvastatin 10', HCTZ 25', labetalol 200'', valproic acid 500'',
lisinopril 40', nicotine patch
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. valproic acid 250 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours).
4. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
6. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for Pain for 5 days.
Disp:*30 Tablet(s)* Refills:*0*
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation for 10 days.
Disp:*20 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Thoracic aortic aneurysm
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 may resume your usual diet.
Please resume your home medications unless specifically
instructed otherwise.
Please take any new medications as directed.
You may shower, and clean your groin puncture sites with soap
and water. Avoid soaking in the tub or swimming until you are
seen in vascular surgery clinic.
Avoid lifting more than 10 pounds or strenuous activity until
cleared by your surgeon.
No dressing is necessary.
Please keep your follow up appointments!
Followup Instructions:
Please call [**Telephone/Fax (1) 1393**] to schedule a follow up appointment
with Dr. [**Last Name (STitle) 1391**] in clinic in one month.
You will be called to schedule an abdominal CT scan prior to
your scheduled appointment.
Please follow up with your PCP for blood pressure management.
|
[
"799.4",
"V12.54",
"285.9",
"441.01",
"V15.82",
"345.90",
"V12.71",
"443.0",
"V45.89",
"272.0",
"V85.0",
"492.8",
"401.9",
"V70.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.39",
"39.73"
] |
icd9pcs
|
[
[
[]
]
] |
4329, 4400
|
1577, 3419
|
328, 394
|
4469, 4469
|
5143, 5437
|
886, 903
|
3566, 4306
|
4421, 4448
|
3445, 3543
|
4652, 5120
|
918, 921
|
1184, 1554
|
264, 290
|
422, 579
|
935, 1170
|
4484, 4628
|
601, 808
|
824, 870
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,163
| 120,851
|
37022
|
Discharge summary
|
report
|
Admission Date: [**2175-10-8**] Discharge Date: [**2175-10-24**]
Date of Birth: [**2131-4-16**] Sex: F
Service: MEDICINE
Allergies:
Calcitonin
Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
hip pain and constipation with new hypercalcemia
Major Surgical or Invasive Procedure:
Bone marrow biopsy
Port a cath placement
Chemotherapy
History of Present Illness:
Ms [**Known lastname 6955**] is a 44 yo female with pmh of metaststic squamous
cell carcinoma of the left mid medial thigh s/p excision in [**7-6**]
who presented to the [**Hospital3 22439**] with hip pain. She had
been experiencing right posterior mid-hip pain for the last 3
weeks. The pain was sharp and did not radiate down her leg. It
got as bad as [**10-7**]. Denies weakness in her legs, sensory
changes, or incontinence. She was taking 1 percocet per day to
help her sleep. She also has had 2 weeks of constipation and
more recently increasing abdominal distension and lower
abdominal pain. She used a saline enema on Wednesday which
produced some stool, then had diarrhea on Thursday. She reports
that her stool is black. For the past few days she has been
experiencing nausea and occasional vomiting after eating. She
also reports she has been gagging on pills recents and has had
headaches on and off.
.
In [**Hospital1 6687**] she was found to have a Ca of 18.7 and was given 1
L IVF. She also had K and Mg repletion and was given zofran for
nausea. She had an X-ray of her lumbar spine which showed no
evidence of metastatic disease. She was transferred to the [**Hospital1 18**]
ED for further evaluation.
.
In the ED, initial vs were: T 97.5 P 94 BP 147/99 R 22 O2 sat
100% on RA. Patient was given 4 L NS and 4 mg IV morphine for
pain. She underwent a hip X-ray which showed no evidence of
metastatic disease.
.
On arrival to the [**Hospital Unit Name 153**] she reports her hip pain is well
controlled with the morphine she received in the ED.
Past Medical History:
1. Metastatic squamous cell carcinoma - Diagnosed within the
last year after presenting to her PCP with [**Name Initial (PRE) **] fungating thigh
mass. Biopsy showed squamous cell carcinoma. Metastatic workup
revealed adenopathy involing the iliac vessles and superficial
inguinal region. She underwent excision of the mass on [**2175-7-18**]
at [**Hospital1 18**]. She was evaluated for XRT, but decided against it as
she felt the chance of reoccurance was low and the risks were
high.
2. Iron deficiency anemia - During workup for her SCC she
underwent an endoscopy and colonoscopy which showed no cause for
her anemia. She was treated with IV iron dextran and epo which
brought her Hct to the low 30's.
Social History:
She is a Jehovah's Witness. She lives in [**Hospital1 6687**] with her
husband. She is a bookkeeper. Denies tobacco, alcohol, or drug
use.
Family History:
Her father and sister have had sebaceous cysts.
There are a number of non-immediate family members with history
of cancer; details are lacking
Physical Exam:
Vitals: T 96.5 P 90 BP 153/79 RR 17 Sat 93% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Patient is breathing comfortably. Inspiratory crackles
bilaterally at the bases.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Linear well-healed scar in her LLQ. Her abdomen is
moderately distended with hyperactive bowelsounds. Slight
tenderness to palpation in her lower quadrants. No rebound or
guarding present. No HSM.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Left mid medial thigh has a large area where a
baseball-sized mass of tissue was removed with well-appearing
scar tissue over it.
Back: No spinal tenderness. Pain to palpation focally over her
right iliac crest. No masses or abnormalities palpated.
Neuro: CN II-XII grossly intact. sensation to light touch intact
throughout. 5/5 strength in her upper and lower extremities.
Pertinent Results:
Admission Labs: [**2175-10-8**]
GLUCOSE-84 UREA N-44* CREAT-2.5* SODIUM-134 POTASSIUM-3.2*
CHLORIDE-101 TOTAL CO2-24 ANION GAP-12
ALT(SGPT)-26 AST(SGOT)-49* ALK PHOS-139* AMYLASE-43 TOT BILI-0.4
LIPASE-153*
Calcium-19.8* Phos-4.9* Mg-2.4
Albumin-2.9* Calcium-15.1* Phos-3.9 Mg-1.9
.
Discharge Labs:
.
.
.
.
Pathology [**2175-10-12**] Ilium/pelvis, right, biopsy: Metastatic
squamous cell carcinoma present.
.
Images:
[**2175-10-10**] Bone biopsy: 1. Known T10 vertebral body and pelvic
osseous metastases do not demonstrate significant tracer
avidity. 2. Marked right upper thoracic anterior chest wall
uptake does not have an obvious CT correlate, though early
rib/chest wall metastasis is a diagnostic consideration. 3.
Bilateral femoral shaft uptake may reflect hypertrophic
pulmonary osteoarthropathy. 4. Difficult to exclude a skull
metastasis in the setting of mild focal uptake.
[**2175-10-9**] CT pelvis: 1. New lytic lesions throughout the pelvis
and new subcutaneous left lower quadrant and left inguinal
nodules, all indicative of marked progression of metastatic
disease. 2. Small amount of free fluid in the pelvis. 3.
Diverticulosis
[**2175-10-9**] CT chest: 1. Marked progression of extensive bilateral
pulmonary nodules with large hilar masses inseparable from
mediastinal lymphadenopathy as well as numerous ossesous lytic
lesions. Overall, these findings are new since [**Month (only) **] and
concerning for rapid progression of neoplastic disease in a
person with known history of previous malignancy.
2. Expansile lesion posteriorly at the T10 veterbral body with
associated
narrowing of the central canal 3. New bilateral pleural
effusions.
4. Inadequately characterized hepatic hypodensities. 5.
Cholelithiasis.
Brief Hospital Course:
This is a 44 yo female with metaststic squamous cell carcinoma
of the left mid medial thigh s/p excision in [**7-6**] admitted with
hypercalcemia of 19.8.
.
# Hypercalcemia: This was most consistent with hypercalcemia [**1-30**]
PTH-rp production and bone metastasis. The patient presents with
constipation and was found to have a Ca of 19.8. Patient was
given IVF and pamidronate. Calcitonin was attempted, but a
sample prior to the full dosage caused the patient swelling, so
she was not given any more of this. She was given lasix as well.
Endocrine was consulted and monitored the patient closely. PTH
was normal at 21. Vit D 25 OH was low at 10. PTH-rP is pending.
Initially patient was unable to take in adequate POs, secondary
to her mucositis, to meet her fluid requirement and her Ca
levels were difficult to control. She required ~6L IVFs daily
to match her urine output. Ultimately, the patient and family
wanted to be discharged and follow up closer to their home. The
decision was made to send her home and follow up with her PCP to
receive [**Name9 (PRE) 83479**] as an outpatient.
.
# Squamous cell carcinoma: Chest and pelvic CT was performed
which was concerning for pulmonary nodules, extensive
lymphadenopathy, and lytic lesions in the pelvis all concerning
for metastatic malignancy. A bone scan was performed which
showed diffuse lytic lesions in pelvis, chest wall, femur, and
possibly skull. All of these findings were highly consistent
with metastatic SCCA. A bone biopsy was scheduled that showed
squamous cell carcinoma in the iliac. A port a cath was placed
and the patient was started on chemotherapy. She tolerate
chemotherapy well except for mucositis that was improving prior
to discharge. She also tempoprarily developed elevated LFTs but
this was an expected side effect of chemotherapy.
.
# HTN: Upon admission the patient's SBP was 140-150. However, in
the [**Hospital Unit Name 153**] her SBP rose to 200. It was thought that the large
amount of fluids she was getting for her hypercalcemia had
contributed to her HTN. She had a good response to labetalol and
amlodopine.
.
# Acute renal failure: The patient's Cr on admission was 3.2
(her baseline is 0.6-0.7). She appeared dry initially on exam
and given her extreme hypercalcemia likely has prerenal ARF vs
ATN from volume depletion. She had an abdominal US at [**Hospital1 6687**]
which showed no evidence of hydronephrosis. Part of her ARF
could also be due to the direct renal vasoconstriction effect of
hypercalcemia on the kidney causing a fall in the GFR.
Nevertheless, she was given significant amounts of IVF's and her
kidney function returned to [**Location 213**] prior to discharge.
.
# Right posterior hip pain: The patient has focal iliac crest
pain on exam, Hip x-ray was negative, but CT showed lytic
lesions in bone which may be the cause of her hip pain. She was
given ms contin and morphine for pain relief.
.
# Chronic iron-deficiency anemia: The patient's initial Hct was
34.2 which was near her most recent baseline since being treated
for iron-deficiency. She is a Jehovah's Witness and therefore
would not want tranfusion of any type of blood products. Her
hematocrit slowly trended downward, without any evidence of
hemolysis. Lab draws were limited to daily basis. Patient
otherwise remained hemodynamically stable.
.
# Tacchycardia: The patient's HR rate was in the 100s on
admission and prior to discharge. Based on previous clinic visit
notes she has had tachycardia before. She was not tachycardic
when her Hgb was around 11 (after iron infusion) so this is
likely [**1-30**] anemia.
Medications on Admission:
Vitamin B12 occasionally
Percocet prn
Discharge Medications:
1. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
Disp:*90 Tablet(s)* Refills:*2*
2. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety/nausea.
Disp:*180 Tablet(s)* Refills:*0*
4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours): Do not drink alcohol
or drive while on this medication.
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
6. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain: Do not drink or drive alcohol while
on this medication.
Disp:*180 Tablet(s)* Refills:*0*
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
10. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
Disp:*120 Tablet(s)* Refills:*0*
11. Oral Wound Care Products Gel in Packet Sig: Fifteen (15)
ML Mucous membrane TID (3 times a day) as needed for mucositis.
Disp:*1350 ML(s)* Refills:*0*
12. Normal Saline
Please administer 4L of NS at 250cc per hour daily.
13. Potassium & Sodium Phosphates 280-160-250 mg Powder in
Packet Sig: One (1) Powder in Packet PO QID (4 times a day).
Disp:*60 Powder in Packet(s)* Refills:*0*
14. Outpatient Lab Work
Please check basic metabolic panel including calcium and
phosphorous daily for the next week. Can start to decrease
frequency as values improve. Please check CBC twice weekly.
15. Heparin Flush 10 unit/mL Kit Sig: One (1) flush Intravenous
twice a day: with accessing port.
Disp:*60 flushes* Refills:*2*
16. Saline Flush 0.9 % Syringe Sig: One (1) flush Injection
twice a day: as needed with accessing port.
Disp:*60 flushes* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Primary Diagnosis:
1) Hypercalcemia
2) Squamous cell carcinoma
3) Acute renal failure
.
Secondary Diagnosis:
1) Anemia
Discharge Condition:
Stable
Discharge Instructions:
You were admitted the the hospital for hypercalcemia. Your
hypercalcemia was treated with IV fluids and medications. It is
improved, but still above normal. You will need to follow up
with your PCP about this issue. After a bone marrow biopsy
showed that you had squamous cell carcinoma in your bones, you
were started on chemotherapy. You tolerated your chemotherapy
well except for the development of oral ulcers. Please use the
medication, gelclair, for your ulcers. They should improve with
time. You will need to follow up with your oncologist. We
treated your pain with pain medications. You also developed high
blood pressure while in the hospital. We treated this with blood
pressure medications.
.
We have made the following changes to your medication list:
1) Zofran 8 mg tablet by mouth every 8 hours as needed for
nausea.
2) Lorazepam 0.5 mg Tablet by mouth every 4 hours as needed for
anxiety/nausea.
3) Labetalol 200 mg Tablet by mouth 2 times a day
4) Amlodipine 5 mg Tablet by mouth once a day
5) Morphine 15 mg Tablet Sustained Release. One tablet by mouth
every 12 hours: Do not drink alcohol or drive while on this
medication.
6) Morphine 15 mg Tablet. 1 tablet by mouth every 4 hours as
needed for pain: Do not drink or drive alcohol while on this
medication.
7) Bisacodyl 5 mg Tablet by mouth Daily as needed for
constipation.
8) Senna 8.6 mg Tablet by mouth 2 times a day for constipation
9) Docusate Sodium 100 mg Capsule by mouth 2 times a day for
constipation
10) Compazine 10 mg Tablet by mouth every six hours as needed
for nausea.
11) Oral Wound Care Products (Gelclair) Apply fifteen ML to the
mucous membranes of your mouth three time a day as needed for
mucositis.
.
Please seek medical help if you develop shortness of breath,
chest pain, nausea vomiting, fevers, chills.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **]. Phone number [**Telephone/Fax (1) 52946**]. An
appointment has been made for you on: Wednesday [**2175-11-1**] at
9:30am.
.
You also need to see him tomorrow. He has been spoken to and
will give you Zometa 4 mg once.
.
Please follow up with an oncologist at [**Location (un) **]. The doctor who
will be in touch with him is Dr. [**Last Name (STitle) **]. His phone number is
([**Telephone/Fax (1) 15328**]. Please call and make a follow up appointment
with him if you need further oncology care in [**Location (un) 86**].
Completed by:[**2175-11-2**]
|
[
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"584.9",
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"276.8",
"280.9",
"275.42",
"401.9",
"196.1",
"511.9",
"780.53",
"196.5",
"198.5",
"577.0",
"528.01",
"E933.1"
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icd9cm
|
[
[
[]
]
] |
[
"77.49",
"99.25",
"86.07"
] |
icd9pcs
|
[
[
[]
]
] |
11767, 11818
|
5812, 9425
|
321, 377
|
11981, 11990
|
4052, 4052
|
13855, 14465
|
2870, 3014
|
9514, 11744
|
11839, 11839
|
9451, 9491
|
12014, 13832
|
4351, 5789
|
3029, 4033
|
233, 283
|
405, 1968
|
11948, 11960
|
4068, 4335
|
11858, 11927
|
1990, 2698
|
2714, 2854
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,644
| 132,736
|
48231
|
Discharge summary
|
report
|
Admission Date: [**2154-8-8**] Discharge Date: [**2154-8-12**]
Date of Birth: [**2081-9-9**] Sex: F
Service: NEUROLOGY/ICU
DIAGNOSIS: Status post right internal carotid artery stent
placement.
HISTORY OF THE PRESENT ILLNESS: This is a 72-year-old woman
with a history of hypertension, peripheral vascular disease,
and left face and arm weakness, who presents for elective
right carotid stenting.
History included the following: Right siphon stenosis
discovered in [**2151**], which was treated with antiplatelet
agents. Subsequent MR imaging on [**2153-12-25**] revealed 40%
to 60% stenosis in the right ICA. The patient has a one year
history of TIA characterized by left hand and face
weakness/numbness and dysarthria. A Carotid ultrasound, in
[**2154-4-24**], revealed 80% to 90% stenosis in the same vessel.
Angiogram at this time revealed severe right ICA stenosis ( >95%)
at the bifurcation with right siphon stenosis and 4 mm aneurysm
at the anterior communicating artery.
The patient underwent right carotid stent without
complications. The patient tolerated the procedure well
Post-procedure the patient was admitted to the Neurology
Intensive Care Unit for postoperative procedural observation with
the neurosurgical Intensive Care House Staff following.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Peripheral vascular disease
3. Degenerative joint disease.
4. Breast cancer status post XRT.
5. Hypothyroidism.
6. Depression.
7. Psoriasis.
ALLERGIES: The patient is allergic to PENICILLIN AND
CODEINE.
MEDICATIONS ON ADMISSION:
1. Levoxyl 175 mcg q.d.
2. Celexa 10 mg q.d.
3. HCTZ 25 mg q.d.
4. Folate 1 mg q.d.
5. Ranitidine 150 mg PO b.i.d.
6. Tamoxifen 10 mg PO b.i.d.
7. Plavix 75 mg PO q.d.
8. Aspirin 325 mg PO q.d.
9. Trazodone 60 mg PO q.h.s.p.r.n.
10. Asacol 800 mg PO t.i.d.
11. Atenolol 25 mg PO q.d.
12. Neurontin 300 mg PO t.i.d.
13. Celebrex 100 mg PO b.i.d.
14. Imdur 30 mg PO q.d.
15. Caltrate D 600 mg PO b.i.d.
16. Sublingual nitroglycerin p.r.n. chest pain.
17. ....................as needed for pain.
SOCIAL HISTORY: The patient lives with her daughter, with
very good social support. She does not smoke. She drinks
only occasionally.
FAMILY HISTORY: History was significant for hypertension,
diabetes mellitus, and coronary artery disease.
PHYSICAL EXAMINATION: Examination revealed the following:
Temperature 97, blood pressure 145/85, heart rate 59, SPO2
99% to 100% SPO2 on a couple of liters. GENERAL: Intubated
patient in no acute distress. HEENT: Normocephalic,
atraumatic, supple, no bruits, no lymphadenopathy.
CARDIOVASCULAR; Regular rhythm, normal rate. PULMONARY:
Clear to auscultation bilaterally. ABDOMEN: Positive bowel
sounds, soft, nontender, nondistended. GROIN: Left sheath
in place with no bruits. No evidence of hematoma or bruits.
NEUROLOGICAL: The patient awake, alert, and following
commands. Pupils are reactive and equal. Extraocular
motions are full. There is a horizontal-gaze nystagmus
bilaterally; moves symmetrically. Sensation was intact to
touch. MOTOR: The patient moves the extremities equally
well with normal bulk and tone. EXTREMITIES: The left leg,
however, is immobilized with sheath in place and, therefore,
not fully tested. REFLEXES: 2+ and symmetrical, with toes
downgoing.
LABORATORY DATA: Laboratory data revealed the following:
White count 8.5, hematocrit 25, MCV 86, platelet count
160,000, sodium 141, creatinine 1.2, BUN 31, chloride 108,
bicarbonate 19. ABG was 7.29, 50, and 215.
HOSPITAL COURSE: Mrs. [**Known lastname 49013**] was admitted to the
Neurointensive Care Service for further postoperative care.
She was found to be anemic postoperatively, therefore, she
was given two units of packed red blood cells with initial
appropriate increase in the hematocrit. She was extubated
uneventfully. The hospital course was complicated by a
moderate left groin hematoma in the setting of heparin
anticoagulation post procedure. The anticoagulation was
discontinued and the sheath removed with pressure applied for
an hour.
She remained stable hemodynamically, however, she required a
total of four units of packed red blood cells before the
hematocrit stabilized in the low 30s, which is her baseline.
While in house, we also note a metabolic acidosis consistent
with elevated lactic acid. This is likely partially
secondary to hypovolemia and, therefore, she was transfused
and the volume status corrected. The lactic acidosis
improved.
Mrs.[**Last Name (STitle) 101641**] also had mild elevation in creatinine likely
secondary to her dye load during the procedure. As the volume
status improved, creatinine returned to baseline within the
hospital stay.
At the time of this dictation, the patient is stable for
discharge home. She is safe from a physical therapy and
occupational therapy perspective. She is able to ambulate
both on a level plane and up and down stairs without
problems. She will follow up with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 5730**].
She will also follow up with her primary physician and
cardiologist while in house. We note that she has a few
episodes of bradycardia down to the low 40s, which are not
sustained. We should further state that she had no evidence
of chronotropic incompetence.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The patient is discharged to home with
follow up.
DISCHARGE DIAGNOSES:
1. Right carotid artery stenting.
2. Left groin hematoma.
3. Previous diagnoses as indicated in the past medical
history above.
4. The patient continued to have an aneurysm in the anterior
communicating artery, which will be monitored by
Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 5730**] and [**Name5 (PTitle) **] considered as
necessary.
DISCHARGE MEDICATIONS: The patient is to continue all of her
outpatient medications with the exception of Zantac b.i.d.,
which is discontinued and the patient was put on
Pantoprazole. This was done as the patient has evidence of
increased creatinine and, therefore, decreased creatinine
clearance.
MEDICATIONS:
1. Levoxyl 175 mcg PO q.d.
2. Celexa 10 mg PO q.d.
3. HCTZ 25 mg PO q.d.
4. Folate 1 mg PO q.d.
5. Pantoprazole 40 mg PO q.d.
6. Tamoxifen 10 mg PO b.i.d.
7. Plavix 75 mg PO q.d.
8. Enteric coated aspirin 325 mg PO q.d.
9. Trazodone 50 mg PO q.h.s.p.r.n.
10. Asacol 800 mg PO t.i.d.
11. Atenolol 25 mg PO q.d.
12. Neurontin 300 mg PO t.i.d.
13. Celebrex 100 mg PO b.i.d.
14. Imdur 30 mg PO q.d.
15. Caltrate D 600 mg p.o.b.i.d.
16. Sublingual nitroglycerin p.r.n.
17. Fioricet as needed for pain.
FOLLOW-UP CARE: The patient is to follow up with
Dr. [**Last Name (STitle) **] and [**Doctor Last Name 5730**]. The patient will also follow up
with her primary physician and cardiologist.
[**Name6 (MD) 725**] [**Name8 (MD) 726**], M.D. [**MD Number(1) 727**]
Dictated By:[**Last Name (NamePattern4) 39653**]
MEDQUIST36
D: [**2154-8-12**] 11:41
T: [**2154-8-12**] 12:11
JOB#: [**Job Number 101642**]
|
[
"998.12",
"443.9",
"401.9",
"276.5",
"285.1",
"276.2",
"584.5",
"244.9",
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] |
icd9cm
|
[
[
[]
]
] |
[
"39.90",
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] |
icd9pcs
|
[
[
[]
]
] |
2234, 2325
|
5436, 5792
|
5816, 7063
|
1576, 2079
|
3561, 5313
|
2348, 3543
|
1317, 1550
|
2096, 2217
|
5338, 5415
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,505
| 156,748
|
6695
|
Discharge summary
|
report
|
Admission Date: [**2129-10-20**] Discharge Date: [**2129-10-22**]
Date of Birth: [**2076-7-29**] Sex: F
Service: MEDICINE
Allergies:
Latex / Neurontin / Morphine / Percocet / Augmentin / Shellfish
/ Iodine / Red Dye / Dilaudid (PF)
Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
broken insulin [**First Name3 (LF) 4581**]
Major Surgical or Invasive Procedure:
none
History of Present Illness:
53 y/o F w/ h/o DMI, CAD s/p CABG, recent discharge from [**Hospital1 18**]
for DKA c/b "vagal" cardiac arrest [**2129-7-4**] p/w tx from OSH (LGH)
for DKA. Patient states her pumped stopped working 1 day PTA.
She presented to OSH and glucose was 705. Got 3L IVFs, 10U
insulin and started at gtt at 4U/hr. Initially had epigastric
pain and chest pain that was resolved on arrival. She denies
dysuria, rashes, diarrhea, cough, shortness of breath, f/c/s in
the past day. She states chest pain is more of an epigastric
burning which was different from her "angina" pain prior to her
CABG in [**2113**]. Her cardiologist is Dr. [**Last Name (STitle) 13114**] who saw her in ED.
.
Initial Vitals: 98.0 90 141/70 16 100%
Gap closed, Cre up to 1.7 from 1.1, WBC 7 trop neg on arrival.
EKG with changes from [**2129-6-10**] (AvR elevation, ST depression in
V5/V6 I, II, AvF. [**Last Name (un) **] was consulted. Recs below:
[**Last Name (un) **] recs: lantus 12U QHS, SS breakfast and dinner 80-120 with
4U, lunch 3U, increase by 1U each 50mg/dl increment in glucose.
HS SS start 200-250 with 4U
During episode after emesis, vagaled to HR 40s SBP 70s, trigger
called. Total IVF = 3L in ED. Decision was to admit for ACS rule
out and hyperglycemia mgmt. BG was >400 when sent to ICU.
.
On Arrival to floor, pt complained of worsening SOB, EKG showed
changes more prominent than prior, Trops were drawn neg >0.5,
WBC 21, other electrolytes ok, CXR showed pulmonary edema. Gap
opened up with HCO3> 11. Cards called, ASA, Metoprolol, Statin,
Heparin GTT started, home plavix given. Dr. [**Last Name (STitle) 13114**] was called,
stated he felt this was Type II or demand MI [**2-10**] DKA and
possible underlying stress/infection. She was kept on heparin
overnight and DKA managed by placing back on insulin gtt at 5/hr
w/ q1-2 FS and q3-4 C10. She was persistently sinus tachy but
felt [**2-10**] beta blocker withdrawal per Dr. [**Last Name (STitle) 13114**]. 20mg IV lasix
given w/ >1000L output.
Past Medical History:
. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
Coronary artery disease, multivessel CABG [**2113-7-10**]
Angiography showing stable disease [**7-/2116**]
Negative stress-nuclear study [**4-13**]
Minimal inferoposterobasal endocardial sclerosis (Echo, [**4-13**])
? angina (effort and stress [**5-16**])
3. OTHER PAST MEDICAL HISTORY:
PVD with distal occlusive disease LLE
Right ophthalmic artery occlusion
Hypotension, prob vasoregulatory, with small vessel
hypoperfusion
Diabetes mellitus, insulin-dependent, brittle, non-ketotic [**2089**]
- diffuse vasculopathy
- peripheral neuropathy, mild, but with autonomic dysfunction
- Retinopathy, advanced
- nephropathy, mild
Cataracts
NLD
Bronchospastic disease
"Spastic colitis" / Celiac Dz / ischemic bowel Dz;
dermatitis herpetiformis
Disseminated Zoster [**5-14**]
Hypothyroidism; possible subacute thyroiditis
Social History:
- tobacco: denies
- illicits: denies
- etoh: glass of wine every 5-6 months
- employement: not currently working, on diability, hoping to
return to school for the school of the blind to develop skills
- education: english/philosophy, some of a masters degree
- housing: widowed 8 years ago, recently sold her home currently
staying with her sister and looking for a place
- social: sister involved in her life
Family History:
- mother: d alzheimers, stroke
- father: d melanoma (brain), CAD
no family h/o colon cancer, breast, ovarianc cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 99.1 115 123/56 25 93 2L
GENERAL: AOx3, NAD
HEENT: MMM. no LAD. JVD to mid neck
HEART: tachy, S1/S2 heard. no murmurs/gallops/rubs.
LUNGS: diffuse crackles, B/L bases up to [**1-10**] way
ABDOMEN: soft, nontender, nondistended. no guarding or rebound,
neg HSM. neg [**Doctor Last Name 515**] sign.
EXT: wwp, no edema. DPs, PTs 2+.
LYMPH: no cervical, axillary, or inguinal LAD
SKIN: dry, no rash
DISCHARGE PHYSICAL EXAM
Pertinent Results:
ADMISSION LABS
[**2129-10-20**] 02:50PM [**Month/Day/Year 3143**] Neuts-78.3* Lymphs-16.4* Monos-2.5
Eos-1.9 Baso-0.9
[**2129-10-21**] 08:15AM [**Month/Day/Year 3143**] PT-11.4 PTT-150* INR(PT)-1.1
[**2129-10-21**] 12:38AM [**Month/Day/Year 3143**] Glucose-343* UreaN-33* Creat-1.5* Na-142
K-4.8 Cl-110* HCO3-11* AnGap-26*
[**2129-10-21**] 12:38AM [**Month/Day/Year 3143**] WBC-20.9*# RBC-3.76* Hgb-11.4* Hct-34.7*
MCV-92 MCH-30.4 MCHC-32.9 RDW-12.0 Plt Ct-299
[**2129-10-21**] 12:38AM [**Month/Day/Year 3143**] ALT-30 AST-54* LD(LDH)-245 CK(CPK)-160
AlkPhos-111* Amylase-39 TotBili-0.8
[**2129-10-21**] 12:38AM [**Month/Day/Year 3143**] Albumin-3.7 Calcium-8.6 Phos-3.9 Mg-1.7
Cholest-198
[**2129-10-21**] 04:58AM [**Month/Day/Year 3143**] %HbA1c-10.2* eAG-246*
[**2129-10-21**] 12:38AM [**Month/Day/Year 3143**] Triglyc-136 HDL-69 CHOL/HD-2.9
LDLcalc-102
[**2129-10-21**] 03:11AM [**Month/Day/Year 3143**] Type-ART pO2-79* pCO2-25* pH-7.23*
calTCO2-11* Base XS--15
[**2129-10-20**] 03:02PM [**Month/Day/Year 3143**] Lactate-1.6
CARDIAC ENZYME TREND
[**2129-10-20**] 02:50PM [**Month/Day/Year 3143**] cTropnT-<0.01
[**2129-10-21**] 12:38AM [**Month/Day/Year 3143**] CK-MB-16* MB Indx-10.0* cTropnT-0.52*
[**2129-10-21**] 08:15AM [**Month/Day/Year 3143**] CK-MB-94* MB Indx-11.9* cTropnT-2.85*
[**2129-10-21**] 12:59PM [**Month/Day/Year 3143**] CK-MB-91* MB Indx-11.3* cTropnT-3.10*
[**2129-10-22**] 05:58AM [**Month/Day/Year 3143**] CK-MB-21* MB Indx-7.0* cTropnT-2.22*
DISCHARGE LABS
MICRO:
[**10-21**] URINE CULTURE NEGATIVE FINAL
[**10-20**] [**Month/Year (2) 3143**] CULTURE __________
IMAGING:
[**10-20**] CXR; FINDINGS: Two views were obtained of the chest. The
lungs are well expanded and clear. There is no pleural effusion
or pneumothorax. Post-CABG changes are seen with normal heart
size and mediastinal contours.
IMPRESSION: No acute intrathoracic process.
[**10-21**] ECHO:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. There
is moderate regional left ventricular systolic dysfunction with
hypokinesis of the septum and anterior wall. The remaining
segments contract normally. Quantitative (3D) LVEF = 36%. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Moderate regional left ventricular systolic
dysfunction, c/w CAD. Mild mitral regurgitation.
Compared with the prior study (images reviewed) of [**2129-7-2**],
the findings are similar.
Brief Hospital Course:
Ms. [**Known lastname 19075**] [**Known lastname **] is a 53 year old female with history of
diabetes mellitus type 1 (DM1), coronary artery disease (CAD)
s/p CABG, recent discharge from [**Hospital1 18**] for diabetic ketoacidosis
(DKA) complicated by "vagal" cardiac arrest [**2129-7-4**] who
presented from OSH (LGH) for elevated [**Month/Day/Year **] sugars and DKA in
setting of insulin [**Month/Day/Year 4581**] battery malfunction. DKA course was
complicated by non-ST elevation myocardial infarction (NSTEMI)
likely secondary to demand ischemia.
.
# DKA: Inciting cause due to insulin [**Month/Day/Year 4581**] malfunction. No
obvious infection although WBC elevated--urinalysis was
negative, no obvious cellulitis or pneumonia. Ischemia is a
possible inciting event since she presented with chest pain
initially and firt enzymes were negative then trended up,
consistent with timing of acute event upon presentation. For
the DKA, [**Last Name (un) **] initially wrote her for sliding scale with
lantus but given increased gap, she was switched to insulin
drip. Her gap closed on the insulin drip and she was
transitioned to subcutaneous insulin. She was volume
resusciated with normal saline and electrolytes were repleted as
necessary.
The patient wanted to restart her insulin [**Last Name (un) 4581**] rather than
be discharged with subcutaneous insulin. She was restarted and
observed for 24 hours before discharge.
.
# NSTEMI/known CAD: Found to have EKG changes, atypical chest
pain and postitive biomarkers concerning for acute coronary
syndrome. Dr [**Last Name (STitle) 13114**], her cardiologist, felt this was more likely
type II demand MI given clinical scenario of stress from DKA
rather than an NSTEMI as cause for DKA. She was initially
started on heparin drip and continued on her aspirin 81 mg daily
and clopidogrel 75 mg daily. She was also started on
atorvastatin 80 mg daily and metoprolol tartrate 12.5 mg Q6H.
The heparin drip was stopped after only a few hours when her
chest pain, EKG changes, and biomarkers trended down. She did
have an ECHO which showed LVEF of 35%, the same as prior in
6/[**2129**].
.
# Acute on chronic systolic CHF: EF from past several months ago
~40%. ECHO during this admission consistent with priors, heart
failure is due to ischemic heart disease. Because she does have
low ejection fraction ischemic heart disease, she should
continue on the medications started above. Also, her bisoprolol
was changed to metoprolol tartrate because it has been studied
better for heart failure patients. She was not discharged on an
ACE inhibitor because she had been on them before and "bottomed
out" her [**Year (4 digits) **] pressure. She preferred to not take a second
[**Year (4 digits) **] pressure medication and will talk with her primary care
doctor about this for the future.
.
# Acute Kidney injury: Likely pre-renal given elevated
BUN/Creatinine. Trended down.
.
# Peripheral vascular disease: Continued clopidogrel.
.
# Hypothyroidism: continued Levothyroxine
TRANSITIONAL ISSUES:
- Needs to have close follow-up with [**Last Name (un) **] for insulin [**Last Name (un) 4581**]
management. Despite insulin [**Last Name (un) 4581**], her HbA1c was still > 10, so
she has poor control of her diabetes
- She was started on metoprolol (instead of bisoprolol) during
this admission for her heart failure because it has stronger
evidene for mortality benefit. She said that sometimes other
beta blockers caused her to feel slowing and depression, if this
happens with metoprolol, she can be switched. She was started
on the short-acting formulation and can be switched to
metoprolol succinate (long acting) if she tolerates this.
- Needs to be started on an ACE inhibitor for her ischemic
systolic heart failure if her [**Last Name (un) **] pressure has room with the
new metoprolol.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Levothyroxine Sodium 175 mcg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Diazepam 2 mg PO TID:PRN vertigo
5. Insulin [**Last Name (un) **] SC (Self Administering Medication)Insulin
Aspart (Novolog) (non-formulary)
Target glucose: 80-180
6. Vitamin D 800 UNIT PO DAILY
7. bisoprolol fumarate *NF* 2.5 Oral [**Hospital1 **]
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Insulin [**Hospital1 **] SC (Self Administering Medication)Insulin
Aspart (Novolog) (non-formulary)
Target glucose: 80-180
4. Levothyroxine Sodium 175 mcg PO DAILY
5. Metoprolol Tartrate 12.5 mg PO Q6H
hold for HR<60, SBP<100
RX *metoprolol tartrate 25 mg half tablet(s) by mouth twice a
day Disp #*30 Tablet Refills:*0
6. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
7. Diazepam 2 mg PO TID:PRN vertigo
8. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
diabetic ketoacidosis
non-ST elevation myocardial infarction due to demand ischemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 19075**] [**Known lastname **],
You were admitted to the hospital because of a complication of
your diabetes called diabetic ketoacidosis (DKA). We think this
happened because your insulin [**Known lastname 4581**] was not working. You were
started on insulin subcutaneously and did well with this but you
were discharged to restart the insulin [**Known lastname 4581**] at home. The [**Last Name (un) **]
doctors checked your [**Name5 (PTitle) 4581**] and think that it otherwise was
working well except for the battery. You should call the [**Last Name (un) **]
doctor if your [**Last Name (un) **] sugar is more than 200 at any time during
the weekend.
As a complication of the DKA, your heart had to work harder and
you had some transient damage, however, it was improving before
discharge.
The following changes were made to your medications:
- STOP bisoprolol, it is replaced with metoprolol
- START metoprolol 12.5 mg twice a day to protect your heart
- START atorvastatin 80 mg daily for high cholesterol
You should followup with your diabetes doctor and your primary
care physician.
It was a pleasure taking care of you in the hospital!
Followup Instructions:
Please call to make an appointment with the [**Last Name (un) **] transition
clinic at [**Telephone/Fax (1) 25521**]. This might not be your primary diabetes
doctor but it will help get an appointment fast since you have
just been discharged from the hospital for diabetes
complications.
Also, call you make an appointment with your primary care
doctor, Dr. [**Last Name (STitle) 13114**] in 1 week.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] J.
Location: DOCTORS [**Name5 (PTitle) **] & VINCH CARDIOLOGY, PC
Address: [**Street Address(2) **], STE 703W, [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 25520**]
Fax: [**Telephone/Fax (1) 25522**]
|
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"250.43",
"250.73",
"440.20",
"244.9",
"410.71",
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] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12219, 12225
|
7278, 10317
|
404, 411
|
12371, 12371
|
4405, 7255
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13728, 14418
|
3795, 3914
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11638, 12196
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12246, 12350
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11165, 11615
|
12522, 13705
|
3954, 4386
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2536, 2792
|
10338, 11139
|
322, 366
|
439, 2433
|
12386, 12498
|
2823, 3352
|
2455, 2516
|
3368, 3779
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,623
| 103,904
|
14978+56591
|
Discharge summary
|
report+addendum
|
Admission Date: [**2146-7-7**] Discharge Date: [**2146-7-25**]
Date of Birth: [**2082-3-15**] Sex: M
Service: [**Hospital1 139**] Medicine
This discharge summary reflects the patient's admission from
[**2146-7-7**] through [**2146-7-17**].
CHIEF COMPLAINT: Transfer from [**Hospital6 8972**]
for right foot gangrene and MRSA sepsis with seating of left
wrist and a left ventricular thrombus.
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old man
who was initially sent from the nursing home where he resides
to [**Hospital6 8972**] on [**2146-7-1**] for gangrene of his
right second and third toes. Upon admission to [**Location (un) **] his
vital signs were temperature 97, heart rate 58, respiratory
rate 16. He was alert and oriented times three and his
physical exam was unremarkable other than the gangrene.
LABORATORY DATA: Initial labs were white blood cell count of
16.7 with 94% neutrophils, hematocrit 33.3, platelet count
240,000, sodium 136, potassium 4.1, chloride 103, CO2 21, BUN
63, creatinine 1.8, glucose 237 with anion gap equal to 12,
albumin .7, normal LFTs, CK of 153, CK MB 5.7. Urinalysis
was positive for nitrites with 11-20 white blood cells, 0-2
red blood cells and many bacteria with tract protein.
Initial chest x-ray showed left lower lobe pneumonia. The
patient was then started on Cipro. The final read of the
chest x-ray showed chronic changes. However, blood cultures
4/4 bottles grew out MRSA. His antibiotics were changed from
Cipro to Vancomycin and Rifampin. Repeat blood cultures from
[**7-4**] and [**7-6**] have been negative to date. The patient's
right foot was managed with local wound care. On [**2146-3-4**] the
patient was found to become increasingly lethargic and
bradycardic to a heart rate of 37. His left wrist was noted
to be inflamed and his BUN and creatinine increased to 85 and
3.6 respectively. His left wrist was tapped and grew gram
positive cocci consistent with MRSA septic arthritis.
Atenolol was discontinued due to bradycardia. Pacemaker was
not placed due to MRSA bacteremia and because the patient was
not hemodynamically stable. From [**7-4**] to [**7-7**] his
bradycardia continued without improvement. A transthoracic
echocardiogram was obtained for evaluation endocarditis and
was notable for a large left ventricular thrombus, a
decreased EF equal to 15-20% with globally decreased systolic
function, moderate pulmonary hypertension, thickening of
aortic valve, trace mitral, aortic, and tricuspid
insufficiency. He was begun on Heparin for the left
ventricular thrombus. Furthermore, the patient was noted to
have colonic distention on KUB consistent with an ileus.
There were also reports of bright red blood per rectum.
Hospital course at [**Hospital1 **] was further complicated
by oliguric acute on chronic renal failure. His renal
function continued to deteriorate with a FENa less than 1,
consistent with a prerenal azotemia. On [**2146-7-7**] the patient
was begun on Dopamine for bradycardia, both sinus and
junctional, with relative hypotension. The patient was then
transferred to the [**Hospital1 69**] MICU
for further management.
PAST MEDICAL HISTORY: 1) Coronary artery disease with
history of a non Q wave myocardial infarction on [**2146-5-31**]. 2)
Arteriosclerotic peripheral vascular disease, status post
left BKA, status post right 4th and 5th toe amputation. 3)
Type 2 diabetes mellitus requiring insulin with retinopathy,
neuropathy and nephropathy. 4) Gout. 5) Depression. 6)
Question benign prostatic hypertrophy.
ALLERGIES: Penicillin.
MEDICATIONS: Outpatient medications: Lipitor 20 mg [**Hospital1 **],
Allopurinol 100 mg q d, NPH 22 units q a.m., 16 units q h.s.,
Humalog 2 units q a.m., 8 units at dinner, Nitro patch 0.4 mg
from 7 a.m. to 10 p.m., Nitro 0.4 mg sublingual prn, Celexa
40 mg q d, Flomax 0.4 mg q d, q h.s., Coumadin 2.5 mg q d,
Colace 100 mg q d, Tylenol prn, Milk of Magnesia prn.
Medications on admission to [**Hospital1 188**]: Dopamine drip 7 mcg/kg/minute, Wellbutrin 50 mg q d,
Lipitor 20 mg q h.s., Colace 100 mg q d, Nitro patch 0.4 mg
on in the a.m. and off at night, Flomax 0.4 mg q h.s.,
Allopurinol 100 mg q d, Celexa 40 mg q d, Rifampin 300 mg
[**Hospital1 **], Vancomycin renal dosing, Insulin NPH 11 units subcu q
a.m., 8 units subcu q p.m. and a regular insulin sliding
scale, Heparin drip as per protocol.
SOCIAL HISTORY: The patient is a [**Country **] veteran. He denies
any alcohol or tobacco use. He resides in a nursing home.
The patient's son [**Name (NI) 1158**] [**Name (NI) 43845**], is his health care proxy and is
making all medical decisions for him. The patient's son is
currently on duty for the National Guard and available only
by cell phone, [**Telephone/Fax (1) 43846**].
FAMILY HISTORY: Significant for cardiac disease.
HOSPITAL COURSE: While in the MICU, the patient's admission
labs at [**Hospital1 69**] were as follows:
White blood count was 22.4 with 96% neutrophils, hematocrit
33, platelet count 353,000, sodium 125, potassium 4, chloride
92, CO2 17, BUN 109, creatinine 4.4, glucose 93, calcium 6.9,
magnesium 3.2, phosphorus 7.5, albumin 2.8, ALT 35, AST 47,
LDH 291, alkaline phosphatase 117, total bilirubin 5.2,
triglycerides 87, Vancomycin level 13.5, lipase 85, troponin
1.9. CK 252. Consults which were obtained during the
patient's MICU stay include ID, renal, plastic, vascular and
psychiatry.
1. ID: The patient was initially begun on Vancomycin and
Rifampin IV. Later due to the patient's hyperbilirubinemia,
Rifampin was discontinued. Plastics and hand surgery were
consulted on [**2146-7-8**] suggesting an MRI of the left hand and
wrist when the patient was stable and to keep the wrist
elevated at all times. Wrist films on [**2146-7-8**] showed no
evidence of osteomyelitis, however, were positive for
osteopenia. Urine cultures were positive for greater than
100,000 yeast. Blood cultures have been negative to date.
2. Vascular: Vascular was consulted on [**2146-7-8**] and their
recommendation was that the patient requires a right above
the knee amputation since transmetatarsal amputation would
not control the infection adequately.
3. Cardiac: A PA catheter was placed on [**7-8**] for management
of acute renal failure. Initial values were CVP 15, wedge
14, cardiac output was 3.4, later improved to 4.0, cardiac
index 1.8, later improved to 2.1 and SVF was normal. The
patient was transfused two units of packed red blood cells
and given fluid to keep wedge greater than 18, however, this
did not improve renal perfusion. Furthermore, Dopamine drip
was attempted to increase cardiac output and chronotropia,
however, this caused his cardiac output to drop and SVR to
increase and therefore was discontinued. The PA catheter was
pulled on [**2146-7-10**] and his blood pressure has since improved.
Transthoracic echocardiogram on [**2146-7-8**] showed a right and
left atrium mildly dilated, mild symmetric left ventricular
hypertrophy, left ventricular function is seriously depressed
with a large left ventricular thrombus, severe global RV wall
hypokinesis, tract AR, physiologic MR, 1+ TR, mild pulmonary
hypertension, no echocardiographic evidence of endocarditis.
The patient had a slight troponin leak without EKG changes or
elevations in CK MB. Currently Aspirin was held given the
risk of bleeding with pericarditis as well as patient being
pre-op for surgery. The patient had episodes of rapid atrial
fibrillation and SVT, then returning to bradycardia in the
50's or 60's. His ectopy seemingly resolves with management
of potassium and magnesium. A uremic friction rub was
auscultated on [**2146-7-9**] indicating uremic pericarditis,
hemodialysis was initiated for treatment of this. A Heparin
drip was continued for the left ventricular clot. At this
point it was unclear if the clot was infected or not.
4. Pulmonary: Mild pulmonary edema by physical exam,
however, patient was maintaining good oxygenation.
5. GI: The patient had a KUB on [**2146-7-8**] which showed
colonic ileus. Reglan was started, however, later
discontinued due to prolonged QT intervals. KUB on [**2146-7-12**]
showed resolving dilated bowel loops. The patient was found
to have hyperbilirubinemia. His Rifampin and Lipitor were
discontinued due to this. Right upper quadrant ultrasound on
[**2146-7-9**] showed sludge in the gallbladder, however, no
pericholecystic fluid or gallbladder wall thickening or
evidence of biliary obstruction.
6. Renal: Hemodialysis was initiated on [**2146-7-9**] for uremic
pericarditis. The patient had a high phosphate level
secondary to acute renal failure which was treated with
calcium carbonate tid. Urine was sent for urine sodium and
creatinine and urine culture showing a prerenal picture.
7. Heme: The patient was transfused two units of packed red
blood cells on [**2146-7-8**] with good response of hematocrit from
28.2 to 35.1. The patient received a dose of Epogen on
[**2146-7-9**]. His iron level is 57, TIBC is decreased at 146, TRF
is decreased at 112, ferritin is 356, consistent with anemia
of chronic disease.
8. Fluids, Electrolytes & Nutrition: Ectopy is decreased
with increasing the potassium during the dialysis. The
patient's high phosphate level is treated with calcium
carbonate tid and Amphojel times two days.
9. Psychiatry: It was recommended by psychiatry consult
that Wellbutrin and Celexa be held at this point. His RPR
was non reactive, his Vitamin B12 was greater than [**2143**], his
Folate was greater than 20 and his TSH was still pending in
the MICU.
Labs on [**2146-7-12**] when the patient was transferred to the
medicine floor, white blood cells 21.3, hematocrit 33.2,
platelet count 138,000, PT 15, PTT 67.8, INR 1.6, sodium 135,
potassium 4.1, chloride 100, CO2 24, BUN 35, creatinine 2.1
and glucose 138, calcium 7.5, magnesium 2.1, phosphorus 3.2,
total bilirubin 13.7.
Physical exam on admission to the medicine floor: Vital signs
were 97.4, blood pressure 112/74, heart rate 67, respiratory
rate 15. In general, the patient was in no apparent
distress, sluggish to response, sleeping yet arousable to
voice. HEENT: Scleral icterus, moist mucus membranes,
slight thrush, right IJ is in place. Chest is clear to
auscultation bilaterally from anterior, however, bibasilar
rales. Cardiovascular, regular rate and rhythm, normal S1
and S2, unable to appreciate friction rub. Abdomen soft,
nontender, minimal distention, positive bowel sounds. GU,
scrotal edema. Extremities, 2+ pitting edema bilateral lower
extremities, 2+ pitting edema in bilateral upper extremities
and hands. The patient is status post left BKA. The
patient's right foot is dressed in a Multi Podus boot. The
patient's left wrist is dressed in a splint.
IMPRESSION: The patient is a 64-year-old man with a history
of coronary artery disease and type 2 diabetes mellitus
requiring insulin, admitted for MRSA bacteremia from primary
infected gangrenous right foot. Admission has been
complicated by a septic left wrist, bradycardia, with
tachycardic episodes, acute on chronic renal failure, uremic
pericarditis and left ventricular thrombus.
HOSPITAL COURSE: While on [**Hospital6 **].
1. Infectious Disease: The patient was continued on
Vancomycin, being dosed according to trough levels less than
15. Vancomycin levels were checked q day to determine
dosing. The patient was treated with Nystatin swish and
swallow to treat his thrush. The patient is currently
awaiting MRI for further evaluation of his septic left wrist.
Due to the 100,000 yeast noted in his urine, the patient's
Foley catheter was discontinued.
2. Vascular: The patient was taken to the operating room on
[**2146-7-15**] for a right guillotine BKA. Due to the patient's
critical condition and after consultation with anesthesia, it
was seemed safer to proceed with the guillotine right BKA
under MAC anesthesia and to proceed with AKA at a later date
after some of the [**Hospital 228**] medical issues have resolved.
The patient's right upper extremity was found to be cool on
[**2146-7-14**] and right upper extremity ultrasound was performed
which ruled out an upper extremity DVT. The patient will be
taken back to the operating room within 5-7 days under
general anesthesia to undergo a right AKA.
3. Cardiovascular: The patient continued to have episodes
of supraventricular tachycardia and paroxysmal atrial
fibrillation, alternating with relative bradycardia to the
50's and 60's. This is somewhat improved when the patient's
potassium and magnesium are above 4 and 2 respectively. The
patient is still medically too unstable to undergo pacemaker
at this time, however, when his infection clears and after
surgery is complete, EP studies will be done and the patient
will require pacemaker. The patient was continued on Heparin
sliding scale for left ventricular thrombus treatment. It is
not thought at this time that the thrombus is infected due to
the fact that blood cultures obtained here at [**Hospital1 346**] all have been negative to date. On
the evening of [**2146-7-13**] the patient was believed to have had
high blood pressure in the right arm ranging from the
200-300/dopplerable to blood pressures of 110-120/dopplerable
in the left arm. The patient also was complaining of some
vague upper back pain, therefore it was decided to rule the
patient out for an aortic dissection. Patient underwent CT
with and without contrast of the chest with pretreatment of
Mucomyst and which showed no evidence of aortic dissection
due to the absence of an intimal flap in the face of fluid
density surrounding the anterior mediastinum adjacent to the
ascending aorta. Calcified aorta of normal caliber; a small
pericardial effusion along with small left and trace right
pleural effusion; left lower lobe patchy coapts adjacent to
the effusion posteriorly; small amount of free fluid in the
abdomen surrounding the liver, spleen and tracking to the
right lower quadrant. Chest x-ray at the time showed no
enlargement of mediastinum and a left basilar opacity. It
was determined with discussions with the attending that the
patient's arteries are significantly calcified and therefore
pose difficulty in obtaining appropriate blood pressures.
When the patient was monitored that day in hemodialysis with
a Dinamap machine there were no problems getting his blood
pressures and they ranged in the 100's to one teens over 50's
to 60's. The patient has been continually monitored with the
Dinamap machine on the floor with no further issues with high
blood pressure.
4. GI: Most recently the patient's stools were guaiac
negative. An abdominal ultrasound obtained on [**2146-7-14**] for
evaluation of the biliary and urinary systems showed no signs
of biliary or urinary obstruction and was positive only for
gallbladder sludge. This study was obtained due to the
patient's continued high creatinine as well as the patient's
continued hyperbilirubinemia.
5. Renal: The patient continues on hemodialysis
approximately every other day. The patient was receiving
hemodialysis through a left femoral Quinton catheter until
[**2146-7-16**] when the catheter was pulled. The patient will
require placement of Perma-cath on Monday, [**2146-7-18**] in
preparation for hemodialysis on Tuesday, [**2146-7-19**].
6. Hematology: The patient is on Heparin sliding scale for
the left ventricular thrombus. His hematocrit was stable
subsequent to his transfusions in the MICU until [**2146-7-15**] when
his hematocrit dropped to 28.7 and after surgery the
patient's hematocrit was 27.8, therefore he was transfused
one unit of packed red blood cells with good response to
hematocrit of 30.3. The patient's PT, PTT and INR were
monitored throughout his stay. It was noted by the blood
bank that the patient had delayed transfusion reaction
forming allo antibodies. This does not preclude him from
getting further transfusions as the blood bank will merely
screen for these antibodies in the future.
7. Fluids, Electrolytes & Nutrition: When the patient was
transferred out from the MICU, he was on tube feeds running
at 35 cc per hour. These were continued throughout his stay
on the medicine floor. The patient began to take better po
on [**2146-7-15**] being begun on a renal diet. Calorie counts will
be performed and need for tube feeding in the future via NG
tube will be assessed.
8. Endocrine: The patient is currently on a regular insulin
sliding scale for his type 2 diabetes. He will be restarted
on his NPH regimen once adequate po intake is established.
9. Psychiatry: The patient has a history of depression, we
are holding his psychiatric medications as per psych
consult's request.
10. Code Status: The patient is a full code.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 1569**] 12-684
Dictated By:[**Last Name (NamePattern1) 7432**]
MEDQUIST36
D: [**2146-7-17**] 00:35
T: [**2146-7-24**] 18:35
JOB#: [**Job Number 20739**]
Name: [**Known lastname 7974**], [**Known firstname **] R Unit No: [**Numeric Identifier 7975**]
Admission Date: [**2146-7-7**] Discharge Date: [**2146-7-25**]
Date of Birth: [**2082-3-15**] Sex: M
Service:
Addendum:
Please add under hospital course under the gastrointestinal
section: Gastrointestinal consultation was obtained to
evaluate the patient's hyperbilirubinemia. This was thought
to be multifactorial, related to sepsis, hypoperfusion, drug
interactions with Rifampin as well as possible decreased
clearance of bilirubin by dialysis in the face of normal
clearance and reflection of the rest of his liver function
tests. The patient was begun on ursodiol 300 mg po tid in
order to treat his hyperbilirubinemia.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Last Name (NamePattern1) 7976**]
MEDQUIST36
D: [**2146-7-16**] 00:39
T: [**2146-7-19**] 11:40
JOB#: [**Job Number 7977**]
|
[
"711.03",
"427.31",
"420.0",
"427.1",
"440.24",
"560.1",
"038.11",
"585",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"39.95",
"84.15"
] |
icd9pcs
|
[
[
[]
]
] |
4810, 4844
|
11223, 18076
|
3632, 4404
|
275, 411
|
440, 3167
|
3190, 3608
|
4421, 4793
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,443
| 115,194
|
32851
|
Discharge summary
|
report
|
Admission Date: [**2172-11-30**] Discharge Date: [**2172-12-22**]
Date of Birth: [**2097-11-24**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
s/p mechcanical [**2097**] w/ right clavicular fracture and
right rib fractures [**2-18**] and right hemothorax
Major Surgical or Invasive Procedure:
Trach, Peg, IVC filter
History of Present Illness:
75 yo F s/p mechcanical fall transferred from [**Hospital **] hospital
w/ right clavical frcature and right rib fractures [**2-18**], right
hemothorax.
Past Medical History:
Diverticulitis, osteoarthritis, osteoporosis, hypothyroidism,
hyperchol, Afib (post-op in 04, resolved), depression, shingles,
L Foot post-herpetc neuralgia
Family History:
non- contributory
Physical Exam:
general; well appareing female w/ trach and passey muir valve in
place
HEENT: trach in place, speaks clearly w/ passey muir.
COR: RRR S1, S2
chest: CTA bilat
abd: Soft, NT, ND, +BS. peg tube in place.
extrem: no c/c/e
neuro: intact.
Pertinent Results:
CXR [**2172-12-20**]
IMPRESSION:
Persistent airspace opacity involving both lungs. Small
right-sided pleural effusion. The findings represent pulmonary
edema and are unchanged. Pneumonia is not excluded. Right-sided
rib fractures, unchanged.
ECHO [**2172-12-14**]
Conclusions
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%) Transmitral Doppler and tissue velocity
imaging are consistent with normal LV diastolic function. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Normal biventricular function. Mild mitral
regurgitation.
[**2172-12-5**] 5:00 pm SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2172-12-8**]**
GRAM STAIN (Final [**2172-12-5**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2172-12-8**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. MODERATE GROWTH.
swallow eval [**2172-12-21**]
SUMMARY / IMPRESSION:
The pt did not have any overt signs of aspiration and can
continue on the current regular diet with thin liquids. She will
benefit from wearing the PMV during POs, but noted she has been
tolerating POs without the PMV in place. She can swallow her
pills whole with water. She reported her intake has been limited
b/c she fatigues, so she may continue to need small amounts of
tube feeds until she can take in more by mouth .
This swallowing pattern correlates to a Dysphagia Outcome
Severity Scale (DOSS) rating of 7, wfl.
RECOMMENDATIONS:
1. Continue on current PO diet of thin liquids and regular
solids.
2. Pills whole with thin liquids.
3. Pt will benefit from wearing the PMV throughout the day,
including when taking Pos.
These recommendations were shared with the patient, nurse and
medical team.
____________________________________
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.S., CCC-SLP
Pager #[**Numeric Identifier 2622**]
Brief Hospital Course:
Pt was admitted to the SICU [**2172-11-30**] for resp compromise d/t rib
fractures, clavicular fractures.
Neuro: awake, alert on arrival. head CT neg for acute process.
Sedated after intubation. Presently wake conversant and approp.
Resp: Required intubation on HD#3 after failing BIPAP and CPAP
support.
Failure to wean from the vent d/t ARDS and required trach and
peg on [**2172-12-9**].
Weaned from vent. Trach down sized [**2172-12-20**]. Passey muir valve
placed and [**Last Name (un) 1815**] well.
CTA was done to r/o PE which was neg. IVC filter was placed
prophlactically given relative risk on [**2172-12-13**].
Right hemothorax was drained and a chest tube was placed for
continued drainage and PTX. Chest tube was removed [**2172-12-10**]
after resolution of PTX and fluid collection drained.
COR: approp tachy initially controlled w/ betablockaide.
TEE nl w/ EF 60%
intermittant lasix diuresis and pressor requirement.
OF note, during removal of arterial line - line cut and slipped
into artery. plastics consulted and line tip retrived w/adeq
profusion.
Nutrition: Dobhoff placed for nutritional support and then peg
tube placed. currently [**Last Name (un) 1815**] TF and reg diet after being seen by
speech and swallow pathology. Can wean from tube feed after
approp po nutrition established.
Heme/ID: Transfused PRBCs for HCT 23.1 w/ approp stabilzation
of HCT- presumed source of loss - right hemothorax.
Cipro was started prophlactically and d/c'd after neg culture
data. Pt spiked on HD #8 pan cultured and started on broad
spectrum IVAB for suspected VAP- vanco, cipro, ceftaz.
sputum [**12-6**]- staph coag postive- sensitive to vanco. cipro
cetaz d/c'd and completed vanco course.
Pain:An epidural was placed for pain control, PCA and toradol
were added.
Now on metadone w/ good coverage.
Rehab: working w/ PT to return to baseline level of functioning.
Medications on Admission:
Atenolol 25', ASA 325, Zoloft 200, lipitor 10, levoxyl 100 mcg,
MVI, Calcium 600", glycolax 17
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
3. Methadone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Sertraline 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Acetaminophen 160 mg/5 mL Solution Sig: 325-650 mgs PO Q6H
(every 6 hours) as needed for pain.
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose
Injection TID (3 times a day).
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
RHCI - [**Hospital **] Hospital of [**Location (un) **] and Islands
Discharge Diagnosis:
s/p fall w/ right clavical fx, right rib fractures [**2-18**] , right
hemothorax
Discharge Condition:
deconditioned
[**Last Name (un) 1815**] Passey Muir valve and tube feeds.
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] if you develop chest
pain, shortness of breath, fever, chills, or if you have issues
with your feeding tube.
If you feeding tube falls out, have it replaced immediately or
if the sutures break, tape the tube securely in place until it
can be resutured.
Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) **] on [**2173-1-5**]
at 10am on the [**Hospital Ward Name **], [**Hospital Ward Name 121**] building [**Hospital1 **] one Chest
disease center. plaese arrive 45 minutes prior to your
appointment and report ot the [**Hospital Ward Name **] clinical center [**Location (un) **] rdaiology for a CXR.
Completed by:[**2172-12-28**]
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,138
| 103,258
|
39301
|
Discharge summary
|
report
|
Admission Date: [**2166-9-5**] Discharge Date: [**2166-9-18**]
Date of Birth: [**2126-3-16**] Sex: F
Service: MEDICINE
Allergies:
Apple / Strawberry / Almond Oil
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
pancreatitis
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Ms [**Known lastname 24110**] is a 40 yo female with hx of alcohol abuse who has
been hospitalized at [**Hospital6 19155**] for acute
pancreatitis complicated by respiratory failure, persistent
acidosis, and pancytopenia.
.
She presented to [**Hospital3 **]Hosptial on [**9-3**] with 4 days
of abdominal pain, alochol use (by report drinking vodka), and
then hematemesis. Also admitted to hematochezia. Per EMS she
was hypotensive when they picked her up, however in the ED was
normotensive. On presentation she had a WBC of 13.6, Cr of 2.3,
amylase of 1206, lipase of 2098, and alcohol level of 98.
Additionally Hct 39.2, Plt 116, Ca was 6.9, albumin 2.8, INR
1.1, AST 227, and ALT 112.
.
She was admitted and given IVF. She was started on an ativan
gtt due to concern for alcohol withdrawal. Renal was consulted
regarding her renal failure and thought it was a combination of
prerenal and ATN. GI saw the patient due to her complaint of
hematemesis and felt she was not acutely bleeding and workup
should be deferred. On [**9-3**] she had a CXR which showed a
developing RLL infiltrate and questionable left lung infiltrate
which was felt to be concerning for developing ARDS. She was
intubated during her hospital course due to concern for her
tiring out. She was hypocalcemic and eventually started on a
calcium gtt. She was found to have a positive urine culture and
staretd on flagyl. She continued to spike and her antibiotics
were broadened to meropenem and levaquin. She had a persistent
metabolic acidosis and was started on IVF with bicarb.
.
On [**9-4**] her platlets dropped from 116 (on admission) to 26, and
her Hct dropped from 39.2 to 29 to 22.9 (in the setting of fluid
resuscitation). She was transfused 2 units of PRBC and 2 packs
of platlets on [**7-5**]. Additionally her WBC dropped from 3.9 on
admission to 2.7 with a predominance of neutrophils; (on [**9-3**]
she had 28% bands; on [**9-4**] she had 3% bands on her
differential).
.
Currently she is intubated and sedated.
.
Review of systems: Unable to obtain as patient is intubated.
.
Past Medical History:
Alcohol Abuse
CVA at age 24 (was found to have an atrial septal defect s/p
repair)
Insomnia
Depression
Seizure disorder
Sciatica s/p right gluteal repair
Chronic back pain
Hx of pancreatitis
Hx of alcoholic ketoacidosis
Transaminitis thought to be secondary to alcohol abuse
s/p appendectomy
s/p right oophorectomy
s/p left shoulder surgery
Social History:
She has a multiple year history of alochol abuse. Also smokes.
Family History:
Family History: Unable to obtain
Physical Exam:
Vitals: T: 99.8 BP: 96/49 P: 106 R: 15 O2: 75% on SIMV, volume
400, RR 20, 100% FiO2
General: Middle-aged female lying in bed sedated and intubated.
HEENT: Sclera anicteric, ETT in place
Neck: supple, JVP not elevated, no LAD
Lungs: Mostly clear with a few scattered rhochi anteriorly.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, hypoactive bowel sounds, striae present.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
[**2166-9-5**] 02:08PM WBC-4.4 RBC-3.00* HGB-9.8* HCT-29.5* MCV-98
MCH-32.6* MCHC-33.1 RDW-21.3*
[**2166-9-5**] 02:08PM NEUTS-66 BANDS-6* LYMPHS-19 MONOS-6 EOS-2
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2166-9-5**] 02:08PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-OCCASIONAL
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL
SPHEROCYT-OCCASIONAL TARGET-OCCASIONAL
[**2166-9-5**] 02:08PM PLT SMR-LOW PLT COUNT-138*
[**2166-9-5**] 02:08PM PT-12.8 PTT-26.6 INR(PT)-1.1
[**2166-9-5**] 02:08PM FIBRINOGE-425*
[**2166-9-5**] 02:08PM GLUCOSE-107* UREA N-26* CREAT-3.1* SODIUM-143
POTASSIUM-3.7 CHLORIDE-112* TOTAL CO2-18* ANION GAP-17
[**2166-9-5**] 02:08PM ALT(SGPT)-31 AST(SGOT)-66* LD(LDH)-481* ALK
PHOS-139* TOT BILI-0.7
[**2166-9-5**] 02:08PM LIPASE-80*
[**2166-9-5**] 02:08PM ALBUMIN-2.9* CALCIUM-8.3* PHOSPHATE-3.3
MAGNESIUM-2.0
[**2166-9-5**] 02:08PM TRIGLYCER-43
[**2166-9-5**] 02:08PM OSMOLAL-311*
IMAGING:
CT SCAN TORSO - [**2166-9-6**] - IMPRESSION:
1. Bilateral moderate-sized pleural effusions, with severe
compressive
adjacent atelectasis. An underlying consolidation cannot be
excluded.
2. Patchy pulmonary parenchymal opacities are compatible with
mild pulmonary edema.
3. Left seventh and eighth rib fractures appear to be recent.
Correlate with any recent history of trauma.
4. Small amount of intra-abdominal free fluid, and moderate
amount of pelvic free fluid. Severe anasarca is present.
5. Stranding around the pancreas may be related to stated
pancreatitis.
RUQ ULTRASOUND - [**2166-9-8**] - IMPRESSION:
1. No cholelithiasis or bile duct dilation. Slightly distended
gallbladder
without other signs of acute cholecystitis is likely secondary
to patient's fasting state pancreatitis.
2. Diffuse fatty deposition within the liver.
DISCHARGE LABS:
[**2166-9-17**] 06:55AM BLOOD WBC-5.9 RBC-2.51* Hgb-8.5* Hct-24.6*
MCV-98 MCH-33.7* MCHC-34.4 RDW-18.7* Plt Ct-515*
[**2166-9-17**] 06:55AM BLOOD Glucose-93 UreaN-8 Creat-1.2* Na-140
K-4.1 Cl-102 HCO3-27 AnGap-15
[**2166-9-17**] 06:55AM BLOOD ALT-22 AST-27 AlkPhos-256* TotBili-0.4
[**2166-9-14**] 04:03AM BLOOD Lipase-43 GGT-562*
[**2166-9-17**] 06:55AM BLOOD Calcium-9.1 Phos-4.6* Mg-1.8 Iron-39
[**2166-9-17**] 06:55AM BLOOD calTIBC-233* VitB12-GREATER TH
Folate-12.5 Ferritn-948* TRF-179*
[**2166-9-5**] 02:08PM BLOOD Triglyc-43
Brief Hospital Course:
Ms [**Known lastname 24110**] is a 40 yo female with hx of alcohol abuse who
presented to an OSH with pacreatitis and hematemesis which was
complicated by respiratory failure / ARDS, acute renal failure,
pancytopenia, and acidosis.
.
# Pancreatitis: The patient presented with abdominal pain and
pancreatitis in the setting of an alcohol binge so alcoholic
pancreatitis was felt to be the most likely eitology. Her RUQ
ultrasound was negative for gallstones. She was not on any
other medications that would likely cause her pancreatitis.
Calcium and triglycerides were normal. The CT of her abdomen
showed stranding around the pancreas but no other complications
from pancreatitis. She was treated with bowel rest, intravenous
fluids, antibiotics given the severity of her pancreatitis and
pain control. She gradually improved. Her lipase normalized
and her LFTs improved. The was able to tolerate a regular diet.
*She should have have follow up on her liver as her RUQ
ultrasound noted a fatty liver. LFT's will be repeated at the
time of her PCP follow up appointment.
.
# Respiratory failure/ARDS: The patient developed ARDS from her
pancreatitis and was intubated prior to admission to the ICU.
She was placed on ARDS net protocol for ventilatory settings.
Her respiratory status gradually improved and she was extubated
on [**9-12**] and her supplemental oxygen was weaned to room air.
.
# Acute kidney injury: Her [**Last Name (un) **] was felt to be from ATN from
hypotension and acute pancreatitis. Her renal function improved
to normal with fluids. She developed a prolonged metabolic
acidosis which was most likely secondary to her [**Last Name (un) **] which also
resolved with resolution of her kidney injury.
.
# Pancytopenia/Anemia: Patient had a pancytopenia on admission.
It was felt to be partially due to marrow suppression from
alcohol and partially from her acute illness. She was not felt
to have any further active bleeding after vomiting blood at OSH
likely from [**Doctor First Name 329**]-[**Doctor Last Name **] tear. However, her hemoglobin and
hematocrit slowly trended down from repeated phelbotomy and
malnutrition. She was offered and additional transfusion but
declined it. Her hematocrit stabilized at 23. She had no
evidence of iron, B12 or folate deficiency. She needs a repeat
CBC at outpatient follow up.
*She should see a gastroenterologist as an outpatient for
EGD/Colonoscopy given hemetemesis and guaic + stools in the
setting of critical illness. She was discharged on a PPI x 2
weeks.
.
# Delerium: The patient had altered mental status which was
likely a combination of delerium secondary to illness and
medication effect on a fragile baseline. Her head CT was
negative for an acute process and she did not have an elevated
ammonia level. She was treated with intravenous thiamine. She
was evaluated by psychitary who recommended controlling her
agitation with her home regimen of seroquel and lamictal. They
felt her home dose lamictal was most likely being used as a mood
stabilizer given it's dosing rather than an anti-epileptic
medication. Her delerium resolved by [**2166-9-17**]. She would benefit
from outpatient psychiatric care; she would like to arrange this
herself.
.
# Urinary Tract Infection: The patient was found to have a
urinary tract infection with Ecoli in her urine at the OSH. She
was treated with a 10 day course of antibiotics.
.
# Alcohol abuse/alcohol withdrawal: The patient was taken off
the ativan drip and instead versed was used for sedation. Was
off the ventilator she was given valium as needed for withdrawal
and eventually weaned off valium due to concern that it was
contributing to her altered mental status. The patient was
advised to stop drinking and social work followed the patient to
assist with substance abuse issues. The patient declined
referral to an outpatient treatment program.
.
# Depression: Her anti-depressants were held while she was
acutely ill. Psych was consulted for management of her
agitation and for a competency evaluation. Her mental status
steadily improved as above, and her delerium resolved. She was
discharged on her prior psychiatric regimen with the exception
of Ativan which was discontinued.
Medications on Admission:
Medications on transfer:
Ativan drip
Morphine drip
Calcium drip
TPN
Meropenem 2 gm IV q8h ([**9-4**]- )
Insulin drip
Protonix 80 mg IV bid
1/2 NS with 2 amps bicarb and 20 mEQ KCl at 70 cc/hr
Haldol 5 mg IV prn
Zofran 4 mg IV q8h prn
Compazine 10 mg IV q6h prn
Calcium gluconate multiple doses
Flagyl 500 mg IV ([**Date range (1) 31970**] x 3) - stopped
Zosyn 3.375 gm IV q8h ([**Date range (1) 6231**])
Levofloxacin
.
Home Medications:
Reglan 10 mg po q4h prn
Ativan 1 mg po q4h prn
Bupropion ER 100 mg po daily
Hydroxyzine 25 mg po qid
Lamictal 25 mg po daily
Promethazine 25 mg po
Quetiapine 25 mg po
Discharge Medications:
1. Outpatient Lab Work
[**2166-9-25**]
CBC, Chem 10, AST, ALT, Alk Phos, TBili, Lipase.
. RESULTS TO: Name: [**Doctor Last Name **],[**Name8 (MD) 86921**] MD
[**Name6 (MD) 86921**] [**Name8 (MD) **], MD. PC, [**Street Address(2) **], UNIT [**Unit Number **], [**Location **],[**Numeric Identifier 21918**], Phone: [**Telephone/Fax (1) 86922**], Fax: [**Telephone/Fax (1) 86923**]
2. Bupropion HCl 100 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
Disp:*14 Tablet Sustained Release(s)* Refills:*0*
3. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*14 Tablet(s)* Refills:*0*
4. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*14 Tablet(s)* Refills:*0*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*14 Tablet(s)* Refills:*0*
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*28 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
7. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
Disp:*1 bottle* Refills:*0*
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]/[**Hospital1 8**] VNA
Discharge Diagnosis:
Acute pancreatitis
ARDS; hypoxic respiratory failure
Acute renal failure
Pancytopenia
Encephalopathy
GI bleed; acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with pancreatitis due to alcohol abuse. You
developed multi system organ failure and were on life support in
the ICU. You should avoid all alcohol in the future as it is
very harmful to your health. We offered to help you find an
alcohol treatment program but you refused. Your PCP will help
you arrange follow up with psychiatry.
You also suffered from some GI bleeding while you were
critically ill. You should be evaluated by a GI doctor [**First Name (Titles) **] [**Last Name (Titles) **]e for an endoscopy and colonscopy to find the source of
your bleeding.
Please take all medications as prescribed. We have given you
enough medications to last until you see your PCP.
Followup Instructions:
Name: [**Doctor Last Name **],[**Doctor Last Name 86921**]
Location: [**Name6 (MD) 86921**] [**Name8 (MD) **], MD. PC
Address: [**Street Address(2) **], UNIT [**Unit Number **], [**Location **],[**Numeric Identifier 21771**]
Phone: [**Telephone/Fax (1) 86922**]
Appointment: Monday [**2166-9-30**] 11:15am
**Please make sure you go to this appointment and if you cant
make it please call the office and reschedule.
|
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57,105
| 154,411
|
33450
|
Discharge summary
|
report
|
Admission Date: [**2142-8-15**] Discharge Date: [**2142-8-21**]
Date of Birth: [**2107-7-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10593**]
Chief Complaint:
Acute alcohol intoxication
Major Surgical or Invasive Procedure:
Endotracheal intubation and extubation
History of Present Illness:
This is a 35 y/o man with a history of alcoholism, active heroin
use, homelessness and hepatitis C who presented with alcohol
intoxication and was intubated for airway protection. His
alcohol level in the ED was 574 and he was completely
unresponsive to noxious stimuli. His sodium was 152, which
improved with fluid resuscitation. He was admitted to the MICU
and started on a propofol gtt. He self-extubated the morning of
[**8-16**]. While in the MICU, he had a fever to 102.5, grew coag
positive staph from his sputum, and grew 1/4 bottles with GPC's
from his blood. CXR showed a possible pneumonitis. He was
started on vancomycin given his history of MRSA and was seen by
social work.
.
On the floor, the patient says he felt "like he was run over by
a truck", but not like he's acutely withdrawing. He feels like
he was sick for about a week before coming in, but with
non-specific symptoms. He has a history of hep C that has never
been treated, and multiple prior hospitalizations for detox, but
no other chronic medical conditions. Has not had endocarditis,
and has previously been HIV negative. He has had withdrawal
symptoms and hallucinations before, but never withdrawal
seizures. His last heroin use was in the couple of days prior to
admission, but he is not sure of which day exactly.
Past Medical History:
ETOH abuse
IV drug abuse
HCV
Social History:
Patient is homeless. He is estranged from his 3 children and
their mother. [**Name (NI) **] has a twin brother who is now living with
the mother of his children. As a child the patient was in [**Doctor Last Name **]
care but then he was eventually adopted (but now estranged from
adopted parents as per OMR notes). He has had multiple
encarcerations. Patient has had two prior suicide attempts, both
while intoxicated. In [**2139**] he jumped in front of a bus, and in
[**2137**] he jumped off a bridge resulting in a broken leg. Mr.
[**Known lastname 77499**] drinks [**12-17**] gallon of ETOH per day. His first drink was
at the age of 14 when he drank a bottle of Southern Comfort and
blacked out. He will pass out, wake up with DTs, and then treat
himself with ETOH (though he says sometimes this is difficult as
he's dry-heaving from the DTs). He has had at least 1 withdrawal
seizure. Mr. [**Name14 (STitle) 77500**] uses IV drugs (that's how he thinks he
contracted HCV) and has shared needles. He is homeless and has
no desire to live in a shelter
Family History:
Per last DC summary, brother with alcoholism and poly-substance
abuse. Other family history unknown.
Physical Exam:
Admission Exam:
Vitals: 97.1 110 112/54 19 99% PS 5/5, 60%
General: Intubated and sedated
HEENT: Sclera anicteric, MMM, ETT in place
Neck: Supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally with ventilator noises,
no wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: Foley in place
Ext: Warm, well perfused with bounding peripheral pulses. Feet
dirty with multiple abrasions.
.
Discharge Exam:
VS: T 98.7 BP 127/91 HR 90 RR 18 O2 Sat 98% RA CIWA 0
GEN: NAD
HEENT: EOMI, NCAT
CV: RRR, no m/r/g. Normal s1/s2, no s3/s4.
PULM: CTAB, no accessory muscle use
ABD: NTND, NABS, no rigidity, rebound or guarding
EXT: WWP, no c/c/e. Ulcerations of the feet bilaterally that the
patient states are from wearing donated shoes that are too
small. No e/o active infection.
NEURO: A/Ox3, CN II-XII intact. Non focal.
Pertinent Results:
Admission Labs:
[**2142-8-15**] 11:46PM LACTATE-2.1*
[**2142-8-15**] 11:35PM GLUCOSE-87 UREA N-8 CREAT-0.6 SODIUM-149*
POTASSIUM-3.6 CHLORIDE-117* TOTAL CO2-23 ANION GAP-13
[**2142-8-15**] 11:35PM CALCIUM-7.1* PHOSPHATE-2.7 MAGNESIUM-1.9
[**2142-8-15**] 05:09PM LACTATE-3.1*
[**2142-8-15**] 04:58PM ALT(SGPT)-206* AST(SGOT)-309* ALK PHOS-89 TOT
BILI-0.6
[**2142-8-15**] 12:59PM ASA-NEG ETHANOL-574* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2142-8-15**] 12:59PM WBC-9.2 RBC-4.10* HGB-13.7* HCT-38.1* MCV-93
MCH-33.4* MCHC-36.0* RDW-12.7
[**2142-8-15**] 12:59PM PT-13.6* PTT-28.2 INR(PT)-1.2*
[**2142-8-15**] 12:59PM PLT COUNT-85*
Discharge Labs:
[**2142-8-21**] 07:55AM BLOOD WBC-6.3 RBC-4.29* Hgb-14.3 Hct-40.5
MCV-94 MCH-33.3* MCHC-35.3* RDW-14.5 Plt Ct-266
[**2142-8-21**] 07:55AM BLOOD Neuts-43* Bands-0 Lymphs-28 Monos-23*
Eos-2 Baso-0 Atyps-4* Metas-0 Myelos-0
[**2142-8-21**] 07:55AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2142-8-21**] 07:55AM BLOOD Glucose-106* UreaN-14 Creat-0.8 Na-137
K-4.6 Cl-101 HCO3-27 AnGap-14
[**2142-8-20**] 03:10PM BLOOD calTIBC-368 VitB12-1469* Ferritn-1218*
TRF-283
[**2142-8-20**] 03:10PM BLOOD HIV Ab-NEGATIVE
RAPID PLASMA REAGIN TEST (Final [**2142-8-21**]):
NONREACTIVE.
Reference Range: Non-Reactive.
[**2142-8-16**] 4:58 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2142-8-20**]**
GRAM STAIN (Final [**2142-8-16**]):
THIS IS A CORRECTED REPORT ([**2142-8-18**]).
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
.
PREVIOULSY REPORTED WITHOUT :.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S)
([**2142-8-16**]).
RESPIRATORY CULTURE (Final [**2142-8-20**]):
Commensal Respiratory Flora Absent.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
GRAM NEGATIVE ROD(S). RARE GROWTH.
STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH.
BETA STREPTOCOCCI, NOT GROUP A. MODERATE GROWTH.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested in cases of treatment
failure in
life-threatening infections..
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
.
[**2142-8-16**] 8:52 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2142-8-19**]**
Blood Culture, Routine (Final [**2142-8-19**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final [**2142-8-17**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by [**First Name8 (NamePattern2) **] [**Doctor Last Name 17975**] @ 8:57AM [**2142-8-17**].
Anaerobic Bottle Gram Stain (Final [**2142-8-17**]):
GRAM POSITIVE COCCI IN CLUSTERS.
[**2142-8-18**] 10:38AM BLOOD Lactate-0.9
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION: 35 year old man with acute alcohol
intoxication and GCS <8 intubated for airway protection.
.
Active Problems:
# Respiratory distress: Was intubated in the ED for airway
protection in the setting of alcohol intoxication. He
self-extubated the morning after admission without difficulty.
.
# Alcohol intoxication: Alcohol level 574 in the ED, with
otherwise negative tox screen. He was initially placed on
propofol gtt and later changed to a valium CIWA scale. He was
given IV thiamine on admission and also received folate, B12 and
multivitamins throughout his course. At the time of discharge
his CIWA score was 0 and he showed no signs of withdrawal.
Social work consult was obtained and Mr [**Known lastname 77499**] was provided
with resource teaching for outpatient detox as well as new
shoes. On the day of discharge, he said he was not interested
in assistance with cutting back on alcohol intake.
.
# Fever: Spiked fever on HD2 felt to likely be aspiration
pneumonitis; his sputum grew coag positive staph sensitive to
Levofloxacin and rare GNR and he was started on Vancomycin given
his history of MRSA. His blood later grew GPCs in clusters in
[**1-17**] bottles of [**12-23**] sets that was later noted to be coag negative
staph. Blood cultures were thought to be [**1-17**] contamination and
Vanc was d/c'ed and he was started on Levofloxacin for PNA. TTE
was also obtained and showed no e/o endocarditis. Pt had no
stigmata of endocarditis and had been afebrile for 48 hours at
the time of discharge.
.
# Hypernatremia: Likely related to volume depletion on
admission, improved with IV fluids and D5W.
.
# Elevated lactate: Likely related to poor perfusion in setting
of volume depletion and alcohol intake. Improved with IV
fluids.
.
# Thrombocytopenia: Likely alcohol related or related to
underlying liver disease and alcohol abuse. Improved.
.
Transitional Issues: Pt was discharged with PCP follow up. He
was provided with resources for detox. He stated he knew how to
access detox resources and would discuss his plans for detox
with his PCP. [**Name10 (NameIs) **] note, he had a negative HIV test on this
admission.
Medications on Admission:
None
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 4 days: take 1 pill by mouth daily for 4 days
starting [**2142-8-22**].
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol intoxication
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname 77499**],
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted for alcohol intoxication and
placed on a breathing machine to protect your airway. While you
were here we found an infection in your lungs that we treated
with antibiotics. We also obtained an echocardiogram to make
sure there was no infection in your heart.
It will be important for you to take the antibiotics we
prescribed you. Additionally, we would recommend you stop using
drugs and alcohol. A follow up appointment has been made with
your primary care physician. [**Name10 (NameIs) **] suggest you talk more with your
outpatient doctor about your plans to stop using drugs and
alcohol.
Thank you for allowing us to partipate in your care.
Followup Instructions:
Name: [**Last Name (LF) **],[**Name (NI) **] A
Location: [**Location **] CENTER
Address: [**Last Name (un) 6949**], [**Location (un) **],[**Numeric Identifier 6950**]
Phone: [**Telephone/Fax (1) 18099**]
When: [**Last Name (LF) 766**], [**8-24**], 4PM
|
[
"305.00",
"287.5",
"070.70",
"276.0",
"507.0",
"305.50",
"V60.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10655, 10661
|
8029, 9925
|
332, 372
|
10726, 10726
|
3971, 3971
|
11665, 11920
|
2843, 2945
|
10257, 10632
|
10682, 10705
|
10228, 10234
|
10877, 11642
|
4651, 8006
|
2960, 3526
|
3542, 3952
|
9946, 10202
|
266, 294
|
400, 1701
|
3987, 4634
|
10741, 10853
|
1723, 1754
|
1770, 2827
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,270
| 128,714
|
2030
|
Discharge summary
|
report
|
Admission Date: [**2199-2-27**] Discharge Date: [**2199-3-5**]
Date of Birth: [**2131-3-1**] Sex: F
Service:
ADMISSION DIAGNOSIS: Transverse colon mass.
DISCHARGE DIAGNOSES:
1. Transverse colon mass.
2. Status post right colectomy and excision of liver
metastases.
3. Status post ureterolysis.
4. Postoperative atrial fibrillation.
HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old
woman from [**State 531**], who was diagnosed with a transverse
colonic mass by colonoscopy. Patient has had repeat
colonoscopy and barium enema, which demonstrated apple core
lesion in the distal transverse colon. Metastatic workup
including a CT scan demonstrated [**12-28**] lesions in the liver,
and the patient is considered for concomitant liver surgery
at the same time as her colectomy.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of the Hepatobiliary and Transplant
services was contact[**Name (NI) **] regarding this, and the patient was
scheduled for combined segmental colectomy and partial
hepatectomy.
PAST MEDICAL HISTORY: Breast cancer.
PAST SURGICAL HISTORY:
1. Right mastectomy with TRAM flap reconstruction
approximately 15 years prior.
2. Hysterectomy.
3. Bladder suspension.
4. Incidental appendectomy.
5. Sinus surgery.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Amitriptyline.
2. Nexium.
3. Quinine 325 mg q.h.s.
4. Dalmane 15 mg q.h.s.
5. Synthroid 100 mg q.d.
PHYSICAL EXAM ON ADMISSION: General: In no acute distress.
HEENT: Pupils are equal, round, and reactive to light.
EOMI. Anicteric. Throat is clear. Neck is supple, midline
with no cervical lymphadenopathy. Chest was clear to
auscultation bilaterally. There is a well-healed soft
reconstruction of her right breast. There are no masses in
the left breast. Cardiovascular is regular rate and rhythm
without murmurs, rubs, or gallops. Abdomen is soft,
nontender, and nondistended with no palpable masses or
organomegaly. There is some mild discomfort in the left
upper quadrant. Rectal examination demonstrates no masses
and no tenderness. Extremities are warm, well perfused with
no peripheral edema, full range of motion with equal strength
and tone.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**2199-2-27**] for planned elective
right colectomy and concomitant liver resection. This is
performed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1888**] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in
combination. For details of this operative procedure, please
see the previously dictated operative note.
Postoperatively, the patient had an episode of atrial
fibrillation in the Post Anesthesia Care Unit, which was
controlled with a small amount of IV Lopressor. The patient
was subsequently transferred to the floor.
On postoperative day #1, the patient again slipped back into
atrial fibrillation with systolic blood pressure around 90.
This was seen to be her baseline and Lopressor 2.5 mg IV was
given to attempt to control the rate of the atrial
fibrillation which was up into the 160s. After the 2.5 mg of
IV Lopressor, the patient's blood pressure dropped into the
70s. Patient was mentating well and Cardiology was
consulted. The patient was transferred to the ICU for he
potentially hemodynamically unstable atrial fibrillation with
a goal of amiodarone drip as well as possible cardioversion.
Patient was started on amiodarone drip and converted to
normal sinus shortly. Cardioversion was averted and thought
not to be not necessary secondary to the relative hemodynamic
stability compared to the patient's baseline.
On the morning of postoperative day #2, the patient's cardiac
status slipped back into atrial fibrillation, although it was
rate controlled at approximately 100-110. Cardiology was
following closely and recommended anticoagulation.
Anticoagulation was contraindicated by the Liver Surgery
service. Patient was begun on low dose beta blocker and diet
was advanced as tolerated.
Subsequent to this, patient went back into normal sinus. She
was followed closely by the Electrophysiology division of the
Cardiology service. The J-P drains were removed
appropriately when drainage was low. Diet was advanced as
tolerated. The patient had a Holter monitor for 24 hours
prior to discharge for analysis by the Electrophysiology
service. Ultimately, the patient was discharged on
postoperative day #6 tolerating a regular diet, and adequate
pain control on p.o. pain medications with all drains and
lines removed, in normal sinus rhythm and being tracked by
the Electrophysiology service.
Of note, the patient had a TSH level drawn in the ICU, which
was low at 0.16. The patient's outpatient Synthroid dose of
100 was readjusted to Synthroid of 75 mcg daily.
DISPOSITION: home.
DIET: Adlib.
MEDICATIONS ON DISCHARGE:
1. Quinine 325 mg q.h.s.
2. Aspirin 325 mg q.d.
3. Percocet 5/325 mg 1-2 tablets q.4h. prn.
4. Amiodarone 400 mg b.i.d. x14 days, subsequently 400 mg
p.o. q.d.
5. Synthroid 75 mg p.o. q.d.
6. Lopressor 25 mg p.o. b.i.d.
DISCHARGE INSTRUCTIONS: Patient is advised not to return to
any strenuous activities or do any heavy lifting greater than
10 pounds for the next three weeks. Patient should follow up
with Dr.[**Name (NI) 4999**] office in two weeks' time. Patient should
also follow up with Dr.[**Name (NI) 670**] office in approximately two
weeks' time. Patient is also carefully instructed to
followup with Electrophysiology cardiologist within the next
2-3 weeks regarding her cardiac status and potential atrial
fibrillation. Otherwise, the patient should follow up with
her cardiologist back in her home state of [**State 531**].
Staples had been removed and Steri-Stripped prior to
discharge.
[**Last Name (NamePattern4) 1889**], M.D. [**MD Number(1) 1890**]
Dictated By:[**Last Name (NamePattern1) 5745**]
MEDQUIST36
D: [**2199-3-5**] 17:55
T: [**2199-3-7**] 12:36
JOB#: [**Job Number 11129**]
(cclist)
|
[
"V10.3",
"458.29",
"427.31",
"E878.8",
"997.1",
"153.1",
"197.7",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.22",
"45.74"
] |
icd9pcs
|
[
[
[]
]
] |
192, 351
|
4892, 5113
|
2222, 4866
|
5138, 6051
|
1117, 1453
|
147, 171
|
380, 1055
|
1468, 2204
|
1078, 1094
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,637
| 148,117
|
54802
|
Discharge summary
|
report
|
Admission Date: [**2133-6-8**] Discharge Date: [**2133-6-16**]
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
nausea/vomiting, cerebellar bleed
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is an 88-year-old woman with a history of a-fib on
coumadin who was transfered from [**Hospital6 3105**]
yesterday after she presented with nausea/vomiting and was found
to have a R cerebellar bleed. Per her family she was in her
usual
state of health when they last saw her on Sunday morning for
breakfast. She did not report a headache or any other symptoms
at
that time, but per her family is not one to complain. She had a
scheduled [**Last Name (un) 8509**] eye procedure at [**Last Name (un) 112015**] Eye Associates
yesterday
morning ([**6-8**]). She lives alone and her family did not see her
or
speak with her that morning, but presume she took a cab to the
appointment as she typically does. After the procedure she
reportedly became diaphoretic and dizzy with nausea/vomiting and
was transported to [**Hospital3 **] ED. There she was initially
awake and alert, and reported that she had been having headaches
since the day before and was not feeling well that morning prior
to the procedure. She also complained of dizziness and diffuse
abdominal pain, and continued to have nausea with several
episodes of vomiting. On exam her pupils were equal and
reactive,
face was symmetric, no focal weakness. BP on arrival was 190/90;
did not receive any intervention. CT head was obtained which
revealed a R cerebellar hemorrhage. INR was 2.3, troponin 0.078.
Rest of labs wnl. She was given 10mg vitamin K IV and 2u FFP.
She
then reportedly became more somnolent during evaluation and had
multiple episodes of vomiting. She was intubated for airway
protection and transferred to [**Hospital1 18**] for further management.
BP on arrival here was 140/74. She was seen by the neurosurgery
service in the ED, at which point her exam was limited by
sedation but revealed pinpoint pupils, intact brain stem
reflexes, purposeful movement of all extremities, and a L
upgoing
toe. A repeat CT at 5:18pm revealed a 2.7 x 3.1 cm R cerebellar
hemorrhage with a small amount of surrounding edema and mild
effacement of the fourth ventricle, overall unchanged from her
prior CT from 11:44am at [**Hospital3 **].
She was admitted to the neurosurgery service overnight for close
monitoring and consideration for possible EVD placement. She was
started on decadron and received an additional 10mg Vitamin K x
2. She was briefly started on a nitroprusside drip but this was
stopped last night and her BP has subsequently been
well-controlled in 130-140's systolic with 2 additional doses of
prn hydralazine. She was extubated last night shortly after
arrival to the ICU and has remained stable on 3L NC. Repeat CT
head this am appeared stable. As no surgical interventions are
currently planned the neurosurgery team requested transfer to
neurology for further management.
She is currently awake, somewhat lethargic but appropriately
arousable. She is able to answer a few yes/no questions and
seems
to understand that she is in the hospital but is unable to tell
us of the events yesterday or why she is here. Speech is
dysarthric and somewhat difficult to understand. She follows
basic commands appropriately and does not appear to have any
evident strength deficits. It is difficult to assess
coordination
given her current lethargy and poor cooperation.
Past Medical History:
Atrial fibrillation with cardiac arrythmia s/p pacemaker
placement (on warfarin), GERD, esophageal varices
PSH: s/p pacemaker placement, s/p probable cholecystectomy
Social History:
Lives alone with son nearby. Very independent, walks with walker
but does own shopping, cleaning, bills, etc. No ETOH or tobacco
use.
Family History:
noncontributory
Physical Exam:
Physical Exam on Admission:
Vitals: 140/74, 60, 12, 99%
General: well-nourished, no acute distress, intubated
HEENT: normocephalic, atraumatic, MMM, intubated, OGT in place
Chest: lungs clear to auscultation bilaterally
Cardiac: RRR, no rubs, murmurs, gallops
Abdomen: soft, non-tender, non-distended, (+) bowel sounds
Extremities: 1+ DPs, no c/c/e
Neuro: (off propofol for 5-10 minutes)
-Mental status: sedated, opens eyes to noxious, does not follow
commands
-Cranial nerves: pinpoint pupils;(-) doll eyes, corneals
intact,
blinks to threat bilaterally, Face symmetric
-Motor: Moves all extremities purposefully
-Reflexes: Symmetric 2's at the biceps, brachioradialis,
triceps, patellar, achilles bilaterally, Upgoing toe on L and
downgoing on right.
Physical Exam on Transfer to floor:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: Awake, somewhat lethargic but easily arousable.
Oriented to self and hospital, does not know name of hospital or
date. Answers a few yes/no questions but otherwise answers
nonsensically. Speech is dysarthric and at times difficult to
understand. Able to follow midline and appendicular commands
with encouragement.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1mm and brisk. VFF to confrontation.
III, IV, VI: EOMI with a few beats of horizontal nystagmus
maximal on leftward gaze.
V: Facial sensation intact to light touch and cold.
VII: Subtle left lower facial asymmetry.
VIII: Hearing intact to loud voice bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No adventitious movements,
such as tremor, noted.
Lifts both arms anti-gravity and hold for 10 seconds. Squeezes
both hands strongly.
Lifts both legs anti-gravity. Does not comply with formal
strength testing at this time but appears to be moving all
extremites symmetrically.
-Sensory: Grossly intact to light touch throughout.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor on R, extensor on L.
-Coordination: Difficult to assess given lethargy and poor
cooperation, reaches b/l without obvious ataxia but unablet to
perform FNF or HKS currently.
-Gait: Deferred
Physical Exam on Discharge:
Vitals: T 98 BP 143/69 HR 60 RR 16 O2 94 RA
SEE BELOW
Pertinent Results:
[**2133-6-8**] 09:20PM UREA N-14 CREAT-0.6 SODIUM-141 POTASSIUM-3.1*
CHLORIDE-102
[**2133-6-8**] 09:20PM PLT COUNT-158
[**2133-6-8**] 09:20PM PT-12.3 INR(PT)-1.1
[**2133-6-8**] 03:22PM TYPE-ART RATES-/12 TIDAL VOL-450 PEEP-5
O2-100 PO2-417* PCO2-36 PH-7.50* TOTAL CO2-29 BASE XS-5
AADO2-257 REQ O2-50 INTUBATED-INTUBATED VENT-SPONTANEOU
[**2133-6-8**] 02:25PM GLUCOSE-154* UREA N-15 CREAT-0.8 SODIUM-144
POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-23 ANION GAP-19
[**2133-6-8**] 02:25PM estGFR-Using this
[**2133-6-8**] 02:25PM cTropnT-<0.01
[**2133-6-8**] 02:25PM WBC-5.8 RBC-4.12* HGB-12.8 HCT-38.8 MCV-94
MCH-31.0 MCHC-33.0 RDW-14.2
[**2133-6-8**] 02:25PM NEUTS-77.6* LYMPHS-17.4* MONOS-3.9 EOS-0.9
BASOS-0.2
[**2133-6-8**] 02:25PM PLT COUNT-149*
[**2133-6-8**] 02:25PM PT-16.6* PTT-29.2 INR(PT)-1.6*
CT head [**6-8**]:
IMPRESSION:
1. Right cerebellar intraparenchymal hemorrhage, unchanged from
11:44 a.m., with mild surrounding edema and mild effacement of
the fourth ventricle. No evidence of supratentorial
hydrocephalus, allowing for atrophy-related enlargement of the
supratentorial ventricles and sulci.
2. No evidence of an underlying mass, within the limitations of
CT technique. It appears that the patient may not undergo MRI
due to a pacemaker. A head CTA would be more sensitive than a
routine contrast-enhanced CT for excluding an arteriovenous
malformation, if indicated.
3. Linear lucency in the right occipital bone, more consistent
with a
prominent nutrient foramen rather than a fracture, particularly
given the lack of any swelling in the overlying scalp.
CT head [**6-9**]:
1. Unchanged appearance of the right cerebellar hemorrhagic
infarction with surrounding edema causing moderate compression
of
the fourth ventricle. The size of the ventricles is unchanged.
2. No evidence of tonsillar herniation.
3. No new hemorrhage.
CXR [**6-9**]:
IMPRESSION: Small bilateral pleural effusions.
Transthoracic echo [**6-9**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
No cardiac source of embolus identified (other than the history
of atrial fibrillation).
CT head [**6-10**]:
IMPRESSION:
1. Unchanged appearance of large right cerebellar hemispheric
hematoma,
associated edema and mass effect, with stable compression of the
fourth
ventricle and very mild right-sided upper transtentorial
herniation.
2. Stable ventricular size, with no definite evidence of
developing
obstructive hydrocephalus.
3. Stable periventricular hypodensities, most likely the
sequelae of chronic small vessel ischemic disease, although a
component of transependymal migration cannot be completely
excluded.
.
Labs on Discharge:
[**2133-6-15**] 05:45AM BLOOD WBC-6.3 RBC-4.59 Hgb-14.1 Hct-43.2 MCV-94
MCH-30.7 MCHC-32.6 RDW-14.4 Plt Ct-157
[**2133-6-15**] 05:45AM BLOOD Glucose-109* UreaN-19 Creat-0.7 Na-138
K-4.4 Cl-100 HCO3-28 AnGap-14
[**2133-6-15**] 05:45AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.4
Brief Hospital Course:
88-year-old woman with a history of a-fib on coumadin who
developed dizziness, nausea, and vomiting after an eye procedure
and was found to have a R cerebellar hemorrhage of unknown
etiology. She was initially admitted to the ICU under the
neurosurgery service on [**6-8**] but remained stable with no
indication for surgical intervention currently. She was
subsequently transferred to the neurology service on [**6-9**] for
further management.
Neuro:
She was monitored closely with Q2 hour neurochecks and remained
clinically stable. Repeat head CT's on [**6-9**] and [**6-10**] appeared
stable. She had initially been started on Decadron for
prevention of cerebral edema and mannitol was placed at bedside
in case she decompensated secondary to acute cerebral edema.
However, pt did well with no edema and decardron was tapered
slowly over 3 days. BP was monitored closely and treated with
hydralazine and metprolol prn with a goal SBP < 160. Her exam
remained stable, significant for disorientation, dysarthria, and
mild nystagmus on leftward gaze but no apparent strength
deficits or ataxia (although formal testing somewhat limited by
lethargy and poor cooperation). She was initially quite
lethargic and disoriented with very delayed responses and
nonsensical, garbled speech. She is now becoming more alert and
lucid, oriented to self and hospital, and able to answer simple
questions appropriately. She remains somewhat abulic with
significant psychomotor slowing.
At this point the etiology of her hemorrhage is unclear.
Possibilities include hypertensive (no known history although BP
was 190/90 on presentation), underlying mass or AVM, amyloid
angiopathy, or hemorrhagic conversion of infarction (although
does not follow a clear vascular distrubiton). MRI could not be
performed due to her pacemaker.
CV:
She was maintained on telemetry monitoring which revealed atrial
fibrillation, occasionally with RVR. Heart rate was controlled
with metoprolol and diltiazem prn, and she was subsequently
started on metoprolol 25mg PO TID for rate control. Day prior
to d/c, pt went into afib with RVR, rate up to 140s. Trated
with metoprolol 2.5mg IV x1 and switched back to her home
sotalol 80mg PO bid and metoprolol was discontinued. HR remained
in 60s. BP was monitored and controlled closely with prn
hydralazine and metoprolol with a goal SBP < 160. TTE was within
normal limits with no evidence of atrial thrombus or valvular
disease.
PULM:
She was extubated shortly after admission to the ICU and her
respiratory status subsequently remained stable. She was
provided low flow O2 via NC as needed to maintain sats. CXR
showed mild pulmonary edema (after receiving 2u FFP). She
received two doses of lasix 20mg IV and volume status was
monitored closely.
ENDO
She was maintained on fingersticks and insulin sliding scale
with a goal of normoglycemia.
ID:
She remained afebrile throughout her ICU stay. CXR showed small
b/l effusions but no infiltrate. WBC began to trend up, peaking
at 14.2 on [**6-10**]. UA was positive and she was started empirically
on ceftriaxone, but discontinued on [**6-15**] since final urine
culture was not c/w UTI.
FEN:
She was initially maintained NPO given her depressed mental
status and an NGT was placed for medications and nutrition. She
was subsequently seen by speech and swallow and was cleared for
a pureed diet with thin liquids.
PPX:
She was maintained on a bowel regimen and famotidine for GI
prophylaxis. She was maintained on pneumoboots for DVT
prophylaxis. SubQ heparin was initially held in the setting of
her bleed and was restarted on [**6-10**]. She was maintained on fall
and aspiration precautions.
Code Status: FULL (reconfirmed with family [**6-9**])
PENDING RESULTS:
none
TRANSITIONAL CARE ISSUES:
- will need to re-start Coumadin at home dose of 2.5mg on [**2133-6-22**]
- will need INR check on [**6-25**] and titration of dose as needed
- will f/u in stroke clinic on [**2133-8-18**] at 2pm
Medications on Admission:
Simvastatin 40mg PO qd
Sotalol 80mg PO bid
Omeprazole 20mg PO qd
Coumadin 5mg on Monday/Thursday and 2.5mg on Tues,Weds,Fri,Sat,
Sun
Discharge Medications:
1. Docusate Sodium (Liquid) 100 mg PO BID
2. Omeprazole 20 mg PO DAILY
3. Senna 1 TAB PO BID
4. Sotalol 80 mg PO BID
5. Simvastatin 40 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
right cerebellar hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neurologic Exam ON DAY OF DISCHARGE [**2133-6-15**]:
Appears comfortable. Smiles, says she feels good. Awake and
alert. Oriented to name/hospital. Somewhat slow to respond with
soft speech. Says she would like to get up and walk. Working
with PT, sitting in a chair. Has not yet gotten up to walk.
Follows simple commands reliably. PERRL, EOMI with no nystagmus.
Speech is somewhat hoarse, and soft. Subtle L facial asymmetry
(noted on admission) not prominent on exam today. Hard of
hearing. Power at least anti-gravity in all extremities; no
drift. No ataxia on FNF. No truncal titubation. Sensation
grossly intact to light touch throughout. Toes=Plantar response
was flexor on R, extensor on L. Reflexes [**12-15**] and symmetric in UE
and LEs. Gait deferred (working with PT, attempting to use
walker -- plan for PT at rehab).
Discharge Instructions:
Dear Ms. [**Known lastname **],
You came to the hospital with dizziness, confusion and nausea
and we found that you had a small bleed in your brain. We
monitored you closely and you gradually improved. While you
were in the hospital, we DID NOT give you Coumadin because we
did not want to exacerbate the bleed in your brain. However, to
prevent stroke, it is VERY important that you resume taking
Coumadin in 1 week ([**2133-6-22**]) at prior dose.
A physical therapist saw you while you were in the hospital and
recommended that you go to a rehab center to regain strength.
It is VERY important that you call registration at [**Hospital1 771**] to update your information regarding
your primary care doctor, etc. Please call [**Telephone/Fax (1) 87261**] BEFORE
your neurology appointment.
We have made the following changes to your medications:
STOP
-taking Coumadin for the next week
RE-START
-Coumadin on [**2133-6-22**]
START
- Colace 100mg liquid twice daily for constipation
- Senna 1 tablet twice per day as needed for constipation
Please see your new neurologist, Dr. [**Last Name (STitle) **], as scheduled
below.
It was a pleasure taking care of you, we wish you all the best!
Followup Instructions:
Follow-Up Appointment Instructions
Department: NEUROLOGY
When: TUESDAY [**2133-8-18**] at 2:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
It is VERY important that you call registration at [**Hospital1 771**] to update your information regarding
your primary care doctor, etc. Please call [**Telephone/Fax (1) 87261**] BEFORE
your neurology appointment.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2133-6-16**]
|
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icd9cm
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[
[
[]
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[
"96.6",
"96.71"
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icd9pcs
|
[
[
[]
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] |
14541, 14588
|
10214, 13963
|
284, 291
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14660, 14660
|
6712, 9902
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16900, 17536
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3952, 3969
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14369, 14518
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14609, 14639
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14212, 14346
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15675, 16502
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5462, 6610
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3984, 3998
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6638, 6693
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16531, 16877
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211, 246
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13989, 14186
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9922, 10191
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319, 3593
|
4012, 4380
|
14675, 15651
|
3615, 3784
|
3800, 3936
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,944
| 180,885
|
14029
|
Discharge summary
|
report
|
Admission Date: [**2126-5-24**] Discharge Date: [**2126-6-7**]
Date of Birth: [**2057-5-3**] Sex: M
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old
gentleman with a history of hypertension and CAD, status post
right RCA stent in [**3-24**] with carotid stenosis, renal
calculi, glaucoma, and no known allergies, who had a headache
x1 week and was seen in an outside hospital where an LP was
positive for red cells. An MRI and MRA showed subarachnoid
hemorrhage in the left sylvian fissure with decreased flare
in the left ICA. The patient was transferred to [**Hospital1 346**] for angio. The patient reportedly
had a headache for one week and was seen at [**Hospital3 **] Hospital
where a CT was essentially negative. The headache persisted,
and the patient was then sent to [**Hospital6 **] on
[**2126-5-23**]. There the LP was performed that showed 4 out of 4
red cells. A repeat LP the following morning was also
positive for blood. His neck was supple. He was
neurologically intact, but then transferred here for an angio
with suspicion of a right MCA aneurysm.
PHYSICAL EXAMINATION: His temperature was 98.7 degrees,
heart rate 60, blood pressure 151/70, respiratory rate 10,
saturations 98 percent on 4 liters. He was a pleasant
gentleman, somewhat sleepy, but easily arousable. His
cardiac status was S1 and S2. No murmur, rub, or gallop,
actually 2/6 systolic murmur. He had no bruits on his
carotids. His abdomen was soft and nontender. He had
positive bowel sounds. His pedal pulses were intact. His
pupils were equal, round, and reactive to light. His EOMs
were full. His smile was symmetric. His tongue was midline.
He had a [**3-27**] grasp and 5/5 strength in all muscle groups.
His deep tendon reflexes were 2 plus throughout. His toes
were downgoing. He had no ankle clonus.
HOSPITAL COURSE: The patient underwent diagnostic angiogram
on the day of admission and attempted coiling without
success, but there were no intraoperative complications. The
patient was transferred to the ICU for close neurologic
observation and taken to the OR on [**2126-5-25**] for right MCA
aneurysm clipping without complication. Postoperatively, his
vital signs were stable. He was afebrile. He was awake,
alert, opening his eyes to voice, following commands. His
pupils were 4, down to 3 mm and briskly reactive. His grasps
were [**3-27**], and he was moving his lower extremities with good
strength. He remained neurologically intact keeping his SBP
130-150. Angiogram also showed a very tenuous right carotid
stenosis. The patient had a head CT on [**2126-5-26**] that showed
no change. On [**2126-5-28**], the patient developed rapid atrial
fibrillation, was seen by cardiology, was placed on
amiodarone IV, and did convert to sinus rhythm. On [**2126-5-28**],
the patient had a repeat angiogram, which showed angio clip
abutting the MCA. The patient's neurologic status remained
stable. He had cardiac enzymes that were negative x2, and he
was being monitored for vasospasm. He had a repeat head CT
on [**2126-5-30**] that was stable with no change. The patient
continued to remain neurologically intact. He was being
watched for vasospasm and treated with HHH therapy.
Cardiology was involved. An echo was done, which showed an
EF of greater than 55 percent, mild MR, mild dilation of the
LA, and no other findings. He did convert to sinus rhythm on
IV amiodarone with no further episodes of atrial
fibrillation. He was also kept on Lopressor for rate
control. The patient remained neurologically stable. His
staples were discontinued on postoperative day seven, which
was [**2126-6-3**], and the patient was transferred to the regular
floor on [**2126-6-4**]. He was discharged to home on [**2126-6-7**] in
stable condition with follow up with Dr. [**Last Name (STitle) 1132**] on [**2126-6-14**] at
11:30 a.m.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d. for his carotid stenosis.
2. Amiodarone 200 mg p.o. q.d.
3. Metoprolol 25 mg p.o. b.i.d.
4. Dilantin 200 mg p.o. t.i.d.
5. Famotidine 20 mg p.o. b.i.d.
6. Tylenol No. 3 one to two tablets p.o. q.4 h. p.r.n. for
headache.
DISCHARGE CONDITION: His condition was stable at the time of
discharge.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 6583**]
MEDQUIST36
D: [**2126-6-7**] 14:20:13
T: [**2126-6-8**] 03:13:43
Job#: [**Job Number 41879**]
|
[
"427.31",
"E878.8",
"V45.82",
"430",
"997.1",
"V13.01",
"272.4",
"414.01",
"433.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"39.51",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
4209, 4512
|
3932, 4187
|
1878, 3909
|
1143, 1860
|
163, 1120
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,946
| 116,888
|
49560
|
Discharge summary
|
report
|
Admission Date: [**2131-10-19**] Discharge Date: [**2131-10-27**]
Date of Birth: [**2064-7-16**] Sex: M
Service: MEDICINE
Allergies:
Levofloxacin / Cefazolin / Coreg / Dopamine
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
fatigue, shortness of breath
Major Surgical or Invasive Procedure:
Right thoracentesis
History of Present Illness:
A 67 year old gentleman recently discharged [**10-5**] from [**Hospital1 1516**]
service for sepsis [**1-27**] R. BKA site complicated by Refractory VT
s/p ablation with a history of DM, CAD s/p PCI distal RCA '[**03**],
ischemic cardiomyopathy EF 20% who was admitted with lethargy
and fatigue from [**Hospital3 **]. He reports an
increase in fluid collection in his upper extremities, shortness
of breath and constipation and general fatigue over past 4 days.
At [**Hospital1 **], it was presumed that this was an exacerbation of
his CHF so Lasix increased from 20mg PO to 80mg IV BID x2 days.
His UOP was negative 1.5 Liters yesterday but he failed to
respond and was persistantly short of breath. However, on
further review he has not recieved any Lasix over past 18 hours.
(pharmacy error per report). He was subsequently transferred for
further managment.
PT was directly transferred to the floor from [**Hospital1 **] where
his VS: 97.3 77 105/66 17 100% 4L. An initial evaluation was
begun on the floor. EKG showed V paced @69 and no ischemic
changes. CXR revealed evidence of pulmonary edema and possible
pneumonia. CT Chest showed large right pleural effusion and no
evidence of pneumonia, BNP 55, 000. CK 36, Trop 0.35. Cr 2.0 (up
from baseline 1.7)
Pt was subsequently transferred to CCU for further management.
On ROS, He denies chest pain, palpitations, N/V, abdominal pain.
Denies PND or orthopnea. Denies cough, fever or chills. He does
report some constipation x2 days but had some BM today. Reports
mild dysuria 2 days ago now resolved. Denies flank pain. He
endorses poor appetite and PO intake over past 3 days. He
reports a pressure ulcer on coccyx.
Past Medical History:
*CARDIAC HISTORY:
-MI [**2103**]- C.CATH [**2121**] showed 60% distal RCA stenosis at
recanalization site
-Systolic Heart Failure- ECHO [**10-3**] with EF 20%
-Refractory VT (dx [**10-3**] in setting of sepsis) now s/p VT
ablation; currently on Mexilitine and Amiodarone
-Atrial Fibrillation s/p ablation, pacemaker
*Hypertension
*Hyperlipidemia
*DMII
*SMA thrombosis: small&large bowel resection and short gut
*Bacterial peritonitis
*PVD s/p R BKA c/b stump infection- completed 10d Vanc/Zosyn
*Hypercoagulable state, DVTs on Lovenox
*Peripheral neuropathy
*Plantar fasciitis
*CVA
*PV/MDS, baseline 20s
*Nonhealing anal fissure
Social History:
Currently lives at [**Hospital3 **], he is a retired systems
programmer for a management consulting firm. He is married with
no children. He denies alcohol, tobacco or drug use. Prior 3 yrs
of tobbaco use.
Family History:
Family history is negative for hypercoagulable state, PVD
Physical Exam:
PE: VS: 97, BP 96/609 HR 74, RR 18 97% 1.5L
Gen: Cachectic male, fatigued appearing, conversing in full
sentences
Neck: JVP 10cm
Pulm: Rales in Bilateral lower lobes, decreased sounds on right
Cards: S1 & S2 regular without murmur
Abd: Soft, mildly distended, tympanitic, non-tender, no
rebound/guarding
Ext: B upper extremity edema. R BKA, stump with no open wounds
or erythema. Wound on L foot, healing well. 1+ DP on L foot.
Neuro: AAO x3
Pertinent Results:
Admission:
[**2131-10-19**] 05:10PM BLOOD WBC-20.4* RBC-5.22 Hgb-12.4* Hct-39.7*
MCV-76* MCH-23.8* MCHC-31.3 RDW-20.9* Plt Ct-382
[**2131-10-19**] 05:10PM BLOOD Neuts-91.4* Lymphs-5.1* Monos-1.8*
Eos-1.4 Baso-0.3
[**2131-10-19**] 05:10PM BLOOD PT-20.5* PTT-51.4* INR(PT)-1.9*
[**2131-10-19**] 05:10PM BLOOD Glucose-85 UreaN-82* Creat-2.0* Na-140
K-4.8 Cl-101 HCO3-25 AnGap-19
[**2131-10-19**] 05:10PM BLOOD CK(CPK)-36*
[**2131-10-19**] 05:10PM BLOOD CK-MB-NotDone cTropnT-0.35* proBNP-[**Numeric Identifier 103666**]*
[**2131-10-19**] 05:10PM BLOOD Calcium-8.0* Phos-6.8*# Mg-2.0
[**2131-10-20**] 12:09PM BLOOD Lactate-0.9
Admission Chest X-ray:
1) New focal opacity overlying the left mid lung field, which
could represent an area of developing pneumonia. Dedicated PA
and lateral views of the chest is recommended.
2) Persistent large right pleural effusion and mild congestive
heart failure.
3) Unchanged bibasilar atelectasis.
CT CHEST W/O CONTRAST [**2131-10-19**]:
1. Severe right pleural effusion and small left pleural
effusion. The left
pleural effusion is loculated and corresponds to the described
density on the recent chest radiographs.
2. No pericardial effusion is noted.
3. Diffuse ground glass opacities of the lungs is most likely
related to
pulmonary edema. More focal patchy opacities at left apex may
represent
asymmetric pulmonary edema although superimposed infectious or
inflammatory process cannot be excluded.
4. Bibasilar pulmonary calcifications or aspirated barium,
unchanged since
[**2129**].
ECHO [**2131-10-20**]:
The left atrium is moderately dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). Left ventricular wall thicknesses are normal.
The left ventricular cavity is moderately dilated. There is
severe global left ventricular hypokinesis with relative
preservation of the anterolateral wall (LVEF = 20 %). The right
ventricular cavity is moderately dilated with severe global free
wall hypokinesis. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) are mildly thickened. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen. There is at least mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2131-10-1**],
the findings are similar.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2131-10-27**]):
Feces negative for C.difficile toxin A & B by EIA.
Brief Hospital Course:
67 year old gentleman with h/o ischemic cardiomyopathy EF 20%,
Refractory VT s/p ablation, CAD s/p MI'[**03**], who presented from
rehab with increasing SOB c/w acute on chronic systolic heart
failure.
# Systolic CHF exacerbation and dyspnea: On admission, clinical
exam revealed bilateral basilar crackles, JVD 12-13cm and
peripheral edema all consistent with volume overload. BNP 55,260
(previous BNP 22,000). CXR showed effusions (right >left) and
left likely loculated fluid per CT. Pt was also hypotensive,
requiring dobutamine drip which was quickly weaned off. Pt
initially was SOB, attributed to largle right pleural effusion.
Symptoms improved with diuresis to good sats on 2L NC. After
anticoagulation was adequately reversed (Vit K, Lovenox held,
heparin bridge until several hours before procedure), pt was
tapped 2.1L of serous fluid, with LDH and TP consistent with
transudate with additional symptomatic improvement.
Pt was aggresively diuresed with Lasix drip and responded well
symptomatically. PO intake was restricted to low salt and 1L
fluid. He was transitioned to PO lasix at 80 mg [**Hospital1 **]. On
discharge, his oxygen saturation was 98 % on room air.
# Rhythm: Pt has history of VF on recent admission in setting of
sepsis (s/p ablation) and afib (also ablated). Pt was monitored
on telemetry and V Paced with no arrhythmias. He was continued
on Mexilitine and Amiodarone.
Anticoagulation was held for thoracentesis (with a heparin drip
for bridging) and restarted after procedure.
- It was noted that he has a pacemaker rather than an ICD.
Although, there are multiple reasons why he might not be a good
candidate for ICD placement, this issue could be readdressed in
the future.
#CAD: h/o MI. Pt was continued on a statin. BB held while
diuresing since initially was hypotensive, and restarted prior
to DC. Although pt had previous history of bleed while on
Lovenox and [**Hospital1 **], after discussion with his PCP, [**Name10 (NameIs) **] was
restarted as the risk of CAD would exceed the risks of bleeding
on [**Name10 (NameIs) **].
#[**Name (NI) **] Pt was initially very somnolent. Lyrica was DCed given
impaired renal function, Oxycodone was decreased to 10mg q12hrs,
and psychotropic meds were held. He quickly returned to his
baseline level of full alertness and remained there for the rest
of the hospital stay.
#Diarrhea/Constipation: Pt has history of short gut syndrome and
constipation, on psyllum, cholestyramine at home. He was
continued on these and had colace, senna, MOM prn, all separated
by 2 hours from antiarrhythmic meds. Pt initially reported
constipation and after a dose of colace had 7 BMs and then
remained without BM for several days. C Diff was negative and
thus he was started on Immodium. PO intake continued to be
adequate.
#CRI: Pt's baseline creatinine is 1.6-1.8, on presentation
BUN/Cr was 81/2.2. Renal function improved as pt was diuresed
and electrolytes remained stable. Renal team was consulted and
followed.
#Hyperphosphatemia: Pt's phosphate was elevated at 5-6s, likely
a consequence of his CKD and question of vitamin D deficiency.
Levels were sent off but pending at time of discharge an pt
started on weekly vit D supplementation empirically.
#DMII: Blood sugars were well controlled on home dose of NPH and
insulin sliding scale
# Leukocytosis: Pt had a WBC of ~20 throughout admission with
infectious workup initially negative (afebrile, UA neg, no cough
or URI sx, urine and blood cultures negative). Diff with
neutrophil dominance but no early forms. Leukocytosis
attributed to MDS. Prior to discharge, pt's WBCs increased to
30, and UA showed WBCs and leuk esterase so pt was started on
Augmentin for 7 day course and simultaneous PO Vancomycin given
history of recurrent C Diff colitis on antibiotics.
****** Please recheck pt's WBCs, urine analysis and urine
cultures after finishing 1 week course of antibiotics. If
continues to have elevated WBCs after UTI resolves, could
evaluate foot ulcer for possible osteomyelitis.********
# Hypercoagulability Disorder: Pt has a history of multiple
embolic events leading to amputation and GI surgery complicated
by short gut syndrome. He had previously failed coumadin, and
was on lovenox but no aspirin (h/o bleed with lovenox and [**Name (NI) **])
at time of admission. Lovenox was held for thoracentesis and pt
anticoagulated with heparin drip. After thoracentesis, pt was
switched back to lovenox. Prior to discharge, pt was restarted
on [**Name (NI) **] (after discussion with PCP) for cardiovascular risk.
# Depression: Pt initially continued on Citalopram 40mg PO daily
as per rehab records, but was noted to be on 60mg based on outpt
OMR records and increased to 60mg daily.
# Sacral decubetous ulcer: He was seen by wound care who
recommended DuoDerm wound gel to wound bed, to assist with
debriding and to change coccyx dressing q3 days, place Allevyn
foam dressing.
# Neuropathy: Patient has been on neurontin in the past, but was
changed to lyrica and then stopped for volume concerns. Pt had
worsening leg pain but refused Neurontin saying that it did not
sufficiently help in the past. He preferred Oxycontin/Oxycodone
which provided adequate relief but Neurontin could be
reconsidered and uptitrated in the future.
Medications on Admission:
1. Citalopram 40 mg PO DAILY
2. Folic Acid 1 mg PO DAILY
3. Ranitidine HCl 150 mg PO Daily
4. Amiodarone 200 mg PO DAILY
5. Enoxaparin 50mg SQ Q12
6. Hydrocodone-Acetaminophen 5-500 mg [**12-27**] PO Q6h PRN Pain
7. Lyrica 200 mg PO Q8h
9. Psyllium 1.7 g Wafer PO Daily
10. NPH 20U SQ QAM
11. Lidocaine HCl 2 % Gel PRN
12. Oxycodone 20 mg PO Q12
13. Lorazepam 0.5 mg [**12-27**] PO QHS PRN Insomnia
14. Metorprolol Succinate 12.5mg PO Q24
15. Mexiletine 200 mg PO Q8hours
16. Cholestyramine-Sucrose 4 gram PO BID
17. Atorvastatin 10 mg PO QDay
18. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
20. Lasix 20 mg PO Daily
21. Fluconazole 200 mg PO Q24hours until [**10-19**]
22. Maalox 30mL PO Q6h PRN
.
Allergies: Levofloxacin, Cefazolin, Coreg, Dopamine
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Citalopram 40 mg Tablet Sig: 1.5 Tablets PO once a day.
3. Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
5. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO once a day.
Wafer(s)
6. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime)
as needed for Insomnia.
7. Mexiletine 200 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
8. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO
BID (2 times a day).
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for pain: for breakthrough pain.
14. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO at bedtime as needed.
15. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO QTHUR (every Thursday).
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
17. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
18. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
19. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
20. Enoxaparin 60 mg/0.6 mL Syringe Sig: Fifty (50) mg
Subcutaneous Q12H (every 12 hours).
21. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
22. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
23. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
24. Augmentin 250-125 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours for 7 days: Take with food.
25. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary: Acute on Chronic systolic CHF exacerbation
Secondary: Pulmonary effusion, Hypercoagulability, Short gut
syndrome, Diabetes Mellitus type 2, Hypertension,
Discharge Condition:
Stable
Na 135, K 4.9.
BUN
creat
Hct
Pt's dry weight is 49.7 kilos.
Discharge Instructions:
You were admitted to the hospital with an exacerbation of your
heart failure causing back up of fluid in your lungs, which made
it difficult to breathe. You breathing improved with diuresis of
this fluid as well as a thoracentesis (drainage of the fluid
around your lung). Also as the fluid was taken off, your heart
was able to pump more efficiently and your kidneys showed signs
of better perfusion. Prior to discharge your bloodwork and urine
studies showed signs of urinary infection so you were given a 7
day course of Augmentin and started on oral Vancomycin
simultaneously to prevent C Diff diarrhea.
We made the following changes in your medications:
1) Start Augmentin
2) Start Vancomycin
3) Start Lasix at 80mg twice a day
4) Start Aspirin 81mg daily
5) Start Vitamin D
6) Start Oxycontin
7) Start Tylenol
8) Stop Lyrica
9) Stop Percocet
10) Change oxycodone dose
Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs,
adhere to 2 gm sodium diet, and restrict your fluid intake to 1L
per day. If you have worsening shortness of breath, chest pain,
lightheadedness or any other concerning symptoms please call
your doctor or return to the hospital.
It was a pleasure taking care of you, we wish you the best!
Followup Instructions:
Primary Care:
Dr [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 250**] Date/Time: Friday [**11-2**] at 2:00pm. With [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP
Cardiology:
Provider: [**Name Initial (NameIs) 2169**]: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2131-11-23**] 2:00
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2131-11-23**]
1:00
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2131-11-23**]
12:30
Provider: [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 5068**] Date/Time:
[**2131-11-15**] at 10:30am.
Completed by:[**2131-10-27**]
|
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"412",
"250.60",
"428.0",
"707.03",
"564.09",
"599.0",
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icd9cm
|
[
[
[]
]
] |
[
"88.73",
"34.91"
] |
icd9pcs
|
[
[
[]
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|
2731, 2938
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,663
| 172,370
|
13131
|
Discharge summary
|
report
|
Admission Date: [**2131-7-15**] Discharge Date: [**2131-7-23**]
Date of Birth: [**2058-7-10**] Sex: M
Service: SURGERY
Allergies:
Iodine-Iodine Containing
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
worsening left sided weakness/ TIA symptoms
Major Surgical or Invasive Procedure:
[**2131-7-17**]
Primary stenting of the right internal carotid artery
Previous admission:
[**2131-7-6**]
coronary aretery bypass grafts x 4
(LIMA-LAD,SVG-dg,SVG-OM,SVG-PDA)
History of Present Illness:
73M POD9 CABGx4 c/b R MCA watershed stroke on POD2
readmitted after going home with recurrent L-sided weakness
characterized by acute loss of L hand grip strength (dropped
glass of water during
dinner) and difficulty getting up from the table afterwards.
Family also noted him to be slurring his speech somewhat,
reminiscent of his periop CVA. Symptoms lasted ~15-30 mins and
then completely resolved. He was readmitted for further eval.
Past Medical History:
CAD
TIAs
carotid stenosis
hypertension
fatty liver
noninsulin dependent diabetes mellitus
paroxysmal atrial fibrillation
s/p appendectomy
Social History:
lives with his wife. 50-100 pk year history prior to 16 years
ago
rare ETOH use
parttime truck driver,retired fireman
Family History:
father and brother with coronary disease in 50s
Physical Exam:
Afebrile
VSS
Gen: WDWN, appearing debilitated,
Neck: Supple, no JVD, trach midline
Chest: Lungs cta bilaterally ; Sternal incision clean/dry/intact
Heart: rrr, no m/r/g
Abdomen: +bs, Soft, no m/t/o
Extremities: Warm, well-perfused, mild Edema bilat L>R
Neuro: Grossly intact, cranial nerves II-XII intact, sensation
to UE/LE intact bilat
M/S: UE/LE movement slightly decreased on left,
Pulses:
Femoral Right: p Left: p
DP Right: p Left: p
PT [**Name (NI) 167**]: p Left: p
Radial Right: p Left: p
Pertinent Results:
[**2131-7-23**] 07:05AM BLOOD WBC-6.0 RBC-3.94* Hgb-11.6* Hct-36.2*
MCV-92 MCH-29.5 MCHC-32.1 RDW-15.3 Plt Ct-407
[**2131-7-23**] 07:05AM BLOOD PT-23.0* PTT-33.1 INR(PT)-2.2*
[**2131-7-23**] 07:05AM BLOOD Calcium-8.4 Phos-3.3 Mg-1.9
[**2131-7-15**] 05:05AM BLOOD Triglyc-90 HDL-39 CHOL/HD-2.8 LDLcalc-52
[**2131-7-19**] 01:09PM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.026
[**2131-7-19**] 01:09PM URINE Blood-LG Nitrite-POS Protein-75
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-9.0* Leuks-SM
[**2131-7-19**] 01:09PM URINE RBC->50 WBC-[**12-22**]* Bacteri-MANY
Yeast-NONE Epi-0-2
/17/10 1:09 pm URINE Source: Catheter.
**FINAL REPORT [**2131-7-21**]**
URINE CULTURE (Final [**2131-7-21**]):
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2131-7-18**] 12:46 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2131-7-20**]**
MRSA SCREEN (Final [**2131-7-20**]): No MRSA isolated.
[**2131-7-16**] 9:00 pm URINE Source: CVS.
**FINAL REPORT [**2131-7-17**]**
URINE CULTURE (Final [**2131-7-17**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
[**2131-7-15**] 9:35 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2131-7-18**]**
MRSA SCREEN (Final [**2131-7-18**]): No MRSA isolated.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2131-7-15**]
12:20 AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**2131-7-15**] 12:20 AM
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 40082**]
Reason: r/o cva
[**Hospital 93**] MEDICAL CONDITION:
73 year old man with new L arm weakness today now resolved
REASON FOR THIS EXAMINATION:
r/o cva
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: GWp SUN [**2131-7-15**] 1:58 AM
Enlarged R centrum semiovale lacunar infarct
New (since [**2131-7-8**]) R frontal 7mm hypodensity - consider MR
for further
eval if no C/I
Final Report
INDICATION: Left arm weakness today, now resolved. Rule out CVA.
COMPARISON: [**2131-7-8**].
TECHNIQUE: Contiguous axial images of the head were obtained
without IV
contrast.
FINDINGS: There is no intracranial hemorrhage. There is
increased size of a
right centrum semiovale hypodensity (series 2, image 17)
suggesting evolution
of infarct. A rounded 7-mm hypodensity along the right frontal
lobe cortex
defined on the previous scan is not well seen on the present
image. There is
a new hypodensity in the right frontal lobe abutting the right
lateral
ventricle (series 2, image 15), age indeterminate. Persistent
rounded
hypodensity along the right cerebellar hemisphere (2:10). There
is no
intracranial hemorrhage. Ventricles, sulci, and cisterns are
again prominent,
probably reflecting volume loss. Mastoid air cells and
visualized paranasal
sinuses are unremarkable.
IMPRESSION:
1. No intracranial hemorrhage.
2. Progressed appearance of hypodensity in the right centrum
semiovale;
progressed to lacunar infarct.
3. New focal 7-mm diameter hypodensity in the right frontal
lobe, age
indeterminant. Consider MR for further evaluation.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2131-7-18**]
10:04 AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2131-7-18**] 10:04 AM
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 40083**]
Reason: serial exam with supratherapeutic INR w/ thrombosed
carotid
[**Hospital 93**] MEDICAL CONDITION:
73M with known 90% R ICA stenosis, s/p recent CABG c/b CVA,
now with recurrent
transient L sided weakness, s/p R carotid stent c/b in stent
thrombus
REASON FOR THIS EXAMINATION:
serial exam with supratherapeutic INR w/ thrombosed carotid
stent
CONTRAINDICATIONS FOR IV CONTRAST:
allergy
Wet Read: LLTc WED [**2131-7-18**] 11:04 AM
multiple hypodense lesions within the right frontal lobe are
unchanged,
compatible with evolving infarcts along the right ACA/MCA
watershed regions.
No new lesions or mass effect is seen.
Final Report
INDICATION: 73-year-old male with known severe right ICA
stenosis with
recurrent transient left-sided weakness.
COMPARISON: CT is available from [**7-8**] through [**2131-7-17**]
and MRI [**2131-7-8**].
TECHNIQUE: MDCT-acquired axial images of the head were obtained
without the
use of IV contrast.
FINDINGS: Multiple hypodense lesions are redemonstrated within
the right
frontal lobe (2:20, 18), seen on the prior CT examination from
[**2131-7-17**].
This is compatible with evolving right ACA/MCA watershed
infarcts, as seen on
the MRI examination from [**2131-7-8**]. No new lesions are
detected. There is
no new mass effect or edema. Mild sulcal and ventricular
prominence is
redemonstrated, compatible with diffuse cortical atrophy. There
is no acute
fracture. Included views of the mastoid air cells and paranasal
sinuses
remain clear.
IMPRESSION: Multiple hypodense areas within the right frontal
lobe, not
significantly changed since [**2131-7-17**], compatible with an
evolving infarct
along the MCA/ACA watershed regions. There is no new mass effect
or
hemorrhage.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2131-7-18**]
10:06 AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2131-7-18**] 10:06 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 40084**]
Reason: assess for infiltated/effusions
[**Hospital 93**] MEDICAL CONDITION:
73 year old man s/p CABG c/b CVA & carotid stenting
REASON FOR THIS EXAMINATION:
assess for infiltated/effusions
Final Report
HISTORY: Status post CABG and coronary stenting.
COMPARISON: [**2131-7-12**].
PORTABLE AP CHEST: Median sternotomy wires and surgical clips
are intact.
The mediastinal and hilar contours are stable. Small right
pleural effusion is
unchanged. Increased small to moderate left pleural effusion.
Mild bibasilar
atelectasis is stable. There is no pneumothorax.
IMPRESSION:
1. Increased left pleural effusion, now small to moderate. Small
right pleural
effusion is unchanged.
2. Mild bibasilar atelectasis is unchanged.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2131-7-19**]
7:43 AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2131-7-19**] 7:43 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 40085**]
Reason: decreased hct
[**Hospital 93**] MEDICAL CONDITION:
73 year old man with s/p carotid stent
REASON FOR THIS EXAMINATION:
decreased hct
Final Report
SINGLE AP PORTABLE VIEW OF THE CHEST
REASON FOR EXAM: Status post carotid stent with decreased
hematocrit.
Comparison is made with prior study performed a day earlier.
Mild-to-moderate cardiomegaly is stable. Small bilateral pleural
effusions,
left greater than right, are minimally decreased in size, its
evaluation is
difficult to compare to prior study given the difference in
positioning of the
patient. Bibasilar opacities, left greater than right,
consistent with
atelectases, have improved. There is no evident pneumothorax.
Sternal wires
are aligned.
[**2131-7-23**]
LLE venous duplex : negative for DVT
Brief Hospital Course:
Admitted on [**7-15**] with TIA like symptoms, having known >90% R
carotid stenosis and R MCA watershed infarct several days
earlier . Admitted to CVICU, where blood pressure was kept
between 120-160 and pt remained asymptomatic from a neuro
standpoint. On [**7-16**] he was transfered to the VICU where he
remained stable. On [**7-17**] he was taken to the OR where the
following operation was performed:
1. Ultrasound-guided puncture of the left common femoral
vein.
2. Ultrasound-guided puncture of the right common femoral
artery.
3. Catheterization of the right internal carotid artery.
4. Arteriogram of the right carotid artery.
5. Primary stenting of the right internal carotid artery.
6. Perclose closure of the right common femoral
arteriotomy.
Mr. [**Known lastname 40080**] [**Last Name (Titles) 8337**] the procedure well and was transfered
to the pacu for further recovery. He was put a nitro gtt and
initially did well. While in the PACU, he had sudden onset dense
left sided weekness. An emergent CTA was done which showed
in-stent thrombosis. He was given an integrillin bolus and
started on a heparin gtt. He was transferred to the ICU and
placed on q1 hour neuro checks. SBP goals of 150-180. While in
the CVICU he was placed on a neo gtt. He was transitioned to
oral coumadin and his neuro signs/symptoms remained stable. Mr.
[**Known lastname 40080**] was seen by PT and OT and found to be a candidate
for acute rehab. On [**7-20**] he was transfered to the step down
VICU where he continued to progress well. His gtts were weaned
off and his INR slowly became therapeutic. He did have a + UA
on [**7-19**] which culture data showed to be PROTEUS MIRABILIS,
sensetive to cipro. He was put on a 5 day course. By [**7-23**], POD6
he was deemed stable for discharge to rehab. He was voiding on
his own and tolerating a regular diet. He was quite anxious to
work more agressively with PT and OT at rehab.
He will need to f/u with [**Month/Year (2) 1106**] in about 2 months with carotid
ultrasound. He should f/u with his cardiologist regarding afib,
and with cardiac surgery as scheduled for post op check. He
should also f/u with PCP when discharged from rehab.
Medications on Admission:
ASA 81', Ranitidine 150'', Tylenol PRN, MOM PRN, GLyburide 5'',
Atorvastatin 10', Percocet PRN, Amiodarone 200'', Lopressor
50'''COumadin 5'
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.
3. Glyburide 5 mg Tablet Sig: 0.5 Tablet PO QPM (once a day (in
the evening)).
4. Glyburide 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): while on narcotics.
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): to be adjusted by cardiologist - dr. [**First Name (STitle) **].
12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
13. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for sore throat.
14. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM: inr goal 2.0-3.0.
15. PT/INR
please check two - three times per week starting weds [**7-25**]
Goal INR 2.0-3.0
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Primary: Symptomatic right internal carotid artery stenosis
Secondary:
TIAs, CAD, HTN, fatty liver, NIDDM, paroxysmal AFib
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Division of [**Hospital3 **] and Endovascular Surgery Carotid Stent
Discharge Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Take Plavix (Clopidogrel) 75mg once daily
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What activities you can and cannot do:
?????? you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
4 weeks - given recent sternotomy and groin puncture
?????? After 4 weeks, you may resume sexual activity
?????? Gradually increase your activities and distance walked as you
can tolerate
?????? No driving until you are no longer taking pain medications
?????? You should not have an MRI scan within the first 4 weeks after
carotid stenting
?????? Keep your follow up appointments
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
[**Hospital3 1106**] office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2131-8-9**] 1:30
Provider: [**Name10 (NameIs) **] [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2131-9-27**]
3:15
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2131-9-27**] 3:45
Dr. [**First Name (STitle) 3646**] (cardiologist) 1-2 weeks
PCP 2 weeks, or when d/c'd from rehab
Completed by:[**2131-7-23**]
|
[
"996.74",
"427.31",
"571.8",
"041.6",
"342.90",
"997.02",
"V45.81",
"250.00",
"401.9",
"433.11",
"790.92",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"00.45",
"00.63",
"88.41",
"00.44",
"00.61"
] |
icd9pcs
|
[
[
[]
]
] |
13794, 13841
|
9967, 12170
|
328, 504
|
14009, 14131
|
1905, 4269
|
16369, 16897
|
1285, 1334
|
12361, 13771
|
9224, 9263
|
13862, 13988
|
12196, 12338
|
14192, 15404
|
15430, 16346
|
1349, 1886
|
245, 290
|
9295, 9944
|
532, 972
|
14146, 14168
|
994, 1133
|
1149, 1269
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,580
| 122,539
|
35818
|
Discharge summary
|
report
|
Admission Date: [**2111-1-9**] Discharge Date: [**2111-1-17**]
Date of Birth: [**2053-9-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9853**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
EGD [**1-10**]
C-scope [**1-14**]
EGD/EUS [**1-15**]
IR embolization GDA aneurysm [**1-16**]
History of Present Illness:
Mr. [**Known lastname **] is a 57 year old Portuguese speaking male with a history
of EtOH abuse who was admitted to [**Hospital3 4107**] on [**2111-1-6**] with
2 days of epigastric pain, nausea and dry heaves. He denied any
melena, hematochezia, or hematemesis. Denies fevers, chills,
diarrhea, constipation, or melena. He had been drinking EtOH
prior to the onset of the epigastric pain.
At [**Hospital1 **], labs remarkable for amylase 826, lipase 2150 and he
was diagnosed with pancreatitis. CT scan of the abdomen showed
large heterogenous inflammatory mass in the head of the pancreas
5x5 cm with dilated pancreatic duct. U/s incompletely visualized
pancreatic head. His mild leukocytosis resolved with IVF. He was
afebrile. He was managed with NPO and IVF. On the morning of
[**2111-1-9**], patient developed melenotic stools. NGT was placed with
return of clear gastric contents without blood. Hct 36->31->28.
He was then transferred to [**Hospital1 18**] where he received 1 PRBC hct
27-29.8. His vital signs remained stable. Given the history of
alcohol abuse and concern for pancreatic head mass the patient
was transferred to the ICU for EGD.
Past Medical History:
Past Medical History:
- EtOH abuse, unclear amount as daughter says the he hides the
amount. He drinks ~ 1 bottle of wine a day, last drink unclear.
hx of withdrawl
- per family hx of pancreatitis in past
- diverticulosis with diverticulitis s/p partial bowel resection
in [**2101**] in [**Country 4194**].
- h/o hemorrhoids found on colonoscopy in [**5-/2107**] for BRBPR
Social History:
Lives in [**Hospital1 392**] with wife and daughter. [**Name (NI) 1403**] in restaurant
kitchen. Heavy smoker, >1ppd x 48 years. Has drank heavily for
30 years. Had drank wine and vodka in past. Quit vodka after
diverticulitis in [**2101**]. Drinks at least one glass of wine daily
and at times will drink more than a bottle, but unclear [**Name2 (NI) 81458**]
his total intake. Denies illicit drugs. Strained relationship
between daughter, [**Name (NI) **] and himself.
Family History:
Brother w/ h/o pancreatitis. Father with [**Name2 (NI) 11964**]. No history
of pancreatic or other GI malignancy
Physical Exam:
Vitals: 97.2 90-100/50-60s 72 18 96%RA
Pain: 0/10
Access: PIV
Gen: nad
HEENT: anicteric, mmm
CV: RRR, no m
Resp: CTAB, no crackles or wheezing
Abd; soft, thin, nontender, no HSM, no masses, +BS
Ext; no edema
Neuro: A&OX3,grossly nonfocal, no tremors
Skin: no changes
psych: appropriate
Pertinent Results:
hgb 11.8, HCT 34.5 (stable)
Chem wnl, BUN 3, Creat 0.6
AST 18, ALT 12, Tbili 1.3, alkphos 30
INR 1.1
Lipase 198 on [**1-13**]
.
.
.
Imaging/results:
CT a/p [**1-10**]: IMPRESSION:
1. Heterogeneous multicystic mass in the head of the pancreas is
difficult to measure due to its somewhat infiltrative
appearance, but currently measures roughly 3 x 2.5 cm. Given
recent pancreatitis, an inflammatory pseudocyst is likely, but a
cystic neoplasm is difficult to exclude. Continued follow up
with imaging in short interval is recommended for further
evaluation.
2. 1.5-cm pseudoaneurysm in the head of the pancreas arising
from the
gastroduodenal artery. Thin crescent of adjacent hypodensity
could represent partial thrombosis of the pseudoaneurysm, versus
edema, or distorted pancreatic duct.
3. Marked dilation of pancreatic duct with transition point at
margin of pseudoaneurysm.
4. Peripancreatic inflammatory stranding, and scattered small
lymph nodes, consistent with recent history of pancreatitis.
5. Left lower lobe consolidation, could be consistent with
aspiration, or infection.
6. 10 mm left upper pole renal cyst with possible septation.
Further
evaluation with ultrasound or MRI recommended when clinically
appropriate.
.
.
EGD [**1-10**]; Mucosa suggestive of Barrett's esophagus, Small hiatal
hernia, Schatzki's ring, Normal mucosa in the third part of the
duodenum, Otherwise normal EGD to second part of the duodenum
.
.
Cscope [**1-14**] : Internal & external hemorrhoids
Diverticulosis of the whole colon
Previous end to end ileo-colonic anastomosis of the ascending
colon
Otherwise normal colonoscopy to ileo-colonic anastamosis and
neo-terminal ileum
No source of bleeding found, but doesnt rule out recent
diverticular bleed
.
EUS: Mass: A 3 cm ill-defined mass was noted in the head of the
pancreas. EUs appearance of this mass was suggestive of an
inflammatory mass, however, neoplasm could not be ruled out.
Given the suspicion for a bleeding pseudoaneurysm, FNA of this
lesion was not performed. The body / tail of the pancreas showed
changes that were c/w moderate chronic pancreatitis.
Recommendations: Follow-up with GI consult service.
Consider an interventional radiology consult for embolization of
the GDA aneurysm.
Surgical consult with Dr. [**Last Name (STitle) **].
Pancreas mass needs to be followed with serial imaging. Once GDA
aneursym has been embolized, FNA of this mass may be considered.
Brief Hospital Course:
57year old male with h/o heavy ETOH use, diverticulosis admitted
to OSH [**1-6**] with pancreatitis, treated with NPO/IVFs/Pain
control. Pancreatitis likely related to ETOH. Subsequently
developed melena, transfered to [**Hospital1 18**] [**1-9**] ICU. Got 7U prbc total
(last [**1-13**]), EGD [**1-10**] and cscope [**1-14**] with no source of
bleeding, hct stable therafter. Transfered from west ICU to
[**Location **] on [**1-15**]. CT on admission showed gastroduodenal
artery aneurysm which may have been source and he underwent IR
embolization GDA aneurysm on [**1-16**]. Also CT with large complex
pancreatic head mass. Attempted EUS for FNA on [**1-15**] (before
embolization) but did not perform FNA due to high risk of
bleeidng. EUS did show dilated ducts c/w chronic pancreatitis.
Will f/u Dr. [**Last Name (STitle) **] [**2-6**] for further w/u, repeat EUS c FNA.
Hospital course complicated, developed florid DTs in ICU,
treated with valium which was then tapered off. Seen by social
worker and counselled on etoh cessation.
Remained stable after GDA embolization and was discharged home
in good condition, to follow up with Dr. [**Last Name (STitle) **] of surgery with
repeat CT scan and Dr. [**Last Name (STitle) **] of GI.
Medications on Admission:
none
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatitis
GI bleed
Alcohol withdrawal
Discharge Condition:
stable, no abdominal pain, no nausea/vomiting, tolerating POs,
ambulating independently
Discharge Instructions:
You were admitted for pancreatitis related to your alcohol
intake.
You also had bleeding from your stomach for which you underwent
EGD/colonoscopy and embolization of the gastroduodenal artery.
Please stop drinking as this is likely the cause of your
pancreatitis.
Please follow up with Dr. [**Last Name (STitle) **] on [**2-6**], please call
[**Telephone/Fax (1) 13246**] to make an appointment.
Please return immediately to ER if you have any more black or
marroon stools.
Please stop smoking. Information was given to you on admission
regarding smoking cessation and alcohol cessation.
Followup Instructions:
Please make an appointment with Dr. [**Last Name (STitle) **] for [**2-6**], please call
[**Telephone/Fax (1) 13246**] to verify the time.
It is VERY important that you follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
of surgery. You will need an appointment in 3 weeks (he sees
patients in his clinic on Fridays). You will need a CT scan of
your pancreas on the morning of your appointment that his office
will arrange for you. Call his office at ([**Telephone/Fax (1) 2363**] to make
an appointment.
Please follow up with Dr. [**Last Name (STitle) 15942**] in [**1-2**] weeks; call her
office at [**Telephone/Fax (1) 60570**] to make an appointment.
|
[
"285.1",
"577.1",
"577.2",
"291.0",
"305.1",
"577.0",
"593.2",
"V45.3",
"442.84",
"562.10",
"578.1",
"530.85",
"303.91",
"455.3",
"455.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"44.44",
"45.13",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
7052, 7058
|
5407, 6650
|
328, 423
|
7142, 7232
|
2951, 5384
|
7869, 8562
|
2512, 2626
|
6705, 7029
|
7079, 7121
|
6676, 6682
|
7256, 7846
|
2641, 2932
|
274, 290
|
451, 1611
|
1655, 2008
|
2024, 2496
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,891
| 168,663
|
6683
|
Discharge summary
|
report
|
Admission Date: [**2177-8-21**] Discharge Date: [**2177-8-26**]
Date of Birth: [**2119-6-9**] Sex: M
Service: Cardiothoracic
CHIEF COMPLAINT: The patient had a recent admission for a
myocardial infarction, referred for cardiothoracic surgery.
He is a scheduled outpatient admission.
HISTORY OF PRESENT ILLNESS: A 58-year-old male admitted with
congestive heart failure on [**2177-8-12**] with new onset
rapid atrial fibrillation and positive non-Q-wave myocardial
infarction, who underwent cardiac catheterization during that
admission which showed 3-vessel disease with an ejection
fraction of 27% and 30% left main. An echocardiogram also
done during that admission showed 1+ mitral regurgitation, 1+
tricuspid regurgitation, and decreased left ventricular
function. He was referred to cardiac surgery for coronary
artery bypass graft and admitted on [**8-21**] to the operating
room for coronary artery bypass graft.
PAST MEDICAL HISTORY: (His past medical history is
significant for)
1. Non-insulin-dependent diabetes.
2. Hypertension.
3. Status post RCA in [**2173**].
4. Status post LCE in [**2175**].
5. Right toe amputation in [**2173**].
6. Cyst removed from right ankle with skin graft also in
[**2173**].
MEDICATIONS ON ADMISSION: Preoperative medications included
Glucotrol 10 mg p.o. b.i.d., Avandia 4 mg p.o. q.d.,
Precose 100 mg p.o. t.i.d., monopril 20 mg p.o. q.d.,
Lovenox 100 mg p.o. b.i.d., and atenolol (dose unavailable).
ALLERGIES: He has no known drug allergies.
SOCIAL HISTORY: He lives alone. Tobacco history was one and
a half to three packs per day times 40 years. He quit one
week ago. Social ethanol drinker only.
PHYSICAL EXAMINATION ON ADMISSION: Preoperatively, heart
rate 80, blood pressure 127/70, respiratory rate 18, height
was 5 feet 8 inches, weight was 207 pounds. In general, a
well-appearing 58-year-old male in no acute distress. Skin
was intact. HEENT was unremarkable. Neck was supple. No
lymphocytes. No thyromegaly. Chest revealed lungs were
clear to auscultation bilaterally. Slightly decreased breath
sounds in the bilateral bases. Heart was regular. No
murmurs were noted. Abdomen was obese, soft, ecchymotic area
from the Lovenox, nontender, and nondistended, positive bowel
sounds. Extremities were warm and pale with no edema.
Varicosities were none. Neurologically, grossly intact.
Femoral pulses were 2+ bilaterally, dorsalis pedis on the
right was 0, on the left 1+, posterior tibialis were 2+ on
the right, and 1+ on the left, radial were 2+ bilaterally.
No carotid bruits.
LABORATORY DATA ON ADMISSION: Urinalysis was negative.
Potassium of 5, BUN of 12, creatinine of 0.8. Hematocrit
was 37.5.
RADIOLOGY/IMAGING: Electrocardiogram showed atrial
fibrillation with a rate in the 70s.
Chest x-ray showed diffuse interstitial disease, opacity at
the right base.
HOSPITAL COURSE: On [**8-21**], the patient was a direct
admission to the operating room where he underwent coronary
artery bypass graft times four which included a left internal
mammary artery to the left anterior descending artery, and
saphenous vein graft to obtuse marginal, and saphenous vein
graft to PL and to posterior descending artery sequentially.
He tolerated the operation well and was transferred from the
operating room to the Cardiothoracic Intensive Care Unit.
The patient did well in the immediate postoperative period.
He arrived in the Cardiothoracic Intensive Care Unit and was
hemodynamically stable on Neo-Synephrine at 1.5 mg/kg/min.
His respiratory status was good, and he was reversed from his
anesthesia, weaned from the ventilator, and extubated within
the first several hours of arriving in the Cardiothoracic
Intensive Care Unit.
Overnight, he continued to have moderate output from his
chest tubes. For that, he received 2 units of fresh frozen
plasma, 1 unit of packed red blood cells, CellCept,
protamine; so that by morning his chest tube output had
diminished significantly. However, it was decided to leave
his chest tubes in on postoperative day one to further
monitor any drainage.
During the course of postoperative day one, he was weaned
from his Neo-Synephrine, and early in the afternoon of
postoperative day one he was transferred from the
Cardiothoracic Intensive Care Unit to Far Six for continuing
postoperative care and cardiac rehabilitation.
Because of the patient's history of new onset atrial
fibrillation, an Electrophysiology consultation was obtained
on postoperative day one.
On the recommendation of Cardiology the patient was begun on
heparin for his atrial fibrillation starting on postoperative
day two. He was scheduled for a transesophageal
echocardiogram and electrocardioversion prior to discharge.
Over the next several days, the patient remained
hemodynamically stable. His respiratory status was quite
good. His activity level was slowly increased over the first
three postoperative days, so that on postoperative day four
he was deemed stable and ready for discharge. However, he
still needed to undergo his electrocardioversion so he was
kept n.p.o. beginning at midnight of postoperative day four
and was brought to the Cardiology Department for his
transesophageal echocardiogram prior to an
electrocardioversion.
The transesophageal echocardiogram showed a dilated left
ventricle with an ejection fraction of 25%, dilated atria
with moderate mitral regurgitation, trace tricuspid
regurgitation, aortic insufficiency, and pulmonary
insufficiency. No left atrial thrombus was noted. The
patient then underwent an elective cardioversion. He was
shocked at 100 joules and went into sinus rhythm with a rate
of 45 to 50. However, he then returned to atrial
fibrillation at a rate of 70. He was bolused with amiodarone
orally and returned to Far Six for continuing postoperative
care.
The patient continued to progress in his activity level
throughout postoperative day four, and on the morning on
postoperative day five his activity level was deemed
sufficient and safe for him to be discharged to home.
Arrangements were made for the patient be discharged to home
with [**First Name (Titles) 407**] [**Last Name (Titles) 21150**] and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts
monitor on postoperative day five.
PHYSICAL EXAMINATION ON DISCHARGE: At that time, his
physical examination was as follows: Vital signs were
temperature of 98.4, heart rate 87 atrial fibrillation, blood
pressure 128/72, respiratory rate 18, oxygen saturation 95%
on room air. Weight preoperatively was 94.2 kg; on discharge
was 98.5 kg. Physical examination revealed alert and
oriented times three. He moved all extremities and followed
commands. Breath sounds were clear to auscultation
bilaterally. Heart sounds were a regular rate and rhythm, S1
and S2, with no murmurs. Sternum was stable. Incision with
staples, open to air. A small amount of serous drainage from
the distal pole of his sternal incision. Abdomen was soft,
nontender, and nondistended, with normal active bowel sounds.
Extremities were warm and well perfused with no clubbing,
cyanosis or edema. Left leg incision with Steri-Strips open
to air, clean and dry.
LABORATORY DATA ON DISCHARGE: White blood cell count 9,
hematocrit 25, platelets 170. Sodium 134, potassium 4.7,
chloride 99, bicarbonate 27, BUN 17, creatinine 0.8,
glucose 150. PT 17.4, INR 2.
MEDICATIONS ON DISCHARGE: (Medications on discharge include)
1. Amiodarone 200 mg p.o. t.i.d. times four weeks, then
q.d.
2. Lopressor 50 mg p.o. b.i.d.
3. Lasix 20 mg p.o. q.d. times 10 days.
4. Potassium chloride 20 mEq p.o. q.d. times 10 days.
5. Coumadin as directed to keep INR 2 to 2.5.
6. Glucotrol 10 mg p.o. b.i.d.
7. Avandia 4 mg p.o. q.d.
8. Precose 100 mg p.o. t.i.d.
9. Monopril 20 mg p.o. q.d.
10. Ibuprofen 400 mg p.o. q.6h. p.r.n.
11. Percocet 5/325 one to two tablets p.o. q.4h. p.r.n.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: He was to be discharged to home with
[**Hospital6 407**].
DISCHARGE INSTRUCTIONS: His INR was to be followed by his
primary care physician. [**Name10 (NameIs) **] was also discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
of Hearts monitor with strips to be forwarded to Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]. He was to have followup with Dr. [**First Name (STitle) **] in four
weeks and also follow up with Dr. [**Last Name (STitle) **] in four weeks.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass graft times four.
2. Non-insulin-dependent diabetes mellitus.
3. Hypertension.
4. Atrial fibrillation.
5. Status post RLE.
6. Status post RCA in [**2173**].
7. Status post LCE in [**2175**].
8. Right toe amputation in [**2173**].
9. Cyst removed from ankle with skin graft also in [**2173**].
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2177-8-26**] 16:04
T: [**2177-8-31**] 07:04
JOB#: [**Job Number 25489**]
|
[
"428.0",
"414.01",
"410.72",
"250.70",
"401.9",
"458.2",
"427.31",
"440.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.13",
"99.61"
] |
icd9pcs
|
[
[
[]
]
] |
8562, 9204
|
7443, 7951
|
1273, 1521
|
2897, 6328
|
8106, 8541
|
7966, 8081
|
7248, 7416
|
160, 302
|
331, 943
|
2616, 2878
|
966, 1247
|
1538, 1704
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,001
| 173,507
|
32571+57813
|
Discharge summary
|
report+addendum
|
Admission Date: [**2136-10-22**] Discharge Date: [**2136-11-1**]
Date of Birth: [**2056-8-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
80 yo male presented to OSH with dizziness and abnormal EKG.
Major Surgical or Invasive Procedure:
Mitral valve repair [**2136-10-24**] ( 30 mm CE annuloplasty band)
History of Present Illness:
80 yo male presented to OSH with dizziness and abnormal EKG with
diffuse ST elevations consistent with pericarditis. Ruled out
for MI and discharged to home. He returned within 6 hours and
was transferred to [**Hospital1 18**] for furtther evaluation.underwent
cardiac cath which revealed EF 70%, severe MR, and no
significant CAD.Referred to [**Hospital1 18**] for MVR.
Past Medical History:
mitral regurgitation
degenerative joint disease
pericarditis [**2132**] and [**2135**]
Social History:
lives with daughter
works PT delivering newspapers
quit smoking 50 years ago; 15 year pack hx
denies ETOH
Family History:
father died at 80 abruptly /?CAD
Physical Exam:
Sr 82 RR 18 right 140/74 left 142/50 6'0" 71.8 kg
NAD
EOMI PERRLA
neck supple with full ROM and no carotid bruits
no lymphadenopathy
CTAB
RRR with 4/6 holosystolic murmur
soft, NT, ND, + BS, no palpable masses
extrems warm, well-perfused, no edema, mult. superficial
varicosities
nonfocal alert and oriented x3
2+ radials/DP/PT
right femoral with [**Doctor Last Name **] closure device;left 2+ fem
Pertinent Results:
[**2136-10-31**] 06:40AM BLOOD WBC-7.4 RBC-3.03* Hgb-9.7* Hct-28.7*
MCV-95 MCH-32.1* MCHC-33.8 RDW-13.8 Plt Ct-360
[**2136-10-22**] 08:05PM BLOOD WBC-7.7 RBC-4.29* Hgb-13.7* Hct-41.2
MCV-96 MCH-32.0 MCHC-33.3 RDW-14.0 Plt Ct-226
[**2136-10-31**] 06:40AM BLOOD Plt Ct-360
[**2136-10-31**] 06:40AM BLOOD PT-14.7* INR(PT)-1.3*
[**2136-10-22**] 08:05PM BLOOD PT-14.6* PTT-25.0 INR(PT)-1.3*
[**2136-10-22**] 08:05PM BLOOD Plt Ct-226
[**2136-10-24**] 12:35PM BLOOD Fibrino-228
[**2136-10-22**] 08:05PM BLOOD ESR-43*
[**2136-10-31**] 06:40AM BLOOD Glucose-100 UreaN-14 Creat-0.9 Na-140
K-4.2 Cl-104 HCO3-28 AnGap-12
[**2136-10-22**] 08:05PM BLOOD Glucose-78 UreaN-12 Creat-0.9 Na-143
K-4.2 Cl-105 HCO3-31 AnGap-11
[**2136-10-22**] 08:05PM BLOOD ALT-10 AST-13 LD(LDH)-211 AlkPhos-61
TotBili-0.8
[**2136-10-31**] 06:40AM BLOOD Mg-2.5
[**2136-10-25**] 02:41AM BLOOD Calcium-7.7* Phos-2.8 Mg-2.2
[**2136-10-22**] 08:05PM BLOOD Albumin-3.8
[**2136-10-22**] 08:05PM BLOOD %HbA1c-5.4
[**2136-10-22**] 08:05PM BLOOD CRP-19.6*
RADIOLOGY Final Report
CHEST (PA & LAT) [**2136-10-29**] 9:39 AM
CHEST (PA & LAT)
Reason: evaluate effusion
[**Hospital 93**] MEDICAL CONDITION:
80 y s/p MVR
REASON FOR THIS EXAMINATION:
evaluate effusion
HISTORY: 80-year-old male status post mitral valve replacement.
PA AND LATERAL RADIOGRAPH OF THE CHEST: Comparison is made with
the chest radiograph of [**2136-10-26**]. Sternotomy wires and skin
staples remain unchanged. There has been interval decrease in
minimal residual pneumomediastinum. There has also been interval
improvement in bilateral pleural effusions; a small pleural
effusion remains on the left. There has also been interval
improvement in the associated retrocardiac atelectasis.
Bilateral apical pleural thickening is unchanged from prior
exams.
IMPRESSION: Interval improvement in bilateral pleural effusions
and left- sided retrocardiac atelectasis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 95**] [**Last Name (NamePattern1) **]
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: TUE [**2136-10-30**] 9:30 AM
Cardiology Report ECG Study Date of [**2136-10-24**] 2:54:50 PM
Technically difficult study
Sinus rhythm
Prolonged P-R interval
Left atrial abnormality
Since previous tracing of [**2136-10-22**], QRS voltage shorter
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
87 248 78 [**Telephone/Fax (2) 75940**] 63
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 75941**],[**Initials (NamePattern4) **] [**Known firstname **] [**2056-8-14**] 80 Male [**-6/4267**]
[**Numeric Identifier 75942**]
Report to: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dif
SPECIMEN SUBMITTED: MITRAL LEAFLETS.
Procedure date Tissue received Report Date Diagnosed
by
[**2136-10-24**] [**2136-10-24**] [**2136-10-26**] DR. [**Last Name (STitle) **]. FU/mb????????????
DIAGNOSIS:
Mitral valve leaflets:
Cardiac valve with myxoid changes.
Clinical: Mitral regurgitation.
Gross:
The specimen is received fresh labeled with "[**Known firstname 3075**] [**Known lastname **]" and
the medical record number and "mitral leaflets" and consists of
two white heart valve leaflets measuring 3 x 2 x 0.5 cm in
aggregate. No calcifications or other lesions are identified.
The specimen is represented in A.
[**Known lastname **], C [**Hospital1 18**] [**Numeric Identifier 75943**]Portable TTE
(Complete) Done [**2136-10-23**] at 4:18:15 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 1112**] W.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2056-8-14**]
Age (years): 80 M Hgt (in): 72
BP (mm Hg): 120/60 Wgt (lb): 158
HR (bpm): 78 BSA (m2): 1.93 m2
Indication: Mitral valve prolapse. Murmur.
ICD-9 Codes: 786.05, 424.0
Test Information
Date/Time: [**2136-10-23**] at 16:18 Interpret MD: [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**],
MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7749**]
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2007W042-0:52 Machine: Vivid [**6-30**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.3 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.3 cm <= 5.2 cm
Right Atrium - Four Chamber Length: 4.6 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.3 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.9 cm
Left Ventricle - Fractional Shortening: 0.45 >= 0.29
Left Ventricle - Ejection Fraction: >= 60% >= 55%
Aorta - Sinus Level: 3.6 cm <= 3.6 cm
Mitral Valve - E Wave: 1.2 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A ratio: 1.33
Mitral Valve - E Wave deceleration time: *253 ms 140-250 ms
Findings
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Overall normal LVEF (>55%). [Intrinsic LV systolic function
likely depressed given the severity of valvular regurgitation.]
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Partial mitral leaflet flail. Severe (4+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are moderately
thickened. There is partial mitral leaflet flail (posterior
leaflet). Severe (4+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
Electronically signed by [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD, Interpreting
physician
Brief Hospital Course:
Transferred from outside hospital for surgical evaluation.
Underwent Mitral Valve repair with Dr. [**Last Name (STitle) **] on [**10-24**]. Please
see operative report for further details. He was transferred to
the CVICU in stable condition on titrated phenylephrine and
propofol drips. He extubated that evening and transferred to the
floor on POD #2 to begin increasing his activity level. Chest
tubes and pacing wires removed without incident. Gently diuresed
toward his preop weight and beta blockage titrated. Had
intermittent Atrial fibrillation starting on POD #4. Amiodarone
and coumadin were started. He has remained in sinus rhythm and
was ready for discharge home with services on post operative day
7.
Medications on Admission:
ASA 325 mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day:
until [**11-5**], then 400 mg daily until [**11-12**], then 200 mg daily
ongoing until discontinued by your cardiologist.
Disp:*64 Tablet(s)* Refills:*0*
6. Outpatient Lab Work
[**Name (NI) **] PT/INR for coumadin dosing (mon-wed-fri) - atrial
fibrillation goal INR 2.0-2.5 to Dr [**Last Name (STitle) 36026**] office coumadin
clinic fax # [**Telephone/Fax (1) 75944**]
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: 2.5 Tablet Sustained Release 24 hrs PO DAILY (Daily): total
dose 125mg .
Disp:*75 Tablet Sustained Release 24 hr(s)* Refills:*0*
8. Warfarin 2 mg Tablet Sig: 1.5 Tablets PO goal inr 2-2.5 :
please take 3mg wed [**10-31**] and thrus [**11-1**] with lab draw fri [**11-2**]
for further dosing by Dr [**Last Name (STitle) 36026**] .
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Mitral valve regurgitation s/p MV repair
Post operative atrial fibrillation
pericarditis [**2132**] and [**2135**]
degenerative joint disease
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**]
[**Name (NI) **] PT/INR for coumadin dosing (mon-wed-fri) - atrial
fibrillation goal INR 2.0-2.5 to Dr [**Last Name (STitle) 36026**] office coumadin
clinic fax # [**Telephone/Fax (1) 75944**]
Followup Instructions:
Please call to schedule all appointments
Dr [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 36026**] in [**12-27**] weeks [**Telephone/Fax (1) 17663**]
Dr. [**Last Name (STitle) 45945**] in [**1-28**] weeks
[**Name (NI) **] PT/INR for coumadin dosing (mon-wed-fri) - atrial
fibrillation goal INR 2.0-2.5 to Dr [**Last Name (STitle) 36026**] office coumadin
clinic fax # [**Telephone/Fax (1) 75944**]
Completed by:[**2136-10-31**] Name: [**Known lastname **],[**Initials (NamePattern4) **] [**Known firstname **] Unit No: [**Numeric Identifier 12438**]
Admission Date: [**2136-10-22**] Discharge Date: [**2136-11-1**]
Date of Birth: [**2056-8-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 4551**]
Addendum:
Pt had some orthostatic hypotension and his toprol and
amiodarone were discontinued, and he was given fluid. He was
ready for discharge on the following day, POD #8.
Brief Hospital Course:
Pt had some orthostatic hypotension and his toprol and
amiodarone were discontinued, and he was given fluid. He was
ready for discharge on the following day, POD #8.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Outpatient Lab Work
[**Name (NI) 12439**] PT/INR for coumadin dosing (mon-wed-fri) - atrial
fibrillation goal INR 2.0-2.5 to Dr [**Last Name (STitle) 10452**] office coumadin
clinic fax # [**Telephone/Fax (1) 12440**]
5. Warfarin 2 mg Tablet Sig: 1.5 Tablets PO goal inr 2-2.5 :
please take 3mg wed [**10-31**] and thrus [**11-1**] with lab draw fri [**11-2**]
for further dosing by Dr [**Last Name (STitle) 10452**] .
Disp:*90 Tablet(s)* Refills:*0*
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 400 mg daily x 1 week, then 200 mg daily ongoing until
discontinued by cardiologist.
Disp:*38 Tablet(s)* Refills:*0*
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 413**] VNA
Discharge Diagnosis:
Mitral valve regurgitation s/p MV repair
pericarditis [**2132**] and [**2135**]
degenerative joint disease
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) 1477**]
[**Name (NI) 12439**] PT/INR for coumadin dosing (mon-wed-fri) - atrial
fibrillation goal INR 2.0-2.5 to Dr [**Last Name (STitle) 10452**] office coumadin
clinic fax # [**Telephone/Fax (1) 12440**]
Followup Instructions:
Please call to schedule all appointments
Dr [**Last Name (STitle) 256**] in 4 weeks [**Telephone/Fax (1) 1477**]
Dr. [**Last Name (STitle) 10452**] in [**12-27**] weeks [**Telephone/Fax (1) 10453**]
Dr. [**Last Name (STitle) 10718**] in [**1-28**] weeks
[**Name (NI) 12439**] PT/INR for coumadin dosing (mon-wed-fri) - atrial
fibrillation goal INR 2.0-2.5 to Dr [**Last Name (STitle) 10452**] office coumadin
clinic fax # [**Telephone/Fax (1) 12440**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 358**] MD [**MD Number(1) 359**]
Completed by:[**2136-11-1**]
|
[
"573.0",
"420.90",
"287.4",
"426.10",
"715.90",
"427.31",
"424.0",
"428.0",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"35.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
14272, 14326
|
12812, 12979
|
336, 405
|
14478, 14485
|
1531, 2660
|
15195, 15804
|
1054, 1088
|
13002, 14249
|
2697, 2710
|
14347, 14457
|
9371, 9389
|
14509, 15172
|
1103, 1512
|
236, 298
|
2739, 8604
|
433, 805
|
827, 915
|
931, 1038
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,816
| 150,862
|
10595
|
Discharge summary
|
report
|
Admission Date: [**2182-10-15**] Discharge Date: [**2182-10-23**]
Date of Birth: [**2126-10-24**] Sex: M
Service: MEDICINE
Allergies:
Cefepime / Demerol
Attending:[**First Name3 (LF) 1850**]
Chief Complaint:
Hypoxia and tachycardia
Major Surgical or Invasive Procedure:
intubation
blood transfusions
History of Present Illness:
Pt is a 55 y/o male with AML who presented to clinic on [**10-15**] for
a scheduled blood transfusion and was found to be satting 62% on
room air and febrile to 100.6. He had been more SOB over the
prior few days but denied f/c. A CXR showed LLL colapse with
mediastinal shift to the right and multifocal cavitary lesions.
He got meropenem and hydrocortisone and was admitted.
He has a history of pulmonary aspergillus infection as well as
multiple bacteremic episodes (staph epi, stenotrophomonus, staph
aureus, micrococcus).
Past Medical History:
1. MDS: Patient's MDS was diagnosed in [**6-/2180**] and initially
treated with danazol and aranesp. In [**6-/2181**] he was hospitalized
for bilateral lung aspergillus infection and enterobacter
bacteremia. A Port-o-cath was placed [**8-/2181**] with three
subsequent hospitalizations for line infection. He was again
admitted from [**Date range (1) 34838**]/05 with pneumonia and bacteremia with
Stenotrophomonus treated with a course of bactrim and
port-o-cath removal. During this course, pulmonary nodules were
visualized and he was treated empirically with voriconazole. He
was again admitted to the hospital on [**2182-4-27**] with febrile
neutropenia and coag(+) staph blood cultures, micrococcus
species, requiring transfer to the ICU for increasing
respiratory distress and multi-focal pneumonia.
2. Hypertension
3. Remote history of kidney stones
4. Hx Sweet's syndrome
5. History of infections with enterobacter, staph epi,
Stenotrophomonus, micrococcus.
Social History:
He lives with his wife at home. Prior history of smoking 15
years ago - 1 [**12-16**] ppd x 20 years. No EtOH since [**2159**]. No drug
use.
Family History:
MGM w/breast CA
Mother with COPD
Father with CAD
HTN
No h/o heme malignancies, blood disorders.
Physical Exam:
PE: t 98.0, bp 110/62, hr 98, rr 18, spo2 96% nrb
gen- chronically ill appear male, sitting up, on nrb-mask,
speaking full sentences, nad
[**Year (4 digits) **]- anicteric sclera, mucosa dry
cv- rrr, s1s2, no m/r/g
pul- moves air well on right, greatly decr bs on l with rales,
egophany
abd- soft, nt, nd, nabs
extrm- no cyanosis/edema, warm/dry
nails- no clubbing no pitting/color change/indentations
neuro- a&ox3, no focal cn/motor deficits
Pertinent Results:
[**2182-10-15**] 10:07AM WBC-0.3* RBC-3.10* HGB-9.1* HCT-26.3* MCV-85
MCH-29.2 MCHC-34.4 RDW-15.4
[**2182-10-15**] 10:07AM NEUTS-0* BANDS-0 LYMPHS-86* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 BLASTS-8*
[**2182-10-15**] 10:07AM PLT SMR-RARE PLT COUNT-10*#
.
[**2182-10-15**] 10:07AM GLUCOSE-125* UREA N-27* CREAT-1.1 SODIUM-130*
POTASSIUM-4.7 CHLORIDE-92* TOTAL CO2-29 ANION GAP-14
[**2182-10-15**] 10:07AM ALBUMIN-2.8* CALCIUM-9.0 PHOSPHATE-4.6*
MAGNESIUM-1.5*
.
[**2182-10-15**] 10:07AM ALT(SGPT)-25 AST(SGOT)-20 LD(LDH)-78* ALK
PHOS-144* TOT BILI-0.5
.
[**2182-10-15**] 11:50AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-6.5 LEUK-SM
[**2182-10-15**] 11:50AM URINE COLOR-Brown APPEAR-Hazy SP [**Last Name (un) 155**]-1.020
[**2182-10-15**] 03:05PM URINE RBC-965* WBC-2 BACTERIA-MANY YEAST-NONE
EPI-<1
.
Chest CT [**10-15**]: 1. Interval progression of extensive bilateral
pulmonary consolidation, most prominent within the left upper
and left lower lobe but also involving the remaining lobes
centrally, consistent with worsening infectious process. There
are several areas of cavitation in the left upper lobes.
2. Increase in moderate left pleural effusion.
3. Stable appearance of mediastinal lymphadenopathy. Additional
numerous nodes within the neck, not meeting criteria for
pathologic enlargement.
.
CXR [**10-18**]: As compared to [**10-16**], there is persistent diffuse
opacification of the left lung, consistent with extensive
consolidation as well as component of pleural fluid. There is no
associated mediastinal shift to indicate volume loss. Stable
moderate pulmonary edema within the right mid lung as well as
improving right basilar subsegmental atelectasis are noted. PICC
catheter remains in stable position.
.
CXR [**10-22**]: Multifocal consolidation remains present bilaterally,
affecting the left upper lobe and lingula to the greatest
degree. There is some associated mild volume loss in the left
upper lobe as well. Additionally, there is vascular engorgement
and perihilar haziness suggesting a component of mild fluid
overload. Bilateral small pleural effusions are noted, left
greater than right.
Brief Hospital Course:
The patient was a 55 y/o male with history of recurrent
pulmonary infections, presenting with LLL collapse and febrile
neutropenia. Differential Diagnosis included recurrent
pulmonary infection, new pleural effusions, or extrinisic
compression. He was transferred to the [**Hospital Unit Name 153**] with increasing O2
requirement, work of breathing, and tachycardia. He was treated
empirically with meropenem, vancomycin, acyclovir, bactrim
(stenotrophomonus), and ambisome. There was significant concern
for fungal infection like mucor. Due to his and his wife's
wishes, intubation was avoided for as long as possible. He was
finally intubated and had an increasing oxygen requirement.
Attempts to extubate were unsuccessful. At the request of Mr.
[**Known lastname 34834**] and his wife, and extensive discussion with his
oncologist, Dr [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1557**], he was switched to comfort measures.
He was extubated and died quietly with his family at the bedside
on [**2182-10-23**].
Medications on Admission:
1. Aranesp 200 mg SC every other week - last dose last week
2. Desferal 500 mg IV 2x/week - last dose 11/1
3. Caspofungin 50 mg IV qd
4. Prednisone 10 mg qd
5. Acyclovir 400 mg [**Hospital1 **]
6. Voriconazole 200 mg [**Hospital1 **]
7. Levaquin 500 mg qd
8. Lasix 20 mg TID
9. Nexium 40 mg qd
10. MVI qd
11. Oxycodone SR 10 mg [**Hospital1 **]
12. Oxycodone 5 mg q4-6 hrs prn
13. Bactrim DS 1 tab 3x/week
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
AML
multilobar pneumonia
respiratoy failure
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
[**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**] MD [**MD Number(2) 1851**]
|
[
"250.00",
"486",
"401.9",
"V13.01",
"518.84",
"427.31",
"117.9",
"484.7",
"423.9",
"528.9",
"205.00",
"288.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.04",
"99.04",
"99.10",
"99.15",
"93.90",
"96.71",
"99.05",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
6386, 6395
|
4861, 5901
|
306, 338
|
6482, 6491
|
2642, 4838
|
6544, 6667
|
2066, 2163
|
6357, 6363
|
6416, 6461
|
5927, 6334
|
6515, 6521
|
2178, 2623
|
243, 268
|
366, 896
|
918, 1888
|
1904, 2050
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,928
| 155,432
|
1234
|
Discharge summary
|
report
|
Admission Date: [**2109-2-26**] Discharge Date: [**2109-3-2**]
Date of Birth: [**2032-3-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
hypotension s/p aflutter ablation and pacemaker insertion
Major Surgical or Invasive Procedure:
Atrial flutter ablation
Permanent pacemaker insertion
History of Present Illness:
The patient is a 76M w/ a h/o CAD s/p CABG approximately 19
years ago, atrial flutter since [**2095**] on Coumadin and Atenolol,
who presented for elective aflutter ablation +/- pacemaker after
increased DOE. He had increased SOB after walking up two flights
of stairs and noted his heart rate (resting in the 70s) had been
rising to 150s with minimal amounts of exercise.
.
After the ablation, he was noted to be in sinus node arrest,
necessitating the need for a pacemaker. During pacemaker
insertion, he became hypotensive to SBP 60s-70s. Dopamine was
started and his SBP returned to 90s-100s. TTE was negative for
pericardial effusion. CT abdomen was preliminarily negative for
RP bleed. The patient denies lightheadedness,
presyncope/syncope, palpitations, chest pain, or shortness of
breath during the procedure. He was transferred to the CCU on
low-dose dopamine (2.5cc/hr) in comfortable and stable condition
for further monitoring.
.
Past Medical History:
Cardiac Risk Factors: (-) Diabetes, (+) Dyslipidemia, (+)
Hypertension
.
Cardiac History: CABG [**2088**], LIMA to LAD, SVG to D1, SVG to OM1,
SVG to PDA
.
Percutaneous coronary intervention: N/A
.
Pacemaker/ICD [**2109-2-26**], [**Company 1543**], DDD
.
Other Past History:
CAD s/p NSTEMI
CABG as above
atrial flutter as above
HTN
Remote bleeding stomach ulcer
Obesity
Lower back pain, particularly with bed rest
Chronic prostatitis with occasional urinary urgency
Social History:
Social history is significant for the absence of current tobacco
use although he has a 20 pack-year history (quit in [**2088**]). There
is no history of alcohol abuse. He is a practicing
ophthalmologist. He is married and has a daughter.
Family History:
Family history is significant for his father with MI at age 55,
mother with MI at age 84. No family history of sudden death.
Physical Exam:
Blood pressure was 100/59 mmHg while supine. Pulse was 80
beats/min and regular, respiratory rate was 11 breaths/min.
Generally the patient was well developed, well nourished and
well groomed. The patient was oriented to person, place and
time. The patient's mood and affect were not inappropriate.
.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The neck was supple with
JVP of ~6 cm. The carotid waveform was normal. There was no
thyromegaly. The were no chest wall deformities, scoliosis or
kyphosis. The respirations were not labored and there were no
use of accessory muscles. The lungs were clear to ascultation
bilaterally with normal breath sounds and no adventitial sounds
or rubs.
.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. There were no thrills,
lifts or palpable S3 or S4. The heart sounds revealed a normal
S1 and the S2 was normal. There were no rubs, murmurs, clicks or
gallops.
.
The abdominal aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft nontender
and nondistended. The extremities had no pallor, cyanosis,
clubbing or edema. There were no abdominal, femoral or carotid
bruits. Inspection and/or palpation of skin and subcutaneous
tissue showed no stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2109-2-26**] 02:45PM WBC-13.9* RBC-4.10* HGB-13.0* HCT-37.3*
MCV-91 MCH-31.7 MCHC-34.8 RDW-13.7
[**2109-2-26**] 02:45PM GLUCOSE-150* UREA N-23* CREAT-1.0 SODIUM-143
POTASSIUM-4.1 CHLORIDE-114* TOTAL CO2-25 ANION GAP-8
CT Abdomen on [**2109-2-26**]:
IMPRESSION:
1. No evidence for retroperitoneal hematoma.
2. Small bilateral pleural effusions and lower lobe
atelectasis.
3. Simple-appearing cysts in the right kidney.
Echocardiogram on [**2109-2-28**]:INTERPRETATION:
Findings:
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA
and extending into the RV.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Overall normal LVEF
(>55%).
PERICARDIUM: Trivial/physiologic pericardial effusion. No
echocardiographic
signs of tamponade.
Conclusions:
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
Compared with the findings of the prior report (images
unavailable for review) of [**2109-2-26**], probably no major
change.
Electronically signed by [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD on [**2109-2-28**] 16:51.
Brief Hospital Course:
## Hypotension: Patient initially admitted to CCU due to
hypotension that occurred in the setting of pacemaker insertion.
Echocardiogram was negative for tamponade. There was no RP
bleed on abdominal CT. Patient was successfully weaned off of
pressors within a few hours of arriving to CCU. Hematocrit was
stable. Likely vasovagal.
.
## Rhythm - Patient received a.flutter ablation and then had
pacemaker inserted for bradycardia post-procedure. He tolerated
this well and was started on anticoagulation. He will need to
follow-up his anticoagulation as he normally does as outpatient
and also follow-up with device clinic.
.
## CAD - No symptoms during this admission. Continued aspirin,
Lipitor, restarted low-dose beta blocker and lisinopril.
.
## Remote history of GI bleed, but hematocrits stable and stools
guaiac negative during this admission. PPI was continued.
Medications on Admission:
Atenolol 100mg qam
Lisinopril 40mg qam
aspirin 81mg daily
Protonix 20mg daily
Lipitor 20mg qhs
Coumadin 2.5mg daily, last dose [**2108-2-22**]
Discharge Medications:
1. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Atrial flutter ablation
Permanent pacemaker insertion
Secondary diagnoses:
Coronary artery disease
Discharge Condition:
Vital signs stable
Discharge Instructions:
You were admitted for ablation of atrial flutter heart rhythm.
You received a pacemaker after this procedure. You had an
episode of low-blood pressure that resolved on its own and was
likely due to slow heart rhythm. You were also started on
warfarin, a blood thinner, after the pacemaker was placed.
Please follow-up with [**Hospital **] Clinic for your pacemaker and
with your primary care physician for management of your
warfarin, as detailed below. If you notice any palpitations,
episodes of passing out, chest pain, shortness of breath, or any
other concerning symptoms, please call 911 or report to the
emergency room.
Followup Instructions:
Please call the Pacemaker and Device clinic at [**Telephone/Fax (1) 59**] on
Monday [**2109-3-4**] to schedule an appointment within 7 days for
follow-up on your pacemaker.
Please call your primary cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7756**], at
([**Telephone/Fax (1) 7757**] on Monday [**2109-3-4**] to schedule follow-up monitoring of
INR, since you have been started on Coumadin.
Completed by:[**2109-3-2**]
|
[
"997.1",
"427.32",
"427.81",
"V45.81",
"401.9",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.72",
"37.83",
"37.26",
"00.17",
"37.34"
] |
icd9pcs
|
[
[
[]
]
] |
6932, 6938
|
5172, 6053
|
372, 428
|
7101, 7122
|
3831, 5149
|
7800, 8258
|
2162, 2288
|
6247, 6909
|
6959, 7033
|
6079, 6224
|
7146, 7777
|
2303, 3812
|
7054, 7080
|
275, 334
|
456, 1401
|
1423, 1891
|
1907, 2146
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,733
| 122,920
|
42605
|
Discharge summary
|
report
|
Admission Date: [**2187-12-13**] Discharge Date: [**2187-12-18**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 4248**] is a [**Age over 90 **] year-old woman with HTN presenting with two
days of worsening dyspnea on exertion. She described that she
initally did not have symptoms at rest, however this on the
morning of presentation she describes dyspnea to the point of
extreme fatigue even with standing still and intermittent left
sided chest discomfort prompting presentation to BIDN ED.
.
Initial vitals at BIDN were 98.4 83 132/59 20 89% RA and was
noted to have difficulty breathing while lying down. Patient's
presenting EKG showed ST elevations in the inferior leads and
symptoms are initially concerning for unstable angina/ ACS. Her
troponin was noted to be elevated to 0.13 and cardiology at BIDN
advised transfer to [**Hospital1 18**] as she was a potential candidate for
cardiac catheterization. Subsequent CTA, performed prior to
starting anticoagulation, revealed bilateral PEs with evidence
of RV>LV suggestive of right heart strain. CT head was negative
for mass or bleed and the patient was started on a heparin drip
and transfered to [**Hospital1 18**] ED.
.
At the [**Hospital1 18**] ED, initial vs were 99 86 139/71 20 97% 4LNC. A
chest X-ray was repeated in the ED and revealed no evidence of
congestive heart failure and right-sided calcified pleural
plaques. Repeat labs revealed troponin 0.13, CKMB 7 and WBC of
12.4 with 80% PMNs. The patient was then admitted to the MICU
given convern for right heart strain in the setting of BL PEs.
Vitals on transfer were 98.6 136/76 81 98% 2LNC.
.
On the floor the patient appears comfortable and is without
chest pain, shortness of breath or additional complaints.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied Denied chest pain or tightness, palpitations.
Denied nausea, vomiting, diarrhea, constipation or abdominal
pain. No recent change in bowel or bladder habits. No dysuria.
Denied arthralgias or myalgias.
Past Medical History:
History of TB in the [**2115**] treated with altitude, sanatorium and
aerosolized drug delivered to her pleura.
HTN
Social History:
Worked in textile factory in her 20s, Widowed in [**2187-2-27**].
Never smoked, no EtOH or ilicit drug abuse
Family History:
No family history of clotting disorder
Physical Exam:
ADMISSION
VS: 97.8, P: 79, BP: 160/64, RR: 20, 93%on 2L NC
:General: Hard of hearing, Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, thyroid is not nontender
and not enlarged
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly
intact in all extremities
DISCHARGE EXAM:
VS: 98.6, P: 83, BP: 120/54, RR: 20, 98% on 3L NC
General: Hard of hearing, Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2187-12-14**] 03:01AM BLOOD WBC-9.8 RBC-3.73* Hgb-10.7* Hct-32.6*
MCV-87 MCH-28.7 MCHC-32.8 RDW-13.0 Plt Ct-171
[**2187-12-13**] 01:00PM BLOOD WBC-12.4* RBC-4.18* Hgb-11.9* Hct-37.1
MCV-89 MCH-28.5 MCHC-32.2 RDW-13.1 Plt Ct-191
[**2187-12-14**] 03:01AM BLOOD CK(CPK)-43
UPRIGHT AP VIEW OF THE CHEST: No evidence of congestive heart
failure. Right-sided calcified pleural plaques.
ECHO: Mildly dilated right ventricle with normal global and
regional biventricular systolic function. Very mild pulmonary
hypertension.
LE DOPPLER: 1. Deep vein thrombosis seen within the left
popliteal and the left posterior tibial veins. 2. Occlusive
thrombus is also noted within the right greater saphenous vein.
CT A/P: 1. A 2 x 3 cm necrotic mass in the tail of the pancreas
most likely represents a primary pancreatic malignancy. 2.
Multiple rim-enhancing lesions within the liver, consistent with
metastases. 3. Upper and lower pole splenic infarcts. 4.
Enhancing nodules within the breast parenchyma bilaterally could
represent metastases versus primary malignancy. Correlation with
mammography may be obtained if clinically indicated.
DISCHARGE LABS:
[**2187-12-16**] 01:05PM BLOOD WBC-7.8 RBC-3.40* Hgb-9.8* Hct-29.7*
MCV-87 MCH-28.6 MCHC-32.8 RDW-13.0 Plt Ct-195
[**2187-12-17**] 05:50AM BLOOD PT-28.1* INR(PT)-2.7*
[**2187-12-16**] 01:05PM BLOOD Glucose-171* UreaN-10 Creat-0.5 Na-133
K-4.1 Cl-98 HCO3-25 AnGap-14
[**2187-12-16**] 01:05PM BLOOD Calcium-8.5 Phos-3.2 Mg-2.1
Brief Hospital Course:
[**Age over 90 **] year-old woman with a history of HTN and remote history of TB
presents with acute onset dyspnea admitted for bilateral
pulmonary emboli found to have evidence of metastatic pancreatic
cancer on CT.
#. Bilateral pulmonary emboli: Patient had evidence of bilateral
pulmonary emboli involving the RML, RUL, LUL nad LLL. There was
a suggestion of right heart strain with flattening on
interventricular septum on chest CT, however bedside ultrasound
in the ED did not reveal evidence of right heart strain. The
patient was started on heparin in the ED. Echocardiogram showed
mildly dilated RV with normal biventricular function. LE
ultrasound showed bilateral DVTs. She was transitioned to
lovenox SC and coumadin on [**12-14**]. She was transferred to the
general medicine floor when stable where she continued to
require 2-3L oxygen by nasal cannula. Chest CTA at [**Hospital1 **]-N showed
multiple nodules in liver so CT A/P was pursued to work up
possible malignancy as source of PE. CT A/P showed necrotic
pancreatic tail mass and "numerous hypodense lesions with
peripheral arterial enhancement most consistent with metastases"
in the liver. In the setting of malignancy, pt was switched to
lovenox for treatment of PE. She was discharged to rehab due to
her continued O2 requirement.
# suspected metastatic pancreatic cancer: PE work up for
hypercoagulability showed necrotic pancreatic tail mass and
"numerous hypodense lesions with peripheral arterial enhancement
most consistent with metastases" in the liver as mentioned
above. This most likely represents a primary pancreatic
malignancy that has metastasized (especially considered it is a
very clot-prone malignancy). There are also some breast
calcifications bilaterally but the significance of this is
unknown. Explained to patient the likelihood that this is a
cancerous process, but that it is difficult to predict prognosis
or treatment options without biopsy. Pt very distressed and
declined to make any decisions on biopsy at this time. Pt
discussed options with social work and palliative care and
decided not to pursue any further work-up or treatment and
prefers not to discuss results any further. She was made aware
that if she developed symptoms such as pain, she could seek
symptomatic treatment at that time.
#. Elevated Troponin: Patient has an elevated troponin to 0.13
at 10AM at BIDN. Follow up troponin at [**Hospital1 18**] at 1PM was 0.13
with CKMB or 7, which was peak level after which it trended
down. Elevated troponin in unlikely to represent ACS and likely
represented right heart strain [**1-31**] PE.
#. HTN: Patient is on Atenolol, Lisinopril and felodipine as an
outpatient. Blood pressure normotensive on admission so
antihypertensives were initially held. BP trended up so
lisinopril and felodipine were added back and lisinopril was
increased to 40mg po daily. In place of atenolol, she was
started on labetalol 200mg po BID due to contrast load patient
received. Pt is OK with continuing this medication. She was
normotensive at the time of discharge on this regimen.
CODE: Full (confirmed with patient)
TRANSITIONAL ISSUES:
1. continue lovenox for PE treatment
2. if begins to develop symptoms such as abdominal pain, pt
should be encouraged to speak with PCP about pain control and
asked if she would like to revisit malignancy work up or
treatment
3. follow up BP on new regimen
Medications on Admission:
- Atenolol 100mg [**Hospital1 **] - [**2187-12-10**]
- Felodipine ER 10mg daily - [**2187-10-19**] - may not be taking
- Lisinopril 30mg daily - [**2187-11-28**]
- Flonase 50mcg nasal spray 2 puffs each nostril once daily -
[**12-10**]
- preservision daily
Discharge Medications:
1. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. felodipine 10 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
3. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
5. PreserVision 7,160-113-100 unit-mg-unit Tablet Sig: One (1)
Tablet PO daily ().
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. polyvinyl alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for dryness.
9. enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg
Subcutaneous Q12H (every 12 hours).
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain/.
11. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 7 days: last dose [**2187-12-24**] PM.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Residence - [**University/College **]
Discharge Diagnosis:
Primary Diagnosis:
pulmonary embolism
bilateral deep vein thrombosis
necrotic pancreatic tail mass with multiple liver nodules on CT
Secondary Diagnoses:
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Thank you for letting us take part in your care at [**Hospital1 771**]. You were admitted to the hospital
because you had a pulmonary embolism in your lungs and deep vein
thromboses (clots) in your legs. You were given medications to
treat the clots and discharged to rehab with oxygen. While you
were here you had a CT to figure out the source of your clots.
It shows nodules in your liver and pancreas. You declined any
further intervention on these. You also developed a urinary
tract infection so you were started on antibiotics for this.
The following changes were made to your medications:
STOPPED atenolol
STARTED labetalol 200mg by mouth twice a day
INCREASED lisinopril to 40mg by mouth daily
STARTED enoxaparin 40mg subcutaneous injection twice a day
STARTED bactrim DS one tab by mouth twice a day for 7 days (last
dose [**2187-12-24**] PM)
Followup Instructions:
Please follow up with your primary care doctor in one week.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
|
[
"V12.01",
"793.89",
"453.41",
"157.2",
"197.7",
"401.9",
"599.0",
"415.19"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10104, 10234
|
5349, 8483
|
261, 268
|
10446, 10446
|
3847, 4983
|
11514, 11699
|
2599, 2640
|
9069, 10081
|
10255, 10255
|
8788, 9046
|
10629, 11491
|
4999, 5326
|
2655, 3330
|
10410, 10425
|
3346, 3828
|
8504, 8762
|
214, 223
|
1964, 2316
|
297, 1946
|
10274, 10389
|
10461, 10605
|
2338, 2456
|
2472, 2583
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,245
| 115,179
|
45607
|
Discharge summary
|
report
|
Admission Date: [**2199-9-2**] Discharge Date: [**2199-10-2**]
Date of Birth: [**2132-7-30**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Erythromycin Base / Demerol
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Abdominal pain, nausea/vomiting
Major Surgical or Invasive Procedure:
[**2199-9-20**]: Removal of tunneled catheter and placement of Hickman
catheter
History of Present Illness:
67F with multiple medical problems, including fibromyalgia, MRSA
osteomyelitis of L2-3, and a history of recurrent SBOs. She
reports increasing abdominal pain since the day prior to
admission, with waves of cramping. She has had PO intolerance
and emesis and dry heaves on day of admission as well. She
reports no flatus, but diarrhea for the past few days. All
these symptoms are typical of her prior episodes of SBO -- her
husband reports that this will be her 89th episode, typically
averaging [**1-29**] hospitalizations per year. This attack to them,
seem less severe than her prior episodes. She denies chest
pain, fevers/chills, or sick contacts.
Past Medical History:
L2-L3 osteomyelitis and discitis
Psoas abscess
Left Upper Extremity Thrombosis
Spinal Stenosis
Multiple admissions for partial small bowel obstruction
h/o ovarian CA diagnosed 23 years ago, s/p abdominal XRT
Chronic abdominal pain
Low back pain
Fibromyalgia
Hypothyroidism
GERD
Hypercholesterolemia
Depression
Radiation enteritis
Elevated creatinine
Cardiomyopathy EF 50%, [**12-28**]+ MR ([**5-31**])
Fe deficiency anemia
Past Surgical History:
TAH/BSO
Exploratory laparotomy with lysis of adhesions
Appendectomy
Laminectomy and Spinal Fusion L4-L5
Social History:
Married. Denies tobacco or alcohol use. Previously worked as a
registered nurse in an outpatient medical practice.
Family History:
Cancer, heart disease in several family members
Physical Exam:
Tc 98.5, HR 84, BP 188/97, RR 20, O2sat 100%
Genl: NAD
CV: RRR
Resp: CTA-B
Abd: soft, tender to LLQ, RLQ, no tap tenderness, no reboud, no
guarding, non-distended
Extr: no c/c/e
Pertinent Results:
[**2199-9-2**] 05:45PM GLUCOSE-87 UREA N-13 CREAT-1.1 SODIUM-139
POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-23 ANION GAP-16
[**2199-9-2**] 05:45PM estGFR-Using this
[**2199-9-2**] 05:45PM ALT(SGPT)-7 ALK PHOS-68 TOT BILI-0.2
[**2199-9-2**] 05:45PM LIPASE-30
[**2199-9-2**] 05:45PM ALBUMIN-3.6 CALCIUM-8.9
[**2199-9-2**] 05:45PM WBC-10.7 RBC-3.25* HGB-8.8* HCT-28.0* MCV-86
MCH-27.1 MCHC-31.5 RDW-16.5*
[**2199-9-2**] 05:45PM NEUTS-65.6 LYMPHS-27.5 MONOS-5.7 EOS-0.8
BASOS-0.5
[**2199-9-2**] 05:45PM PLT COUNT-579*
[**2199-9-14**] 05:23AM BLOOD WBC-6.2# RBC-2.60* Hgb-7.2* Hct-22.1*
MCV-85 MCH-27.8 MCHC-32.7 RDW-16.1* Plt Ct-477*
[**2199-9-15**] 07:00AM BLOOD WBC-7.6 RBC-2.73* Hgb-7.5* Hct-23.2*
MCV-85 MCH-27.5 MCHC-32.3 RDW-16.3* Plt Ct-485*
[**2199-9-16**] 04:39AM BLOOD WBC-8.9 RBC-2.77* Hgb-7.7* Hct-23.6*
MCV-85 MCH-27.6 MCHC-32.4 RDW-16.2* Plt Ct-536*
[**2199-9-21**] 04:17AM BLOOD WBC-12.3* RBC-2.44* Hgb-7.0* Hct-21.1*
MCV-86 MCH-28.8 MCHC-33.3 RDW-16.1* Plt Ct-446*
[**2199-9-21**] 09:24PM BLOOD WBC-12.1* RBC-3.63*# Hgb-10.4*#
Hct-31.2*# MCV-86 MCH-28.6 MCHC-33.2 RDW-16.3* Plt Ct-398
[**2199-9-22**] 05:06AM BLOOD WBC-15.8* RBC-3.62* Hgb-10.6* Hct-30.9*
MCV-85 MCH-29.4 MCHC-34.4 RDW-16.5* Plt Ct-418
[**2199-9-28**] 05:57PM BLOOD WBC-11.8* RBC-3.12* Hgb-9.0* Hct-27.2*
MCV-87 MCH-28.7 MCHC-32.9 RDW-16.3* Plt Ct-492*
[**2199-9-29**] 05:04AM BLOOD WBC-10.8 RBC-3.18* Hgb-8.9* Hct-26.9*
MCV-85 MCH-28.1 MCHC-33.2 RDW-16.1* Plt Ct-509*
[**2199-10-2**] 04:05AM BLOOD WBC-8.4 RBC-3.03* Hgb-8.6* Hct-26.2*
MCV-87 MCH-28.3 MCHC-32.6 RDW-16.2* Plt Ct-520*
[**2199-9-18**] 04:48AM BLOOD PT-13.7* PTT-44.7* INR(PT)-1.2*
[**2199-9-22**] 05:06AM BLOOD ESR-15
[**2199-9-9**] 04:50PM BLOOD ESR-60*
[**2199-9-2**] 05:45PM BLOOD Glucose-87 UreaN-13 Creat-1.1 Na-139
K-3.5 Cl-104 HCO3-23 AnGap-16
[**2199-9-3**] 05:20AM BLOOD Glucose-99 UreaN-10 Creat-1.0 Na-140
K-3.6 Cl-107 HCO3-21* AnGap-16
[**2199-9-3**] 06:06PM BLOOD K-4.8
[**2199-9-14**] 05:23AM BLOOD Glucose-102 UreaN-5* Creat-1.2* Na-136
K-3.3 Cl-105 HCO3-22 AnGap-12
[**2199-9-15**] 07:00AM BLOOD Glucose-105 UreaN-4* Na-135 K-3.1* Cl-105
HCO3-20* AnGap-13
[**2199-9-16**] 04:39AM BLOOD UreaN-4* Creat-1.2* Na-137 K-3.7 Cl-106
HCO3-20* AnGap-15
[**2199-9-24**] 04:26AM BLOOD Glucose-105 UreaN-11 Creat-1.3* Na-130*
K-4.2 Cl-100 HCO3-21* AnGap-13
[**2199-9-25**] 04:06AM BLOOD Glucose-109* UreaN-11 Creat-1.4* Na-129*
K-4.5 Cl-98 HCO3-21* AnGap-15
[**2199-9-26**] 11:18AM BLOOD Glucose-86 UreaN-14 Creat-1.5* Na-131*
K-5.2* Cl-103 HCO3-18* AnGap-15
[**2199-9-26**] 11:42PM BLOOD Glucose-90 UreaN-12 Creat-1.5* Na-130*
K-4.6 Cl-100 HCO3-19* AnGap-16
[**2199-9-27**] 05:30AM BLOOD Glucose-79 UreaN-13 Creat-1.6* Na-130*
K-4.5 Cl-99 HCO3-20* AnGap-16
[**2199-9-28**] 05:12AM BLOOD Glucose-54* UreaN-17 Creat-1.5* Na-129*
K-4.4 Cl-100 HCO3-15* AnGap-18
[**2199-9-28**] 05:57PM BLOOD Glucose-103 UreaN-24* Creat-2.0* Na-129*
K-4.2 Cl-100 HCO3-16* AnGap-17
[**2199-9-29**] 05:04AM BLOOD Glucose-101 UreaN-24* Creat-2.0* Na-128*
K-4.0 Cl-100 HCO3-16* AnGap-16
[**2199-9-30**] 05:26AM BLOOD Glucose-82 UreaN-19 Creat-2.0* Na-129*
K-4.0 Cl-102 HCO3-17* AnGap-14
[**2199-10-1**] 07:59AM BLOOD Glucose-98 UreaN-18 Creat-1.8* Na-135
K-3.6 Cl-105 HCO3-18* AnGap-16
[**2199-10-2**] 04:05AM BLOOD Glucose-92 UreaN-17 Creat-1.6* Na-135
K-4.1 Cl-108 HCO3-19* AnGap-12
[**2199-10-2**] 04:05AM BLOOD Calcium-9.0 Phos-3.0 Mg-1.8
[**2199-9-13**] 02:25AM BLOOD TSH-28*
[**2199-9-16**] 06:45PM BLOOD Prolact-58*
[**2199-9-15**] 07:00AM BLOOD Free T4-1.5
[**2199-9-22**] 05:06AM BLOOD CRP-1.3
[**2199-9-9**] 04:50PM BLOOD CRP-2.6
[**2199-9-15**] 07:00AM BLOOD Vanco-21.1*
[**2199-9-9**] 08:09PM BLOOD Vanco-20.1*
[**2199-9-16**] 01:08PM BLOOD tTG-IgA-3
[**2199-9-13**] 02:50AM BLOOD Type-ART pO2-92 pCO2-27* pH-7.46*
calTCO2-20* Base XS--2
[**2199-9-12**] 07:09PM BLOOD Type-ART pO2-104 pCO2-30* pH-7.42
calTCO2-20* Base XS--3
[**2199-9-13**] 02:36AM BLOOD Lactate-1.1
[**2199-9-13**] 02:50AM BLOOD Lactate-0.9
[**2199-9-13**] 02:50AM BLOOD freeCa-1.13
Brief Hospital Course:
# Gastrointestinal
The patient was admitted to the hospital for partial small bowel
obstruction. Patient initially refused a NGT and foley
catheter. She was maintained NPO and started on maintenance
fluid. She underwent serial examinations with improvement in
her abdominal pain. In the emergency department, she had a KUB
performed:
HISTORY: 67-year-old female with history of small bowel
obstructions, now
with similar symptoms. Evaluate for obstruction.
COMPARISON: CT [**2199-5-23**].
ABDOMEN, SUPINE AND LEFT LATERAL DECUBITUS: Spinal fusion
hardware is noted
at L4-L5. There are gas-filled loops of small bowel, with
several bowel loops
borderline in size, similar to the prior study. Though there is
a relative
paucity of bowel gas in the colon, air is evident in the rectum.
No free air
or pneumatosis is identified.
IMPRESSION: Borderline dilated small bowel loops, which can be
seen with an
ileus, though an early and/or partial small bowel obstruction
cannot be
excluded.
Patient was started on pain control with Dilaudid. Patient had
persistent diarrhea during her hospitalization and had at least
8 C. Difficile samples sent to the laboratory, all of which have
returned negative.
The GI service was consulted for persistent diarrhea. They
initially recommended stool cultures (negative), a clear liquid
diet, and observation for clinical improvement. The patient was
later ordered for an MR enterography, however, her diarrhea
improved prior to obtaining the study.
An Anti-transglutaminase was sent to evaluate for Celiac disease
and was in the normal range.
Disease
The patient
# Infectiouswas maintained on her home dose of Vancomycin for
her previous MRSA bacteremia and MRSA L2-L3 osteomyelitis. The
Infectious Disease service was consulted on [**2199-9-4**] and followed
her for several weeks. Patient had been on vancomycin since
[**2199-5-24**]. ID recommended continuing vancomycin.
On [**2199-9-12**], the patient was found to have a urinary tract
infection. she was started on Ciprofloxacin, though this was
changed to Bactrim as cipro can lower the seizure threshold.
The sensitivities returned on the urine culture, and was
resistant to Bactrim. Ultimately, she completed her treatment
for UTI with macrobid. There was no further dysuria, frequency,
or urgency.
On HD # 20, her vancomycin was discontinued and she was started
on Bactrim DS for her discitis This was discontinued after 3
days due to worsening renal function. Infectious disease did
not feel as though additional antibiotics were necessary for the
discitis.
On HD # 11, blood cultures were sent and returned with [**Female First Name (un) 564**]
Parapsilosis. Unfortunately, the sensitivities showed that the
[**Female First Name (un) **] was resistant to fluconazole and oral therapy was not
available. The patient was started on Micafungin 100mg IV daily
on [**2199-9-16**]. ID recommended last dose of Micafungin on [**2199-9-28**].
Micafungin was discontinued prior to discharge.
On [**2199-9-20**], the patient was brought to the operating room to
have her existing tunnelled catheter removed due to the fungemia
and a new Hickman catheter was placed without incident.
Due to the fungemia, the patient had an Ophthalmology consult
and was evaluated. They found no evidence of fungal
endophthalmitis. .
She also had a TTE performed:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 0-5 mmHg. Left ventricular
wall thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
low normal (LVEF 50%). The estimated cardiac index is normal
(>=2.5L/min/m2). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
([**12-28**]+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is high normal. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2199-5-27**],
left ventricular systolic function is less dynamic and increased
PCWP is now suggested.
# Renal
on [**2199-9-24**] the patient was noted to have hyponatremia with a
sodium of 130. She had a nadir of 129. She further was noted
to have worsening of her creatinine (baseline 1.0-1.2). As the
creatinine continued to elevate, nephrology was consulted.
Nephrology recommended discontinuation of the bactrim as this
was likely contributing to her worsening creatinine level.
Further, the hyponatremia was attributed to SIADH likely
secondary to the patient's opiate use. Her opiate use was
curtailed and her free fluid was limited and her hyponatremia
resolved.
Renal service also made recommendations regarding the patient's
labile blood pressures. She had intermittent periods where her
systolic blood pressure was 220s with diastolics in the 110s.
She was being treated with IV lopressor and ultimately with IV
hydralazine. She was started on metoprolol by mouth and this
was titrated to effect. Renal recommended the discontinuation
of all IV blood pressure medications as they were likely causing
relative hypotension and hypoperfusion of her kidneys. She was
maintained on Coreg and started on amlodipine 2.5 mg PO daily.
If her blood pressure is not well controlled, we would recommend
increasing her amlodipine to 5 mg PO daily.
The patient's urine output was low on occasion and she did
require small boluses of IVF. The IVF likely worsened her
hyponatremia, however. In her extended care facility, she
should be encouraged to drink fluids. If she does require a
fluid bolus, would recommend a 500ml bolus given over 5 hours.
Her creatinine peaked at 2.0 and has continued to trend down.
Her most recent creatinine was 1.6 on [**2199-10-2**]. Her sodium and
creatinine should be monitored in her extended care facility.
# Hematology
The patient was maintained on Lovenox 60mg SC BID for her recent
LUE DVT (~[**2199-5-27**]). During the admission, she complained of
RUE numbness and tingling and had a negative duplex ultrasound
performed. After her Hickman line placement on [**2199-9-20**], she was
noted to have oozing around the insertion site. Shortly
thereafter, her lovenox was discontinued for several days.
After the oozing resolved, she was restarted on Lovenox, but at
a prophylactic dose only.
On [**2199-9-21**], the patient was noted to have a hematocrit of 21.1
due to blood loss on top of anemia of chronic disease and she
was transfused 2units of pRBCs with appropriate increase in
hematocrit.
# Neurologic
On HD # 10, a trigger was called as the patient was exhibiting
seizure like behavior. Nursing staff and the patient's husband
report [**Name2 (NI) 97262**] but rhythmic contractions and relaxations of
her upper extremities. This reportedly lasted for two minutes
at which point she appeared to have a blank stare and was
non-verbal. Two minutes later her confusion cleared. She
showed no evidence of tongue laceration or incontinence.
At that time she obtained a head CT:
HISTORY: 67-year-old female with small-bowel obstruction, now
with tonic-
clonic seizure. Here to assess for intracranial process.
COMPARISON: CT head, most recently of [**2199-8-3**].
TECHNIQUE: MDCT axial imaging was performed through the brain
before and
after administration of 90 mL of IV Optiray 350.
CT HEAD BEFORE AND AFTER IV CONTRAST: No evidence of acute
intracranial
hemorrhage, edema, mass effect, hydrocephalus, or large vascular
territory
infarction is seen. Periventricular white matter hypodensities
are mild,
likely due to chronic microangiopathic ischemic change. After
administration
of gadolinium, no abnormally enhancing mass is seen. Vascular
calcifications
are noted along the dominant right vertebral artery, as well as
the carotid
siphons. While the current study is not tailored towards the
study of such,
there is apparent normal enhancement of the vessels of the
circle of [**Location (un) 431**].
There is also normal enhancement of the venous sinuses. The soft
tissues,
orbits, and skull appear unremarkable. The mastoid air cells and
middle ear
cavities are normally aerated. Minimal layering fluid or mucosal
thickening
is noted along the sphenoid sinus, which was not present on
[**2199-8-3**].
IMPRESSION: No evidence of acute intracranial process nor
abnormal enhancing
mass seen. If there remains concern for subtle process, MRI
would be
recommended for more sensitive evaluation
While down at CT, the patient reportedly exhibited further
seizure activity and she received Ativan. She was transferred
to the Trauma-Surgery ICU where she had a Neurology evaluation.
Neurology commented on how the postictal period was remarkably
short and atypical for a tonic-clonic seizure. They recommended
a 24 hour EEG with video as well as a lumbar puncture. The
patient continues to refuse lumbar puncture.
EEG on [**2199-9-14**]:
FINDINGS:
ROUTINE SAMPLING: Showed a 9 Hz predominant biposterior rhythm
in the
most awake parts of this recording. There were no areas of
prominent
focal slowing or epileptiform features seen.
SLEEP: The patient progressed from wakefulness to sleep with no
additional findings.
CARDIAC MONITOR: Showed a generally regular rhythm.
SPIKE DETECTION PROGRAMS: Showed no clear epileptiform features.
SEIZURE DETECTION PROGRAMS: There were eight entries in this
file for
muscle and movement artifacts, rhythmic alpha activity but no
ongoing
seizure activity.
PUSHBUTTON ACTIVATIONS: There were none.
IMPRESSION: This telemetry captured no pushbutton activations
and no
interictal epileptiform activity. The background activity was
normal.
EEG [**2199-9-15**]:
FINDINGS:
ROUTINE SAMPLING: Showed a 9 Hz predominant biposterior rhythm
in
wakefulness. There were no areas of prominent focal slowing or
epileptiform features seen.
SLEEP: The patient progressed from wakefulness to sleep with no
additional findings.
CARDIAC MONITOR: Showed a generally regular rhythm.
SPIKE DETECTION PROGRAMS: There were no entries in this file.
SEIZURE DETECTION PROGRAMS: There were three entries in this
file for
movement and muscle artifacts. There was no ongoing seizure
activity
seen.
PUSHBUTTON ACTIVATIONS: There were none.
IMPRESSION: This telemetry captured no pushbutton activations
and no
ictal or interictal epileptiform activity. The background
activity was
normal.
An MRI/MRA of the brain was ordered, however, the patient was
not able to comply with the study for several days. The study
was obtained on [**2199-9-19**]:
HISTORY: 67-year-old female patient with osteomyelitis and
discitis. Patient
with mental status changes and new onset seizures.
TECHNIQUE: MRI of the head was performed with and without IV
contrast and MRA
of the brain was also performed.
COMPARISON: CT scan dated [**2199-9-12**]. No previous MRI.
FINDINGS:
MRI BRAIN:
There are nonspecific non-enhancing T2/FLAIR hyperintense foci
within the
bilateral centra semiovale and periventricular regions likely
representing
chronic small vessel ischemic changes in a patient of this age.
There is an
ill-defined focus of FLAIR-hyperintensity, with no enhancement,
within the
medial inferior right cerebellar hemisphere/lateral vermis, with
no evidence
for restricted diffusion likely representing chronic infarction.
There is
moderate diffuse parenchymal volume loss with associated
proportionate
prominence of the ventricles and sulci, likely reflecting
age-related volume
loss.
There is no evidence of acute infarction, hemorrhage, abnormal
enhancement, or
hydrocephalus. No mesial temporal sclerosis, cortical dysplasia
or heterotopia
is seen. The visualized major vascular flow voids are normal.
Orbital
structures are unremarkable. There is mucosal thickening of the
bilateral
ethmoid air cells and a mucus-retention cyst in the right
sphenoid sinus.
Otherwise, the remainder of the paranasal sinuses as well as
mastoid air cells
are clear.
MRA BRAIN:
ANTERIOR CIRCULATION: The bilateral MCAs and ACAs are
unremarkable without
evidence for aneurysm (greater than 3 mm), AVM, or stenosis.
Incidental note
is made of fenestration at the ACA-ACom complex, a normal
variant.
POSTERIOR CIRCULATION: Bilateral PCAs and basilar artery are
unremarkable.
The right vertebral artery is dominant. The left vertebral
artery is
non-dominant and becomes more diminutive, just distal to the
takeoff of the
left PICA, also a normal variant. There is no evidence for
aneurysm (greater
than 3 mm), AVM, or stenosis.
IMPRESSION:
1. No acute infarction or hemorrhage, and no pathologic focus of
enhancement.
2. Right inferior cerebellar/lateral vermian chronic infarction,
and likely
mild chronic small vessel infarction in a patient of this age.
3. Fenestration of the ACom complex, a normal variant. No
significant
neurovascular abnormality identified.
After this extensive workup, it was ddecided that the patient
had pseudoseizures rather than a true seizure disorder and that
anticonvulsants were not required.
During the hospitalization, the patient had waxing and [**Doctor Last Name 688**]
mentals status. She reportedly was seen talking to her finger
and calling out for her mother (who is deceased) on multiple
occasions. Psychiatry was consulted for her abnormal behavior.
Psychiatry recommended antidepressant -- sertraline begin at 50
mg qd, after
4 days increase to 100 mg daily. Further, they recommended that
the patient would benefit from outpt psychiatry or therapy.
# Musculoskeletal
The patient was evaluated by Orthopaedics/Spine due to her
recent L2-L3 osteomyelitis. A L spine MRI was obtained:
LUMBAR SPINE MRI.
HISTORY: 67-year-old female presents with history of lumbar
osteomyelitis.
COMPARISON: Prior lumbar spine MRIs, [**2191-4-11**] through [**2199-7-24**].
FINDINGS: The patient was unable to tolerate the examination,
only a sagittal
T2 sequence was acquired. The configuration of the lumbar spine
appears
similar, with marked abnormality of the disc space at L2-L3 with
an associated
fluid cleft. Fusion is noted just inferior to this. There is
likely at least
moderate narrowing of the spinal canal at the L3 level. There is
slightly
increased prevertebral soft tissue, displacing the aorta
anteriorly. This may
relate to progressive inflammatory change, though is
incompletely evaluated.
Again noted is a kyphotic deformity at T10 associated with the
disc protrusion
and associated osteophytes.
IMPRESSION: Incomplete examination demonstrates grossly similar
appearance to
the previous MRI from [**7-24**] on limited sagittal T2 seqeunce.
Complete
study to be performed when pt. is co-operative for complete
assessment.
Severe central canal stenosis with possible compression on the
cauda at L2-3
and L3-4 levels, incompletely assessed.
A repeat lumbar spine MRI is recommended as an outpatient if
clinically indicated.
Medications on Admission:
1. Carvedilol 3.125 mg PO BID
2. Lisinopril 10 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
5. Cholecalciferol 1000u PO DAILY
6. Sertraline 100 mg PO DAILY
7. Alendronate 70 mg PO QSUN
8. Lorazepam 0.5 mg PO Q6H as needed for anxiety.
9. Senna 8.6 mg
10. Fentanyl 100 mcg/hr Patch Q72H
11. Calcium Carbonate 500 mg PO QID
12. Levothyroxine 150 mcg PO DAILY
13. Zoloft 100mg PO DAILY
14. Vicodin 5/500mg 1-2 tabs QID prn pain
15. Lovenox 1mg/kg [**Hospital1 **]
16. Vancomycin 500mg IV daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
3. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours
as needed for pain for 10 days.
10. Simvastatin 40 mg PO daily
11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Tunneled Access Line (e.g. Hickman), heparin dependent: Flush
with 10 mL Normal saline followed by Heparin as above daily and
PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 33039**] - heathwood
Discharge Diagnosis:
partial small bowel obstruction
hyponatremia
acute renal failure
fungemia
pseudoseizures
depression
Discharge Condition:
stable, afebrile
Discharge Instructions:
You were evaluated and treated for a partial small bowel
obstructions. You had a lengthy hospitalization with multiple
other treatments.
Please adhere to a renal diet. You are encouraged to drink
fluids.
Please call your primary care physician or return to the
emergency department for any of the following:
* Fever greater than 101
* Severe abdominal pain
* Persistent nausea/vomiting
* confusion
* seizure activity
* any new or concerning symptom
Followup Instructions:
Please make an appointment to see Dr. [**Last Name (STitle) **] in 2 weeks. His
office number is ([**Telephone/Fax (1) 39326**]. You should also schedule an
appointment to see your regular physician.
You should also follow up with the Infectious Disease clinic in
[**1-30**] weeks. Their telephone number is [**Telephone/Fax (1) 457**].
Completed by:[**2199-10-2**]
|
[
"293.0",
"V12.04",
"117.9",
"558.1",
"E879.2",
"530.81",
"285.29",
"E879.8",
"729.1",
"724.02",
"780.39",
"V15.3",
"909.2",
"425.4",
"311",
"253.6",
"584.9",
"401.9",
"V45.4",
"V12.51",
"280.0",
"112.2",
"999.31",
"560.9",
"V10.43",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
23012, 23076
|
6111, 13577
|
332, 414
|
23220, 23239
|
2091, 6088
|
23740, 24112
|
1828, 1877
|
21978, 22989
|
23097, 23199
|
21409, 21955
|
23263, 23717
|
1573, 1679
|
1892, 2072
|
261, 294
|
442, 1104
|
13587, 21383
|
1126, 1550
|
1695, 1812
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,955
| 185,708
|
18359
|
Discharge summary
|
report
|
Admission Date: [**2199-9-3**] Discharge Date: [**2199-9-17**]
Date of Birth: [**2134-9-20**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
cardiac arrest
Major Surgical or Invasive Procedure:
Endotraceal intubation on [**2199-9-3**]
Central line placement
Cardiac catheterization with no intervention
History of Present Illness:
65M w/PMHx CAD s/p 5v CABG, aortic valve replacement, aortic
arch graft, DM, HLD, HTN was transferred to the CCU s/p cardiac
arrest. Patient was found by family members to suddenly slump
over while sitting. Per family he was having problems with GI
upset and breathing after returning from a trip to CVS. He was
dyspneic which turned to lethargy, cold clammy skin,
diaphoretic, pale, and finally unresponsiveness. He was held in
sitting position by family member. [**Name (NI) **] EMS, he was found to be
in agonal respirations shortly followed by cardiac arrest,
received 2min of CPR AED with no shock advised, had ROSC. He was
subsequently intubated in the field using RSI. EKG in the field
reported 2nd degree AV block type 1 with LBBB.
On presentation to the ED, he was initialy HDS and a cardiology
consult was called. Given setting of high K (6.7) and old LBBB
and possible respiratory arrest, cardiology decided to not take
patient to cath lab.
Patient continued to be persistently hypotensive and cards
consult was called back. At this time levophed was started 0.03
which corrected the hypotension, and the fellow did a bedside
echo. EF mildly depressed about 40% with possible apical
hypokinesis. However, patient was bradycardic to 40s during
bedside Echo and received 0.5 g atropine which increased his
rate to the mid 60s transiently. Also given 2L and put out
about 1 L
The patient's intial hyperkalemia was treated with 2g of calcium
gluconate for membrane stabilization, as well as 10U of insulin
with concomittant D50 administration. Repeat measurement of
potassium demonstrated an appropriate decrease. He was also
given albuterol/ipatropium nebs which decreased his peak
pressures and improved breath sounds. Vanc/Zosyn were started
for empiric antibiotic coverage. A R femoral central line was
placed due to his persistent hypotension- RIJ was not
accessible. CT head obtained and neg for acute intracrainal
process per wet read. CTA also obtained for concern of PE and
found no PE but bilateral groundglass opacities and widespread
consolidation.
On arrival to the floor, patient was intubated and sedated.
Dopamine drip started and levophed weaned off.
REVIEW OF SYSTEMS: Not able to obtain as patient is intubated
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
[**2190**] abnl nuc went to cath, had to fix dilated ascending aorta,
avr, 5 vessel cabg. Not much f/u last couple of years. Did
have a nuc that was abnl in [**2197**] that showed moderate lateral
ischemia- looked like his OM graft went down. Had 70% stenosis
of [**Last Name (LF) 18683**], [**First Name3 (LF) **] maybe some perfusion through [**First Name3 (LF) 18683**]. Last echo 1 year
ago pretty normal. Incomplete LBBB on nuclear in [**2197**]. Follows
with Dr. [**Last Name (STitle) 911**]
[**Name (STitle) 50568**]: [**2190**]
-AVR replacement
-Asc Aortic aneurysm
-GERD
Social History:
The patient lives with his wife
Occupation: Retired pharmaceutical industry
Mobility: unaided although does still walk with cicrumduction of
his right leg
Smoking: Ex-smoker quit 20 years ago previosu 20/day
Alcohol: Rare
Illicits: No
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death;
Father - DM
Sibs - 2 brothers - 1 died from sequelae of drig use, other
brother well
Physical Exam:
Vitals: T:36.9oC P:68 R:20 BP:141/64 SaO2:100% 40% O2
General: Intubbated, drowsy and agitated on awakening not
following commands.
HEENT: NC/AT, no scleral icterus noted
Neck: Reduced ROM, no carotid bruits appreciated. No clear
nuchal
rigidity.
Pulmonary: Lungs CTA bilaterally with decreased breath sounds
both bases.
Cardiac: RRR, nl. no ESM with prosthetic S2.
Abdomen: soft, normoactive bowel sounds.
Extremities: Slight ankle edema, 2+ radial, DP pulses
bilaterally. Calves soft bilaterally.
Skin: no rashes or lesions noted.
Pertinent Results:
Admission Labs:
[**2199-9-3**] 02:00AM BLOOD WBC-9.4 RBC-3.08* Hgb-9.5* Hct-29.2*
MCV-95 MCH-30.7 MCHC-32.4 RDW-13.3 Plt Ct-225
[**2199-9-3**] 02:00AM BLOOD Neuts-78.7* Lymphs-13.2* Monos-5.4
Eos-2.4 Baso-0.2
[**2199-9-3**] 12:00AM BLOOD PT-10.6 PTT-30.5 INR(PT)-1.0
[**2199-9-3**] 12:00AM BLOOD Glucose-257* UreaN-16 Creat-1.4* Na-133
K-6.7* Cl-100 HCO3-26 AnGap-14
[**2199-9-3**] 12:00AM BLOOD ALT-31 AST-60* AlkPhos-93 TotBili-0.2
[**2199-9-3**] 12:00AM BLOOD cTropnT-<0.01
[**2199-9-3**] 08:51AM BLOOD CK-MB-5 cTropnT-<0.01
[**2199-9-3**] 05:35PM BLOOD CK-MB-5 cTropnT-<0.01
[**2199-9-3**] 12:00AM BLOOD Albumin-4.2 Calcium-8.6 Phos-6.0* Mg-2.5
Iron-72
[**2199-9-3**] 12:00AM BLOOD TSH-13*
[**2199-9-3**] 12:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2199-9-3**] 12:14AM BLOOD Lactate-2.5* Na-135 K-6.3* Cl-103
.
Discharged Labs:
[**2199-9-16**] 10:40AM BLOOD WBC-8.4 RBC-3.11* Hgb-9.6* Hct-29.1*
MCV-94 MCH-30.8 MCHC-32.9 RDW-13.4 Plt Ct-422
[**2199-9-7**] 04:59AM BLOOD Neuts-66.4 Lymphs-21.1 Monos-7.2 Eos-5.0*
Baso-0.3
[**2199-9-16**] 10:40AM BLOOD PT-11.4 PTT-35.6 INR(PT)-1.1
[**2199-9-16**] 10:40AM BLOOD Glucose-195* UreaN-24* Creat-1.2 Na-139
K-4.7 Cl-103 HCO3-26 AnGap-15
[**2199-9-6**] 03:13AM BLOOD ALT-21 AST-26 LD(LDH)-170
[**2199-9-15**] 07:55AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.3
.
[**9-4**]: Cardiac Echo
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. A bioprosthetic aortic valve prosthesis is present. The
aortic valve prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2199-9-3**], no
clear change.
[**9-3**]: Head CT w/o Contrast
1.There is no evidence of acute hemorrhage, edema or acute
territorial infarction.
2.There are multiple areas of hypoattenuation that likely
represent encephalomalacia from prior chronic infarctions.
3.The left maxillary sinus is completely opacified with
high-density material that could be due to inspissated
secretions or possibly due to fungual nfection. Clinical
correlation is recommended to exclude a fungal infection.
.
[**9-3**]: CT Chest with and without contrast: IMPRESSION:
1.No evidence of pulmonary embolism or acute aortic pathology.
2.Status post aortic valve replacement and ascending aorta graft
placement for aneurysm repair, with no evidence of graft
failure.
3.Dependent patchy pulmonary consolidations likely represent
aspiration and or evolving pneumonia, in the appropriate
setting. Upper lung ground glass opacities could reflect
additional component of pulmonary edema.
4.Low-lying ET tube extends only 1.1 cm above the carina, and
should be
retracted by at least 2 to 3 cm.
[**9-5**]: [**Doctor First Name **] Duplex upper extermity: Normal appearance of the
bilateral internal jugular and subclavian veins.
[**9-5**]: Carotid U/S: The study is somewhat limited due to the
dressing for the right internal jugular line and the neck
swelling. There is mild heterogenous plaque bilaterally in the
internal carotid arteries. On the right side, the peak systolic
velocity in the common carotid artery is 114 cm/sec, in the ICA
proximally is 96 cm/sec, in the mid portion of the ICA is 111
cm/sec and in the distal portion 132 cm/sec. This yields an
ICA/CCA ratio of 1.2, within normal limits. The right vertebral
artery could not be clearly seen.
The peak systolic velocity in the left common carotid artery was
124 cm/sec. The peak systolic velocity in the left ICA
proximally was 140 cm/sec, in the mid portion 121 cm/sec and
distally 99 cm/sec yielding an ICA/CCA ratio of 1.1, within
normal limits. The vertebral artery on the left demonstrates
antegrade flow.
[**9-6**]: EEG: This is an abnormal continuous ICU EEG monitoring
study because
the background activity is continuous diffuse polymorphic delta
and occasional [**5-17**] Hz theta activity. This is suggestive of
moderate diffuse encephalopathy of nonspecific etiology. With
history of cardiac arrest, hypoxic brain injury is one of the
possibilities along with sedative medication, as the patient is
still on a midazolam infusion. There are no epileptifrom
discharges or electrographic seizures. Compared to the prior
day's EEG, background activity is slightly slower, indicating
slight worsening of cerebral function or additional medication
effects.
.
[**9-10**]: Cardiac Cath:
1. Selective coronary angiography of this right dominant system
demonstrated severe three vessel native coronary artery disease.
The LMCA had a distal 20% stenosis. The LAD was totally occluded
proximally. The LCx had a totally occluded OM2. The RCA had a
new appearing total occlusion distally and an 80% AM stenosis
similar to cath in [**2190**].
2. Selective arterial conduit angiography revealed a patent
LIMA-LAD.
3. Selective venous conduit angiography revealed a patent
SVG-LAD. The SVG-OM-D1 and SVG-RPDA were occluded.
4. Limited resting hemodynamics revealed systemic arterial
hypertension with central aortic pressure of 156/68 mmHg.
5. Unsuccessful attempt at opening CTO of RCA
6. No other suitable targets for intervention
FINAL DIAGNOSIS:
1. Native three vessel coronary artery disease.
2. Patent LIMA-LAD.
3. Patent SVG-LAD. Occluded SVG-OM-D1 and SVG-RPDA.
4. Systemic arterial hypertension.
5. Unsuccesful attempt at opening CTO of RCA.
.
[**9-13**]: ECHO
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. The
aortic valve is not well seen. No aortic stenosis is seen. Trace
aortic regurgitation is seen. The mitral valve leaflets are not
well seen. Trivial mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global left ventricular systolic
function.
.
[**9-16**]: EP study
1. No inducible sustained tachyarrythemias
2. No evidence of an accessory pathway
3. No evidence of conduction system abnormalities
Brief Hospital Course:
64 y/o male with PMHx of 5 v CABG, aortic valve replacement, and
asc aortic aneurysm repair with CVA, was admitted to the CCU s/p
"cardiac arrest" of unclear etiology.
.
ACTIVE ISSUES:
#Cardiac Arrest/Syncope: The etiology of the patient's loss of
consciousness remains in question. It is undocumented whether he
ever truly lost his pulse. Given the patient's extensive cardiac
history, arrhythmia, ischemia, and poor contractile function
were considered as potential etiologies. The patient presented
initially with unresponsiveness and with presumed conduction
delays given his prolonged QRS and bradycardia. He was also
hypotensive in the ED. Echo was relatively unrevealing at
bedside (EF 45%)and his troponins was stable over subsequent
days. ARDS, PE, Pneumonia, and aspiration were considered. The
chest CT suggested a pulmonary process, but greatly improved on
the second day, suggesting aspiration pneumonitis. Patient was
initially also started on broad spectrum antibiotics which were
discontinued on subsequent days as he remained afebrile with
normal urine and blood cultures and without any source of
infection.
.
The patient received 0.5mg of atropine in the emergency
department for bradycardia and was admitted to the cardiac care
unit. He was stuporous; he had non-purposeful movement to
noxious stimuli. Patient was continued on pressors for better BP
management. He was brought to the CCU intubated and he was
easily ventilated and oxygenated. Based upon presumption
diagnosis of cardiac arrest, the cooling protocol was initiated
and continuous EEG was started, revealing nonspecific slowing.
The patient's primary process was thought unlikely neurologic in
origin given dramatic hemodynamic sequelae of the event and
negative CT head along with nonspecific slowing on EEG. On
[**9-8**] patient was weaned off sedation and weaned off pressors.
The patient was extubated as he was following commands and
appeared to be neurologically intact although he was delirious.
He was orientated to person and time and intermittently to
place.
.
During his CCU stay he had an episode of bradycardia with
complete heart block in the setting of severe GERD symptoms. He
was found to have lost his consciousness temporarily. Based on
this episode, it was felt that his initiall presenting symptom
may have also been vagally mediated due to severe GERD. He was
started on PPI and ranitidine with no further episode of
arrhythmias on telemetry. He also had a cath which showed
severe three vessel disease with new occlusion in the RCA and
attempt at opening CTO of RCA was unsuccessful. Subsequently he
han EP study which did not reveal any inducible tachyarrhythmia
or any new conduction abnormalities. He will follow up with Dr.
[**Last Name (STitle) 911**] as an outpatient for further evaluation and management of
his CAD.
.
# Delirium: After coming off of sedation and being extubated
patient was agitated and delirious. No infectious or neurologic
etiologies were identified. CT's showed no acute bleed, no Sz
activity, neuro has signed off. His mental status continued to
improve as he was moved to the floors. On the day of discharge
patient was able to carry out intelligent conversations. Patient
was seen by PT and OT who initially recommended rehab however
after his quick recovery recommended sending patient home with
services and with outpatient OT. Patient was also seen by
speech and swallow and his diet was advanced from nectar thick
diet to full diet on discharge. Since being extubated patient
continued to have horse voice therefore he will follow up with
ENT on outpatient basis if his voice does not return completely.
INACTIVE ISSUES:
#CAD s/p 5v CABG, aortic aneurysm repair, and AVR: ASA, plavix,
statin, coreg were continued.
.
#DM: the patient received ISS while in house to good effect. He
was discharged on his home metformin and Glyburide.
.
#HLD: The patient's atorvastatin was increased to 80mg daily.
.
# HTN: Patient was continued on his lisinopril.
.
TRANSITIONAL ISSUES:
- Patient will follow up with PCP for further management of his
severe GERD
- Patient will follow with Dr. [**Last Name (STitle) 911**] for further evaluation for
his CAD.
- Patient will follow up with ENT if his hoarse voice does not
become normal.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Clopidogrel 75 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. GlyBURIDE 5 mg PO DAILY
4. Coreg CR *NF* (carvedilol phosphate) 20 mg Oral daily
5. Lisinopril 10 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Ferrous Sulfate 27 mg PO DAILY
Discharge Medications:
1. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg one tablet(s) by mouth dailyi Disp #*30
Tablet Refills:*2
2. Clopidogrel 75 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Coreg CR *NF* (carvedilol phosphate) 20 mg Oral daily
5. Ferrous Sulfate 27 mg PO DAILY
6. GlyBURIDE 5 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg one capsule(s) by mouth daily Disp #*30
Tablet Refills:*2
8. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg one tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*2
9. MetFORMIN (Glucophage) 500 mg PO BID
10. Aluminum-Magnesium Hydrox.-Simethicone 15-30 mL PO QID:PRN
heartburn
11. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Vagal response with sinus arrest
Hypotension
Delerium
Coronary artery disease
Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**].
You collapsed at home and came to [**Hospital1 18**]. You were on a breathing
machine with low blood pressure and underwent a cooling
protocol. A cardiac catheterization showed blockages in your
arteries but the physician was unable to open any artery. You
did not have a heart attack and your heart function is strong
according to the echocardiogram. An electrophysiology study to
assess your conduction system did not show any abnormalities
besides a known mild type of heart block (left buncle branch
block). We think that severe heartburn led to your collapse and
we have started three new medicines to help prevent another
episode. Dr. [**Last Name (STitle) **] may be able to further assess your heartburn
and may change your medicines or treatment for this.
You had delerium that was caused by your illness and sedatives
that was exacerbated by lack of sleep. It is unclear if lack of
oxygen to your brain has been a factor in your confusion as
well. Your memory is improving quickly and you are safe to go
home with continued occupational therapy at home. Your voice is
hoarse after the breathing tube and you have an appt with an
ear, nose and throat doctor on [**9-26**]. You can cancel this if your
voice returns to normal before the appt.
Followup Instructions:
PCP [**Name Initial (PRE) 648**]: Tuesday, [**9-24**] at 1:15pm
With:[**Doctor First Name 20**] [**Last Name (NamePattern4) 50569**],MD
Address: [**Apartment Address(1) 23478**], [**Location (un) **],[**Numeric Identifier 14512**]
Phone: [**Telephone/Fax (1) 3259**]
Department: OTOLARYNGOLOGY-AUDIOLOGY
When: THURSDAY [**2199-9-26**] at 9:15 AM
With: [**Name6 (MD) 15040**] [**Last Name (NamePattern4) 15041**], MD [**Telephone/Fax (1) 41**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 895**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
** Please arrive at 9am for this appointment and be aware the
building is being redone so you might experience dust in the
halls.
Department: CARDIAC SERVICES
When: WEDNESDAY [**2199-10-2**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2199-9-17**]
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22,667
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736
|
Discharge summary
|
report
|
Admission Date: [**2125-11-14**] Discharge Date: [**2125-11-20**]
Service: MEDICINE
Allergies:
Enalapril / Amlodipine
Attending:[**First Name3 (LF) 4760**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 89 year-old female with a history of MDS, hip
fracuture [**2-16**], living at [**Doctor Last Name 5396**]Rehab who presents with
shortness of breath. Per nursing home staff, patient has been
coughing with chest congestion, fatigue, and poor PO intake for
1 week. Additionally, staff states that she is the 4th patient
hospitalized for pnemonia and th 10th with chest cold symptoms
and fevers.
.
CXR on [**11-6**] was without cardiopulmonary process and labs were
significant for Hct of 60, WBC 26.3 (90%neut, 1%lymph), Cr of
1.5, and proBNP of 6000 (3000 1 month earlier). Patient was
started on Lasix 40mg [**Hospital1 **] for presumed CHF exacerbation, but
continued to have cough, fatigue, poor PO intake and on [**11-14**],
desated to the 70's.
.
In the ED, patient's initial vitals were T 96.6, BP 111/58, HR
64, RR 30, sating 90% on NRB. While in ED she spiked to 101.8,
with continued low sat on NRB and was placed on BiPAP as patient
is DNR/DNI. BP dropped to 83/41 but responded to 1L NS back to
102/41. [**Month/Day (1) **] Cx sent and patient was given Vanc and Cefipime.
.
On ROS, patient was oriented x 2 (did not know which hospital).
ROS likley inaccurate as patient denied Fevers/chills and SOB
which were documented in ED.
.
Past Medical History:
Myeloproliferative syndrome
Hypothyroidism
GI bleeds, diverticular, last [**6-15**]
R bell's palsy
Hypertension
Osteoporosis
s/p hip fracture with surgical treatment [**2-/2125**] ([**Hospital3 **])
One previous episode of atrial fibrillation
.
Social History:
Has lived in rehab at [**Doctor Last Name 5396**]in [**Hospital1 **] since hip surgery
[**2-/2125**], ambulates with cane or walker.
No smoking, quit 35 years ago, about 20-30 pack year history, no
alcohol, no drug use.
Family History:
The patient's mother died of peritonitis.
The patient's father had an unknown cancer. No history of
gastrointestinal bleeding in the family
Physical Exam:
Vitals: T: 98.5 BP: 102/42 HR: 97 RR: 17 O2Sat: 95% BiPAP 10/5
40%
GEN: No acute distress, elderly woman, mildly somnolent with
BiPAP mask on
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MM dry
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: Tachy but regular, no M/G/R, normal S1 S2, radial pulses +2
PULM: Decreased breath sounds throughout with fine crackles at
bases
ABD: Soft, NT, mild distention, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: decreased turgor, No jaundice, cyanosis, or gross
dermatitis. No ecchymoses
Pertinent Results:
[**2125-11-14**] 03:10PM WBC-50.7*# RBC-6.30* HGB-18.6*# HCT-56.0*#
MCV-89 MCH-29.5# MCHC-33.2 RDW-14.8
[**2125-11-14**] 03:10PM NEUTS-96.1* LYMPHS-1.1* MONOS-2.5 EOS-0.1
BASOS-0.2
[**2125-11-14**] 03:10PM PLT SMR-VERY LOW PLT COUNT-627*
.
[**2125-11-14**] 03:10PM GLUCOSE-115* UREA N-53* CREAT-1.6* SODIUM-139
POTASSIUM-4.9 CHLORIDE-90* TOTAL CO2-34* ANION GAP-20
[**2125-11-14**] 03:10PM ALT(SGPT)-9 AST(SGOT)-26 CK(CPK)-33 ALK
PHOS-145* TOT BILI-1.0
.
[**2125-11-14**] 03:10PM cTropnT-0.28*
[**2125-11-14**] 03:10PM CK-MB-6 proBNP-[**Numeric Identifier 5400**]*
[**2125-11-14**] 09:30PM CK-MB-6 cTropnT-0.28*
[**2125-11-14**] 09:30PM CK(CPK)-24*
.
Admit CXR: IMPRESSION: Limited examination. A left lower lobe
infiltrate cannot be excluded. A dedicated lateral view may be
helpful. Tiny bilateral pleural effusions.
.
CXR [**2125-11-16**] FINDINGS: In comparison with the study of [**11-14**],
there is little change except for somewhat better degree of
inspiration. Bilateral pulmonary opacifications continue at the
bases, consistent with some combination of atelectasis or/and
effusion. Enlargement of the cardiac silhouette with pulmonary
vascular congestion persists.
Brief Hospital Course:
This is an 89 year-old female with a history of MDS, hip
fracuture [**2-16**], living at rehab who presented with shortness of
breath, hypoxia, leukocytosis and ? R pleura
effusion/infiltrate. Pt made comfortable with morphine/ativan
per family/pt wishes. Upon discharge to [**Hospital1 1501**], we were notified
she expired shortly upon arrival there. The following is her
course by problem.
.
# Hypoxia/Health Care Associated PNA - Patient c/o SOB and
sating only 90 on NRB so transitioned to BiPAP. Most likely
pneumonia. Influenza negative. Hyperviscousity syndrome
possible with polycythemia, but resolved with IVF. Patient
appeared hemoconcentrated on labs and was given IVF. She was
started on Vanc, cefipime from ED and levoquin was added for
increased psuedomonal and atypical coverage. Patient wean off
BiPAP breifly, but was again found to be lethargic with PCO2 in
70s. She is noted to be quite delerious in the PM. By day 4 in
the ICU, patient refused suctioning and many PO meds. Per her
daughter and HCP, the patient was changed to comfort-oriented
care. Continue Abx, but can give morphine for pain/respiratory
discomfort. HCP is aware that this may lead to her demise, but
feel that she should be comfortable at this point. The pt will
complete a 10 day course of levofloxacin, as the family refused
midline to continue Cefepime treatment. The pt was seen by
gerontology, who made recommendations on her medications from a
palliative care perspective. For discomfort the pt will be
discharged on both standing ativan and ativan as needed (which
often helped her) as well as concentrated morphine solution
(both standing and as needed) which can be titrated up as
needed. She was satting 90% on 5L NC at discharge, mildly
dyspneic. She was given a 1 time dose of levsin and started on
scopolamine patch. Humidified shovel mask plus extra morphine
can be considered (if pt tolerates) if she becomes more
dyspneic. Pt is refusing suctioning.
.
Mental status: Mild delirium present with dementia at this time.
[**Hospital1 3894**] is to avoid triggers. However some triggers below are
to be used with pt's wishes.
- Avoid Foley catheters
-try to avoid anticholinergics, and sleeping medications.
- Avoid physical restraints. They do not prevent falls or
pulling out lines. They increase aggitation. If needed, can
obtain a sitter. If pharmacologic intervention is needed, would
use low dose haldol 0.25 mg IV up to TID PRN or zyprexa 2.5 mg
x1.
- Please provide frequent reoorientation
- Minizmize disruptions to sleep wake cycle
<br>
# ARF - Cr to 1.6 with baseline of 1.0. Unable to place foley
as met obstruction both in ED and on floor. Cr back to 0.8 on
last lab draw.
<br>
# ? Aspiration - Patient apparently aspirates while delerious at
night, but passed a swallow study. She can take regular diet
with thin liquids under aspiration precautions.
.
# A-fib RVR - Patient went into a-fib with RVR when PO
metoprolol was stopped for risk of aspiration. She was rate
controlled and flipped in and out of A-fib with IV doses of
metoprolol. Eventually agreed to standing IV metoprolol.
Changed IV lopressor to po lopressor. Po lopressor can be
discontinued given goals of care/comfort measures if pt has
difficulty swallowing pills.
.
# Elevated CE - Trop elevated to 0.28, but CK normal and trend
was flat. Likely demand ischemia in setting of pneumonia.
.
# Myeloproliferative syndrome - with baseline leukocytosis and
thrombocytosis. Followed by Dr. [**Last Name (STitle) **]. Per heme/onc, no
more phlebotomy in the setting of comfort measures
.
# Goals of care: Comfort measures, no lab draws, vital signs
check daily ok per family; morphine/ativan standing and as
needed for comfort.
.
# Code: DNR/DNI
.
# Comm: Daughter and HCP, [**Name (NI) **] [**Name (NI) 5401**] (c) [**Telephone/Fax (1) 5402**], (h)
[**Telephone/Fax (1) 5403**]
Medications on Admission:
Milk of Mag PRN
Tylenol 325-650 PRN
Lorazepam 0.5mg HS PRN
CaCO3 500mg TID
MVI qday
Docusate 100mg qday
FeSO4 325mg qday
KCL 20 mEQ qday
Lasix 40mg [**Hospital1 **] (presumably started [**11-6**] with elevated BNP)
Levothyroxine 150 mcg qday
Metoprolol 12.5mg [**Hospital1 **]
Omeprazole 40mg qday
Alendronate 70mg qWed
.
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for wheeze.
5. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
6. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day: can
substitute 5 mg/ml solution if needed.
7. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for agitation, discomfort: can substitue 5 mg/ml
solution if needed.
8. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO q48 hr for
2 doses.
9. Morphine Concentrate 20 mg/mL Solution Sig: Two (2) mg PO
every six (6) hours.
10. Morphine Concentrate 20 mg/mL Solution Sig: 2-4 mg PO Q2H as
needed for breakthrough.
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day.
12. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) patch
Transdermal every seventy-two (72) hours.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5399**] Nursing Home - [**Hospital1 **]
Discharge Diagnosis:
Primary Diagnosis:
Pneumonia with hypoxia
Acute mental status change
<br>
Secondary Diagnosis:
Acute Renal Failure
A-fib with RVR
Myelodysplastic syndrome
Discharge Condition:
stable
Discharge Instructions:
You were diagnosed with pneumonia. You were treated with
antibiotics while you were here. In discussion with your family,
it was decided we should treat you with comfort measures
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
<br>
Continue antibiotic regime as prescribed for complete course.
Please discuss hospice care at the nursing facility you are
going to.
<br>
Pt is noted for comfort care measures, also with h/o delirium
please institute the following precaustions as best as possible:
- Avoid Foley catheters
-Avoid benzos, anticholinergics, and sleeping medications.
- Avoid physical restraints. They do not prevent falls or
pulling out lines. They increase aggitation. If needed, can
obtain a sitter. If pharmacologic intervention is needed, would
use low dose haldol 0.25 mg IV up to TID PRN or zyprexa 2.5 mg
x1.
- Please provide frequent reoorientation
- Minimize disruptions to sleep wake cycle
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 5404**] as needed.
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,091
| 100,099
|
33590
|
Discharge summary
|
report
|
Admission Date: [**2118-5-7**] Discharge Date: [**2118-5-19**]
Date of Birth: [**2047-9-30**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
Chest pain and anemia
Major Surgical or Invasive Procedure:
Colonoscopy and Upper Endoscopy
History of Present Illness:
70 year old man with afib on coumadin, insulin dependent DM,
obseity, systolic and diastolic heart failure LVEF 40-45%, CAD
s/p CABG '[**93**], PTCA'[**15**], STEMI with BMS to the SVG-OM graft
[**2118-4-8**], presents with fatigue and dyspnea on exertion over past
week. He was initially feeling well after discharge [**3-/2117**] and
began exercising and losing weight. However, this past week
dyspnea increased and exertional capacity decreased. He called
his cardiologist who thought he might be overdiuresed, therefore
his lasix and spironolactone were reduced to half prior doses.
Dyspnea worsened despite this change. Then on the day of
admission he had 2 bowel movements, the second of which was dark
black. The bowel movement was preceeded by crampy abdominal
pain. He attempted to walk from the bathroom to the kitchen but
because acutely dyspneic. He sat down and then developed chest
pain, took a nitro with relief. Tried to walk again but the
chest pain returned, thus called EMS and was brought to an OSH.
There his chest pain was relieved by repeated nitroglycerin and
he was eventually started on a nitroglycerin drip. Labs at OSH
were notable for HCT 25, INR 3.7, K 7. Enroute to [**Hospital1 18**], his
SBP dropped with increasing nitro drip doses.
Upon arrival to [**Hospital1 18**], he was chest pain free with VS 97.6
99/56, 74 16 97% 2L. ECG showed a new LBBB, trop negative.
Labs notable for K 7.2 (not hemolyzed) and thus he received
calcium, D50/insulin, and kayexalate. INR was 4.9. GI was
called given HCT drop from 31 to 25 and made plans to scope in
the morning. Rectal exam notable for brown stool guaiac
positive with specks of black stool. Nitroglycerin drip was
stopped and his pain was controlled with morphine PRN. He
received 1L NS. Vitals prior to transfer 98.1 69 109/41 16 99%
RA pain 0.
On arrival to the MICU, he was initially comfortable, but then
developed chest pain prompting morphine 2mg x3 without relief.
SL nitro was given with improvement in pain. ECG showed narrow
complex sinus rhythm with ST depressions in I, V4-V6. He later
had another episode of pain relieved by SL nitroglycerin.
Past Medical History:
CAD s/p CABG in [**2093**], s/p cath in [**2103**] wiuth BMS to Lcx, [**2113**]
revealing a severe stenosis in the SVG to the OM s/p BMS x 3,
[**2115**] at [**Hospital1 112**] (patient says stent but unknown location)
IDDM
morbid obesity
COPD
sleep apnea on BiPAP
CHF, diastolic, with EF 71% per OSH reports
afib
HTN
CVA with right sided numbness
history of rheumatic fever
Social History:
Lives with wife and four children. Worked as a carpenter. No
tob/ETOH/IVDA.
Family History:
Adopted, unknown
Physical Exam:
Admission exam:
Vitals: 98F 108/44 71 9 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
Discharge exam:
VS - 98.0, 98.6, 96/49 (94-145/48-71), 71 (52-81), 20, 100RA
GENERAL - Obese late-middle aged man in NAD. Oriented x3.
HEENT - NCAT. Oropharynx clear
NECK - Supple, unable to assess JVD due to habitus
CARDIAC - RRR, normal S1, S2. No m/r/g. No S3 or S4.
LUNGS - CTAB, no crackles, wheezes or rhonchi.
ABDOMEN - Soft, obese NTND. No HSM or tenderness.
EXTREMITIES - WWP, no LE edema, no clubbing
SKIN - Multiple scars across lower extremities from vein
harvesting, some chronic stasis changes
Pertinent Results:
Admission Labs:
===============
[**2118-5-6**] 11:55PM BLOOD WBC-11.2* RBC-2.82* Hgb-8.0* Hct-24.7*
MCV-87 MCH-28.3 MCHC-32.3 RDW-19.2* Plt Ct-178
[**2118-5-6**] 11:55PM BLOOD Neuts-85.1* Lymphs-10.4* Monos-3.0
Eos-1.3 Baso-0.2
[**2118-5-6**] 11:55PM BLOOD PT-49.3* PTT-56.2* INR(PT)-4.9*
[**2118-5-6**] 11:55PM BLOOD Glucose-187* UreaN-78* Creat-1.9* Na-131*
K-7.2* Cl-99 HCO3-22 AnGap-17
[**2118-5-7**] 03:20AM BLOOD Calcium-9.6 Phos-4.1 Mg-2.6
Pertinent Labs:
===============
[**2118-5-6**] 11:55PM BLOOD cTropnT-<0.01
[**2118-5-7**] 03:20AM BLOOD CK-MB-4 cTropnT-0.02*
[**2118-5-7**] 08:55AM BLOOD CK-MB-5 cTropnT-0.04*
[**2118-5-7**] 10:58PM BLOOD CK-MB-4 cTropnT-0.05*
[**2118-5-12**] 10:50AM BLOOD Hapto-164
[**2118-5-12**] 10:50AM BLOOD LD(LDH)-195 TotBili-2.0* DirBili-0.5*
IndBili-1.5
HELICOBACTER PYLORI ANTIBODY TEST: POSITIVE BY EIA.
Urine culture [**5-9**]- no growth
Discharge Labs:
===============
[**2118-5-19**] 06:35AM BLOOD Hct-29.5*
[**2118-5-17**] 11:00AM BLOOD PT-11.9 PTT-33.3 INR(PT)-1.1
[**2118-5-18**] 11:10AM BLOOD Glucose-108* UreaN-21* Creat-1.1 Na-136
K-4.6 Cl-100 HCO3-28 AnGap-13
[**2118-5-18**] 11:10AM BLOOD Calcium-8.0* Phos-3.5 Mg-3.2*
Micro/Path:
===========
URINE CULTURE (Final [**2118-5-10**]): NO GROWTH.
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2118-5-9**]): POSITIVE BY
EIA.
MRSA SCREEN (Final [**2118-5-9**]): No MRSA isolated.
Imaging/Studies:
================
CXR [**5-9**]- Status post sternotomy, with mild prominence of the
cardiomediastinal silhouette. There is upper zone
re-distribution without overt CHF. There is minimal atelectasis
at both bases. No frank consolidation or effusion.
EKG [**5-9**]- LBBB -> sinus rhythm narrow complex, ST depressions
V4-V6 and I, avL
EGD [**5-9**]- Nodularity in the whole stomach compatible with
nodular gastritis. Normal EGD to third part of the duodenum.
CT abd/pelvis [**5-12**]-
1. No evidence of retroperitoneal bleed or acute
intra-abdominal process.
2. Fatty infiltration of the liver.
3. Cholelithiasis.
4. Right renal cyst.
Colonoscopy [**2118-5-18**]:
Impression:
Grade 1 internal hemorrhoids
Diverticulosis of the sigmoid colon
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
70 year old man with afib on coumadin, insulin dependent DM,
obseity, systolic and diastolic heart failure LVEF 40-45%, CAD
s/p CABG '[**93**], PTCA'[**15**], STEMI with BMS to the SVG-OM graft
[**2118-4-8**], presents with fatigue and dyspnea on exertion, found to
have hematocrit drop secondary to GI bleed.
ACTIVE DIAGNOSES:
=================
# Chest Pain: Demand ischemia in setting of GI bleed. He has
known coronary vascular disease with refractory angina that is
not amenable to intervention per cardiology team. No evidence of
consolidation or PTX on CXR to suggest pulmonary cause. Patient
was transfused a total of 8 units pRBCs; hematocrit initially
stabilized and when heparin gtt and coumadin were re-started,
hematocrit dropped again and chest pain returned without EKG
changes. He was continued on aspirin, plavix, and ranolazine.
Imdur was started at a lower dose than home dose given concern
for hypotension in setting of bleeding, but BP remained stable
so imdur was titrated up to his home dose. He then had return of
chest pain, with dynamic ST changes in V3-V5 and I/avL,
consistent with known non-intervenable areas of disease. His
imdur was increased to 240mg and metoprolol was increased to
tartrate 150mg PO BID without further episodes of chest pain.
# UGIB/H.Pylori + Nodular Gastritis: On EGD, patient had
evidence of nodular gastritis with superficial erosions.
H.pylori returned positive and patient began triple therapy with
amoxicillin (not candidate for clarithromycin given interaction
with ranolazine), metronidazole and pantoprazole. Coumadin was
held and INR was reversed with vitamin K. Patient had ongoing
hematocrit drop without obvious bleeding once heparin drip was
restarted, so both coumadin and heparin were stopped. Patient
will complete 2 weeks of triple therapy, then continue [**Hospital1 **]
pantoprazole. He does not require GI follow-up or test of cure.
He also underwent colonoscopy which did not reveal an additional
or alternative source of his bleeding. If he continues to bleed,
the next step would be a capsule endoscopy. He will have a [**Hospital1 **]
check prior to his PCP appointment to assess his hematocrit.
# Acute blood loss anemia: Source suspected to be gastritis as
above. Coumadin was held on admission to the ICU and reversed
with vitamin K and FFP. He was transfused a total of 8 units
during admission; initially 4 units in the ICU as he had an
inappropriate response to blood, then again on the floor as with
initiation of coumadin and bridge with heparin drip, patient's
hematocrit drifted down. Haptoglobin and LDH were normal, and
indirect bilirubin was only slightly elevated (and was post
transfusion) so low suspicion for hemolysis. With
discontinuation of heparin drip and coumadin, hematocrit
stabilized and patient did not require transfusion for >72 hours
prior to discharge.
# Constipation: Significantly constipated during admission.
Required 2 days of prep prior to his colonoscopy. Patient
discharged on senna/colace/miralax to prevent further
constipation.
# Acute on chronic systolic heart failure: On admission,
patient had mild pulmonary edema secondary to decreased lasix
and spironolactone dose over past week prior to admission.
Patient was diuresed in the ICU, and was euvolemic on transfer
to the floor. He was continued on home lasix 40mg daily, with
extra doses with transfusions. He had a few episodes of
orthostatic hypotension prompting decrease of his lasix dose to
20mg PO daily. Patient was euvolemic at the time of discharge,
and weight was stable at 120 kg.
# Hyperkalemia: 7.2 on admission likely secondary to ARF,
spironolactone, and lisinopril. ECG improved to narrow complex
once potassium normalized. Potassium remained stable for
remainder of admission. Spironolactone was not restarted, and
lisinopril was restarted at lower dose of 5mg PO daily.
# LBBB: Suspect metabolic etiology given improved with K
correction. Trop negative suggesting against acute coronary
syndrome. LBBB resolved after correction of K.
# Acute renal failure: Likely secondary to systolic CHF with
poor forward flow with second hit of poor perfusion due to acute
GIB. Patient's creatinine trended down and was 1.1 on day of
discharge.
# Leukocytosis: Unclear etiology, but may be due to stress of
GIB. No evidence of infectious colitis, UA without evidence of
infection and no consolidation seen on CXR. White count
resolved and remained normal for remainder of admission.
CHRONIC DIAGNOSES:
==================
# HLD: continued atorvastatin
# Depression: continued venlafaxine
# DMII: Blood sugar well controlled during admission.
Transitional issues:
# Spironolactone held on discharge given hyperkalemia to 7.2 on
admission.
# Coumadin held on discharge -> we anticipate holding this
medication for about a month while his gastritis heals with
protection against stroke with aspirin 325mg and plavix 75mg in
the interim.
# Lisinopril decreased to 5mg daily to prevent hyperkalemia and
increase pressure room to uptitrate Imdur to 240mg PO daily and
metoprolol to 150mg tartrate [**Hospital1 **]
# H.pylori triple therapy treatment to continue through [**2118-5-23**]
# Hematocrit and electrolytes should be rechecked by PCP at
[**Name9 (PRE) 702**] appointment, he has a script for this.
# Insulin decreased to 70/30 mix 80 units daily given in-house
hypoglycemia. We suggest setting him up with [**Last Name (un) **] for further
diabetes management but wanted him to discuss this with his PCP
[**Name Initial (PRE) **].
# Weight on discharge 120kg, discharged on furosemide 20mg
daily.
Medications on Admission:
1. aspirin 325 mg DAILY
2. nitroglycerin 0.4 mg q5min PRN
3. furosemide 40 mg PO daily
4. lisinopril 10 mg PO DAILY
5. atorvastatin 80 mg PO DAILY
6. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: One Hundred (100) units Subcutaneous twice a day.
7. metformin 500 mg PO daily
8. venlafaxine 75 mg PO DAILY
9. warfarin 5 mg PO once a day.
10. pantoprazole 40 mg PO once a day.
12. ranolazine 1,000 mg PO twice a day.
13. clopidogrel 75 mg PO daily
14. isosorbide mononitrate 60 mg PO once a day.
15. metoprolol succinate 200 mg PO once a day.
16. spironolactone 25 mg PO once a day.
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. ranolazine 500 mg Tablet Extended Release 12 hr Sig: Two (2)
Tablet Extended Release 12 hr PO BID (2 times a day).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
[**Name Initial (PRE) **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
7. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
8. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 4 days.
[**Name Initial (PRE) **]:*12 Tablet(s)* Refills:*0*
9. amoxicillin 500 mg Tablet Sig: Two (2) Tablet PO twice a day
for 4 days.
[**Name Initial (PRE) **]:*16 Tablet(s)* Refills:*0*
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
[**Name Initial (PRE) **]:*30 Tablet(s)* Refills:*0*
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
[**Name Initial (PRE) **]:*30 Capsule(s)* Refills:*2*
12. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
13. metoprolol tartrate 50 mg Tablet Sig: Three (3) Tablet PO
twice a day.
[**Name Initial (PRE) **]:*180 Tablet(s)* Refills:*2*
14. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Eighty (80) units Subcutaneous twice a day.
15. Imdur 60 mg Tablet Extended Release 24 hr Sig: Four (4)
Tablet Extended Release 24 hr PO once a day.
16. Miralax 17 gram Powder in Packet Sig: One (1) PO once a
day.
[**Name Initial (PRE) **]:*30 packets* Refills:*2*
17. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
[**Name Initial (PRE) **]:*30 Tablet(s)* Refills:*0*
18. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
[**Name Initial (PRE) **]:*30 Tablet(s)* Refills:*0*
19. Outpatient [**Name Initial (PRE) **] Work
Please obtain CBC, Chem 7 prior to your appointment.
Have the results communicated to your PCP:
[**Name Initial (NameIs) 7274**]: [**Name Initial (NameIs) **],[**Name Initial (NameIs) **]
Address: [**Hospital1 29147**], [**Location (un) **],[**Numeric Identifier 29160**]
Phone: [**Telephone/Fax (1) 29149**]
Fax: [**Telephone/Fax (1) 29155**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary diagnosis:
# Unstable Angina
# H. pylori + nodular gastritis with erosions
# Blood loss anemia
Secondary diagnosis:
# Coronary artery disease
# Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(rolling walker)
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you! You were admitted to [**Hospital1 18**]
for evaluation and treatment of chest pain, shortness of breath,
and GI bleeding. You were found to have a low blood count likely
due to a slow bleed in your GI tract related to all of your
blood thinners and gastritis with erosions from H. pylori (a
bacteria that pre-disposes to gastritis and ulcers). You were
started on a medication to protect your GI tract, treatment for
your infection, and you were given blood transfusions to improve
your blood counts. You underwent an upper endoscopy which showed
the inflammation of the stomach and erosions and a colonoscopy
which was without source of bleeding.
You also had an elevation in your potassium level, so your
spironolactone was discontinued.
We attempted re-starting anticoagulation but you began to bleed
again. As a result, your coumadin is being held until resolution
of your gastritis. We suggesting waiting a month or so until
resuming coumadin and would like to re-assure you that you are
recieving protection against stroke from your afib from your
aspirin and plavix.
The following changes were made to your medication regimen:
- START Metronidazole three times day through Monday [**2118-5-23**] to treat the infection in your stomach
- START Amoxicillin twice a day through Monday [**2118-5-23**] to
treat the infection in your stomach
- INCREASE pantoprazole to twice a day to protect your stomach
lining
- INCREASE Imdur to 240mg by mouth daily
- CHANGE to Metoprolol Tartrate 150mg by mouth twice daily
- DECREASE Lisinopril to 5mg daily
- DECREASE Lasix to 20mg daily
- DECREASE Insulin 70/30 to 80 units twice daily
- STOP Spironolactone
- STOP Coumadin -> you will have to discuss with your primary
care doctor restarting this medication about a month from now
once your gastritis has healed
- START Senna and Colace twice a day as needed for constipation
- START Miralax once daily as needed for constipation
Please follow up as suggested below.
Followup Instructions:
Name:[**Name6 (MD) **] [**Name8 (MD) **],MD
Specialty: Primary Care
Address: [**Hospital1 29147**], [**Location (un) **],[**Numeric Identifier 29160**]
Phone: [**Telephone/Fax (1) 29149**]
When: Tuesday, [**5-24**] at 3:15pm
-Please have your labs checked prior to this appointment, on
discharge your hematocrit was 29.5
Department: CARDIAC SERVICES
When: THURSDAY [**2118-5-26**] at 9:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2118-5-20**]
|
[
"411.89",
"311",
"V45.82",
"401.9",
"496",
"286.9",
"427.31",
"278.01",
"276.7",
"782.0",
"250.00",
"428.23",
"535.41",
"562.10",
"V58.61",
"428.0",
"285.1",
"426.3",
"041.86",
"564.00",
"288.60",
"412",
"584.9",
"V58.67",
"414.00",
"438.89",
"327.23",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
15200, 15257
|
6420, 6731
|
326, 359
|
15474, 15474
|
4203, 4203
|
17717, 18356
|
3055, 3074
|
12684, 15177
|
15278, 15278
|
12061, 12661
|
15656, 17694
|
5104, 6397
|
3089, 3674
|
3690, 4184
|
11091, 12035
|
264, 288
|
387, 2546
|
15403, 15453
|
4219, 4651
|
15297, 15382
|
15489, 15632
|
4667, 5088
|
6749, 11070
|
2568, 2943
|
2959, 3039
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,879
| 172,483
|
121+122
|
Discharge summary
|
report+report
|
Admission Date: [**2130-12-15**] Discharge Date: [**2130-12-18**]
Date of Birth: [**2057-10-30**] Sex: M
Service:
DIAGNOSIS: Sepsis.
HOSPITAL COURSE: (Summary of the patient's medicine
Intensive Care Unit course from [**2130-12-15**] until
[**2130-12-18**])
HISTORY OF PRESENT ILLNESS: The patient is a 73 year old
male with recently diagnosed nonHodgkin's lymphoma in
[**2130-9-11**]. The patient presented with low back pain
and was found to have a poor compression. The patient was
treated with radiation and steroids from [**Month (only) **] until
[**2130-10-18**] and then discharged to [**Hospital **]
Rehabilitation for rehabilitation. The patient was
readmitted on [**2130-11-8**] for Rituxan treatment per
oncology, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. After receiving first dose of
Rituxan the patient had an adverse reaction including
hypotension, tachycardia, fever and hypoglycemia. The
hospital course was notable for syndrome of inappropriate
antidiuretic hormone, change in mental status and anemia.
The patient was then discharged to [**Hospital1 **] on [**2130-11-12**]. The patient now returns to the Emergency Room on the
day of admission with lethargy and shortness of breath. The
patient has been undergoing treatment with Levofloxacin for
presumed pneumonia since [**12-11**]. At [**Hospital1 **] the patient
was short of breath and was given in addition to Levofloxacin
Vancomycin for treatment of presumed pneumonia and referred
to the Emergency Room. In the Emergency Room the patient had
a temperature of 100.8 and was hypotensive with a systolic
blood pressure of 77. In addition, the patient was in mild
respiratory distress and was hypoxic with an oxygen
saturation of 88% on 4 liters. The patient was diagnosed
with presumed sepsis from pneumonia and started on
intravenous fluid resuscitation, and sent to the Intensive
Care Unit.
PAST MEDICAL HISTORY: 1. NonHodgkin's lymphoma as per
history of present illness, follicular. 2. Type 1 diabetes.
3. Benign prostatic hypertrophy. 4. Anemia. 5.
Depression.
MEDICATIONS ON ADMISSION:
1. Celexa 20 mg p.o. q.d.
2. Aranesp 100 mcg q. weekly
3. Colace 100 mg p.o. b.i.d.
4. Lantis insulin 10 units q. PM
5. Prevacid 30 mg p.o. q.d.
6. Magnesium oxide 400 mg p.o. q.d.
7. Remeron 15 mg p.o. q.h.s.
8. Multivitamin one tablet p.o. q.d.
9. Senna two tablets p.o. q.d.
10. Levaquin 500 mg p.o. q.d. started on [**2139-12-16**]. Humalog sliding scale 201 to 250 2 units, 251 to 300 4
units, 301 to 350 6 units, 351 to 400 8 units, 401 to 450 12
units, 451 to 500 15 units.
ALLERGIES: Rituxan.
SOCIAL HISTORY: The patient is single, has no children. The
next closest [**Doctor First Name **] is his brother. Lives alone prior to recent
illnesses.
PHYSICAL EXAMINATION ON ADMISSION: General: Alert and
oriented to person, hospital and year but drowsy. Head,
eyes, ears, nose and throat, oropharynx with dry mucous
membranes, no jugulovenous distension. Cardiovascular,
regular rate and rhythm with no murmurs. Lungs with crackles
at bases bilaterally. Abdomen, soft, nontender,
nondistended. Positive hepatomegaly. Spleen not palpated.
Extremities, no edema, 2+ dorsalis pedis pulses. Skin, warm.
LABORATORY DATA: Significant laboratory data on admission
revealed white count 16.9, hematocrit 27.1, platelets 329,
creatinine normal at 0.7.
Microbiology - Blood cultures from [**2130-12-15**] with no
growth. Urine, Legionella antigen negative.
Chest x-ray from [**2130-12-15**], development of diffuse
bilateral interspace disease.
Echocardiogram, [**2130-12-18**], ejection fraction of 45%,
left atrium normal in size. Left ventricular wall thickness
and cavity size were normal. Mild globar left ventricular
hypokinesis, right ventricular systolic function was normal.
No valvular disease. No pericardial effusion.
HOSPITAL COURSE: While the patient was in the Medicine
Intensive Care Unit from [**12-15**] to [**12-18**]:
1. Sepsis - The patient presented with fever of 100.8,
hypotension and tachycardia consistent with sepsis.
Differential diagnosis included pneumonia with admission
chest x-ray showing bilateral diffuse patchy infiltrate. In
addition, the patient with PICC line and concern for line
sepsis. The patient was started on broad spectrum
antibiotics with Vancomycin, Levaquin, Ceptaz and Flagyl.
The patient was volume resuscitated with 10 liters of normal
saline. The patient was started on stress dose steroids with
Hydrocortisone 100 mg q. 8. The patient required pressors
with Levophed to maintain blood pressure for approximately 24
hours and was then weaned off. The patient's respiratory
status remained stable on 4 liters of nasal cannula. For
evaluation of pneumonia, the patient was unable to produce
sputum sample on admission. Blood cultures drawn showed no
growth. In addition the PICC line was removed and tip
culture was sent which showed no growth. Likely the patient
has atypical pneumonia given chest x-ray findings. On
hospital day #3 Ceftazidime and Flagyl were discontinued as
unlikely that the patient had aspiration or pseudomonas
pneumonia.
2. Hematology/oncology - Patient with a history of
nonHodgkin's lymphoma, follicular type. He received one dose
of Rituxan in [**2130-10-11**] and had an adverse reaction. In
reviewing medical records, the patient with abdominal
computerized tomography scan in [**Month (only) 359**] which showed
retroperitoneal and mesenteric lymphadenopathy. In addition
there was lymphadenopathy at the gastroesophageal junction
and anterior pancreas. There was also noted to be an L3
vertebral body lytic lesion. Further chemotherapy treatment
was postponed given current active infection issue.
3. Cardiovascular - The patient with no known history of
coronary artery disease. Echocardiogram done on hospital day
#3 showed moderately reduced left ventricular ejection
fraction of 45% with no focal wall motion abnormalities or
valvular disease. After receiving multiple intravenous fluid
boluses for volume resuscitation for treatment of sepsis, the
patient was subsequently diuresed when hemodynamically
stable.
4. Psychiatry - The patient with a history of paranoid
depression. On the hospital day #3, the patient was
restarted on outpatient medications, Celexa and Remeron.
Further hospital course while on medical floor to be
dictated.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1296**], M.D. [**MD Number(1) 292**]
Dictated By:[**Last Name (NamePattern1) 1297**]
MEDQUIST36
D: [**2130-12-18**] 14:11
T: [**2130-12-18**] 15:53
JOB#: [**Job Number 1298**]
Admission Date: [**2130-12-15**] Discharge Date: [**2130-12-21**]
Date of Birth: [**2057-10-30**] Sex: M
Service: Medicine
ADDENDUM TO [**2130-12-18**] DISCHARGE SUMMARY - SUMMARY OF HOSPITAL
COURSE FOLLOWING MICU CALL OUT: In summary, this is a
73-year-old male, with a history of non-Hodgkin's lymphoma,
cord compression, depression, BPH, who was transferred to
[**Hospital1 18**] for sepsis and respiratory failure, treated in the ICU,
and called out to the floor with resolving respiratory
failure, sepsis, with a presumed pneumonia. Please see above
dictation for ICU course.
1) SEPSIS: The patient was called out from the MICU with
resolving sepsis. He remained hemodynamically stable on the
floor. The patient finished his 7-day course of
hydrocortisone, was continued on Levofloxacin IV with
transition to PO, and continued on vancomycin. Sepsis was
presumed to be due to underlying pneumonia, as evidenced by
chest x-ray, though no organisms was ultimately identified in
either the blood, sputum, or urine. Prior PICC line site
catheter tip was also negative.
2) PNEUMONIA: The patient was treated for bilateral
interstitial fluffy infiltrates on chest x-ray. Differential
diagnosis including atypicals and PCP. [**Name10 (NameIs) **] patient improved
clinically on broad-spectrum antibiotics initially, and
subsequently continued on Levaquin and vancomycin. There was
some initial suggestion that the chest x-ray looked
consistent with PCP, [**Name10 (NameIs) 3**] the patient had been on long-term
steroids for cord compression. However, the patient
clinically improved without bactrim, or treatment for his
Pneumocystis carinii, for suspected PCP [**Name Initial (PRE) 1064**]. The
patient will be discharged on a 7-day course of Levofloxacin
500 mg po qd, and vancomycin 1 gm IV q 12 h x 7 days. The
patient will be discharged on prophylactic dose of bactrim,
as the patient will continue decadron 4 mg po qd for cord
compression and for continued treatment of non-Hodgkin's
lymphoma. On discharge, the patient was breathing
comfortably on room air with resolved respiratory failure.
3) TYPE 2 DIABETES, INSULIN DEPENDENT: The patient's blood
sugars were relatively uncontrolled during his hospital stay,
as the patient was given IV steroids as part of the sepsis
protocol. The patient's Lantus dose was increased to 20 U q
hs with an aggressive Humalog sliding scale, and on the day
of discharge blood sugars remained in the 150s-250 range.
The patient will need careful follow-up as high-dose steroids
will be discontinued on the day of discharge, with assessment
of blood sugar and need to titrate down on the Lantus and
Humalog as needed.
4) NON-HODGKIN'S LYMPHOMA: The patient will be continued to
be followed at [**Hospital1 **] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for continued
management of his non-Hodgkin's lymphoma. The patient will
be discharged on decadron 4 mg po qd.
5) ANEMIA: The patient was transfused 2 units for acute
blood loss in the ICU. The patient's hematocrit remained
greater than 30. On discharge, the patient will continue his
Epogen 4,000 units twice a week for persistent and chronic
anemia.
6) DEPRESSION: The patient's affect was relatively flat with
some evidence of paranoia. He will continue on his
citalopram 20 mg po qd with follow-up with his primary care
physician for further management.
7) DECONDITIONING: The patient has a long history of
rehabilitation, inactivity and loss of function secondary to
cord compression. Cord compression has improved per
information from his prior extended care facility. He will
need aggressive physical therapy and occupational therapy at
his new extended care facility.
DISCHARGE CONDITION: Stable. The patient is breathing
comfortably on room air, attempting ambulation with
assistance, and tolerating PO.
DISCHARGE STATUS: The patient is expected to be discharged
to the [**Hospital1 **] acute care facility for rehabilitation, with
transfer to lower level care as needed.
DISCHARGE DIAGNOSES:
1. Sepsis.
2. Respiratory failure.
3. Pneumonia, bacterial, unspecified.
4. Type 2 diabetes, uncontrolled.
5. Anemia, acute blood loss.
6. Lymphoma.
7. Failure to thrive and deconditioning.
DISCHARGE MEDICATIONS:
1. Tylenol 325-650 mg po q 4-6 h prn pain.
2. Pantoprazole 40 mg po qd.
3. Heparin subcu 5,000 U q 8 h.
4. Citalopram 20 mg po qd.
5. Mirtazapine 50 mg po q hs.
6. Epoetin Alfa 4,000 U 2 x week--Monday, Thursday.
7. Colace 100 mg po bid--hold for loose stools.
8. Senna 1-2 tabs po bid--hole for loose stools.
9. Levofloxacin 500 mg po qd x 7 days.
10.Lantus 20 U subcutaneous at bedtime.
11.Humalog sliding scale.
12.Decadron 4 mg po qd.
13.Bactrim 1 tab qd for PCP [**Name Initial (PRE) 1102**].
FOLLOW-UP:
1. The patient will continue to have his oncology care
coordinated via Dr. [**First Name (STitle) **] at [**Hospital1 **].
2. The patient will have a new primary care physician, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Name (STitle) 1299**], at [**Company 191**] Associates, telephone# ([**Telephone/Fax (1) 1300**].
First appointment is [**2131-1-22**] at 1:30 pm at [**Hospital3 1301**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1302**], M.D.
Dictated By:[**Last Name (NamePattern1) 1303**]
MEDQUIST36
D: [**2130-12-21**] 11:06
T: [**2130-12-21**] 11:17
JOB#: [**Job Number 1304**]
|
[
"V58.65",
"038.9",
"336.3",
"285.1",
"518.81",
"202.80",
"250.02",
"783.7",
"482.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10476, 10764
|
10785, 10976
|
10999, 12184
|
2142, 2655
|
3918, 10454
|
311, 1934
|
2848, 3900
|
1957, 2116
|
2672, 2833
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,301
| 180,224
|
37991
|
Discharge summary
|
report
|
Admission Date: [**2191-7-28**] Discharge Date: [**2191-8-3**]
Date of Birth: [**2124-2-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
fatigue, nausea
Major Surgical or Invasive Procedure:
right IJ temporary dialysis catheter placement
tunneled HD line placement for permanent HD access
hemodialysis initiation
History of Present Illness:
History of Present Illness:
67 y/o M with vague medical hx presents to the ED w/ complaint
of dyspnea and nausea with vomiting over last 3-4 days. Pt is
from former Soviet Republic of [**State 3908**], and arrived to US 1
month ago. Pt only speaks Georgian and is accompanied by
son-in-law who is bilingual and provides medical hx. Pt had been
experiencing increasing fatigue over recent months and was
encouraged to join family in US for support. Since arrival 1
month ago, Pt has not sought out medical care. Since arriving Pt
has been noted to be fatigued, and alert and oriented but
seemingly "slow" mentally. Pt has been dyspneic at times, but
worse over past week, and over past 3-4 days Pt had nausea,
vomiting. Taken to private doctor by family, who drew labs and
recommended that he go to ED after finding lab abnormalities. Pt
denies CP, recent fevers, chills.
.
In the ED, initial vs were: T 98.5 P 108 BP 118/56 RR 18 O2 sat
98% RA. Initial labs found the Pt to be hyperkalemic to 6.0, w/
a creatinine of 15.4, and anemic to Hct 19.8. Pt was given ASA,
calcium, dextrose, insulin, vancomycin, zosyn, thiamine and
transferred to the CCU.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied chest pain or tightness, palpitations. Denied
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denied arthralgias or
myalgias.
Past Medical History:
According to son in law, Pt has hx of stroke (with left facial
weakness and numbness, resolving over 2-3 weeks), shortness of
breath and cough which was treated with albuterol, high blood
pressure and "heart problems". Denies history of kidney problems
or kidney stones.
Social History:
Pt moved to US 1 month ago from former Soviet Republic of
[**State 3908**] to live with daughter and son-in-law for increased
social support due to ongoing fatigue. Pt only speaks Russian
and is accompanied by son-in-law who is bilingual and provides
medical hx.
significant smoking history (3ppd/40 years)
rare ETOH
no known drugs
Family History:
unknown
Physical Exam:
Admission Vitals: T: 98.5 BP: 118/58 P: 88 R:18 O2: 100 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not [**State **], no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: non-tender, distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Rectal: guiac negative, moderately enlarged prostate.
.
Discharge Vitals: T: 98.2 BP: 130/80 P: 87 R:16 O2: 99%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not [**State **], no LAD
Lungs: few crackles at L base
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes noted
Neuro: CN2-12 intact, strength intact U&LE ([**3-29**]), sensation
intact, 2+ DTRs patellar, independent ambulation
Pertinent Results:
Admission labs:
WBC 7.1 RBC 2.32* Hb 6.4* Hct 20.7* MCV 90 MCH 27.6
MCHC 30.9 plt 216
[**2191-7-28**] GLUCOSE-122 UREA N-151 CREAT-15.4 SODIUM-141
POTASSIUM-6.0 CHLORIDE-107 TOTAL CO2-15 ANION GAP-25
CALCIUM-5.7 PHOSPHATE-11.0 MAGNESIUM-2.7
HbA1c-5.5
[**Doctor First Name **]-NEGATIVE
SPEP-NO SPECIFIc, UPEP - no specific
HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc Ab-NEGATIVE IgM HBc-NEGATIVE
ANCA - neg, Complement - normal
Urine lytes: Creat:62 Na:75 TotProt:50 Prot/Cr:0.8
Renal ultrasound:
[**Doctor Last Name **] scale and color Doppler son[**Name (NI) 493**] images were obtained
that demonstrate the right kidney to measure 8.5 cm pole to pole
and the left 7.4 cm. Due to patient factors Doppler ultrasound
was nondiagnostic. Grossly, flow is demonstrated into the right
kidney. On the right there is no nephrolithiasis or
hydronephrosis. Several round avascular anechoic
structures with increased through-transmission are demonstrated,
the largest measuring 1.3 x 1.5 x 1.5 cm, likely renal cysts. In
the left kidney there moderate hydronephrosis and a hyperechoic
linear structure with posterior shadowing that may represent a
stone. Several avascular anechoic round structures are seen
measuring to 2.0 x 1.8 x 1.8 cm, likely renal cysts.
IMPRESSION:
1. Moderate left hydronephrosis. Probable nephrolithiasis on the
left. A
downstream cause for hydronephrosis is not elucidated by this
study.
2. Multiple bilateral simple renal cysts.
3. Non-diagnostic Doppler ultrasound study.
TTE:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Transmitral
Doppler and tissue velocity imaging are consistent with Grade I
(mild) LV diastolic dysfunction. There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. There are complex (>4mm) atheroma in the descending
thoracic aorta (cine loop #80). The number of aortic valve
leaflets cannot be determined. 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 pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild diastolic LV dysfunction. Aortic atherosclerosis
Renal scan:
INTERPRETATION: Flow and dynamic images were obtained after
intravenous administration of tracer.
Blood flow images show no appreciable flow to the left or
right kidney.
Renogram images show faint uptake in the left kidney and slow
persistent uptake with significant retention in the right
kidney.
The differential function obtained by analysis of tracer
concentration in the parenchyma from 2 to 3 minutes post tracer
injection shows the left kidney to be performing 37% of the
total renal function and the right kidney to be performing 63%.
Due to significant bilateral renal impairment, lasix was not
administered.
IMPRESSION: There is no significant flow to either kidney. There
is severe left greater than right renal impairment.
Non-contrast abd ct scan: IMPRESSION: 1. 13 mm obstructing left
pelvic-ureteral junction calculus with proximal hydroureter and
pelvicaliectasis.
2. 9 mm and 4-mm left renal pelvis calculi. 3. Numerous
bilateral renal cysts likely related to acquired cystic disease
of
dialysis.
Brief Hospital Course:
This is a 67 yo M, w/ vague past medical hx who presented to the
ED and was found to have acute kidney injury, hyperkalemia, and
anemia, of unclear etiology.
# Renal failure: Given history of chronic fatigue over last few
months, anemia, and Pt's relative stability in context of highly
[**Name (NI) **] BUN/Creatinine, suspect that Pt's renal failure likely
represents acute worsening of chronic renal insufficiency,
rather than a completely new acute event. He had an extensive
work up for his renal failure including: Renal ultrasound showed
moderate left hydronephrosis; Urine lytes showed FENa 13.2%
suggesting pre-renal etiology less likely; Other studies
including UPEP nonspecific, SPEP nonspecific, Serum [**Doctor First Name **] neg, ASO
negative, CK normal, complement normal, Hgb A1C <6, ANCA
negative, hepatitis serlogies negative, PSA 7, anti-GBM pending;
Renal scan showed no significant flow to either the right or
left kidney; CT abd showed multiple left-sided kidney stone.
Urology was consulted who felt these stones were most likely
chronic given that the patient was completely asymptomatic. His
kidney failure is likely multifactorial in etiology, with both
nephrolithiasis and hypertension contributing. He was initiated
on hemodialysis and had a right tunneled line placed while
admitted. He will have dialysis T/TH/Sat at [**Location (un) **] [**Location (un) **] and
will be followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with nephrology. He will
need follow up with his regular doctor [**First Name (Titles) **] [**Last Name (Titles) **] PSA and
enlarged prostate as an outpatient.
#Hyperkalemia: The patient's hyperkalemia is likely related to
his kidney disease. His potassium normalized while admitted and
after initiated on HD. Serial ECGs were followed, showing
resolution of peaked T waves seen on admission.
# Anemia: The patient's anemia is most likely chronic and
related to suspected chronic renal failure, especially
considering Pt's hx of medication to increase blood counts. Iron
studies were unrevealing for iron deficiency and there was no
evidence of hemolysis. This is likely anemia of chronic disease
as well as anemia of renal insufficiency. The patient was
started on Epo with dialysis. The patient will also need age
appropriate cancer screening as outpatient; this can be
scheduled by his regular doctor.
#Hypocalcemia/Hyperphosphatemia/Secondary hyperparathyroidism:
The patient's PTH was 397 in the setting of hypocalcemia and
hyperphosphatemia, suggesting secondary hyperparathyroidism in
the setting of renal failure-related hypocalcemia and
hyperparathyroidism. The patient's calcium was initially
repleted, and then remained in the 7-8 range after initiation of
dialysis. He was also started on TID Calcium Acetate and
Paricalcitol with dialysis.
# Hypertension: The patient's blood pressures were initially in
the 160s-170s/90s. He was started on Amlodipine 5mg daily, and,
after initiation on dialysis, had BPs in the 120-130/80 range.
His Cozaar was discontinued given concern for hyperkalemia as
well as concern for worsening kidney failure with [**Last Name (un) **] use in the
setting of acute kidney failure.
Medications on Admission:
albuterol
crestor
cozaar
plavix - per family, patient was put on this medication after
TIA
unknown "medication to increase blood counts"
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
2. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Capsule(s)* Refills:*0*
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Take after dialysis on Tues/Thurs/Saturday.
Disp:*30 Tablet(s)* Refills:*0*
4. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
ASDIR (AS DIRECTED).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB, wheeze.
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Paricalcitol 2 mcg/mL Solution Sig: 1.5 doses Intravenous
3X/WEEK (TU,TH,SA): give 3mcg with HD session three times per
week. .
9. Crestor Oral
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: 1. renal failure
Secondary diagnoses:
1. hypertension
2. hyperkalemia
3. hypocalcemia
4. anemia
5. [**Last Name (un) **] PSA
6. nephrolithiasis
7. hyperphosphatemia
Discharge Condition:
Improved, with HR 89, BP 125/87, resolution of shortness of
breath and nausea.
Discharge Instructions:
You were admitted to the hospital with fatigue and nausea.
While in the ED, lab tests showed that your kidneys were not
working. You were admitted to the ICU and started hemodialysis
(kidney replacement therapy). Dialysis does what your kidneys no
longer do--cleans toxins out of your blood. You need to get
dialysis regularly or you will feel ill and your heart could
beat abnormally.
We changed some of your medications and started some new ones:
1) We stopped your Cozaar.
2) We started you on Amlodipine 5mg by mouth daily for your
blood pressure.
3) You should take a Neprocaps vitamin once daily.
4) We started Calcium Acetate 1334mg by mouth three times a day
with meals.
Please call your regular doctor or return to the ED in case of
nausea, vomiting, diarrhea, all over itching, chest pain,
difficulty breathing, abdominal pain, the sensation of your
heart racing, fluttering or skipping beats, or any other new and
concerning symptoms.
Followup Instructions:
Your has been confirmed to begin out-patient dialysis on:
Thursday, [**2191-8-4**] at 3:15pm.
The address and phone number of the treatment facility is:
[**Location (un) **]-[**Location (un) **] Dialysis Center
[**State **]
[**Location (un) **] [**Numeric Identifier 1415**]
Phone: [**Telephone/Fax (1) 5972**]
Nephrologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Your schedule will be every Tues, Thurs and Sat at 3:30pm.
You will be seen by your Nephrologist (kidney doctor), Dr.
[**Last Name (STitle) **], while at dialysis.
You also have an appointment with: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with Priamry
[**Hospital 84877**] [**Hospital **] Clinic
Date and time: [**8-12**] at 3:30pm
Location: [**Hospital3 **], [**Hospital Ward Name 23**] Clinical Center, [**Apartment Address(1) 84878**] North
Phone number: [**Telephone/Fax (1) 250**]
|
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icd9cm
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icd9pcs
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[
[
[]
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11936, 12017
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2292, 2626
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,256
| 150,719
|
12441
|
Discharge summary
|
report
|
Admission Date: [**2162-8-16**] Discharge Date: [**2162-9-1**]
Date of Birth: [**2123-3-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
PNA, worsening respiratory status on chronic vent
Major Surgical or Invasive Procedure:
Dobhoff replacement
History of Present Illness:
Mr. [**Known lastname 38598**] is a 39 year-old male with hx of non-Hodgkin's
lymphoma s/p allsoSCT s/p DLI, complicated by PTLD treated with
rituxan, GVHD of the gut, liver, and lung with BOOP/pulmonary
fibrosis with chronic trach brought from [**Hospital1 **] with
increaseing sputum production and leukocytosis.
.
He was seen the week prior to admission in the [**Hospital 3242**] clinic and
was found to have a WBC of 19, however had been afebrile. He was
started on ceftazidime 2 gm IV q8h, and IV colistin at 150 mg IV
q 12 hours, and continued on inhaled colistin 75 mg (given hx of
recurrent pseudomonas PNAs). Sputum cultures were unremarkable
and his WBC improved to 11 with noted clinical improvement. He
was continued on the ceftaz (to complete a 14-day course). Dr.
[**Last Name (STitle) 724**] (his ID doctor) was called by [**Hospital1 **] this morning with
report of increasing oxygen requirement, blocked feeding tube,
and leukocytosis to 17.5. Also reportedly had an VBG with a pH
of 7.20, PCO2 of 68 on [**8-14**]. The pulmonologist who saw him felt
he wasn't ventilating enought and increased his PS from 14 to 18
cm H2O to increase TV to 480 cc.
.
He acutely became short of breath at [**Hospital1 **] today in the
setting of having increased cough and pulmonary secretions, and
increasing WBC, so was brought to the ED for evaluation.
.
In the ED, initial vs were: T 98.5 P 111 BP 135/91 R 30 100% on
O2 sat. CXR showed a retrocardiac opacity stable from prior.
Patient was given 1 gm IV vancomycin, 4.5 gm IV zosyn, and 4 mg
morphine IV.
.
On admission he denied shortness of breath, pain, or other
symptoms. Per report from his rehab, his feeding tube is
clogged.
.
Past Medical History:
Past Oncologic History:
- [**4-/2154**] p/w fevers, night sweats, and weight loss in the
setting of a left inguinal lymph node.
- CT scan: 15x14x10cm mass in the LUQ.
- Bx grade II/III follicular lymphoma.
- Treated with six cycles of CHOP/Rituxan with good response,
but showed evidence for relapse in [**12/2154**] and was treated with
MINE chemotherapy for two cycles.
- [**3-/2155**]: Underwent stem cell mobilization with Cytoxan followed
by autologous stem cell transplant in
- [**7-/2155**]: Noted for disease recurrence. He was initially treated
with a course of Rituxan without response followed by Zevalin
with
- [**3-/2156**]: Noted progression of his disease. He was treated with
one cycle of [**Hospital1 **] followed by one cycle of ESHAP.
- [**2156-7-29**]: Nonmyeloablative allogeneic stem cell transplant
with a [**5-30**] HLA-matched unrelated donor with Campath conditioning
- Six-month follow-up CT noted for disease progression.
- [**1-/2157**]: Received donor lymphocyte infusion in , complicated by
acute liver/GI GVHD grade IV, for which [**Known firstname **] required a
prolonged hospitalization in the summer of [**2156**].
- Multiple GI bleeds requiring ICU admissions and multiple
transfusions and embolization of his bleeding.
- Noted to have CNS lesions felt consistent with PTLD and this
was treated with a course of Rituxan. No evidence for recurrence
of the PTLD.
- Acute liver GVHD, on CellCept, prednisone, and photophoresis.
- [**2157-12-28**] Photophoresis was d/c'd due to episodes of
bacteremia and eventual removal of his apheresis catheter.
- [**2158-6-13**] restarted photopheresis on a weekly basis on , but
then discontinued this again on [**2158-9-7**] as this was felt not
to be making any impact on his liver function tests.
- undergone phlebotomy due to iron overload with corresponding
drop in his ferritin. He has continued with transient rises in
his transaminases and bilirubin and has remained on varying
doses of CellCept and prednisone which has been slowly tapered
over the time.
- [**2160-1-10**] CellCept discontinued.
- [**2159-1-19**] admission due to increasing right hip pain. MRI
revealed edema and infiltrating process in the psoas muscle
bilaterally. After extensive workup, this was felt related to an
infection and required several admissions with completion of
antibiotics in 03/[**2158**].
- [**7-/2160**]: Last scans showed no evidence for lymphoma and he has
remained in remission.
- [**2160-10-20**]: URI and treatment with course of Levaquin.
- [**2160-11-13**] completed a 4 week course of Rituxan to treat his
GVHD.
-In [**5-/2161**], noted to have tiny echogenic nodule on abdominal
[**Year (4 digits) 950**]. MRI of the liver also showed this nodule but was not
as concerning on review and he is due to have a repeat MRI
imaging in early [**Month (only) **].
-- GI varices and attempts at banding have been unsuccessful due
to difficulty with passing the necessary instruments. He has
been on a low dose beta blocker as well as simvastatin, which
was started on [**2161-7-7**] to help with medical management of his
varices.
-On [**2161-8-3**], worsening cough and was noted to have a small
new pneumothorax in the left apical area. This has essentially
resolved over time
- Issues with weight loss (followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]);
multiple tests done with no etiology found; question
malabsorption related to GVHD
- Has on and off respiratory infections and has been treated
with antibiotics (now colistin inhaled and IV) for resistant
pseudomonas. Question underlying exacerbations of pulmonary GVHD
in setting of his URIs.
- Currently receives IVIG every month.
.
Other Past Medical History:
1. Non-Hodgkin's lymphoma s/p allo SCT
2. Grade 4 Acute GVHD of GI/liver following DLI with GI bleed,
chronic transaminitis, portal HTN with esophageal varices (not
able to band)
3. History of intracranial lesions felt consistent with PTLD.
4. Extensinve chronic GVHD of lung, liver, skin, mucous
membranes.
5. Grade II esophageal varices, intollerant to beta blockade.
6. HSV in nasal washing [**11/2159**](completed course of Valtrex)
7. Hypothyroidism
8. hx of Psoas muscle infection
9. Recurrent resistant Pseudomonal PNAs on long term inhaled
Colistin
Social History:
Smoke: never
EtOH: none currently; occassional use prior to NHL dx
Drugs: never
Born in [**Country **] and moved to the U.S. for college ([**Hospital1 **]).
Married in [**2160-8-25**] and lives in [**Location **]. No children.
Stays at home and writes (currently writing a book on being
diagnosed with cancer at young age).
Family History:
No lymphoma or other cancers in the family. Father had CAD s/p
PCI.
Physical Exam:
Admission Physical Exam:
Vitals: T: 98.2 BP: 127/89 P: 96 R: 19 O2: 100% on PS 15, PEEP 5
fiO2 35%
General: Young, thin male lying in bed in NAD.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: trach in place with the ventilator attached
Lungs: Being ventilated comfortably. Coarse breath sounds
bilaterally.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: +BS, soft NTND
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE
Vitals: T: 98.4 BP: 120/80 P: 97 R: 19 O2: 100% on Assist
Control
General: cachectic, thin male, flat affect
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: trach in place, no JVD
Lungs: Coarse breath sounds bilaterally stable from prior
CV: mildly tachycardic, RRR, nlS1/S2, no mrg
Abdomen: +BS, soft NTND
Ext: WWP, 2+ pulses, no clubbing, cyanosis or edema
Pertinent Results:
DISCHARGE LABS ([**2162-9-1**])
Chem7
140 104 33
--------------<81
3.8 23 0.6
Ca: 9.1 Mg: 2.0 P: 3.9 ∆
CBC
WBC12.0
Hgb 8.0
Hct 25.4
Plt 423
ALT: 131
AP: 938
Tbili: 0.5
Alb: 3.2
AST: 164
LDH: 275
IMAGING:
[**8-16**] CXR - IMPRESSION: Left retrocardiac atelectasis/pneumonia,
stable to mildly improved. Trace right pleural effusion.
[**8-17**] [**Last Name (un) **]-INTESTINAL TUBE PLACEMENT: Successful replacement of
feeding tube which is post-pyloric in location.
[**8-17**] CT Chest
1. Multifocal predominantly peribronchovascular nodular and
ground-glass
opacities, suggestive of an infectious process which is improved
in certain
areas and unchanged to worst in certain other areas. Atypical
infections are a
consideration.
4. Smaller right and unchanged small left pleural effusion and
more confluent
left lower lobe opacity, could be atelectasis or consolidative
manifestation
of the infectious process.
5. Coronary artery calcifications including vascular
calcifications, atypical
in this age group.
6. Three sclerotic left sided rib lesions, two of which are new,
could
represent lymphomatous involvement.
[**8-23**] CXR
IMPRESSION: Worsening retrocardiac opacity. Otherwise, no
significant interval change.
CULTURE DATA:
[**2162-8-17**] 10:59 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2162-8-31**]**
GRAM STAIN (Final [**2162-8-17**]):
THIS IS A CORRECTED REPORT ([**2162-8-18**]).
REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 38653**] 8:10AM.
[**10-18**] PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
CONSISTENT WITH
CORYNEBACTERIUM OR
PROPIONIBACTERIUM SPECIES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
PREVIOUSLY REPORTED ([**2162-8-17**]) AS:.
[**10-18**] PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
CONSISTENT WITH
CORYNEBACTERIUM OR
PROPIONIBACTERIUM SPECIES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2162-8-31**]):
MODERATE GROWTH Commensal Respiratory Flora.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
DORIPENEM SUSCEPTIBILITY REQUESTED BY DR. [**Last Name (STitle) **].
SATYANARAYANA
(#[**Numeric Identifier 38654**]) [**2162-8-20**].
DORIPENEM: SENT TO [**Hospital1 4534**] FOR SENSITIVITIES.
DORIPENEM = >2 UG/ML NOT SUSCEPTIBLE (BOTH TYPES).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 16 S
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- =>16 R
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ =>16 R
[**2162-8-25**] 9:32 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2162-8-25**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Preliminary):
RARE GROWTH Commensal Respiratory Flora.
COLISTIN REQUESTED BY DR. [**Last Name (STitle) 2323**] #[**Numeric Identifier 38654**].
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| PSEUDOMONAS AERUGINOSA
| |
AMIKACIN-------------- 16 S 16 S
CEFEPIME-------------- 16 I 32 R
CEFTAZIDIME----------- 16 I 16 I
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ =>16 R =>16 R
MEROPENEM------------- =>16 R =>16 R
PIPERACILLIN/TAZO----- =>128 R =>128 R
TOBRAMYCIN------------ =>16 R =>16 R
Brief Hospital Course:
Mr. [**Known lastname 38598**] is a 39 year-old male with hx of non-Hodgkin's
lymphoma s/p allsoSCT s/p DLI, complicated by PTLD treated with
rituxan, GVHD of the gut, liver, and lung with BOOP/pulmonary
fibrosis with chronic trach here with increasing sputum
production and leukocytosis.
.
# PNA: He presented for this hospital admission with increasing
sputum production, increasing respiratory requirements, and SOB.
As per his ID attending, at that time the patient was continued
on inhaled colistin, IV colistin and IV fluconazole. On
admission, these were continued and the patient's coverage was
broadened by replacing IV ceftazadine with IV doripenem. His
admission sputum culture grew out multidrug resistant
pseudomonas, sensitive to amikacin and intermediate for
ceftazadine. In response to these sensitivities, the patient
was restarted on ceftazadine (with extended infusion times in
order to maximize time dependent bacterial killing) and his
doripenem was stopped. At this point, the patient had
increasing secretions in setting of a WCC spike, bandemia and
fever. It was believed that this represented evolving
resistance to ceftazadine versus a new infection not otherwise
covered. Patient's coverage was rebroadened--doripenem was
added back (as his decline in respiratory functioning began
after it had been stopped). His fungal coverage was eventually
changed to micafungin in order to more broadly cover against
potential fungal infections. Patient had clinical improvement,
with WCC trending down, afebrile status, ability to tolerate
assist control on ventilator. Cetazadine was stopped at this
time. At this time, on the patient's admission sputum culture,
a send-out sensitivity to doripenem came back resistant;
however, after discussion with the ID team, it was decided that
given his clinical response to doripenem, he would be continued
on this therapy. He was scheduled for outpatient follow-up with
Dr. [**Last Name (STitle) 724**] on [**9-14**].
.
#Respiratory Requirements: Aside from those respiratory issues
discussed above relating to the patient's PNA, issues relating
to his respiratory status have included the patient's need for
pressure support, but refusal of this setting. He can
moderately tolerate assist control, and prefers it, despite
recommendations that he remain on pressure support. He has
requested a swallow study and P-M valve, but is not a candidate
for it unless he agrees to have his settings changed over to
pressure support.
.
# Clogged feeding tube/Nutrition: The dobhoff tube was replaced
by IR and he was continued on tube feeds in addition to TPN
(given his inability to tolerate heavy feeding via dobhoff).
Given the tendency of crushed cellcept pills to clog the
patients dobhoff, he is only able to receive cellcept
suspension. However, his oncologist felt that it would be
reasonable to stop cellcept for a short time. He is currently
off this medication. His tube feeds are to be administered at
half strenght. Whenever available liquid suspensions of
medications should be given per NGT rather than crushing the
tablets.
# s/p alloSCT complicated by GVHD: He was transitioned to PO
Predinisone. He was maintained on his prophylaxis regiment of
Acyclovir and bactrim. His LFTs have an elevated baseline [**1-26**]
to GVHD, but were noted to be trending upward during the course
of this hospitalization. To aid in treatment of his PNA, his
cellcept was discontinued on [**2162-8-31**]. He was discharged with
instructions to have his LFTs followed q3days, and restarting
cellcept would be considered at follow-up oncology appointment.
An appointment was also made for the patient with the Lung
[**Hospital 1326**] Clinic at [**Hospital6 **]. His IgG was followed
over the course of the admission--it was 705 on [**8-16**], but had
dropped to 480 on [**8-25**]. He received IVIG on [**8-26**].
.
# Chronic anemia: Hct of 30 on admission with baseline in the
mid to high 20's. His HCT, varied between the low and high 20s.
He was asymptomatic and did not require any transfusions.
Medications on Admission:
Medications:
1. Acetylcysteine 20 % (200 mg/mL) Solution [**Month/Day (2) **]: 1-10 MLs Q6H
prn
2. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup 5 ML PO Q6
prn
3. Pantoprazole 40 mg IV daily
4. Lorazepam 0.5 mg Tablet, 1-2 Tablets PO HS prn
5. Methylrednisolone 10 mg IV daily
6. Zinc Sulfate 220 mg po daily
7. Ascorbic Acid 500 mg po daily
8. Cyanocobalamin 250 mcg po daily
9. Ergocalciferol 50,000 unit Capsule PO QSAT
10. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid 5 mL po
daily
11. Simethicone 80 mg po TID prn
12. Acyclovir 400 mg PO Q12H
13. Lorazepam 2 mg PO Q4H prn
14. Voriconazole 200 mg PO Q12H
15. SQH tid
16. Levothyroxine 125 mcg po qMON-SAT
17. Insulin Lispro 100 unit/mL Solution [**Month/Day (2) **]: 2-12 units SQ per
sliding scale
18. Colistimethate Sodium 150 mg Recon Soln 75 mg Injection [**Hospital1 **]
19. Albuterol 90 mcg/HFA Aerosol Inhaler 6 Puff Inhalation Q4H
prn
20. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
21. Mycophenolate Mofetil HCl 500 mg Recon Soln 500 mg IV BID
22. CefTAZidime 2 g IV Q8H
23. Bactrim DS 800-160 mg Tablet PO qMWF
24. Zofran 2 mg/mL Solution 2 mg Intravenous every 6-8h prn
25. Morphine 3 mg IV q2 hrs prn
26. Fluticasone 50 mcg/Spray 1 Nasal once a day.
27. Colisin Inh 75 mg [**Hospital1 **]
Discharge Medications:
1. Acyclovir 400 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every 12
hours): per NGT.
2. Acetaminophen 650 mg/20.3 mL Solution [**Hospital1 **]: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for fever or pain.
3. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Age over 90 **]: Six
(6) Puff Inhalation Q6H (every 6 hours) as needed for SOB.
4. Ascorbic Acid 500 mg/5 mL Syrup [**Age over 90 **]: Five (5) ML PO once a
day.
5. Colistin 125 mg IV Q12H
d1 [**8-17**]
6. Colistin Sulfate (Bulk) 1,000,000,000 unit Powder [**Month/Year (2) **]:
Seventy Five (75) MG Miscellaneous [**Hospital1 **] (2 times a day): INHALED
to be administered over 10 minutes.
7. Cyanocobalamin (Vitamin B-12) 1,000 mcg/15 mL Suspension [**Hospital1 **]:
Two [**Age over 90 1230**]y (250) MCG PO once a day.
8. Docusate Sodium 50 mg/5 mL Liquid [**Age over 90 **]: One Hundred (100) MG
PO BID (2 times a day).
9. Doripenem 500 mg Recon Soln [**Age over 90 **]: 1000 (1000) MG Intravenous
every eight (8) hours: Please infuse over 4 hours. .
10. Lovenox 40 mg/0.4 mL Syringe [**Age over 90 **]: Forty (40) MG Subcutaneous
once a day: For DVT prophylaxis.
11. Outpatient Lab Work
Please check CBC, ALT, AST, Alk Phos, Total bilirubin, LDH every
third day until [**2162-9-15**]
12. DiphenhydrAMINE 12.5 mg IV Q6H:PRN itching
13. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Year (4 digits) **]: Three
Hundred (300) MG PO once a day.
14. Guaifenesin 100 mg/5 mL Syrup [**Year (4 digits) **]: Ten (10) ML PO Q6H (every
6 hours).
15. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
16. Levothyroxine 125 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Daily
[**Last Name (STitle) 766**] through Saturday.
17. Humalog 100 unit/mL Solution [**Last Name (STitle) **]: 2-10 units Subcutaneous
every six (6) hours: As directed according to sliding scale. .
18. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime) as needed for insomnia: Per NGT. .
19. Lorazepam 1 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q4H (every 4
hours) as needed for anxiety: Per NGT.
20. Micafungin 100 mg IV Q24H
21. Zofran 4 mg/5 mL Solution [**Last Name (STitle) **]: 4-8 MG PO every eight (8)
hours as needed for nausea.
22. Prednisone 5 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO DAILY
(Daily): Per NGT.
23. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation: Per NGT.
24. Sulfamethoxazole-Trimethoprim 200-40 mg/5 mL Suspension [**Last Name (STitle) **]:
Twenty (20) ML PO M/W/F ().
25. Zinc Sulfate 220 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY
(Daily).
26. Normal Saline [**Last Name (STitle) **]: 250-500 ML Intravenous once a day as
needed for Fever, Dehydration: Please administer over 30-60
minutes.
27. Normal Saline [**Last Name (STitle) **]: Fifty (50) ml/hr Intravenous continuous
infusion for 2 days: Please administer NS at the above rate in
between antibiotics. Please re-evaluate need for continous fluid
after 1-2 days and discontinue as appropriate. .
28. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnosis:
Recurrent Pneumonia
Respiratory Failure, chronically on ventillator
Secondary Diagnosis:
Bronchiectasis
GVHD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 38598**]-
Thank you for receiving your care at [**Hospital3 **] Hospital. You
were admitted to the hospital for recurrent pneumonia in the
setting of Graft versus Host Disease. A culture of your sputum
revealed that the bacteria pseudomonas was likely the cause of
your pneumonia. Your intravenous and inhaled colistin
(antibiotics) were continued, and you were also started on
intravenous doripenem for improved treatment of your pneumonia.
The infectious disease specialists and the bone marrow
transplant team also followed your clinical course. You will be
discharged to a rehabilitation facility for continued following
and treatment of your respiratory status.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Hospital 1326**] Clinic
Location: [**Hospital6 **] Hospitalk, [**Last Name (NamePattern1) **],
[**Location (un) 86**], MA
Date/Time: Friday, [**2162-9-3**] at 11:30am
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD
Phone: [**Telephone/Fax (1) 3241**]
Location: [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
Date/Time: [**2162-9-14**] 1:00 pm
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], [**Name12 (NameIs) 280**]
Phone: [**Telephone/Fax (1) 3241**]
Location: [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
Date/Time: [**2162-9-14**] 1:00pm
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD
Phone:[**Telephone/Fax (1) 3241**]
Location: [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
Date/Time:[**2162-9-14**] 1:30 pm
Provider: [**Name10 (NameIs) 13645**],[**Name11 (NameIs) **]
Department: Endocrinology
Time/Date: [**2162-9-23**] 02:30p
Location: [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
Telephone: ([**Telephone/Fax (1) 9072**]
Should patient request to have a Swallow evaluation, he will
need to be stable with pressure support ventilator settings.
Should he agree to be placed on pressure support (so far he has
refused), an appointment can be made for an evaluation at [**Hospital1 18**]
by calling [**Telephone/Fax (1) 38655**].
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"202.80",
"279.53",
"285.22",
"456.8",
"V46.11",
"E849.8",
"V44.0",
"783.3",
"996.59",
"516.8",
"518.83",
"456.1",
"482.1",
"996.85",
"785.0",
"244.9",
"E879.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"99.15",
"97.01"
] |
icd9pcs
|
[
[
[]
]
] |
20888, 20958
|
12089, 16164
|
371, 392
|
21131, 21131
|
7743, 11169
|
22030, 23620
|
6787, 6856
|
17489, 20865
|
20979, 20979
|
16190, 17466
|
21307, 22007
|
6896, 7724
|
11210, 12066
|
282, 333
|
420, 2111
|
21088, 21110
|
20998, 21067
|
21146, 21283
|
5871, 6429
|
6445, 6771
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,830
| 193,970
|
21368
|
Discharge summary
|
report
|
Admission Date: [**2106-8-8**] Discharge Date: [**2106-9-3**]
Date of Birth: [**2061-2-9**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
Presented after Fall
Major Surgical or Invasive Procedure:
craniotomy
EVD placement
tracheostomy
PEG
ARF
History of Present Illness:
Ms. [**Known lastname **] is a 45 yo woman with a history of type 1 diabetes
mellitus status post live donor renal transplant [**2-10**], cavaderic
pancreas transplant [**2-11**], CMV infection, pancreatic head AV
fistula s/p embolization [**3-14**], medication induced pancytopenia,
who presents as transfer from OSH after found to have
intraparenchymal cerebellar hemorrhage s/p fall. The patient
has reportedly been well for the 1-2 years and was walking her
neighbor's dog on the day of admission when she was reportedly
pulled down by the dog, striking the back of her head. There
was bleeding and she was taken to an OSH in [**Location (un) 20291**]. There
was no report of LOC and she was reported to be neurologically
intact at the OSH. There was an intraparenchymal hemorrhage
found and she was transferred here by [**Location (un) **]. En route she
was given fentanyl 50 mcg IV x 2 doses for pain. On arrival to
our ED she was alert and oriented, following commands but
drowsy.
She was unable to give any other account of the accident. Her
children were the only witnesses to the event and are not
present.
ROS: she endorses pain in her head but is otherwise unable to
give ROS.
Past Medical History:
1. Live donor kidney transplant in [**2103-4-8**] in the left lower
quadrant
2. Cadaveric pancreas transplant in [**2104-2-6**] complicated by
pancreatic head AV fistula/pancreatitis status post AV fistula
embolization [**3-/2104**]
3. Type I DM
4. Hypothyroid
5. ESRD previously on peritoneal dialysis
6. Retinopathy
7. Left tib-fib fracture with internal fixation
8. Right and left breast lumpectomy
9. Restless legs syndrome
Social History:
Social Hx: Husband died 1 year ago, two young children. Siblings
are next of [**Doctor First Name **]: Brother [**Name (NI) **] [**Name (NI) 56461**] [**Telephone/Fax (1) 56462**]. Sister [**Name (NI) **]
also present [**Telephone/Fax (1) 56463**].
Family History:
Non-contributory.
Physical Exam:
PHYSICAL EXAM:
On admission T: BP: 155/51 HR: 70 R 23 O2Sats 100 on
NRB
Gen: lethargic, calling for help and complaining of pain
intermittently.
HEENT: cannot evaluate fracture of occiput currently secondary
to
collar
Neck: in hard collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Back: no point tenderness along T/L spine
Extrem: Warm and well-perfused. Left arm in short cast.
Neuro:
Mental status: Awake, sleepy, following simple commands x 4,
answering some simple questions initially, but unable t give
account of accident. Orientation: Oriented to person, M/D/yr.
Calling out for "help", asking to have NRB mask removed. Speech
mildly dysarthric.
Cranial Nerves:
I: Not tested
II: Pupils: right 3 to 2 and left 4 to 2 initially EOMs:
right eye deviated downwards slightly, tracks past midline to
left and only past midline slightly to right, but difficult to
assess if there is some degree of inattention here.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: V [**1-10**] intact to LT bilaterally. Right facial excursion
somewhat decreased compared to left.
VIII: Hearing intact to voice.
IX, X: Palatal elevation difficult to assess with hard collar in
place
[**Doctor First Name 81**]: trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. Antigravity x 4 and [**4-12**]
in triceps bilaterally.
Sensation: not assessed on initial eval secondary to time
contraints.
Reflexes: B T Br Pa Ac
Right 2+ throughout
Left 2+ throughout
Toes up bilaterally
Coordination: unable to assess as patient was intubated by this
time.
Exam on Discharge:
XXXXXXXXXXXXXXXXX
Pertinent Results:
Imaging:
On [**8-8**] Head CT in the [**Hospital1 18**] ED showed increased area of
hemorrhage 4.7 cm x 4.0 cm with effacement of 4th ventricle
(which is new from prior) and masseffect. Also ascending
herniation. Possibly very small left frontal SAH.
[**8-8**] Post-op Head CT:No new regions of intraparenchymal
hemorrhage, with stable appearance of remaining right cerebellar
hemorrhage and intraventricular hemorrhage, without evidence of
hydrocephalus. Less conspicuous left frontal subarachnoid
hemorrhage, consistent with evolving blood products.
[**8-14**] MR [**Name13 (STitle) 430**]:Post-traumatic sequela in the brain. Blood products
in bilateral cerebellar hemispheres with extensive surrounding
edema. There is a small amount of edema in the right aspect of
the pons and bilateral middle cerebellar peduncles. There is
ascending transtentorial herniation. The ventricles are
unchanged in size compared to the prior study.
[**8-16**] Head CT: Persistent hypodensities in the bilateral superior
cerebellar
hemispheres, suggestive of the superior cerebellar infarcts.
Intraparenchymal hemorrhage and postsurgical hematoma in the
right cerebellum is stable without new bleeding. The degree of
mass effect resulting from cerebellar cytotoxic edema has
decreased since prior study.
[**8-26**] Head CT:1. Removal of ventricular catheter. Interval
development of small subdural collection at the previous site of
catheter entry, without significant associated mass effect. 2.
Continued evolution of cerebellar hemorrhage, without evidence
for new bleed. 3. Stable hypodensities of the bilateral
cerebellar hemispheres, of unclear etiology, likely chronic.
4. Stable mucosal thickening in the paranasal sinuses with
partial opacification of the mastoid air cells.
[**8-31**] CT abdomen with po contrast: 2-mm nonobstructing stone in
the transplant kidney. There is linear atelectasis within the
visualized lung bases. The liver, gallbladder, spleen, and
adrenal glands are unremarkable. The native kidneys and pancreas
are atrophic. A G-tube lies within the stomach. There are no
enlarged mesenteric or retroperitoneal lymph nodes. There is no
free air or free fluid in the abdomen.
Labs on Admission:
[**2106-8-8**] 06:52PM GLUCOSE-191* UREA N-19 CREAT-1.0 SODIUM-138
POTASSIUM-3.8 CHLORIDE-109* TOTAL CO2-18* ANION GAP-15
[**2106-8-8**] 06:52PM CALCIUM-9.4 PHOSPHATE-1.0*# MAGNESIUM-2.0
[**2106-8-8**] 06:52PM WBC-12.2* RBC-5.06 HGB-15.6 HCT-46.7 MCV-92
MCH-30.8 MCHC-33.4 RDW-15.0
[**2106-8-8**] 06:52PM PLT COUNT-225
Labs on Discharge:
[**2106-9-3**] 06:30AM BLOOD WBC-5.7 RBC-3.43* Hgb-10.8* Hct-33.0*
MCV-96 MCH-31.6 MCHC-32.8 RDW-17.3* Plt Ct-329
[**2106-9-3**] 06:30AM BLOOD Glucose-115* UreaN-19 Creat-0.8 Na-136
K-3.9 Cl-103 HCO3-25 AnGap-12
[**2106-9-3**] 06:30AM BLOOD ALT-17 AST-23 LD(LDH)-253* AlkPhos-56
Amylase-189* TotBili-0.3
[**2106-9-3**] 06:30AM BLOOD Albumin-3.6 Calcium-10.1 Phos-3.0 Mg-1.6
Brief Hospital Course:
Neurosurgical Course: admitted to the Neurosurgery service after
a fall and was emergently taken to the OR, where under general
anesthesia, she underwent external ventricular catheter
placement and left craniectomy and evacuation of hemorrhage.
Procedure was well tolerated and then she was transferred to
ICU, where she was closely monitored. She did spike several
fevers and subsequent work up revealed H. flu in sputum and
C.Diff and she was treated with antibiotics. She has had
negative cultures for MRSA and CSF. Her EVD was slowly raised
and clamped over several days and then removed on [**8-20**]. Repeat
CTs showed resolving blood and persistent hypodensities in the
bilateral cerebellar hemispheres. Her sutures and staples were
later removed. On [**8-25**] she was having guaiac positive stools and
episodes of hypotension. GI was consult and stated there was no
need to scope on an inpatient basis, and she could be followed
as an outpatient. Given her medical history of transplant, the
[**Hospital1 18**] transplant service has been following her hospital course.
Her amylase and lipase have been slowly and consistently rising.
Transplant service was notified, and they suggested monitoring
these labs QOD. She was then transferred to step down and her
blood pressure continued to be labile. She also had an episode
of tachycardia in the 130s in which her BP was stable, and
responded well to lopressor. Her lopressor was adjusted and she
had episodes of lower BP while sleeping and it appropriately
responds with stimulation. Her exam has consistently waxed and
[**Last Name (un) **] ed. On [**8-30**] she did have slight spontaneous movement with
the LUE however, no movement with the RUE with noxious stimuli.
She did have bilateral spontaneous movements of Lower
extremities (L>R). Evaluations with Physical and occupational
therapy deemed her to be an appropriate candidate for
rehabilitation however on [**8-31**] her Lipase continued to rise and
Cr bumped although neurologic exam was stable. [**8-31**] CT
abd/pelvis done showing no significant abnormalities. In
collaboration with transplant it was agreed to hydrate
aggressively and check Cr in am. Cr on [**9-1**] up to 1.8 and it was
agreed to transfer patient to the transplant service for medical
management.
Medical Course: Ms. [**Known lastname **] was transferred to the medical
service on [**2106-9-1**] because of acute renal failure. She was
hydrated and her creatinine returned to [**Location 213**] (0.8 at
discharge). The patient had developed significant diarrhea on
the days preceding transfer, thought to be due to the increase
in tube feed rate vs. refractory C. difficle infection. Her tube
feed rate was decreased and the diarrhea resolved. This is less
likely a C.difficle infection given the lack of fever, no
leukocytosis and the rapid improvement in decrease in tube feed
rate. Should her diarrhea return, would consider checking for
C. difficle. She had persistent mild hypercalcemia and was
treated with lasix (improved at discharge). She had significant
polyuria (2-3 liters UOP per day) thought to be due to
hypercalcemia, the normal saline resuscitation and the tube
feeds). At rehabilitation, she needs to have approximately 2.5-3
liters per day of intake (tube feeds and free water boluses).
Lastly, she had persistent tachycardia with HR 110-120. This
continued after volume resuscitation and pain control. She was
treated with escalating doses of metoprolol. As it was unlikely
(no change in ECG or oxygen requirement), imaging to rule out
pulmonary embolism was not obtained. Given her intracranial
bleed, she is not a candidate for anticoagulation. Lastly, she
was continued on her anti-rejection medications and follow up
with her transplant physician was arranged prior to discharge.
Medications on Admission:
Medications prior to admission:
Unclear what medications patient is taking exactly as she has no
list, brother and sister who are next of [**Doctor First Name **] do not know her
medications other than ativan prn and "transplant meds", and her
pharmacy [**Location 56464**] Pharmacy ([**Telephone/Fax (1) 56465**] is closed today.
Preliminary list based on medications recently refilled in OMR
is:
Bactrim 400/80 once daily, refilled [**11-14**] with 9 mo supply
Cellcept 250mg PO BID, refilled [**4-15**]
Prograf 1mg PO BID, refilled [**11-14**] with 9 mo supply
Levoxyl 100 mcg daily, refilled 7/08
Per brother: ativan prn anxiety dose unknown
Per notes, may be taking amiodarone but cannot confirm.
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO BID (2 times a day)
as needed.
3. Docusate Sodium 50 mg/5 mL Liquid [**Month/Year (2) **]: 10cc PO BID (2 times
a day).
4. Mycophenolate Mofetil 200 mg/mL Suspension for Reconstitution
[**Month/Year (2) **]: Five Hundred (500) mg PO BID (2 times a day).
5. Levothyroxine 100 mcg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
6. Trimethoprim-Sulfamethoxazole 40-200 mg/5 mL Suspension [**Month/Year (2) **]:
Ten (10) ml PO DAILY (Daily).
7. Levetiracetam 500 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2
times a day).
8. Regular Insulin Sliding Scale
Sliding scale per the Nursing Sliding Scale Form
9. Tacrolimus 1 mg Capsule [**Month/Year (2) **]: Three (3) Capsule PO BID (2
times a day): Please open capsule and place medication on spoon
and give sub lingual.
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
11. Heparin, Porcine (PF) 10 unit/mL Syringe [**Last Name (STitle) **]: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
12. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
13. Acetaminophen 500 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO every six
(6) hours as needed for fever or pain: not to exceed 4 grams/24
hours.
14. Oxycodone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every four (4)
hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Traumatic brain injury
Cerebellar hemorrhage
Clostridium difficle colitis
Acute renal failure in allograft
Polyuria
Sinus tachycardia
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with a head injury and bleeding into your
brain. While in the hospital, you required the placement of a
feeding tube and tracheostomy. Also, you developed an infection
in your colon requiring antibiotics and acute renal failure in
the setting of dehydration.
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
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
1. Neurosurgery follow up: PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE
AN APPOINTMENT WITH DR.[**Last Name (STitle) 739**] TO BE SEEN IN 4 WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST
2. Transplant Medicine follow up: Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2106-9-22**] 10:30. [**Hospital **] Medical
Building, [**Location (un) **]
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
|
[
"333.94",
"E884.9",
"362.10",
"427.89",
"276.7",
"V42.83",
"V42.0",
"787.91",
"276.1",
"276.2",
"788.42",
"275.42",
"584.9",
"008.45",
"250.01",
"041.5",
"244.9",
"853.00",
"401.9",
"285.9",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.39",
"43.11",
"38.93",
"93.90",
"31.1",
"38.91",
"01.39",
"03.31",
"96.04",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
13255, 13327
|
7022, 10828
|
286, 334
|
13505, 13514
|
4064, 4336
|
15177, 15193
|
2295, 2314
|
11581, 13232
|
13348, 13484
|
10854, 10854
|
13538, 15154
|
2344, 2748
|
15418, 15729
|
10886, 11558
|
226, 248
|
6624, 6999
|
362, 1560
|
3033, 4007
|
4026, 4045
|
5377, 6263
|
6277, 6605
|
2763, 3017
|
1582, 2011
|
2027, 2279
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,036
| 164,343
|
14145+14146+14147
|
Discharge summary
|
report+report+report
|
Admission Date: [**2109-7-24**] Discharge Date: [**2109-8-1**]
Date of Birth: [**2046-6-13**] Sex: F
Service: [**Hospital1 212**]
HISTORY OF PRESENT ILLNESS: The patient is a 63 year old
female with a complicated history including Sjogren's
syndrome and a hip replacement [**2109-4-16**]. Her immediate
postoperative course was complicated by a right thigh hematoma
requiring evacuation, renal failure secondary to acute tubular
necrosis and right leg neurologic deficit. She was discharged to
rehabilitation on [**2109-5-3**], but was readmitted on [**2109-5-9**], for
recurrence of the right thigh hematoma. Cultures from this
evacuation grew Staphylococcus epidermidis and extended spectrum
lactamase producing Klebsiella pneumoniae requiring removal
of the right hip prosthesis and placement of a cement spacer
on [**2109-5-20**], which subsequently fractured.
admission despite anticoagulation. She had a prior history
of deep vein thrombosis and is documented to have an
antiphospholipid antibody syndrome. An inferior vena cava
filter was placed on [**2109-6-4**], and she was maintained on
Lovenox. She developed a painful neuropathy in her right
foot since the original operation on [**2109-4-16**], which has been
controlled with Neurontin. She has developed pressure ulcers
on her sacral decubitus and bilateral heels, having been
bedridden since [**Month (only) 116**] of this year. In addition, she had
symptoms of depression and adjustment disorder and was
started on Ritalin and Remeron with good response. She was
discharged to [**Hospital1 **] Rehabilitation on [**2109-6-17**].
Her stay at rehabilitation was notable for hypercalcemia
treated with intravenous Lasix and intravenous fluids,
Klebsiella urinary tract infection and was found to be
Clostridium difficile positive on [**2109-7-17**], for which she was
started on Flagyl. She continued on a total of 6 weeks of IV
antibiotics ( vancomycin and meropenem).
One week prior to admission and 1-2 weeks after completing her
antibiotic course her right hip was aspiration
to document clearance of the infection with reportedly negative
cultures. She was admitted preoperatively to go to the operating
room for removal of cement spacer and new hip prosthesis.
Review of systems on admission was positive for diarrhea for
about one week with associated abdominal cramping. She also
reported arthritic pains, particularly in her hands. She
denied fever, chills, chest pain, shortness of breath, cough,
nausea, vomiting or dysphagia.
PAST MEDICAL HISTORY:
1. Sjogren's syndrome- diagnosed [**2090**]. Dry mouth and eyes.
Raynaud's phenomena. Positive SS-a and SS-b antibiody, high
titer [**Doctor First Name **] and +RF. Question associated SLE. Maintained on
prednisone 5 mg qd.
2. Right THR [**2109-4-17**]
3. Spinal stenosis with sciatica since [**2108-11-27**].
4. History of multiple deep vein thromboses,
antiphospholipid antibody syndrome, status post inferior vena
cava filter [**2109-5-27**].
5. Anemia
6. Coronary artery disease, status post myocardial
infarction, angioplasty in [**2102**]. Three vessel disease on cath at
[**Hospital 4415**] [**2102**]
7. Hypothyroidism.
8. Peripheral vascular disease- s/p embolectomies and
angioplasties for embolic disease as well. LE ulcers.
9. Right congenital renal agenesis?.
10. Chronic renal failure- although creatine ~.7- 1.0 she is bed
bound and has little muscle mass
11. Status post tubal ligation.
ALLERGIES: Penicillin causes rash. Sulfa causes rash.
Codeine causes rash. Imuran causes rash. Questionable
allergy to Narcan.
SOCIAL HISTORY: The patient lives with her husband. [**Name (NI) **]
daughter and son live nearby. She is retired from office
work in [**2105**]. She has a remote history of smoking and
alcohol use and has no history of drug abuse.
PHYSICAL EXAMINATION: On admission, vital signs revealed
temperature 98.1, heart rate 74, blood pressure 142/90,
respiratory rate 16, oxygen saturation 100% in room air. In
general, she was lying flat in bed, obese, appears
comfortable lying still, in no acute distress. Head, eyes,
ears, nose and throat examination - The pupils are equal,
round, and reactive to light and accommodation. Sclerae
anicteric. Slightly dry eyes and oropharynx. The neck is
supple with no lymphadenopathy, no jugular venous distention.
Chest is clear to auscultation anteriorly and laterally.
Cardiovascular - Distant heart sounds, normal S1 and S2, no
audible extra sounds. The abdomen reveals normoactive bowel
sounds, obese, nondistended, soft, nontender, no masses.
Extremities are warm and well perfused. No lower extremity
asymmetrical edema. Swollen proximal interphalangeal joints
of hands bilaterally. Skin - Healing scar on right hip,
dressings clean, dry and intact on sacral decubitus plus heel
ulcers bilaterally. Neurologically, cranial nerves II
through XII are intact bilaterally. Absent sensation to the
right toes and plantar surface of the right foot. Otherwise,
sensory is grossly intact, unable to move right toes.
Strength - grip is [**3-31**] bilaterally, right upper extremity
[**3-1**], left upper extremity [**3-31**], right lower extremity 0/5,
left lower extremity [**12-1**]. Deep tendon reflexes - biceps 2+.
LABORATORY DATA: On admission, white blood cell count 10.8,
hematocrit 29.9, MCV 93, RDW 17.5, platelet count 273,000.
Prothrombin time 12.5, partial thromboplastin time 30.6.
Sodium 141, potassium 5.3, chloride 113, bicarbonate 18,
blood urea nitrogen 33, creatinine 0.9, glucose 124, calcium
11.7, magnesium 1.8, phosphate 3.3. Liver function tests
within normal limits.
HOSPITAL COURSE: The patient went to the operating room on
[**2109-7-25**], for removal of her right hip cement spacer and
repeat right total hip replacement. Immediate postoperative
period was complicated by hypotesnion, tachycardia with low
grade temperatures and an elevated white blood cell count to
34.0. She received transfusions in the operating room and
intravenous fluids plus Neo-Synephrine in the Post Anesthesia
Care Unit and was admitted to the Surgical Intensive Care
Unit [**2109-7-26**]. She continued to be febrile and received one
unit of packed red blood cells on postoperative day one, but
was able to maintain her pressures off Neo-Synephrine by that
night. She was placed on stress dose steroids. Her clinical
status improved on postoperative day two and she maintained her
blood pressure off pressors with intravenous fluids and an
additional transfusion. She was the floor on postoperative day
three for further management. She remained hemodynamically
stable on the floor and anticipated discharge is on postoperative
day eight at the time of this summary.
On review of her medical records from [**Hospital3 2737**] the path
report states that the right hip had acute osteomyelitis rather
than AVN from [**2109-4-17**].
1. Cardiovascular - The patient remained hemodynamically
stable after postoperative day two, and her blood pressure
medications were restarted during her hospital course. She
had an echocardiogram on [**2109-7-26**], which showed an ejection
fraction of 55%, normal left atrium and left ventricle,
possible mild aortic stenosis, trivial mitral regurgitation,
but the study was noted to be limited by patient tolerance.
At the time of this summary, the patient is being maintained
on Metoprolol 50 mg three times a day, Captopril 50 mg three
times a day, with good blood pressure control. She was
continued on her Atorvastatin 10 mg once daily.
2. Hematology - The patient has a complicated coagulation
history that includes multiple deep vein thromboses on
coagulation with a reported antiphospholipid antibody
syndrome, but also multiple hematomas of her right hip. She
has been maintained on Lovenox since a prior admission. We
titrated her Lovenox by checking a Factor X-A level and at
this time, she is on Lovenox 40 mg subcutaneous twice a day
with no complications. Her hematocrit remained relatively
stable around 30.0 throughout her hospital stay. Her factor 10a
levels (heparin levels) were ~0.6 on this regimen with
therapeutic range at out lab (0.5- 1.0). Goal level should be on
the lower end in the range of .5-.7 to minimize risk of
bleeding.
An anemia workup was done that was most consistent with
anemia of chronic disease. The patient's iron
supplementation was discontinued due to a highly elevated
ferritin level suggesting good iron stores. An Epo level is
pending at this time, but the patient was started on Epo
5,000 units three times per week for high suspicion of
erythropoietin deficiency secondary to chronic renal
insufficiency. The patient should be checked for ferritin level
periodically as she may deplete her iron stores on this new
medication. SHe should not be placed on iron tablets as she is
not presently iron deficient.
3. Infectious disease - The patient was empirically started
on Vancomycin and Meropenem initially after the operation for
suspicion of sepsis given her hypotension and low grade
fevers. These were discontinued when she was transferred to
the floor and she remained afebrile except for very low grade
fever to 100.0 on postoperative day six. She is not on
antibiotics at the time of this summary. She was admitted on
Flagyl that was to be continued through [**2109-7-31**], for
Clostridium difficile. She had recurrence of diarrhea on
[**2109-7-31**], that was suspected to be due to a Boost intolerance
but given the recurrence of her diarrhea, it was decided to
continue Flagyl through [**2109-8-8**]. A c. diff toxin was positive
and the decision was made to start a po vanco 3 week course.
4. Endocrine - The patient had a complicated electrolyte
picture during her hospital stay. She was hypercalcemic on
admission with a calcium of 11.7. Her calcium remained
elevated with a stable phosphate and magnesium and then her
phosphate and magnesium began to drop, with mild response to
repletion. Her calcium then began to drop while her
phosphate and magnesium stabilized. A PTH and Vitamin D 25OH
are pending at the time of this summary. While she was
hypercalcemic, a SPEP and UPEP were checked, which were both
negative. Given her low calcium, she was empirically started
on Vitamin D supplementation.
She was given stress dose steroids during her operation given
her long term history of steroid treatment. She was
continued on stress dose steroids given her hypotension
postoperatively and was quickly tapered off on postoperative
day two to her baseline dose of Prednisone 5 mg once daily.
6. Orthopedic - As above the patient underwent a repeat
right total hip replacement on [**2109-7-25**]. Please see the
operative report for details of the surgery. She is
nonweight-bearing for her right lower extremity.
Postoperatively, she complained of some right shoulder
tenderness and difficulty moving her right shoulder. A right
upper extremity ultrasound to rule out deep vein thrombosis
was negative.
Plain films of the right shoulder were negative for fracture
or dislocation although did note diffuse osteopenia. She is
suspected to have a right frozen shoulder or possibly
tendinitis which is improving at the time of this summary.
She will require aggressive physical and occupational therapy
given her limited mobility since [**Month (only) 116**] of this year. She is to
follow-up with Dr. [**First Name (STitle) 1022**] two weeks from discharge ([**Telephone/Fax (1) 42114**]).
7. Neurologic - The patient has had right lower extremity
sensory and motor deficits since the initial surgery in [**2109-3-27**]. She has no movement of her right lower extremity
including her toes and no sensation to her right toes and
plantar surface of her foot. An EMG was obtained on
[**2109-7-30**], which was consistent with profound right sciatic
neuropathy or less likely a low lumbosacral plexopathy,
severe axonal sensorimotor polyneuropathy, and a mild to
moderate generalized myopathy.
A neurologic consultation was obtained and noted that she had
a superficial peroneal and sural nerve numbness with a
flaccid foot and ankle. Her findings were severe and
subacute and the prognosis is unclear. She will require
extensive rehabilitation of this extremity. She suffers from
a great deal of neuropathic pain in her right lower extremity
and her Neurontin dose was increased to 800 mg three times a
day.
8. Psychiatric - The patient was started on Ritalin and
Remeron for symptoms of depression/adjustment disorder during
a previous admission. She was maintained on these
medications throughout this hospitalization and while she is
clearly frustrated by her situation, she did not show signs
of worsening depression.
9. Rheumatology - Her Sjogren's syndrome has remained stable
on Prednisone 5 mg once daily.
10. Dermatology - The patient has several pressure ulcers
that require careful wound care. She has a large 5.0 by 4.0
centimeter sacral decubitus ulcer that while about one
centimeter deep does not appear infected and did not require
debridement. Recommended wet to dry dressing changes
multiple times a day. She has stable bilateral heel ulcers
that require dry dressings. She has a new left ankle ulcer
that is about one centimeter in diameter and one half
centimeter deep that will also require wet to dry dressings.
11. FEN - The patient was followed by nutrition during her
hospital stay. She developed a suspected intolerance to
Boost and should be encouraged to try other calcium and high
protein supplements. She has required electrolyte repletion
as described above.
12. Prophylaxis - The patient should be continued on Lovenox,
pneumatic boots, a proton pump inhibitor and aggressive
wound care.
13. Code Status - Full code.
Discharge is pending at the time of this summary.
[**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1775**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1776**]
Dictated By:[**Male First Name (un) 42115**]
MEDQUIST36
D: [**2109-8-1**] 16:23
T: [**2109-8-1**] 16:37
JOB#: [**Job Number **]
Admission Date: [**2109-7-24**] Discharge Date: [**2109-8-11**]
Date of Birth: [**2046-6-13**] Sex: F
Service:
NOTE: Please see the previous two Discharge Summaries for
Ms. [**Known lastname **] hospital course prior [**2109-8-16**].
HOSPITAL COURSE: Ms. [**Known lastname **] is an 63-year-old Caucasian
female who was admitted [**2109-7-24**] for a right hip
replacement.
Of note, she has a past medical history significant for
Sjogren syndrome and was on chronic prednisone until early
[**Month (only) 116**] when she suffered a hip fracture, status post hip
replacement on [**2109-4-16**]. Her hip replacement was
complicated by recurrent infections requiring the removal of
the orthopaedic hardware. Subsequently, she had recurrent
and space infection but was discharged to rehabilitation.
Upon re-admission for hip replacement, she had this performed
on [**2109-7-25**]. This was again complicated by
vancomycin-resistant enterococcus and candidal hip
infections; for which she was initially treated with
linezolid and then switched to Synercid. She was treated
with AmBisome as well for the candidal infection. The
patient's hardware was removed on [**2109-8-12**] with
Girdlestone procedure.
Unfortunately, Ms. [**Known lastname **] experienced many recurrent
complications including new hematoma formation in the right
hip extending into the right thigh requiring surgical
intervention; specifically, evacuation with persistent vacuum
suction to the open wound. Ms. [**Known lastname **] also had complications
including recurrent hypotension which required a Medical
Intensive Care Unit admission which was thought secondary to
volume depletion, sepsis, and adrenal insufficiency. She
required a short course of pressors; specifically a dopamine
drip. These were weaned as she received volume and packed
red blood cells.
Unfortunately, upon stabilization and transfer out of the
Medical Intensive Care Unit, Ms. [**Known lastname **] mental status
continued to decline. Initially, this was thought secondary
to narcotics, and these were withheld.
However, she never returned to her baseline mental status,
and discussions with the family resulted in her code status
being changed do not resuscitate/do not intubate on [**2109-9-6**]. Intravenous antibiotics, transfusion support,
intravenous fluids, and continued hip evacuation through
suction was pursued. The patient's mental status continued
to decline. Her renal function worsened, and her oxygenation
remained difficult.
In discussion with the family regarding Ms. [**Known lastname **] poor
prognosis, she was comfort measures only (according the
patient's family and what her wishes would be at that time).
This was decided on [**2109-9-9**].
She died at 2:45 a.m. on [**2109-9-10**]. At that time, Dr.
[**Last Name (STitle) **] was called to the patient's bedside, and her
physical examination was notable for absent pulse,
respirations, and corneal reflex. The patient's husband was
at the bedside at the time death. Mr. [**First Name4 (NamePattern1) **] [**Known lastname **] declined
a voluntary postmortem examination after the Medical Examiner
had declined the case.
TIME/DATE OF DEATH: [**2109-9-10**] at 2:45 a.m.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4122**], M.D.
Dictated By:[**Last Name (NamePattern1) 20054**]
MEDQUIST36
D: [**2109-12-13**] 15:32
T: [**2109-12-16**] 07:43
JOB#: [**Job Number 42116**]
Admission Date: [**2109-7-24**] Discharge Date: [**2109-9-10**]
Date of Birth: [**2046-6-13**] Sex: F
Service: MEDICINE
DIAGNOSES:
1. Status post repeat right total hip replacement,
[**2109-7-25**].
2. Status post incision and drainage of right hip
[**2109-8-5**].
3. VRE and [**Female First Name (un) 564**] infection of right hip.
4. Status post removal of right hip replacement (Girdlestone
procedure) [**2109-8-12**].
5. VRE bacteremia.
6. Multi-resistant Enterobacter and multi-resistant
Klebsiella urinary tract infection.
7. Clostridium difficile positive.
8. Sjogren's Syndrome.
9. Anti-phospholipid antibody syndrome.
10. Coronary artery disease.
11. Chronic renal insufficiency.
12. Depression.
HISTORY OF PRESENT ILLNESS: This is a 63 year old woman with
a history of Sjogren's, anti-phospholipid antibody syndrome,
coronary artery disease, chronic renal insufficiency, and
hypothyroidism, who has had a complicated course after a
right hip replacement for acute osteomyelitis. The patient's
initial operation was in [**2109-3-27**]. The prosthesis
subsequently became infected with Staphylococcus epidermidis
and multi-resistant Klebsiella resulting in removal and
replacement of cement spacer. She was readmitted on this
occasion for a repeat right total hip replacement and further
details of her initial hospital course are in the previous
discharge summary.
This summary contains her hospital course from [**2109-8-2**]
through [**2109-8-16**].
SUMMARY OF HOSPITAL COURSE BY SYSTEM:
1. INFECTIOUS DISEASE: The patient began to spike low-grade
fevers on [**2109-7-31**], and continued to spike through
[**2109-8-5**], with a temperature maximum of 101.5 F. On [**8-4**],
her urine culture began to grow Gram negative rods and she
was started on Levofloxacin. On [**8-5**], her blood cultures
from the previous day began to grow Gram positive cocci and
she was started on Vancomycin. That day her right hip
incision was also noted to drain purulent fluids and she was
taken to the Operating Room that evening for a incision and
drainage of her right hip.
Her subsequent cultures, both the blood culture and cultures
from her hip were found to be positive for Vancomycin
resistant enterococcus and the patient was switched to
Linezolid. The urine culture also was notable for highly
resistant Enterobacter and Klebsiella pneumonia and the
patient was switched from Levofloxacin to Meropenem.
On the 13th, the hip cultures also were noted to be growing
out [**Female First Name (un) 564**] and the patient was started on AmBisome for her
Candidal hip infection. The patient was also restarted on
Levofloxacin for Pseudomonas that was growing from a swab of
her sacral decubitus ulcer. At this point, it was clear that
her VRE and [**Female First Name (un) 564**] infections of her hip prosthesis would
require its removal.
On [**2109-8-12**], she was taken back to the Operating Room for a
Girdlestone procedure which involved complete removal of the
right hip prosthesis with no replacement.
At the time of this Discharge Summary, the patient had
completed a ten day course of Meropenem for her Enterobacter
and Klebsiella urinary tract infection (with extended
coverage through her operation for skin coverage). She
completed a short course of Levofloxacin for the Pseudomonas
growing from her sacral decubitus ulcer. She remains on
Linezolid, day 11 out of 42 Linezolid for her VRE
bacteremia/hip infection. She is on day 8 of 28 of AmBisome
for her candidal hip infection. This will likely need to be
followed by a long term course of Fluconazole.
She has also been on Flagyl throughout her hospital course
for Clostridium difficile colitis. Her diarrhea has resolved
and her Flagyl was discontinued on [**2109-8-16**], with a plan to
start p.o. Vancomycin if her diarrhea returns. She will need
follow-up with Infectious Disease in the Infectious Disease
Clinic one to two weeks after discharge.
2. ORTHOPEDIC: The patient had a repeat right total hip
replacement on [**2109-7-25**]. She then had a incision and
drainage of her right total hip replacement on [**2109-8-5**].
She then had a Girdlestone procedure with complete removal of
her right total hip replacement on [**2109-8-12**]. See details
above. She is non-weight bearing of her right lower
extremity for at least six weeks.
She has also been noted to have a possible right rotator cuff
injury that Dr. [**First Name (STitle) 1022**] only feels needs Physical Therapy at this
time. She will require follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**] in
approximately two weeks from discharge ([**Telephone/Fax (1) 42117**]).
3. HEMATOLOGY: At the time of this summary, the patient's
most concerning medical issue is her decreasing platelets.
They were at a high around 300 on [**2109-8-9**], and have been
slowly decreasing to 104 on [**2109-8-16**]. It is unclear what
is the cause of her thrombocytopenia at this time but
possible causes include heparin induced or heparin associated
thrombocytopenia versus thrombocytopenia caused by her
antibiotics, most likely Linezolid or less likely AmBisome.
At this time, HIT antibodies are pending. If these are
positive, the patient will be taken off Lovenox and put on
Coumadin for anti-coagulation. If they come back negative,
we will continue to follow the platelets closely. If they
continue to trend down, we will try discontinuing the
Linezolid and treating her VRE with Synercid (to which it is
sensitive). The last option would be to discontinue her
AmBisome and start her on Fluconazole for her [**Female First Name (un) 564**]
infection.
The patient has required multiple transfusions through her
hospital course and has been transfused to maintain her
hematocrit above 30 to 32. Her hematocrit has been stable
over the past few days, around 32. The patient was started
on Epogen for her chronic anemia. The patient was taken off
iron supplementation as she was found to have adequate iron
stores.
The patient is currently on Lovenox 40 mg subcutaneously
twice a day. Her Factor X-A levels have been checked every
few days with a goal of 0.5 to 0.7. She will need to have
her Factor X-A levels checked about every one to two weeks
and adjusted with that goal in mind.
4. CARDIOVASCULAR: The patient had hypotensive episodes
each time after going to the Operating Room. She was on
Neo-synephrine after her initial right total hip replacement
and after her incision and drainage. She otherwise remained
hemodynamically stable although required adjustments of her
hypertensive medications. Currently, she is on Metoprolol 50
mg p.o. twice a day and Captopril 75 mg p.o. three times a
day. She was maintained on her Lipitor, and started on
aspirin for her history of coronary artery disease.
Her electrocardiograms were notable for an old inferior
myocardial infarction and on [**8-5**], she was noted to have a
possible new anterior lateral myocardial infarction when
compared to a previous EKG from [**7-26**], however, she ruled out
by enzymes that day and her troponin was also negative a few
days later.
5. RENAL: The patient's BUN and creatinine remained
relatively stable throughout her hospitalization. She had
poor urine output on [**8-13**], with a slight bump in her BUN and
creatinine, however, her urine output quickly picked back up
and her BUN and creatinine returned to where they have been
previously with a BUN of 24 and a creatinine of 0.6. At the
time of this dictation, a 24 hour urine is pending to
determine her creatinine clearance.
6. GASTROINTESTINAL: The patient has had diarrhea on and
off throughout her hospitalization. She was admitted on
Flagyl for a positive Clostridium difficile assay on
[**2109-7-17**], at Rehabilitation. She was continued on her p.o.
Flagyl through [**2109-8-16**], as her diarrhea had resolved. The
plan is to clinically follow her and if her diarrhea returns,
to start her on p.o. Vancomycin.
7. ENDOCRINE: The patient displayed evidence of adrenal
insufficiency on all three of her trips to the Operating
Room. She was placed on stress dose steroids each time, and
then rapidly tapered back to her standing Prednisone 5 mg
p.o. q. day. Her Levoxyl was continued at 125 micrograms
p.o. q. day and her TSH was found to be in the normal range.
She was also found to be Vitamin D deficient with an
undetectable Vitamin D level and was thus started on high
doses of Vitamin D.
8. PSYCHIATRIC: The patient exhibited understandable
feelings of depression and frustration dealing with her
difficulty hospital course. Psychiatry was re-consulted
during this admission and recommended continuing her Ritalin
and Remeron. There was some concern for a potential
interaction with Linezolid which is a partial MAO-I. This
potential risk was felt to be outweighed by her need for her
medication, although she should be monitored carefully for
serotonin syndrome.
9. NEUROLOGIC: Neurology was consulted during this
admission regarding her right lower extremity neurologic
deficit which has persisted since [**2109-3-27**]. No further
work-up was recommended at this time and she should have
follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10029**] in one to two months
([**Telephone/Fax (1) 42118**]).
10. RHEUMATOLOGY: Her Sjogren's Syndrome appeared stable
throughout her hospitalization and she was continued on
Prednisone 5 mg p.o. q. day when not on stress-dosed
steroids. Consideration in the near future should be made
regarding taking her off steroids completely, as this may be
impairing her immune system and ability to heal.
11. DERMATOLOGY: On admission, the patient was noted to have
a large sacral decubitus ulcer as well as bilateral heel
pressure ulcers. She also developed a small left ankle
ulcer. These required careful dressing care, including
application of Bacitracin and wet-to-dry dressing changes for
the sacral decubitus ulcer.
12. PAIN: Her pain has been well controlled throughout this
hospitalization with Dilaudid as needed, and standing
Neurontin 800 mg p.o. three times a day.
13. FLUIDS, ELECTROLYTES AND NUTRITION: The patient's
nutritional status is notably poor with an albumin of 2.0.
She was placed on a full diet throughout her hospitalization
except when NPO for procedures, and encouraged to take
supplements. Her electrolytes were frequently repleted
throughout her hospitalization, including her potassium, her
magnesium and occasional phosphate.
14. PROPHYLAXIS: The patient was continued on Lovenox
throughout her hospitalization and was noted to be status
post an IVC filter placed in [**2109-5-27**]. She was also kept
on Pneumoboots. She was also placed on a proton pump
inhibitor.
15. ACCESS: Her most recent PICC on her right upper
extremity was placed on [**2109-8-14**].
16. CODE STATUS: Full code.
MEDICATIONS AT THE TIME OF THIS DISCHARGE SUMMARY:
1. Linezolid 600 mg intravenously q. 12 hours (started
[**2109-8-6**]).
2. AmBisome 230 mg intravenously q. day (started
[**2109-8-9**]).
3. Lovenox 40 mg subcutaneously twice a day.
4. Metoprolol 50 mg p.o. twice a day.
5. Captopril 75 mg p.o. three times a day.
6. Lipitor 10 mg p.o. q. day.
7. Aspirin 81 mg p.o. q. day.
8. Levoxyl 125 micrograms p.o. q. day.
9. Pantoprazole 40 mg p.o. q. day.
10. Gabapentin 800 mg p.o. three times a day.
11. Zinc sulfate.
12. Multivitamin.
13. Vitamin C, vitamin E.
14. Calcium carbonate 500 mg p.o. three times a day.
15. Vitamin B 50,000 Units p.o. two times per week, times
total of ten doses.
16. Epogen 5000 Units subcutaneously three times per week.
17. Prednisone 5 mg p.o. q. day.
18. Ritalin 2.5 mg q. a.m. and 5 mg q. noon.
19. Remeron 30 mg p.o. q. h.s.
20. Colace 100 mg p.o. twice a day.
21. Lasix 20 mg p.o. q. day.
22. Dilaudid 0.5 to 2 mg intravenously/intramuscularly/subq
p.r.n.
23. Milk of Magnesia p.r.n.
CONDITION AT DISCHARGE: Her condition at the time of this
discharge summary is stable.
[**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1775**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1776**]
Dictated By:[**Male First Name (un) 42119**]
MEDQUIST36
D: [**2109-8-16**] 14:11
T: [**2109-8-16**] 14:29
JOB#: [**Job Number **]
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48,647
| 146,670
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38193
|
Discharge summary
|
report
|
Admission Date: [**2166-7-7**] Discharge Date: [**2166-7-16**]
Date of Birth: [**2081-2-13**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1945**]
Chief Complaint:
Fall with broken nose, SDH
Major Surgical or Invasive Procedure:
Multiple blood and platelet transfusions
History of Present Illness:
85 year old female with NHL on chemotherapy, CAD s/p MI and
CABGx1 in [**2135**] admitted with syncopal episode and SDH.
Patientreported that she was fixing breakfast, noted epistaxis,
turned to the left and lost consciousness. There was no prodrome
ofdiaphoresis, nausea, lightheadednes, blurry vision. Patient
didnot know the duration of loss of consciousness but believed
itcould not be more than a few minutes. She did not have loss
ofbowel or bladder function. There was no associated chest
pain,dyspnea or palpitations. She has no prior history of
syncope.
This episode occurred in the context of ongoning anemia
requiring blood transfusion on [**2166-7-2**], likely related to her
oncologic treatment and NHL. On cardiac review of symptoms,
patient reports increased exertional dyspnea compared to
baseline but no angina, dyspnea, or PND. Reports stable 2 pillow
orthopnea and denies any regular aerobic activity other than
walking around her house.
She was taken to the OSH via EMS. Labs were significant
forplatelets of 6, WBC of 1, Hct 23.1, and tbili of 2.2. CT of
the head was significant for bilateral subdural hematomas with a
midline shift. She was intubated briefly for airway protection
because she had blood in the oropharynx. [**Hospital **]
transferred to
[**Hospital1 18**] for further care. She was admitted to the SICU for closer
monitoring. No neurosurgical intervention has been performed. An
echocardiogram done on [**7-8**] was notable for an EF of 20%.
Past Medical History:
- NHL
- CAD s/p CABG x 4
- HTN
- CHF
- Osteoarthritis
Social History:
Patient lives with her husband, who has [**Name (NI) 11964**]. She reported
smoking 6 cigarettes per week for 1 to 2 years and endorses
occasional social EtOH.
Family History:
Father passed away from MI at 52. No other significant cardiac
history.
Physical Exam:
Physical exam in ED:
Constitutional: Uncomfortable due to pain. She is able to
converse with us an answer questions. However this is limited.
HEENT: She is in a collar and has multiple facial ecchymoses
No neck tenderness and the collar
Chest: Clear to auscultation
Cardiovascular: No murmur
Abdominal: Soft, Nontender
Neuro: The patient is intubated\she can move all 4
extremities weakly but symmetrically
Physical exam on medicine floor:
General: NAD, resting comfortably in chair
HEENT: Extensive bruising to face, injected sclera on right
Neck: no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Quiet heart sounds, S1, S2
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pulses,
Neuro: CN II-[**Doctor First Name 81**] intact, 5/5 strength in all extremities
Pertinent Results:
Admission labs:
[**2166-7-7**] 01:45PM WBC-0.5* RBC-2.08* HGB-6.8* HCT-18.7* MCV-90
MCH-32.5* MCHC-36.3* RDW-19.0*
[**2166-7-7**] 01:45PM NEUTS-40* BANDS-6* LYMPHS-32 MONOS-20* EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-0
[**2166-7-7**] 01:45PM CALCIUM-8.3* PHOSPHATE-3.2 MAGNESIUM-1.9
[**2166-7-7**] 01:45PM PT-12.6 PTT-18.6* INR(PT)-1.1
[**2166-7-7**] 01:45PM FIBRINOGE-324
[**2166-7-7**] 01:45PM GLUCOSE-145* UREA N-21* CREAT-0.6 SODIUM-137
POTASSIUM-3.0* CHLORIDE-98 TOTAL CO2-24 ANION GAP-18
[**2166-7-7**] 03:00PM PLT SMR-VERY LOW PLT COUNT-28*
[**2166-7-7**] 03:00PM WBC-0.5* RBC-2.04* HGB-6.7* HCT-18.2* MCV-89
MCH-32.9* MCHC-36.8* RDW-18.8*
[**2166-7-7**] 07:52PM PLT COUNT-85*#
Discharge labs:
[**2166-7-16**] 06:20AM BLOOD WBC-0.9* RBC-2.88* Hgb-8.8* Hct-24.7*
MCV-86 MCH-30.4 MCHC-35.5* RDW-16.9* Plt Ct-58*
[**2166-7-15**] 07:30AM BLOOD Neuts-66 Bands-1 Lymphs-21 Monos-5 Eos-5*
Baso-0 Atyps-2* Metas-0 Myelos-0 NRBC-1*
[**2166-7-16**] 06:20AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.1
[**2166-7-16**] 06:20AM BLOOD Phenyto-2.6*
Imaging:
CT HEAD W/O CONTRAST
IMPRESSION:
1. Bilateral subdural hematomas, right greater than left,
similar in size to the recent CT examination approximately three
hours prior. Stable leftward midline shift, accounting for
differences in technique, measuring approximately 6 mm.
2. Bilateral nasal bone fractures.
CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS
IMPRESSION:
1. Bilateral supratentorial acute subdural hematomas as
described. The
degree of mass effect is stable from the study earlier the same
day. Chronic bilateral posterior fossa subdural collections.
2. Mild narrowing of the cervical right vertebral artery at the
level of C4 due a facet osteophyte. Otherwise, no evidence of
flow-limiting stenosis, occlusion, or aneurysm of vessels in the
head or neck.
3. Nasal bone fractures. Nasal and maxillary soft tissue
swelling, right
worse than left.
4. Right thyroid nodule, which could be better assessed by
ultrasound, if not done previously.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is mildly dilated. There
is severe global left ventricular hypokinesis (LVEF = 20 %). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. with mild global free wall
hypokinesis. The aortic root is moderately dilated at the sinus
level. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
([**1-11**]+) mitral regurgitation is seen. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Dilated cardiomyopathy.
CT HEAD W/O CONTRAST
IMPRESSION:
1. Bilateral fronto temporoparietal and tentorial subdural
hematomas witha
cute component, right larger than left and similar in appearance
from
[**2166-7-7**]. Follow up as clinically indicated if no intervention
is
contemplated. See details above.
2. Slightly decrease of leftward midline shift.
3. Bilateral nasal bone fractures with mild soft tissue swelling
on the right.
CHEST (PORTABLE AP)
FINDINGS: As compared to the previous examination, there is a
slight increase in extent of the bilateral pleural effusions.
Moderate increase in extent of the retrocardiac atelectasis.
Otherwise, there is no relevant change. Unchanged moderate
cardiomegaly.
CT head w/ contrast:
Slight increase in size of right subdural collection (7mm,
previously 5 mm) and material layering along tentorium, with
interval evolution of blood products and no new hemorrhage.
Slight increase in leftward midline shift and compression of
right lateral ventricle.
Brief Hospital Course:
Mrs. [**Known lastname 13257**] is an 85 y.o woman with past medical history of
coronary artery disease, s/p CABG x4, non-hodgkin's lymphoma
most recently treated with Zevalin in [**Month (only) 116**], radiation therapy who
presented to an outside hospital after a syncopal event and was
found to have a subdural hematoma. She was subsequently
transferred to [**Hospital1 18**] for further care.
Neuro ICU course:
In the ICU, the patient received 6 units of PRBCs and 4 units of
platelets. The volume caused her to go into heart failure. The
patient was then given lasix for diuresis, 10mg IV pushes, to
which she responded well. A subsequent ECHO showed 20% dilated
cardiomyopathy. The patient was placed on neutropenic
precautions secondary to a WBC 0.6. She was also alkalotic and
started on acetazolamide. This was discontinued upon discharge
from the ICU.
.
Cardiology was consulted in the ICU and recommended that the
patient be kept euvolemic and started on lisinopril at 5 mg. Due
to the patient's ongoing oncologic problems and
thrombocytopenia, ICD placement was not recommended. Heme/Onc
was consulted and recommended that platelets be kept above
50,000, as also recommended by Neurosurgery.
.
Medical floor course:
.
# Subdural hematoma, stable
The patient was placed on neurological checks every 4 hours. Her
physical exams consistently demonstrated no neurological
deficits. The goal for platelets was 50,000. After three units
of platelets on the medicine floor, she finally obtained a
platelet count of 50,000. The patient was also placed on seizure
prophylaxis with phenytoin. First phenytoin level on the floor
was well below therapeutic levels, so the dose was increased.
The patient's last dilantin level prior to discharge on [**2166-7-16**]
was 2.6, and the patient was discharged on 100mg of dilantin tid
for seizure prophylaxis. The patient underwent repeat CT scan
on [**2166-7-16**] to evaluate for interval change of her subdural
hematoma, and this showed no interval worsening of her subdural
hematoma. The initial read showed that the subdural had
increased from 5mm to 7mm; however, there was no evidence of new
bleeding with interval evolution of blood products.
Neurosurgery reviewed the films and agreed, and that her
platelets no longer needed to be maintained above 50,000 with
transfusions.
It is recommended that the patient have a follow up scan in 2
days on [**2166-7-18**] as well as 1 week after that. The patient should
follow-up with her surgeon Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 88**] in
2 weeks time.
.
# Dilated cardiomyopathy
The patient consistently appeared euvolemic to physical exam and
had, at most, minimal crackles on lung exam. Per Cardiology
recommendations, the patient was started on 5 mg lisinopril.
Telemetry consistently showed ectopy, non-sustained V tach,
PVCs. The patient was also started on metoprolol 25mg [**Hospital1 **]. Her
hydrochlorothiazide was stopped in light of the addition of the
beta blocker, as the patient remained normotensive throughout
her stay. The patient was discharged without addition of a loop
diuretic on discharge given her euvolemic status. This was
communicated to her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 70216**] who agreed to follow her
volume status closely.
.
# Pancytopenia:
The patient was placed on neutropenic precautions. On [**7-1**], the
patient had received Neupogen from her oncologist. Treatment in
the ICU included multiple transfusions of 6 units of PRBCs and 4
units of platelets. On the medicine floor, patient received a
further 4 units of platelets. At discharge, her platelets were
at 58,000.
.
# Alkalosis, resolved
Within a day of patient arriving on medicine floor, her
alkalosis resolved. Her acetazolamide was discontinued.
Medications on Admission:
aldactazide 25/25 daily
mirtazapine 15 mg QHS
nitrostat 1/200 SL prn
lansoprazole 30 mg [**Hospital1 **]
procardia LA 60 mg po daily
zocor 40 mg po daily
celebrex 200 mg po daily
zofran prn
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO twice a day.
3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO at bedtime.
4. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain and temp > 100.4.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Phenytoin 125 mg/5 mL Suspension Sig: Four (4) mL PO Q8H
(every 8 hours).
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] northeast - [**Location (un) **]
Discharge Diagnosis:
PRIMARY:
Subdural hematoma
Non-Hodgkins lymphoma
Heart failure
Secondary:
Coronary artery disease
Osteoarthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 13257**],
It was truly a pleasure to treat you at [**Hospital1 **]
Hospital.
We treated you for a fall you sustained that resulted in a
subdural hematoma, which is bleeding that occurs inside your
head. You did not need surgery for this bleeding, and we believe
that the blood that collected is stable. You were carefully
monitored to make sure that you did not have any signs of
excessive pressure in your brain, and you did not. You have
been started on a medication called phenytoin as prevention
against possible seizures from this bleeding.
It is unclear whether your fall was caused by a bad heart rhythm
that caused you to pass out and then hit your head or if you had
bleeding in your brain first that then caused you to fall. We
did notice that your blood counts were very low, probably
because of the chemotherapy you received for your lymphoma. We
tried to keep your platelet level high enough to keep you from
bleeding in your head. We also montiored your heart to try to
stop any dangerous rhythms. You have been started on a
medication called metoprolol for this condition.
Finally, while you were here, we found that you had evidence of
You will now go to a rehabilitation facility where they will
look after your blood count and work to make you stronger. Your
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 70216**] will see you there.
You have had the following changes to your medications:
Your aldactazide (hydrochlorothiazide/spironolactone) has been
STOPPED
Your Procardia (nifedipine) has been STOPPED
Your celecoxib has been STOPPED. You should discuss with Dr.
[**Last Name (STitle) 70216**] when you should restart these medications.
You have been started on spironolactone 50mg daily; this was
previously a medication that was in your aldactazide.
You have been started on lisinopril 5mg daily
You have been started on phenytoin 100mg three times a day.
This is for seizure prophylaxis and should be taken for another
6 weeks.
You have been started on metoprolol 25mg twice a day to help
control your heart rhythm.
Followup Instructions:
*PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 70216**], [**First Name3 (LF) **] personally visit patient on daily basis
while patient is at [**Location (un) 38**] facility.
.
*Your Cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11850**], [**First Name3 (LF) **] contact you with an
appointment. Please call ([**Telephone/Fax (1) 85172**] if you do not hear from
them.
.
You also have an appointment with your oncologist as below:
.
Appointment
With: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
When: FRIDAY, [**2167-8-1**]:15AM
Location: [**Hospital1 12716**], Suite # 206, [**Location (un) 1110**], [**Numeric Identifier 8057**]
Phone: [**Telephone/Fax (1) 62090**]
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21,088
| 127,532
|
2522
|
Discharge summary
|
report
|
Admission Date: [**2120-3-18**] Discharge Date: [**2120-3-28**]
Date of Birth: Sex: M
Service: MED
HISTORY OF PRESENT ILLNESS: This is a 76-year-old male with
a history of bladder cancer status post resection and
chemotherapy, prostate cancer status post XRT, renal stones,
history of postobstructive acute renal failure, penile
implant, hypertension, and type 2 diabetes who presented on
[**2120-3-18**] with left flank pain, fevers, chills, and dysuria.
The patient was found to have left hydroureter and
hydronephrosis with questionable caliceal rupture by CAT
scan. The patient was started on Levaquin. The patient
subsequently had an episode of hypotension requiring pressors
on [**2120-3-19**] and was therefore transferred to the ICU. He was
electively intubated on [**2120-3-19**] for impending ventilatory
failure and for upcoming IR GU procedures. Upon initial
presentation in the Emergency Department, the patient
described half an hour of chest discomfort without radiation,
nausea, vomiting, diaphoresis or shortness of breath, which
resolved without any intervention. The patient had V/Q scan,
which was normal.
PAST MEDICAL HISTORY: Bladder cancer, status post surgery
and chemo in [**2109**].
Prostate cancer, status post XRT in [**2119**].
Hypertension.
Non-insulin dependent diabetes mellitus.
Postobstructive acute renal failure.
Kidney stones times 1 one year ago.
Penile implant.
ALLERGIES: PENICILLIN WHICH CAUSES PALPITATIONS.
MEDICATIONS ON ADMISSION: Norvasc.
SOCIAL HISTORY: The patient lives with his cousin. [**Name (NI) **] has 2
daughters. [**Name (NI) **] denies tobacco, alcohol or drug abuse.
FAMILY HISTORY: Notable for coronary artery disease,
hypertension, myocardial infarction, and diabetes.
PHYSICAL EXAM FROM ADMISSION: Temperature notable for T-max
of 99.6 degrees, blood pressure 97/65, heart rate 110,
respiratory rate 20, 97 percent on room air. Lungs were
clear to auscultation. Cardiac exam regular, tachycardia.
Abdominal exam was benign. There was CVA tenderness. No
clubbing, cyanosis or edema.
LABORATORY DATA FROM ADMISSION: White blood cell count 3.6,
hematocrit 42.2, platelets 135. CK 123, troponin less than
0.01, D-dimer 2,214. BUN 15, creatinine 1.3.
RADIOGRAPHIC STUDIES: EKG showed ST depressions in V3
through V6, normal sinus rhythm, no T-wave inversions, no ST
elevations. Chest x-ray, no infiltrate. CAT scan,
persistent obstruction at the left UV junction with marked
hydroureter, and perinephric stranding.
HOSPITAL COURSE: Sepsis secondary to presumed renal source.
The patient was transferred to the ICU on [**2120-3-19**] for
hypotension and septic physiology. He was intubated there
and was transferred back to the floor on [**2120-3-24**]
postextubation, and overall stable. The patient was treated
with levofloxacin and ceftriaxone. He had had vancomycin
dose by level initially, which was discontinued per the
Infectious Disease team. Flagyl had been added on [**2120-3-23**]
to cover for potential GI sources of the persistent ________
and cultures grew pansensitive E. coli in the urine.
Leukocytosis was persistent, but fever curve was improving
overall. The question was raised about potential
cholecystitis in the setting of elevated LFTs. However,
there was no evidence of this by ultrasound, and his
abdominal exam was overall normal. The CAT scan of his
abdomen was negative for any evidence of an active GI
infection. The patient was also maintained on topical
acyclovir for oral HSV.
GU: The patient was status post percutaneous nephrostomy
tubes placed through Interventional Radiology on [**2120-3-19**]
with drainage of bloody material. He had a redo on [**2120-3-22**]
with tube in 1 collecting system, ureter and bladder draining
all urine down the right to the bladder and then out of the
left tube. The patient has stricture at the level of the
bladder. There was no need to replace the Foley as long as
the left nephrostomy tube was still draining. The patient
was maintained on Ditropan for bladder spasms, and his urine
output remained to be adequate.
Hypoxia: The patient was intubated on [**2120-3-19**] to [**2120-3-23**]
secondary to sepsis. His respiratory status was now much
more stable on room air, not requiring any further
intervention.
DIC: Initially noted from sepsis, his INR was as high as
2.7, PTT 59.6 and platelets in the 20s. The patient received
platelets, FFP, and RBCs around his GU procedures. He was
stable since arrival to the floor. The patient was HIT
negative, but heparin was held anyway. His coagulopathy was
corrected.
Acute renal failure: This was resolving with a peak
creatinine of 3.7 secondary to ATN versus postobstructive.
Now with post ATN or postobstructive diuresis upon time of
discharge with resolution of his renal failure, his
creatinine decreased to 1 upon discharge.
Cardiac: The patient had troponin leak of 0.02. He had an
echocardiogram performed on [**2120-3-23**], which showed an
ejection fraction of 45-50 percent, mild global LV
hypokinesis, trace MR. [**Name13 (STitle) **] ruled out by enzymes. He was
maintained on beta-blocker and calcium channel blocker. The
patient will require an outpatient stress test upon
discharge.
Liver: The patient had elevated LFTs during his
hospitalization. It was likely related to shock liver in the
setting of hypotension, which resolved upon discharge.
Diabetes: The patient currently is not on any medications at
home. However, he was maintained on sliding scale during his
hospital course with adequate glycemic control.
DISCHARGE DIAGNOSES: Urosepsis, status post ureteral stent
for ureteral stricture.
Acute renal failure.
Hypertension.
History of bladder cancer.
Diabetes type 2.
Prostate cancer.
History of renal stones.
History of penile implant.
DISCHARGE CONDITION: The patient is stable.
DISCHARGE STATUS: He will be discharged home with services.
RECOMMENDED FOLLOW-UP: The patient was instructed to follow
up with his PCP. [**Name10 (NameIs) **] patient is also to have his NU stent
and brush biopsy followed up by Dr. [**Last Name (STitle) 986**] in Urology.
Additionally, the patient is to follow up with Interventional
Radiology for NU stent exchange in 3 months from discharge.
SURGICAL/INVASIVE PROCEDURES PERFORMED DURING THIS
HOSPITALIZATION: Status post percutaneous nephrostomy tube.
Status post NU stent and brush biopsy.
Status post intubation and extubation.
Status post central venous line placement.
DISCHARGE MEDICATIONS:
1. Tylenol 325 mg p.o. q.6 hours p.r.n.
2. Sucralfate 1 tablet p.o. q.i.d.
3. Metoprolol 50 mg p.o. t.i.d.
4. Acyclovir topical ointment.
5. Oxybutynin chloride 5 mg p.o. t.i.d.
6. Amlodipine 10 mg p.o. q.d.
7. Ocean Spray q.i.d.
8. Levofloxacin 500 mg p.o. q.d. for 7 days.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12865**], M.D. [**MD Number(1) 6757**]
Dictated By:[**Last Name (NamePattern1) 12866**]
MEDQUIST36
D: [**2120-6-12**] 14:19:59
T: [**2120-6-13**] 00:11:35
Job#: [**Job Number 12867**]
|
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icd9cm
|
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icd9pcs
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[
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5878, 6540
|
1697, 2542
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5638, 5856
|
6563, 7119
|
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|
159, 1164
|
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|
1552, 1680
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,423
| 165,796
|
11437+56237
|
Discharge summary
|
report+addendum
|
Admission Date: [**2169-7-4**] Discharge Date: [**2169-7-8**]
Date of Birth: [**2112-10-11**] Sex: F
Service: MEDICINE
Allergies:
Dilaudid / Prilosec
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
EGD
EUS
History of Present Illness:
History of Present Illness: 56 y/o F with PMHx of eosinophilic
gastroenteritis, who is presenting with abdominal pain similar
to prior flares of her eosinophilic gastroenteritis. Pt reports
that she was admitted to [**Hospital6 8283**] earlier this
month with abdominal pain, presumed to be related to a flare of
her eosinophilic gastroenteritis. She was treated with steroids
(chronic home prednisone of 30 mg daily was increased to 60 mg
[**Hospital1 **]) and IV fluids. However, since returning home, she has not
continued to improve. She was seen by her PCP yesterday, who
referred her to the ED for IV fluids and IV solumedrol. In the
ED, she spiked a temp to 104. Blood cx were drawn, she was
given cipro flagyl. After discussion with Dr. [**First Name (STitle) 1356**], decision
was made to transfer to [**Hospital1 18**] for further evaluation. Of note,
during this time, blood cx grew out GNR in both the aerobic and
anerobic bottles.
In the ED, initial VS were: 98.0 108 108/66 16 98% 3L Nasal
Cannula.
Initial exam was significant for tender abdomen w/out rebound.
Labs demonstrated wbc 12.2, hct 31.8, creatinine 0.8, lactate
2.0 and normal LFTs. A CT abdomen and pelvis was obtained which
revealed intrahepatic biliary ductal dilatation, a distended
gallbladder, a dilated CBD (10mm) without stone or mass in the
biliary system. An acute care service consult was placed who
advised no surgical issue. She was given zofran 4mg IV x 1 for
nausea, morphine sulfate 5mg x 1 for pain, fentanyl citrate
50mcg x 2 for pain. She was started on vancomycin/zosyn. Her
blood pressures were in the low 100s throughout her ED visit,
with a single drop to the 80s. She was afebrile. She received
3L IVF. She was admitted to the ICU given concern for
bacteremia, and lower than normal blood pressures. Vitals on
transfer were: 97.6 86 12 95% on RA 100/60.
On arrival to the MICU, the patient reports continued abdominal
pain. Mild nausea, no vomitting or diarrhea. She also endorses
diffuse non-descript back pain recently, which is not typical
for her flares. She denies any other complaints.
Past Medical History:
Past Medical History:
- eosinophilic gastroenteritis s/p partial gastrectomy
Social History:
No tobacco, alcohol, or illicit drug use. Lives at home with
husband and son.
Family History:
Mother with bladder cancer. Father with OA. No family history of
GI disease.
Physical Exam:
Physical Exam on Admission to MICU:
Vitals: T: BP: 118/68 P: 90 R: 16 O2: 98%
General: Alert, oriented, uncomfortable
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, tender to palpation on the right side
Back: no tenderness to palpation along the spine or in the
paraspinal regions
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: non focal
Discharge exam:
VSS, Afebrile
Abdomen: soft, non-distended, non-tender, bowel sounds present,
no organomegaly
Exam otherwise unchanged since admission
Pertinent Results:
Admission labs:
[**2169-7-3**] 11:12PM WBC-12.2* RBC-3.78* HGB-10.3* HCT-31.8*
MCV-84 MCH-27.1 MCHC-32.3 RDW-14.5
[**2169-7-3**] 11:12PM NEUTS-93.3* LYMPHS-3.1* MONOS-2.9 EOS-0.5
BASOS-0.1
[**2169-7-3**] 11:12PM cTropnT-<0.01
[**2169-7-3**] 11:12PM LIPASE-22
[**2169-7-3**] 11:12PM ALT(SGPT)-36 AST(SGOT)-37 ALK PHOS-74
AMYLASE-34
[**2169-7-3**] 11:12PM GLUCOSE-144* UREA N-9 CREAT-0.8 SODIUM-143
POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-22 ANION GAP-17
[**2169-7-3**] 11:32PM LACTATE-2.0
Micro:
OSH BCx - cultures at [**Hospital6 **] ([**Telephone/Fax (1) 31996**])
-> serratia marcescens
-- sensitive to bactrim, amikacin, ctx, gent, levo, [**Last Name (un) 2830**],
ticaricillin/clavulonic acid
-- resistant to ampicillin, cafazolin, cefuroxime
-- indeterminant to amp/sul
blood culture [**7-4**] NGTD
Images:
[**2169-7-4**] CT abdomen/pelvis - intrahepatic biliary ductal
dilatation. distended gallbladder. CBD is dilated to 10mm. no
stone or mass seen within the biliary system. Proximal segment
of the pancreatic duct is also prominent, over 4mm. no
pancreatic mass seen.
EKG: NSR 95 bpm TWI III, AVF, V1-V3.
Discharge labs:
[**2169-7-7**] 05:40AM BLOOD WBC-6.9 RBC-3.34* Hgb-9.0* Hct-27.4*
MCV-82 MCH-27.1 MCHC-33.1 RDW-14.1 Plt Ct-332
[**2169-7-7**] 05:40AM BLOOD Plt Ct-332
[**2169-7-7**] 05:40AM BLOOD Glucose-88 UreaN-10 Creat-0.7 Na-142
K-3.4 Cl-103 HCO3-32 AnGap-10
[**2169-7-7**] 05:40AM BLOOD ALT-15 AST-11 LD(LDH)-170 AlkPhos-59
TotBili-0.3
[**2169-7-7**] 05:40AM BLOOD Albumin-3.3* Calcium-8.6 Phos-2.8 Mg-2.0
Pathology:
[**2169-7-5**]
A. Proximal esophagus:
Squamous epithelium, unremarkable; no glandular mucosa present.
B. Mid esophagus:
Squamous epithelium, unremarkable; no glandular mucosa present.
C. Distal esophagus:
Squamous epithelium, unremarkable; no glandular mucosa present.
D. Stomach:
Fundal mucosa, no diagnostic abnormalities recognized.
E. Small bowel:
Small bowel mucosa, no diagnostic abnormalities recognized.
EUS [**7-5**]:
Impression:
Dilation of the main bile duct to the level of the ampulla was
noted. No stones or strictures were noted.
The pancreatic duct was dilated to 5 mm in the head of pancreas
to the level of the ampulla
The ampulla was normal.
Normal but limited EUS exam of the Pancreas [exam was limited
due to surgically altered anatomy].
EGD [**7-5**]:
Normal mucosa in the esophagus (biopsy, biopsy, biopsy)
Erythema in the stomach body (biopsy)
S/P partial gastrectomy with B-1 anastomosis noted.
Normal mucosa in the duodenum (biopsy)
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
56 y/o F with eosinophilic gastroenteritis (s/p partial
gastrectomy and requiring chronic steroids and opiates) admitted
to the MICU with a flare of eosinophilic gastroenteritis
complicated by transient hypotension and serratia bacteremia.
Active Diagnoses
# Bacteremia: Pt initially febrile with transient hypotension.
Patient grew Serratia in [**4-12**] bottles from OSH BCx. Unclear
etiology of source, possible GI. Treated with Zosyn which
resolved fevers. Then switched to PO cipro the day prior to
discharge, plan 14-day course to end on [**7-18**]. Surveillance
cultures negative.
# Flare of eosinophilic gastroenteritis: Pt's abdominal pain
similar to other previous flares. Pt treated with IV
methylprednisolone. Continued on sucralfate, protonix and
morphine for pain control. EGD showed gastritis, biopsy with
normal tissue. CT abdomen with question of ampullary mass. EUS
showed dilation of the main bile duct to the level of the
ampulla. No stones or strictures were noted. The pancreatic
duct was dilated to 5 mm in the head of pancreas to the level of
the ampulla. The ampulla was normal. On discharge,
transitioned to home dose PO prednisone. To follow up with
outpatient GI physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 1356**].
# Non-specific ECG Changes: She remained chest pain free
throughout the admission. Troponin negative. No history of
chest pain. Very low likelihood that patient's presentation is
related to cardiac issues.
Transitional Issues:
- code status: full code
- new medications:
started Bactrim for PCP [**Name9 (PRE) 36554**] in the setting of chronic
high dose prednisone
started cipro (last day [**2169-7-18**])
- follow up: PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 1356**] (GI)
Medications on Admission:
1. Sucralfate 2gm tid w/ meals and before bedtime
2. Calcium Carbonate- vitamin 3
3. Multivitamin
4. Morphine 30mg tablet tid w/ meals and before bedtime,
alternating with Oxycodone 15 mg QID
5. Oxycodone 160mg ER (confirmed with pharmacy)
6. Protonix 40 mg daily
7. Prednisome 30 mg daily (had recently been increased and
currently tapering; taking 50 mg qAM and 35 mg qPM)
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 Tablet(s) by mouth every twelve (12)
hours Disp #*22 Tablet Refills:*0
2. Sucralfate 1 gm PO QID
2gm with meals and before bedtime
3. Multivitamins 1 TAB PO DAILY
4. Morphine Sulfate IR 30 mg PO Q8H:PRN pain
tid with meals and before bedtime, alternating with oxycodone
5. Oxycodone SR (OxyconTIN) 160 mg PO Q12H
6. Vitamin D 1000 UNIT PO DAILY
7. Calcium Carbonate 500 mg PO BID
8. Pantoprazole 40 mg PO Q24H
9. PredniSONE 50 mg PO QAM
10. PredniSONE 35 mg PO QPM
11. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
RX *Bactrim DS 800 mg-160 mg 1 Tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Serratia Bacteremia
Eosinophilia gastroenteritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 582**],
You were admitted because of abdominal pain due to an
exacerbation of your eosinophilic gastroenteritis. We also
found that you had a bacterial infection in your blood stream.
We treated you with IV steroids and antibiotics, which we
switched to antibiotics by mouth.
We made the following changes to your medications:
STARTED Calcium/Vitamin D to protect your bones
STARTED Bactrim (this is to prevent pneumonia while you are
taking high dose steroids, you can discuss this on your follow
up with Dr. [**First Name (STitle) 1356**]
STARTED Ciprofloxacin (last day [**2169-7-18**])
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Address: [**Street Address(2) 36555**], [**Location (un) 36556**],[**Numeric Identifier 36557**]
Phone: [**Telephone/Fax (1) 36558**]
When: Monday, [**7-17**], 2:45 PM
We are working on a follow up appt in the GI department with Dr.
[**First Name8 (NamePattern2) 6665**] [**Name (STitle) 1356**] in the 1-2 weeks. You will be called at home with
the appointment. If you have not heard or have questions,
please call [**Telephone/Fax (1) 463**].
Completed by:[**2169-7-8**] Name: [**Known lastname **],[**Known firstname 6508**] Unit No: [**Numeric Identifier 6509**]
Admission Date: [**2169-7-4**] Discharge Date: [**2169-7-8**]
Date of Birth: [**2112-10-11**] Sex: F
Service: MEDICINE
Allergies:
Dilaudid / Prilosec
Attending:[**First Name3 (LF) 1880**]
Addendum:
The patient presented initially with sepsis - fever, hypotension
and tachycardia due to bloodstream infection.
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1881**] MD [**Last Name (un) 1882**]
Completed by:[**2169-9-6**]
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10946, 11110
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6144, 7636
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294, 303
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8,188
| 130,277
|
2081
|
Discharge summary
|
report
|
Admission Date: [**2161-9-9**] Discharge Date: [**2161-9-23**]
Service: [**Hospital Unit Name 196**]
Allergies:
Neurontin / Topamax / Aldactone / Dicloxacillin / Amiodarone
Attending:[**First Name3 (LF) 9569**]
Chief Complaint:
failure of outpatient diuresis
Major Surgical or Invasive Procedure:
AVJ ablation
History of Present Illness:
84 yo Russian-speaking man with CAD, s/p MIx2, s/p CABG '[**37**], '[**51**]
(Lima->LAD, SVG->OM, SVG->PDA), dilated ischemic CM EF 30%
([**12-27**]) 2+TR/2+MR/1+AR, and A fib on coumadin and BIV-AICD (VVIR)
recently off amiodarone who has had multiple admissions for CHF
and tailored therapy. He failed outpt diuresis, with shortness
of breath and generalized fluid overload. He was admitted for
nesiritide and dopamine diuresis. INR found to be 5.
Past Medical History:
1. CAD status post CABG in [**2137**].
2. Status post MI x2.
3. CHF, dilated ischemic cardiomyopathy with
systolic/diastolic heart failure, EF 30 percent, 1 plus
AR, 2 plus TR, 2 plus MR in [**10-28**].
4. Paroxysmal atrial fibrillation.
5. Low back pain status post laminectomy/fusion.
6. Peripheral neuropathy.
7. Chronic renal insufficiency.
8. Benign prostatic hypertrophy.
9. Dementia
10. DM
11. Depression
Social History:
Patient lives with wife. [**Name (NI) **] and [**Name2 (NI) 11295**] very involved in
medical care. Denies tobacco or EtOHuse.
Family History:
non-contributory
Physical Exam:
Vitals: 97 88/50 86 18 96%on NRB wt 87.1 kg
Gen: alert, responsive, distressed expression coughing frothy
pink sputum
HEENT:anicteric, mmm, op clear, neck supple, jvd 12 cm, no jvp
appreciated
CV:irreg rate, quiet s1/s2, 2/6 systolic murmur, no r/g
appreciated, radial and dp pulses 1+ b/l
RESP: coarse bs throughout
ABD:s/nt/nd/nabs
EXTREM:cool, dry, no c/c, pedal edema 2+, 1+ dependently
NEURO:CN 2-12 grossly intact
SKIN:ecchymosis on shoulders and at IV sites
ACCESS:b/l arm piv
Pertinent Results:
[**2161-9-9**]
8:00p
chem 7 134 100 84 141
5.1 22 2.7
CK: 250 MB: 20 MBI: 8.0 Trop-*T*: 0.06
Comments: Note Updated Reference Ranges As Of [**2160-6-24**]
Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
Ca: 8.0 Mg: 2.4 P: 4.6 D
75
CBC 5.7 8.5 181
27.4
PT: 28.1 PTT: 45.9 INR: 5.0
Discharge labs:
EKG [**9-21**]
Regular ventricular pacing
Pacemaker rhythm - no further analysis
Since previous tracing of [**2161-9-17**], paced spikes are no longer
synchronized to
QRS complexes during atrial fibrillation
[**2161-9-23**] 05:42AM BLOOD WBC-5.9 RBC-3.65* Hgb-9.0* Hct-29.9*
MCV-82 MCH-24.7* MCHC-30.1* RDW-20.8* Plt Ct-202
[**2161-9-23**] 09:51AM BLOOD PT-15.3* PTT-37.1* INR(PT)-1.5
[**2161-9-23**] 05:42AM BLOOD Glucose-109* UreaN-57* Creat-1.5* Na-137
K-3.9 Cl-100 HCO3-28 AnGap-13
Brief Hospital Course:
Rhythm: After admission, the patient went into Afib with RVR
rates up to 150s, SBP as low as 50s, which could have
contributed to his worsening failure. The amiodarone that the
patient was maintained on as an outpatient was discontinued due
to side effect of ataxia. Metoprolol was increased and he was
maintained on dopamine and natrecor for 6 days, diuresing well,
maintaining MAP's > 55, and HR's between 80-120. When
stabilized, EP was [**Month/Day/Year 4221**] and inpatient AV junction ablation
with permanent biventricular pacing was performed on [**2161-9-21**].
Due to his persistent atrial fibrillation, and akinetic apex on
echo, heparin and warfarin 5 po qhs was started
prophylactically. His INR prior to discharge was 1.5, so he was
bridged with lovenox and will have close laboratory follow up.
*
Pump: The paitent has a history of failure with an EF of 25%.
The patient wwas admitted in decompensated CHF, with unclear
causes, possibly due to suboptimal filing due to his atrial
fibrillation and diet non-compliance, or worsening renal
function leading to failure of oupt diuresis. Transiently, he
decompensated further, evidenced by increased pulm edema on CXR
and worsening MR [**First Name (Titles) **] [**Last Name (Titles) **] on echo despite support with dopamine
and natrecor. As tolerated by his kidneys, he was aggressively
diuresed with lasix and chlorthiazide, responding well with
urine output and without further increase in his creatinine. It
is likely that the EP procedure improved renal perfusion, so he
was discharged home on torsemide 80 mg po qd and with specific
instructions on salt and fluid restriction.
*
Coronaries: The patient is s/p CABG, He was ruled out for an
ischemic event by EKG and serial enzymes. Echo showed EF of
25%, 4+TR, 3+MR, akinetic apex. The patient was continued on asa
81mg, lipitor 20mg, toprol XL 12.5mg PO. Lisinopril was held
during the patient's stay in the hospital, due to elevated Cr
and labile BP's, but was restarted prior to discharge home.
*
Anemia: unclear etiology, probably mixed Fe deficiency and
anemica of chronic disease. will have low threshold to
transfuse. Iron supplementation should be considered as an
outpatient when the patient is stable.
*
CRI: patient had a hx of CRI and came in with a Cr of of 2.2, up
from his baseline closer to 1.5. He was supported with dopamine
and natrecor which improved his creatinine.It also improved with
post-procedure. A chem 7 will be checked at close follow up.
*
GI: patient was constipated throughout his stay. aggressive
bowel regiment was started and maintained at discharge.
Outpatient f/u for constipation is recommended. patient was
discharged home on lactulose, dulcolax and colace.
*
GU: patient had significant penile and scrotal edema and BPH on
finasteride and tamsulosin. during the hospital stay, the
patient developed an Enterococci UTI, sensitive to levaquin and
was treated with a 10 day course of abx. during admission, foley
was placed, and patient developed hematuria due to traumatic
placement and clotted the foley off. GU was called, and
recommended condom cath placement. however patient's UOP
dropped, and foley was replaced wihtout incident. patient was
given pyridium to decrease bladder discomfort. After foley
removal, the patient was noted to have post-void residual volume
of 300 cc twice. The patient was observed to be continent and
able to urinate despite this. It was recommended to the family
that the patient be discharged with a foley catheter, but they
reported that they would prefer none since the patent has a
history of pulling the catheter, with copious bleeding because
of anticoagulation. They were instructed to look for specific
warning signs of retention, and will have follow up with Urology
in less than 1 week.
*
Dementia: The patient had significant sundowning in the
hospital. He was placed with a 1:1 sitter. It was felt that the
major reason was probably due to being in an unfamiliar
surroundings and the language barrier. He had one episode of
threatening the sitter with closed fists, for which haldol 2.5mg
IV was given which making the patient more confused. The family
got involved and threatened legal action if anti-psychotics are
used for this patient, and came in to spend nights with the
patient. Risk management, geriatrics and a social worker were
involved and recommended no haldol, close follow-up with family.
The family agreed to olanzipine for emergency situations.
*
Back pain: Pt has chronic back pain, and was maintained on home
pain regiment of oxycontin.
*
Skin: patient developed venous ulcer on his R leg and a pressure
ulcer on his sacrum, as well as a skin tear of his right arm.
Wound care nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] and the ulcers improved prior to
discharge. He will have visiting nurse assistance with wound
care.
*
Access: A PICC was placed during hospitalization and removed
prior to discharge.
*
Code: Full code during admission, confirmed with family.
Medications on Admission:
toprol XL 25,
lisinopril 5
asa 81,
lipitor 10,
torsemide 40 [**Hospital1 **],
proscar 5,
flomax 0.4,
gabitril 8 qam, 12 qhs,
aricept 10,
oxycontin 10 qam, 5 qpm
Discharge Medications:
1. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
2. Donepezil Hydrochloride 10 mg Tablet Sig: One (1) Tablet PO
HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
4. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*15 Tablet(s)* Refills:*2*
5. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
0.5 Tablet Sustained Release 24HR PO QD (once a day).
Disp:*15 Tablet Sustained Release 24HR(s)* Refills:*2*
6. Tiagabine HCl 4 mg Tablet Sig: Three (3) Tablet PO 2 PO QAM,
3 PO QHS.
Disp:*150 Tablet(s)* Refills:*2*
7. Oxycodone HCl 10 mg Tablet Sustained Release 12HR Sig: as
directed Tablet Sustained Release 12HR PO 1 tablet po QAM, [**12-26**]
tablet PO QPM as needed for back pain.
Disp:*30 Tablet Sustained Release 12HR(s)* Refills:*0*
8. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
9. Aspirin Low Dose 81 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
10. Enoxaparin Sodium 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours): Please discontinue when your
INR is above 2.0. Please have your blood drawn on Friday
[**2161-9-25**].
Disp:*6 syringes* Refills:*2*
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
13. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*QS bottles* Refills:*2*
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
QD (once a day) as needed for constipation.
Disp:*30 Suppository(s)* Refills:*0*
16. Torsemide 20 mg Tablet Sig: Four (4) Tablet PO QD (once a
day).
Disp:*120 Tablet(s)* Refills:*2*
17. Outpatient Lab Work
Please draw PT/INR and Chem 7 on Friday, [**2161-9-25**], and Monday
[**2161-9-28**] if necessary.
Ordering physician is [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 2031**] (can notify [**First Name8 (NamePattern2) 698**] [**Last Name (NamePattern1) 2087**]
[**Telephone/Fax (1) 11296**] with results).
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
1. congestive heart failure, decompensated
2. Diabetes mellitus, type II
3. anemia of chronic disease
4. Benign prostatic hypertrophy
5. dementia
6. pressure ulcers
7. chronic renal insufficiency (cr 1.6-2.2)
8. peripheral neuropathy
Discharge Condition:
fair: ambulatory, vital signs stable, 02 sats 95-96% on room
air. Continent of bladder without post void fullness, abd pain,
or agitation.
Discharge Instructions:
1. Weigh yourself every morning, call Dr. [**First Name (STitle) 2031**] or [**First Name8 (NamePattern2) 698**]
[**Last Name (NamePattern1) 2087**] if weight > 3 lbs.
2. Adhere to 2 gm sodium diet. This is the most important thing
you can do. Less is more - the less salt overall, the better.
Keep in mind that many prepared foods have a lot of salt such as
soups. The "No Salt Cookbook" may be helpful in preparing a low
salt diet.
3. Fluid Restriction: 2000cc/day
4. F/U with primary physician, [**Name10 (NameIs) 11297**], urology, neurology
5. Take your medications as directed.
6. Walking with assistance as tolerated
New Medications: lovenox: continue twice a day until INR > 2.0
as determinted by Dr. [**First Name (STitle) 2031**].
Warning signs: if pt has chest pain, shortness of breath,
fevers, increased swelling, agitation, increased confusion,
abdominal pain, decreased urine output, bladder fullness, or
other concerns, please call Dr. [**First Name (STitle) 2031**] or the [**Hospital 1902**] clinic
immediately or return to the ED.
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 986**] (urology), [**Telephone/Fax (1) 990**], on
Monday [**2161-9-28**] at 3:30 pm, on the [**Location (un) 470**] of the [**Hospital Ward Name 23**]
building for urinary retention. ***PLEASE SEND ENGLISH SPEAKING
FAMILY MEMBER WITH PATIENT OR CALL OFFICE SO THEY CAN ARRANGE
TRANSLATION BEFOREHAND.***
Provider: [**First Name8 (NamePattern2) 674**] [**Last Name (NamePattern1) 11298**], RN,BSN,MSN Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2161-10-1**]
11:20, ensure pt is stable follow up hyperglycemia in hospital.
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. Where: [**Hospital 4054**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 3512**]
Date/Time:[**2161-10-1**] 4:30 pm
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2161-10-15**] 3:30
Please also follow up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], Neurology ([**Telephone/Fax (1) 11299**] [**10-16**] at 1:00 pm for confusion at night
"sundowning".
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2304, 2793
|
1443, 1939
|
248, 280
|
361, 813
|
835, 1249
|
1265, 1393
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,776
| 171,158
|
53757
|
Discharge summary
|
report
|
Admission Date: [**2184-6-29**] Discharge Date: [**2184-7-1**]
Service: CARDIAC CA
CHIEF COMPLAINT: Dyspnea on exertion.
HISTORY OF PRESENT ILLNESS: This is a 78 year old male with
hypertension and hyperlipidemia who was in his usual state of
health until two weeks prior to admission when he noted
increasing shortness of breath on exertion, especially with
stairs. Since that time, the patient reports decreased
exercise tolerance but denied any orthopnea, paroxysmal
nocturnal dyspnea, or lower extremity swelling. He denies
any dizziness or lightheadedness. He was seen in Dr. [**Last Name (STitle) 46329**]
[**Name (STitle) 110331**] Clinic the day of admission and was found to have
high grade infra-nodal heart block and was sent to the
Emergency Room. A central line was placed with temporary
pacing wire placed overnight.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hyperlipidemia.
3. Exercise thallium stress test in [**2181**] showed a small
basal inferior fixed defect.
4. Mild asthma.
5. Hemorrhoids.
6. Colonic polyps.
7. Left bundle branch block since [**2178-12-12**].
8. Bilateral hernia repairs.
ALLERGIES: He has no known drug allergies.
MEDICATIONS:
1. Hydrochlorothiazide 12.5 mg p.o. q. day.
2. Lipitor 40 mg p.o. q. h.s.
3. Enalapril 20 mg p.o. twice a day.
4. Cardizem 180 mg p.o. q. day.
5. Aspirin 81 mg p.o. q. day.
SOCIAL HISTORY: He has a remote tobacco history; quit over
25 years ago. He has a remote alcohol history; quit over 17
years ago.
FAMILY HISTORY: Family history of stroke but denies any
family history of coronary artery disease or malignancy.
PHYSICAL EXAMINATION: Temperature is 98.0 F.; heart rate 35
to 45; blood pressure 161/32; respiratory rate 19; 98% on
room air. In no acute distress. Pupils were reactive to
light; the left was 3 millimeters to 2 millimeters; on the
right it was 2 millimeters to 1 millimeters. Extraocular
movements intact. Mucous membranes were moist. Jugular
venous pressure at about 7 centimeters. Lungs were clear to
auscultation bilaterally. He is bradycardic with normal S1
and S2 with I/VI systolic murmur at the apex. His abdomen
was soft, nontender, nondistended, with normoactive bowel
sounds. No edema. In his extremities he had two plus
dorsalis pedis bilaterally.
LABORATORY: EKG showed sinus with atrial rate of 70, 2:1
heart block with ventricular rate of 35 and an old left
bundle branch block.
White blood cell count 11.3, hematocrit 34.6, platelets 298.
Sodium 140, potassium 4.1, chloride 102, bicarbonate 25, BUN
26, creatinine 1.3, glucose 129. CK 96. Troponin less than
0.3.
Echocardiogram in [**2183-4-11**] showed a large left atrium,
ejection fraction 60 to 65% with mild symmetric left
ventricular hypertrophy, trace aortic regurgitation, mild
mitral regurgitation.
INR was 1.2, PTT 22.7. Total cholesterol in [**2184-4-10**]
showed total cholesterol of 161, LDL 89, HDL of 35,
triglycerides of 184. Urinalysis was negative.
Chest x-ray was negative.
HOSPITAL COURSE: The patient remained stable in the
hospital. He underwent electrophysiology study and pacemaker
placement. He remained stable and asymptomatic. He was then
discharged home.
DISCHARGE INSTRUCTIONS:
1. Not to lift anything heavier than ten pounds for two
weeks with the left arm.
2. He was asked to call his cardiologist with any fatigue or
shortness of breath.
3. He was to follow-up in Device Clinic in one week.
4. He was to follow-up with his cardiologist in two to three
weeks.
DISCHARGE DIAGNOSES:
1. Complete heart block.
MAJOR INTERVENTIONS:
1. Transvenous pacer wire placement on [**6-29**].
2. Pacemaker placement on [**6-30**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Enalapril 20 mg p.o. twice a day.
2. Hydrochlorothiazide 12.5 mg p.o. q. day.
3. Lipitor 40 mg p.o. q. h.s.
4. Percocet p.r.n.
5. Keflex 500 mg p.o. q. six hours for three days.
6. Ativan 1 mg p.o. q. h.s. as needed.
7. Diltiazem 180 mg p.o. q. day.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Name8 (MD) 6371**]
MEDQUIST36
D: [**2184-7-2**] 11:19
T: [**2184-7-5**] 21:56
JOB#: [**Job Number 110332**]
|
[
"426.53",
"414.01",
"493.90",
"272.4",
"427.89",
"424.0",
"402.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.83",
"37.26",
"37.72"
] |
icd9pcs
|
[
[
[]
]
] |
1530, 1628
|
3543, 3683
|
3741, 4278
|
3032, 3209
|
3233, 3522
|
1652, 3013
|
112, 134
|
163, 850
|
872, 1378
|
1396, 1512
|
3709, 3718
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,756
| 154,649
|
6433+55756
|
Discharge summary
|
report+addendum
|
Admission Date: [**2197-2-12**] Discharge Date: [**2197-2-27**]
Service:
CHIEF COMPLAINT: 80 year old male with vague abdominal
complaints.
HISTORY OF PRESENT ILLNESS: This is an 80 year old male with
a past medical history significant for dementia, though mild,
who presents with vague complaint of abdominal and chest
discomfort. The patient was unable to provide a clear or
full history, but at the time of the interview stated that he
had problems for a couple of weeks in terms of belly pain and
unable to distinguish between diarrhea and constipation at
the time of admission. He says that he has had a bowel
movement on the day of admission, but also notes that he has
some vague chest discomfort at baseline, two to three times a
week. At the time of admission, denied any abdominal
discomfort, shortness of breath or palpitations.
PAST MEDICAL HISTORY:
1. Laryngeal cancer.
2. Chronic obstructive pulmonary disease.
3. Left shoulder fracture with chronic pain.
4. Dementia.
5. PSA elevation.
6. Spinal stenosis.
ALLERGIES: No known drug allergies.
MEDICATIONS: Denies taking any medicines at home.
SOCIAL HISTORY: Lives with wife in a home in [**Name (NI) 8391**].
Has a history of tobacco use in the past.
PHYSICAL EXAMINATION: On presentation, temperature 97.0 F.;
pulse 88; respiratory rate 18; blood pressure 98/60; 98% on
four liters. Generally speaking, in no apparent distress.
HEENT: Pupils equally round and reactive to light and
accommodation. Small OM clear. Mucous membranes dry.
Heart: Regular rate and rhythm, S1 and S2 positive. No
murmurs, gallops or rubs. Lungs clear to auscultation
bilaterally with bilateral crackles, no wheezes. Abdomen
soft, nontender, nondistended; 5 cm mass in right lower
quadrant. Extremities with no edema. Neurologic: Alert and
oriented times two. Cranial nerves II through XII intact.
LABORATORY: Admission laboratories were white count of 17.3,
hematocrit of 41.6, platelets of 341,000, sodium of 144,
potassium of 4.0, chloride of 106, bicarbonate of 24, BUN 19,
creatinine 0.9, glucose 123. Normal liver function tests,
total bilirubin and alkaline phosphatase. INR is 0.8,
negative troponin and CKs.
Chest x-ray was negative at time of presentation. An EKG on
presentation was sinus at 103 with multiple premature atrial
contractions, normal axis, baseline left bundle branch block,
T wave inversions in I; no change on comparison to
[**2196-11-25**].
HOSPITAL COURSE: The patient was admitted to the Medical
Service where he was ruled out for a myocardial infarction.
He was also noted to be in atrial fibrillation. Ultimately,
the patient had a CT scan that revealed a right lower
quadrant mass and ultimately was seen by Surgery on the 31st,
that recommended GI and Cardiology consults for evaluation as
well as NPO and NG tube decompression. The patient continued
to be decompressed for several days with only complaints of
nausea and abdominal discomfort.
Ultimately, the patient was seen by Gastroenterology that
recommended the same NG suction and observation for potential
procedure in the future. The patient again continued to be
decompressed for several days. Ultimately on the [**1-17**], the patient pulled out his NG tube and while doing
that had an episode of what appears to be aspiration.
Ultimately, the patient was transferred to the Intensive Care
Unit on the [**Hospital Ward Name 516**], intubated secondary to hypoxic
respiratory distress, and for likely aspiration pneumonia.
The patient had a Swan placed and was hypotensive,
transiently on Dopamine, ultimately on Levophed and
vasopressor that were both weaned off within three days.
The patient was put on Vancomycin, Levofloxacin and Flagyl.
The patient with right upper lobe pneumonia and left lower
lobe pneumonia that are gradually increasing rather than
improving. He has been continued on his Amiodarone drip for
atrial fibrillation since p.o. load has been impossible. The
patient was afebrile after weaning off his pressors on the
[**1-22**], continued to be afebrile until the 10th, at
which point he spiked a fever to 101.0 F.
The patient had five sputum cultures grow out MRSA which
correlated with the Gram stain and also had a right IJ that
was discontinued that grew out MRSA from a blood culture
drawn from the central line. The patient had an NG tube
changed to an OG tube on the 11th. His cordis was removed
and the patient had a quadruple lumen put in its place. The
first Swan numbers revealed a PA pressure of 42/20, a wedge
of 15 to 22, a CVP of 13 to 15, cardiac output of 5.13 and
SVR of 920. Initially, his SVR was 360, cardiac output in
the 6 range and a wedge around 8.
After repletion, his cardiac output and his wedge improved,
and the patient appeared to be improving until the fever
spike, at which point he became more distressed in terms of
his respiratory status, requiring increasing ventilations and
ultimately going from SIMV and pressure support to assist
control ventilation at 630 by 20 with an FIO2 of 55%.
Arterial blood gases revealed a pH of 7.3, 45, 40, with
correction by the change in the ventilator.
Ultimately, the family decided that they wanted the patient
transferred to the [**Hospital6 1708**] for
evaluation by Dr. [**Last Name (STitle) 8635**]. Based on this, the decision
has been made to transfer the patient.
SYSTEM BY SYSTEM PROBLEM LIST:
1. [**Name2 (NI) 24763**]lar: The patient, prior to having his
surgery planned, had a MIBI that revealed reversibility and
also an echocardiogram that revealed a depressed ejection
fraction in the 25 to 30% range. The patient ultimately
continued to be in atrial fibrillation, was loaded on
amiodarone intravenous. Because of his obstruction and
uncle[**Name (NI) **] obstruction, Cardiology here felt that he should
continue his drip at 0.5 mg per hour. Otherwise, the patient
has been hemodynamically stable since weaned off pressors
from the septic physiology that he was displaying.
2. Infectious Disease: The patient with right upper
lobe, left lower lobe Methicillin resistant Staphylococcus
aureus pneumonia. Also, with new left pleural effusion,
increasing white count, ongoing fevers and increasing
respiratory distress. Plan should be to continue
antibiotics, specifically Vancomycin. Consider further
addition of Rifampin if the patient's clinical situation
continues to worsen. Plan should also include a tap of the
patient's left pleural space to rule out empyema in case the
patient needs a chest tube. This was planned at the [**Hospital1 18**]
for today, but given transfer, should be done at his new
location. No other positive cultures for now.
3. Pulmonary: Methicillin resistant Staphylococcus
aureus pneumonia and congestive heart failure. Continuing
antibiotics. He is currently day 11 of all of his
antibiotics. Based on his worsening clinical scenario, we
have switched him from SIMV to assist-control. He is
currently on assist-control 630 by 20, with FIO2 of 55%. We
also initiated diuresis today with 40 mg of intravenous
Lasix.
4. Renal Function: Stable; follow BUN and creatinine.
5. Gastrointestinal: The patient with an obstructing
mass in his right cecum. Will print out reports for you of
CT scan. Would consider surgery if more stable. The patient
felt not to be a surgical candidate at the time of this
dictation.
[**Doctor Last Name **] goal for the day of one liter negative. Electrolytes are
stable. Will forward a copy of his electrolytes.
CODE STATUS: Code status is Full Code.
PROPHYLAXIS: The patient is on:
1. Protonix 40 twice a day.
2. On pneumoboots.
HEME: The patient with low platelets on heparin. Heparin
induced thrombocytopenia antibody pending. With
discontinuation of heparin, the patient returned his platelet
count to normal.
NOTE: The patient should not be given any heparin
subcutaneously, intravenous or in flushes.
DISPOSITION: Discharged to the [**Hospital6 1708**]
under the care of Dr. [**Last Name (STitle) 8635**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Name8 (MD) 24764**]
MEDQUIST36
D: [**2197-2-27**] 14:30
T: [**2197-2-27**] 14:31
JOB#: [**Job Number 24765**]
Name: [**Known lastname 4208**], [**Known firstname **] E Unit No: [**Numeric Identifier 4209**]
Admission Date: [**2197-2-12**] Discharge Date:
Date of Birth: [**2116-10-17**] Sex: M
Service:
DISCHARGE MEDICATIONS:
1. Fentanyl drip 2535 mcg/hr.
2. Amiodarone 0.5 mg iv/hr, continue while NPO.
3. Protonics 40 mg intravenous b.i.d.
4. Levofloxacin 500 mg intravenous q.d., day 11.
6. Flagyl 100 mg intravenous t.i.d., day 11.
7. Regular insulin sliding scale.
8. Nystatin swish and suction 10 cc q.i.d.
9. Artificial Tears.
10. Combivent 6 puffs q.6h.
11. Tylenol 650 mg q.6h. p.r.n.
12. Ativan 0.5 to 1 mg intravenous q.2h. p.r.n.
14. Total parenteral nutrition.
ALLERGIES: Please note the patient is allergic to heparin
producing heparin induced thrombocytopenia. Avoid all
heparin products.
DR.[**Last Name (STitle) 4210**],[**First Name3 (LF) 963**] 11-933
Dictated By:[**Name8 (MD) 2512**]
MEDQUIST36
D: [**2197-2-27**] 14:37
T: [**2197-2-27**] 14:57
JOB#: [**Job Number **]
|
[
"996.62",
"038.19",
"507.0",
"427.31",
"496",
"276.5",
"560.9",
"263.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04",
"89.64",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
8566, 9383
|
2480, 5389
|
1270, 2462
|
102, 153
|
182, 858
|
5403, 8543
|
880, 1136
|
1153, 1247
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,033
| 147,301
|
43037
|
Discharge summary
|
report
|
Admission Date: [**2186-12-17**] Discharge Date: [**2186-12-22**]
Date of Birth: [**2148-4-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
38 y/o M w/ HTN, DM c/b diabetic gastroparesis, ESRD, who
presented to the ED c/o abdominal pain, nausea and vomiting. At
triage he had difficulty answering questions.
.
In the ED, patient's vitals were HR 100, BP 200/132, RR 22, O2
95%
EKG demonstrated diffuse anterior ST elevations V2-V5, with
q-waves in V2-V5, lateral t-wave inversions, and occasional
PVC's.
.
Patient was taken to Cath lab for emergent revascularization.
Cath results revealed normal left main, LAD with proximal
occlusion after D1, a CTO of D1. LCx non-dominant w/o disease,
RCA was not injected. A BMS was placed in the proximal LAD. D1
was not crossed. CI was 2.46 pre-intervention, 3.01
post-intervention, PCWP 22, mean PA 25, mean RA 6.
.
Patient was started ASA, and [**First Name3 (LF) 4532**]. Integrillin was held given
his labile BP and concern for possible intracranial bleed.
.
Patient was transferred to the CCU for management.
.
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.
Past Medical History:
Of note, recently hospitalized for bacteremia with coagulase
negative staph in [**11/2186**], tunnelled dialysis catheter was
changed at that time - patient discharged on 14 day course of
vancomycin to be dosed at dialysis.
1. Diabetes mellitus type I - last A1c 7.1% ([**2185**]) c/b
gastroparesis requiring multiple hospitalizations.
2. End-stage renal disease on hemodialysis started [**2-/2184**]
TuThSa
3. Severe autonomic dysfunction with multiple hospitalizations
for hypertensive emergency, and orthostatic
hypotension
5. History of esophageal erosion, [**Doctor First Name **]-[**Doctor Last Name **] tear
6. Coronary artery disease with 1-vessel disease (50% stenosis
D1)
- Fixed, small, moderate severity perfusion defect involving the
LAD (diagonal) territory by MIBI on [**2186-6-7**]
7. History of foot ulcer - 2 months, healing slowly
8. History of clot in AV fistula clot on coumadin - [**Month (only) 958**]/[**Month (only) 205**]
of [**2185**] s/p multiple attempts to remove clot
9. CVA
[**89**]. History of coagulase negative Staphylococcus bacteremia
11. Recent admission and discharge AMA for
klebsiella/enterobacteremia
12. History of MRSA from sputum in [**2185**].
Social History:
Denies alcohol or tobacco use or marijuana.
Family History:
His father died of ESRD and diabetes. His mother is in her 50s
and has hypertension. He has two sisters, one with diabetes, and
six brothers, one with diabetes.
Physical Exam:
VS: T 97.8, BP 118/66 , HR 101, RR 16, O2 98% on NRB
Gen: Young Man, visibly uncomfortable, vomiting into basin and
c/o belly pain, mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple, unable to assess JVP, no carotid bruits.
CV: PMI located in 5th intercostal space, laterally displaced
from midclavicular line. RR, normal S1, S2. No S4, no S3. Mild
[**2-18**] early systolic murmum best heard at the apex.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Occasional wheezes
anteriorly.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: Warm No c/c/e. No femoral bruits. Central line in R-groin.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; DP dopplerable, PT dopplerable
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Neuro: Easily arousable, but nods off to sleep during interview.
AOx3, follows commands.
Pertinent Results:
[**2186-12-17**] 01:35AM PT-15.0* PTT-31.6 INR(PT)-1.3*
[**2186-12-17**] 01:35AM PLT COUNT-325
[**2186-12-17**] 01:35AM WBC-17.1*# RBC-3.39* HGB-8.9* HCT-28.3*
MCV-83 MCH-26.4* MCHC-31.7 RDW-19.2*
[**2186-12-17**] 10:55AM CK-MB-15* MB INDX-3.6 cTropnT-10.30*
[**2186-12-17**] 04:29AM CK(CPK)-448*
[**2186-12-17**] 04:29AM CK-MB-14* MB INDX-3.1
Echo Report:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
to moderate regional left ventricular systolic dysfunction with
severe hypokinesis/akinesis of the mid to distal septum,
anterior wall and inferior and anterior apex. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. The mitral valve leaflets
are mildly thickened. There is borderline pulmonary artery
systolic hypertension.
Compared with the prior study (images reviewed) of [**2186-11-23**],
there is now severe hypokinesis/akinesis in the distribution of
the left anterior descending artery. The left ventricular wall
thicknesses have decreased slightly and the estimated pulmonary
artery systolic pressure has increased.
EKG [**2186-12-19**]: Sinus tachycardia. There are Q waves in leads I,
aVL and V2-V6 with
ST segment elevation suggesting extensive anterolateral
myocardial infarction.
Since tracing of [**2186-12-18**] there is no significant change.
CT Head: FINDINGS: There is no evidence of intracranial
hemorrhage, shift of normally midline structures, mass effect,
hydrocephalus, or acute major vascular territorial infarction.
The [**Doctor Last Name 352**]-white matter differentiation is preserved. Iodinated
contrast is present within the cerebral vasculature from recent
cardiac catheterization. The paranasal sinuses and mastoid air
cells are clear. The surrounding soft tissues and osseous
structures are unremarkable.
IMPRESSION: No intracranial hemorrhage or mass effect.
MR is more sensitive than CT in depicting acute brain ischemia.
Cardiac Cath:
1. Coronary angiography in this right dominant system
demonstrated one
vessel disease. The LMCA had no angiographically apparent
disease. The
LAD was occluded proximally after D1. The D1 had a chronic total
occlusion. The LCx was a non-dominant vessel without lesions.
The RCA
was not injected.
2. Resting hemodynamics revealed top normal right and elevated
left
sided filling pressures with RVEDP of 7 mmHg and mean PCW of 22
mmHg.
There was moderate pulmonary arterial systolic hypertension with
PASP
of 51 mmHg. There was moderate to severe systemic arterial
systolic and
diastolic hypertension with SBP of 200 mmHg and DBP of 107 mmHg.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Moderate-severe systemic arterial hypertension.
3. Left ventricular diastolic dysfunction.
Brief Hospital Course:
Patient was admitted to the CCU following placement of a BMS to
the LAD on presentation.
.
#On Arrival to the CCU the patient as on nitro gtt for control
of his BP. That was transitioned to labetalol drip with good
effect and patient was able to be transitioned to PO labetalol
within a short period of time. His BP remained labile and in
the setting of fevers there was concern for low grade sepsis.
Ultimately, patient was controlled on labetalol and lisinopril.
.
#CAD: Patient was not given integrillin due to hypertensive
urgency and concern for ICH. CT head negative for bleed. He
was continued on ASA and [**Doctor Last Name 4532**], labetalol, lisinopril, and
atorvastatin. Repeat echo showed no evidence of any LV
aneurysm. Patient was advised to continue all medications -
especially ASA and [**Doctor Last Name 4532**] on discharge.
.
#ID: Vancomycin and ceftazidime were started and dosed as per HD
protocol for possible line sepsis. Culture data at the time of
discharge showed no significant growth (+culture a very probably
contaminant). Optimal duration of therapy had not been
determined prior to patient's leaving AMA. Patient defervesed
prior to discharge.
.
#GI: Continued symptomatic gastroparesis throughout his
hospitalization. AXR demonstrated no SBO. Not significantly
improved with reglan, and erythromycin. Mr. [**Known lastname **] insisted on
dilaudid and ativan for his abdominal pain with good response,
however team was concerned dilaudid was exacerbating his GI
complaints. Attempts to transion to PO dilaudid and to wean the
dose resulted in patient leaving AMA.
.
#Drug Abuse: +Utox for cocaine in setting of STEMI. Patient
advised to discontinue all cocaine use due to concern about
coronary vasoconstriction. On discussion, he denied an illicit
substance abuse although he admitted to having recently been at
a party where marijuana was being smoked.
.
#Renal: Dialyzed as per usual protocol. T/Th/Sat.
- Vanco dosed at dialysis. Elevated Ca/Phos product on
discharge but patient at nearly maximum dose of phos binder.
Plan to discuss with renal possible additional [**Doctor Last Name 92860**], but
patient left AMA. Concern for exacerbating GI upset with
increasing dose/use of phosphate binders.
.
The remainder of Mr. [**Known lastname **] hospital stay was uneventful.
Patient ultimately left AMA before work-up could be completed.
.
Medications on Admission:
1. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTUES (every Tuesday) as needed for HTN.
2. B Complex-Vitamin C-Folic Acid 1 mg PO DAILY (Daily).
3. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
4. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO HS (at bedtime).
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO HS
7. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID
8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 10 days.
9. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous HD PROTOCOL (HD Protochol) for 11 days.
10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. Reglan 10 mg Tablet Sig: One (1) Tablet PO QIDACHS.
12. Zolpidem 5 mg Sig: One (1) Tablet PO at bedtime as needed.
13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Three
(3) units Subcutaneous twice a day.
14. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale units Injection QIDACHS: per sliding scale.
15. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. 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*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Docusate Sodium 50 mg/5 mL Liquid Sig: [**2-14**] PO BID (2 times a
day).
Disp:*1 bottle* Refills:*2*
4. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day): Do not take your morning dose on day of dialysis.
Disp:*180 Tablet(s)* Refills:*2*
8. Erythromycin Ethylsuccinate 200 mg/5 mL Suspension for
Reconstitution Sig: One (1) PO Q 8H (Every 8 Hours).
Disp:*1 bottle* Refills:*2*
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*2*
11. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
12. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous qhd
for 5 days: at HD per protocol.
13. Ceftazidime 1 gram Recon Soln Sig: One (1) gram Intravenous
qhd for 5 days: at HD per protocol.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
15. Insulin Glargine 100 unit/mL Solution Sig: Five (5) units
Subcutaneous at bedtime.
Disp:*1 bottle* Refills:*2*
16. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
attached units Subcutaneous qachs.
Disp:*1 bottle* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: ST elevation MI
Secondary Diagnoses: Diabetes, End Stage Renal Disease,
Gastroparesis
Discharge Condition:
Stable, with home PT and cardiac rehab
Discharge Instructions:
You were admitted to the hospital for evaluation of chest pain.
On arrival to the Emergency Department, it was determined that
you had suffered a large heart attack. You were taken for a
cardiac catheterization where a bare metal stent was placed into
one of your arteries to restore blood flow to your heart. You
were then observed in the Cardiac Care unit where your blood
pressure was controlled with IV medications.
You have decided to leave against medical advice as is therefore
putting your health at risk with possible adverse effects
including death. Please know that we would gladly have you come
back to the hospital at any time. We have tried to put together
your follow-up care including your medications to the best of
our abilities under the circumstances.
Upon leaving the hospital please take all medications as
directed. In particular, you MUST continue to take Aspirin, and
[**Month/Day (2) **] as directed. Please do not stop taking aspirin and
[**Month/Day (2) 4532**] unless told by a cardiologist to do so. Please keep all
follow-up appointments or call if you are going to be unable to
attend.
Followup Instructions:
Primary Care: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 216**] (pls set up an appointment to be seen
within 1-2 weeks)
Renal: Dr. [**Last Name (STitle) 1366**] (pls set up an appointment to be seen within
1-2 weeks)
Please go to your regularly scheduled hemodialysis appointments
Cardiology: Dr. [**First Name (STitle) 2572**] on [**1-1**] at 11:00
.
Prev scheuduled appt's
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK
Date/Time:[**2187-1-8**] 1:30
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2187-1-8**] 3:30
|
[
"414.01",
"536.3",
"410.11",
"250.61",
"250.41",
"305.60",
"585.6",
"V12.54",
"403.01",
"337.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"88.56",
"00.40",
"88.52",
"00.45",
"37.23",
"36.06",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
12915, 12921
|
7250, 9646
|
331, 357
|
13070, 13111
|
4208, 5817
|
14284, 14922
|
2954, 3116
|
10917, 12892
|
12942, 12942
|
9672, 10894
|
7092, 7227
|
13135, 14261
|
3131, 4189
|
12998, 13049
|
277, 293
|
385, 1658
|
5826, 7075
|
12961, 12977
|
1680, 2874
|
2890, 2938
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,554
| 196,596
|
26217
|
Discharge summary
|
report
|
Admission Date: [**2105-10-28**] Discharge Date: [**2105-11-5**]
Date of Birth: [**2050-6-20**] Sex: F
Service: MEDICINE
Allergies:
telaprevir
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
Rash
Major Surgical or Invasive Procedure:
Right internal jugular central venous line placement.
Transesophageal echocardiogram [**2105-11-3**]
History of Present Illness:
55 y/o HCV on telaprevir, hypothyroidism, depression, presents
with diffuse rash. Rash began 5 weeks ago and telaprevir was
given for a 12 week course (finished on [**2105-10-19**]). However, rash
has persisted despite stopping telaprevir. She denies fevers,
nausea, vomiting, diarrhea. She has denies oral lesions. Rash
burns and is pruritic.
In the ED initial vitals were: 109 122/81 14 100%. Rectal temp
101.6. Exam was notable for mild lethargy and confusion and
some dyspnea. Labs showed lactate 6.1, HCO3 21, AST/ALT 65/28,
LDH 660, TBili 2.8, DBili 1.4, HCT 29 (baseline 35 prior to
telaprivir), WBC 7.8 with 18.4% eosinophils. UA notable for WBC
51, leuk/nitrite negative. CVL placed. CXR showed appropriate
CVL placement, otherwise no acute intrathoracic process. RUQ US
showed thickened gall bladder edema. CT torso showed no
PE/dissection, but cirrhosis with extensive varices and
mesenteric/colonic/gallbladder edema. Hepatology and surgery
were consulted. Surgey did not feel gallbladder edema was
related to an acute infectious process, but rather secondary to
cirrhosis. She received vancomycin 1g, metronidazole 500mg and
ciprofloxacin 400mg. She was also seen by dermatology who send
DFA for VZV/HSV, recommended topical agents and covering for
bacterial superinfection and will preform punch biopsy in the
morning. She was also seen by hepatology (Dr. [**Last Name (STitle) **] who
recommended MICU admission). She was given 4L NS with
improvement in lactate 6.1 to 4.2. Also received 30mL
lactulose. Vitals prior to transfer HR 80-90 SBP 123.
.
On arrival to the MICU, her vitals were 96.6 (oral), 94, 129/63,
RR- 98% on RA.
Past Medical History:
HYPOTHYROIDISM
DEPRESSION
HEPATITIS C
OBESITY
MIGRAINE HEADACHES
PERIPHERAL EDEMA
*S/P ADJ GASTRIC BAND (VG) & HIATAL HERNIA REPAIR [**2104-7-8**]
s/p hystorectomy due to excessive vaginal bleeding and
?precanerous condition
ANEMIA
Social History:
Social History:
- Tobacco: never
- Alcohol: only as a teenager
- Illicits: never
Family History:
Family History: husband also has hep C, but patient had Hep C
prior to meeting husband.
Physical Exam:
Vitals: 96.6 (oral), 94, 129/63, RR- 98% on RA.
General: Alert, oriented x3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, R IJ in place
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic murmur
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: obese soft, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Extensive erythrodermic rash with confluent erythematous
eruption with scaling over 80-90% of body, sparing distal
extremities
Physical Exam on Discharge:
VSS, afebrile
O: GENERAL AAOx3 in NAD,
HEENT: No erythema on the face, no lesion in the oropharynx, MMM
Cardiac: RRR, no MRG appreciated
Lungs: CTAB
Abdomen: Soft, nontender nondistended, no rebound or guarding
Extremities: 1+pitting edema L>R , warm well perfused
Skin: Mostly normal skin with a few patchy areas on lower
extremities of healing rash.
Pertinent Results:
Admission labs:
[**2105-10-28**] 01:45PM BLOOD WBC-7.8# RBC-2.68* Hgb-9.2* Hct-29.1*
MCV-109* MCH-34.1* MCHC-31.4 RDW-20.4* Plt Ct-93*
[**2105-10-28**] 01:45PM BLOOD Neuts-52.6 Bands-0 Lymphs-23.9 Monos-4.5
Eos-18.4* Baso-0.6
[**2105-10-28**] 01:45PM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-2+
Macrocy-2+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ Tear Dr[**Last Name (STitle) **]2+
[**2105-10-28**] 02:28PM BLOOD PT-19.5* PTT-43.4* INR(PT)-1.8*
[**2105-10-28**] 01:45PM BLOOD Glucose-137* UreaN-13 Creat-0.7 Na-139
K-4.5 Cl-105 HCO3-21* AnGap-18
[**2105-10-28**] 01:45PM BLOOD ALT-28 AST-65* LD(LDH)-660* CK(CPK)-104
AlkPhos-94 TotBili-2.8* DirBili-1.4* IndBili-1.4
[**2105-10-28**] 01:45PM BLOOD Lipase-75*
[**2105-10-28**] 01:45PM BLOOD CK-MB-3 proBNP-156
[**2105-10-28**] 01:45PM BLOOD cTropnT-<0.01
[**2105-10-29**] 02:50PM BLOOD cTropnT-<0.01
[**2105-10-28**] 01:45PM BLOOD Calcium-8.0* Phos-3.0 Mg-1.8
[**2105-10-28**] 02:55PM BLOOD Lactate-6.1*
[**2105-10-28**] 09:59PM URINE Color-[**Location (un) **] Appear-Clear Sp [**Last Name (un) **]-1.041*
[**2105-10-28**] 09:59PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-8* pH-6.0 Leuks-NEG
[**2105-10-28**] 09:59PM URINE RBC-6* WBC-51* Bacteri-NONE Yeast-NONE
Epi-0 RenalEp-<1
[**2105-10-28**] 09:59PM URINE CastHy-4*
[**2105-10-28**] 09:59PM URINE Mucous-MANY
[**2105-10-28**] 09:59PM URINE Eos-NEGATIVE
[**2105-10-28**] 09:59PM URINE Hours-RANDOM UreaN-615 Creat-153 Na-<10
K-50 Cl-17
[**2105-10-28**] 09:59PM URINE Osmolal-541
Discharge labs:
[**2105-11-4**] 06:35AM BLOOD WBC-2.6* RBC-2.10* Hgb-7.3* Hct-23.3*
MCV-111* MCH-34.7* MCHC-31.3 RDW-21.5* Plt Ct-40*
[**2105-11-4**] 06:35AM BLOOD PT-15.7* PTT-40.1* INR(PT)-1.4*
[**2105-11-4**] 06:35AM BLOOD Glucose-137* UreaN-10 Creat-0.5 Na-137
K-3.6 Cl-104 HCO3-28 AnGap-9
[**2105-11-4**] 06:35AM BLOOD ALT-28 AST-70* AlkPhos-87 TotBili-2.0*
[**2105-11-4**] 06:35AM BLOOD Albumin-2.1* Calcium-8.0* Phos-2.6*
Mg-1.8
Pertinent Labs:
[**2105-10-29**] 03:36AM BLOOD I-HOS-DONE
[**2105-10-30**] 05:30PM BLOOD Fibrino-61*
[**2105-10-29**] 10:30AM BLOOD Thrombn-26.2*
[**2105-10-29**] 10:30AM BLOOD Ret Man-4.1*
[**2105-10-29**] 10:30AM BLOOD ACA IgG-2.6 ACA IgM-2.6
[**2105-11-1**] 05:28AM BLOOD calTIBC-165* VitB12-1787* Folate-10.3
Ferritn-649* TRF-127*
[**2105-10-29**] 10:30AM BLOOD Cryoglb-NO CRYOGLO
[**2105-10-28**] 01:45PM BLOOD Hapto-<5*
[**2105-11-3**] 05:40AM BLOOD TSH-0.60
[**2105-10-28**] 01:45PM BLOOD TSH-2.4
[**2105-10-28**] 01:45PM BLOOD Free T4-0.97
[**2105-10-30**] 03:06AM BLOOD freeCa-1.19
Micro:
[**2105-10-28**] 2:45 pm BLOOD CULTURE
**FINAL REPORT [**2105-10-31**]**
Blood Culture, Routine (Final [**2105-10-31**]):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL
SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
CLINDAMYCIN-----------<=0.25 S <=0.25 S
ERYTHROMYCIN----------<=0.25 S <=0.25 S
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- 0.25 S 0.25 S
OXACILLIN------------- 0.5 S <=0.25 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
Anaerobic Bottle Gram Stain (Final [**2105-10-29**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Reported to and read back by DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5386**] [**2105-10-29**] AT
10:42.
Aerobic Bottle Gram Stain (Final [**2105-10-29**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
[**2105-10-28**]: Direct Antigen Test for Herpes Simplex Virus Types 1 &
2 (Final
[**2105-10-29**]): UNINTERPRETABLE DUE TO INADEQUATE SPECIMEN.
[**2105-10-28**]: DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS (Final
[**2105-10-29**]):
UNINTERPRETABLE DUE TO INADEQUATE SPECIMEN.
[**2105-10-29**]: URINE CULTURE (Final [**2105-10-31**]):
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
NITROFURANTOIN-------- <=16 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
[**2105-10-30**]: BLood cultures- NGTD
[**2105-10-31**]: RAPID PLASMA REAGIN TEST (Final [**2105-11-2**]):
NONREACTIVE.
Imaging:
[**10-28**] RUQ U/S: IMPRESSION: 1. New circumferential gallbladder
mural thickening and edema. In a patient with a history of
cirrhosis, considerations include cholecystitis or alternatively
third spacing of fluids in a patient with hypoalbuminemia,
hepatitis or right heart dysfunction. 2. Coarse hepatic
echotexture consistent with cirrhosis.
3. Patent portal venous system.
[**10-28**] CXR: AP AND LATERAL VIEWS OF THE CHEST: There is mild
cardiomegaly which is unchanged. Mediastinal and hilar contours
are normal. The lungs show no focal consolidation, pleural
effusion or pneumothorax.
[**10-28**] CT Chest + Abdomen + Pelvis:
1. No evidence of pulmonary embolism, aortic dissection or
aortic aneurysm. 2. Nodular liver consistent with the provided
history of cirrhosis, with splenomegaly and extensive varices.
3. Anasarca and diffuse mesenteric edema. In that context,
circumferential gallbladder mural edema is likely related to
third spacing of fluids or hepatitis, with a similar process
possibly also explaining moderate colonic mural
thickening/edema. 4. 3mm left lower lobe pulmonary nodule. In
the absence of risk factors for pulmonary malignancy, no
specific followup is necessary. In the presence of those
factors, would recommend dedicated chest CT in 12months.
[**10-28**] Echo: The left atrium is elongated. No atrial septal defect
is seen by 2D or color Doppler. The estimated right atrial
pressure is 0-5 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). There is a mild
resting left ventricular outflow tract obstruction. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic arch is mildly
dilated. The abdominal aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. Mild (1+) mitral regurgitation
is seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with mild
symmetric left ventricular hypertrophy and preserved global and
regional biventricular systolic function. Mild resting left
ventricular outflow tract obstruction. Mildly dilated ascending
aorta, aortic arch, and abdominal aorta. Mild mitral
regurgitation. Mild pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of [**2104-6-6**], a
mild resting LVOT obstruction is now present. Mild dilitation of
the aortic arch and abdominal aorta is now seen. The severity of
pulmonary artery systolic hypertension has increased and is now
mild.
[**2105-11-3**]: Transesophageal echo: No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is normal
(LVEF>55%). The ascending, transverse and descending thoracic
aorta are normal in diameter and free of atherosclerotic plaque
to 30 cm from the incisors. The aortic valve leaflets (3) are
mildly thickened. There are filamentous strands on the aortic
leaflets consistent with Lambl's excresences (normal variant).
No masses or vegetations are seen on the aortic valve. The
mitral valve leaflets are mildly thickened/myxomatous. Mild
posterior leaflet mitral prolapse may be present. No mass or
vegetation is seen on the mitral valve. Mild (1+) (late
systolic) mitral regurgitation is seen. There is mild tricuspid
regurgitation, which may be underestimated due to an eccentric
jet. No mass or vegetation is seen on the tricuspid valve. No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
IMPRESSION: No mass or vegetation seen. Normal left ventricular
function
CXR [**2105-11-4**]: IMPRESSION: 1. New right PICC terminating 1 cm
beyond superior cavoatrial junction. 2. Unchanged mild pulmonary
vascular congestion.
Pathology:
DIAGNOSIS:
Skin, right upper arm; punch (A):
Epidermal spongiosis with neutrophil-containing
parakeratotic scale, surface bacterial organisms and focal
interface changes (see microscopic description and comment).
Microscopic description: Sections show epidermis with semi
confluent parakeratotic scale which contains neutrophils and
scattered surface bacterial organisms (highlighted on a Gram
stain). There is epidermal acanthosis with spongiosis and
lymphocyte exocytosis. There are focal interface changes, and
rare dyskeratotic cells are seen. In the dermis there is a
predominantly perivascular mononuclear infiltrate with spill
into the interstitium. Occasional superficial dermal neutrophils
and rare eosinophils are also seen. Focal red blood cell
extravasation is present. No fungal organisms are seen on a GMS
stain. A specific immunostain for CMV is negative. A specific
treponemal immunostain is in process and the result will be
reported in an addendum. Multiple tissue levels have been
examined.
Comment. The histologic features in this sample are
consistent with a reaction to telaprevir, although a reaction
(in whole or in part) to other drugs cannot be excluded. If
there is continuing clinical concern re-biopsy may yield
additional information. Clinical correlation is suggested.
Brief Hospital Course:
55F with hep C cirrhosis, anemia, hypothyroidism, depression who
developed erythroderma on telepavir and ribavarin complicated by
MSSA bacteremia.
.
#. Rash- Extensive erythrodermic rash with confluent
erythematous eruption with scaling over 80-90% of body, sparing
distal extremities at the time of admission. This rash worsened
after having stopped telepavir and still taking the [**Last Name (LF) 64965**], [**First Name3 (LF) **]
patient will no longer be able to be on either of these
medications. She was originally managed in the MICU, as she had
evidence of DRESS syndrome. She was evaluated by dermatology who
held off on treating her with PO steroids as she was recently on
telepavir. She had a punch biopsy which showed the type of rash
that would be expected with telepavir reaction. She was treated
with topical steroids and the rash had improved significantly at
the time of discharge. On dishcarge she had no crusting or
blistering areas of the skin. Her face had no rash on it, her
legs had some scattered areas of peeling skin, but no papules.
The lesions on her palms had resolved. SHe was discharged on
triamcinalone 0.1% topical steroid twice a day for up to 2
weeks.
#MSSA Bacteremia- patient developed bacteremia. This was most
likely due to her diffuse skin infection which became
secondarily infected. She was originally treated with Vancomycin
and then once speciated was switched to nafcillin. She underwent
a TTE and a TEE which showed no evidence of endocarditis. She
became afebrile and her repeat cx on [**10-30**] was NGTD at the time
of discharge. She was seen by ID who felt that she would
require at least 3 weeks of IV nafcillin and will follow-up with
ID who will determine if further treatment is necessary. She had
a PICC Line placed for this treatment course. She will need to
go to a [**Hospital1 1501**] to have this IV medication administered.
.
#. Hep C Cirrhosis- chronic hepatitis C (genotype 1a) with no
clear risk factors, diagnosed in [**2093-9-23**]. Currently on
ribavirin and peginterferon alfa-2a having completed a 12-week
course of Incivek 650mg 10 day prior to admission ([**2105-10-18**]).
RUQ ultrasound demonstrates circumferential gallbladder mural
thickening and edema, and cirrotic liver, but no evidence of
ascites. Most recent HCV viral load was undetectable at week 8
of Telepavir. She was restarted on her peginterferon prior to
discharge.She should not be continued on ribavarin. Because the
pts platelet count dropped to 35, we decreased the dose of
peginterferon to 130mcg per week. Platetlet count will need to
be closely monitored.
.
#Anemia- Patient was pancytopenic which can be a side effect of
the interferon. She has been on procrit in the past and was
restarted on this prior to discharge. She will need to continue
on this. Her HCT was around 23-25 during her admission and is
opposed to blood product administration due to religious reasons
so never received any blood transfusions during her stay.
#. Hepatic encephalopathy- patient had altered mental status
with elevated ammonia levels at the oSH prior to transfer likely
due to hepatic encephalopathy in the setting of acute infection
and reaction. She was treated with lactulose and this resolved
completely and she was not continued on this at the time of
discharge as she was stable without it.
.
#. hypothyroidism-Patient was originally on her home dose of
levothyroxine (150mcg/day) hwoever she was complaining of
feeling tremulous so this dose of decreased to 100mcg prior to
discharge and she noted an improvement in symptoms.
#. depression- No current SI/HI. continue home dose of
venlafaxine
Transitional Issues:
Pending labs: Skin biopsy results, blood cultures from [**2105-10-30**]
Medications started:
1. Nafcillin (antibiotic),
2. Procrit (injection for anemia)
3. Spironolactone 50mg by mouth once a day (diuretic to get
fluid out of your legs)
4. Furosemide 20mg by mouth once a day (diuretic to get fluid
out of your legs)
5. Ointment for your legs
6. Benadryl as needed for the itching
7. Oxycodone as needed for pain
8. Triamcinolone ointment for affected rash areas
Medications changed:
1. Levothyroxine decreased to 100mcg per day
2. Pegasys interferon decreased from 180mcg per week to 130mcg
per week because of low platelets
Medications stopped:
2. Ribavarin- b/c of worsening rash while on it.
Follow-up
You will need to have your platelet count and your hematocrit
counts checked while you are at rehab as these numbers are low
and you are starting on treatment for your anemia
You have follow-up appointments schedule with Dr. [**Last Name (STitle) **] to
discuss your further treatment for your HCV (for now you are
continuing on the interferon shots every week)
You also have a follow-up appointment scheduled with dermatology
to ensure that your rash is resolving.
**You will need weekly blood draws while at rehab with the
results to be faxed to the ID office here at [**Hospital1 18**]***
-CBC, Basic metabolic panel, LFTs faxed to [**Telephone/Fax (1) 1419**] Attne:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Medications on Admission:
LEVOTHYROXINE 150mcg dialy
PEGINTERFERON ALFA-2A [PEGASYS CONVENIENCE PACK] - (recording
only) - 180 mcg/0.5 mL Kit - Inject 180mcg/0.5mL SQ once weekly
RIBAVIRIN - 600 mg [**Hospital1 **]
SPIRONOLACTONE 100mg Daily
TELAPREVIR 375 mg Tablet - 2Tablet(s) by mouth Every 8 hours
VENLAFAXINE 150 mg Capsule,Ext Release dialy
Medications - OTC
CALCIUM CITRATE-VITAMIN D3 [CALCET CREAMY BITES] - (Prescribed
by Other Provider; OTC) - 500 mg (calcium)-400 unit Tablet,
Chewable - one Tablet(s) by mouth twice daily
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - (Prescribed by Other
Provider) - 1,000 unit Capsule - 1000 units Capsule(s) by mouth
once daily
MULTIVITAMIN - (OTC) - Capsule - 1 Capsule(s) by mouth once a
day
Discharge Medications:
1. spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. petrolatum Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
6. venlafaxine 150 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime) as needed for puritis/insomnia.
9. peginterferon alfa-2a 180 mcg/mL Solution Sig: One (1)
injection Subcutaneous 1X/WEEK (MO): please give 130mcg once a
week on mondays.
10. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. triamcinolone acetonide 0.1 % Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) for 2 weeks: apply to affected areas
.
12. Nafcillin 2 g IV Q4H
13. 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.
14. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day) as needed for constipation.
15. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain for 2 weeks.
Disp:*20 Tablet(s)* Refills:*0*
16. epoetin alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare - [**Location (un) 23638**]
Discharge Diagnosis:
Primary: Erythroderma, Hepatitis C cirrhosis, Bacteremia
Secondary: Hypothyroidism, Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure caring for you while you were here at [**Hospital1 18**].
You were admitted to the hospital because you had a full body
rash that was felt to be a reaction to the telapavir medication
that you were taking for your HCV. You had already completed
this treatment and were still on the ribavarin so we also
stopped your ribavarin. You were origianlly in the ICU because
your rash so so diffuse. Dermatology saw you and took a biopsy
of the rash, and started you on some creams to help with it. At
the time of your discharge your rash was much improved with just
a little left on your legs.
One of the complications from having such a large rash is that
your skin was not protecting you from normal bacteria and you
got a bacterial infection in your blood called bacteremia. You
were seen by the infectious disease specialists who felt that
you would require a total of at least 3 weeks of IV antibotics
for this (nafcillin). They will be following up with you to
determine if more is needed. You had a PICC line (long IV line)
placed for this to be done at rehab. You had no signs that the
infection had affected your heart valves.
Transitional Issues:
Pending labs: Skin biopsy results, blood cultures from [**2105-10-30**]
Medications started:
1. Nafcillin (antibiotic),
2. Procrit (injection for anemia)
3. Spironolactone 50mg by mouth once a day (diuretic to get
fluid out of your legs)
4. Furosemide 20mg by mouth once a day (diuretic to get fluid
out of your legs)
5. Ointment for your legs
6. Benadryl as needed for the itching
7. Oxycodone as needed for pain
8. Triamcinolone ointment for affected rash areas
Medications changed:
1. Levothyroxine decreased to 100mcg per day
Medications stopped:
2. Ribavarin- b/c of worsening rash while on it.
Follow-up
You will need to have your platelet count and your hematocrit
counts checked while you are at rehab as these numbers are low
and you are starting on treatment for your anemia
You have follow-up appointments schedule with Dr. [**Last Name (STitle) **] to
discuss your further treatment for your HCV (for now you are
continuing on the interferon shots every week)
You also have a follow-up appointment scheduled with dermatology
to ensure that your rash is resolving.
**You will need weekly blood draws while at rehab with the
results to be faxed to the ID office here at [**Hospital1 18**]***
-CBC, Basic metabolic panel, LFTs faxed to [**Telephone/Fax (1) 1419**] Attne:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Followup Instructions:
Name: [**Last Name (LF) 64966**], [**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 4094**]: FAMILY MEDICINE
Address: 65 RT 134, [**Location **], [**Numeric Identifier 64967**]
Phone: [**Telephone/Fax (1) 64968**]
**Please discuss with the staff at the facility the need for a
follow up appointment with your PCP when you are ready for
discharge**
.
Department: ORTHOPEDICS
When: TUESDAY [**2105-11-17**] at 11:15 AM
With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST
Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: LIVER CENTER
When: TUESDAY [**2105-11-17**] at 12:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST
Best Parking: [**Hospital Ward Name **] Garage
.
Department: INFECTIOUS DISEASE
When: TUESDAY [**2105-11-17**] at 1:30 PM
With: [**First Name11 (Name Pattern1) 3049**] [**Last Name (NamePattern4) 14666**], 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: DERMATOLOGY
When: WEDNESDAY [**2105-11-18**] at 1:45 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16424**], MD [**Telephone/Fax (1) 1971**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST
Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
|
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"571.5",
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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22404, 22493
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14918, 18568
|
277, 380
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22628, 22628
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3583, 3583
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2464, 2538
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22514, 22607
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5116, 5537
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2553, 3183
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23983, 25334
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233, 239
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408, 2074
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2096, 2330
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2362, 2431
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,410
| 131,700
|
34675
|
Discharge summary
|
report
|
Admission Date: [**2131-9-6**] Discharge Date: [**2131-9-10**]
Date of Birth: [**2058-1-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Mental Status Changes
Major Surgical or Invasive Procedure:
Central venous line placement
History of Present Illness:
Patient is a 73 year old male with a past medical history of
AVR/MVR for VRE endocarditis and abscess [**7-6**], discharged
[**2131-9-4**] with recurrent abscess and new MVR vegetation, now
admitted with altered mental status. Patient was admitted to
MICU for multisystem organ failure in setting of likely
recurrent VRE endocarditis on multiple valves breaking through
therapy.
MICU Course: Initial lactate 8.9 with improvement to 6.6 on
dobutamine. Patient was placed on Daptomycin/Zosyn in MICU.
Patient weaned off pressors. Lacate improved to 3.7. Patient
noted to have liver dysfunction, acute on chronic renal failure,
and worsening diastolic and valvular function. Patient remained
altered and oriented only to self. Patient remains not a
surgical candidate. After detailed discussion with family,
decision was made to make patient DNR/DNI, Comfort Measures, No
dialysis. Patient self discontinued his central line and family
agreed with no further antibiotics. Patient followed by
Palliative Care team. Patient started on scopolamine patch,
hyoscyamine, ativan, dilaudid and haldol prn for comfort.
Patient originally from [**State 108**] and unable to go home. Patient
transferred to floor for palliative care.
Past Medical History:
s/p aortic valve replacement [**8-5**]
hypertension
chronic renal insufficiency
abdominal aortic aneurysm
sleep apnea
benign prostatic hypertrophy
hypercholesterolemia
s/p bilateral cataract extractions
cardiomyopathy
sp/ redo sternotomy, redo aortic valve replacement, mitral valve
replacement, closure aorto-[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]
Social History:
Married, retired computer programmer, lives with wife in
[**Name (NI) 108**].
No current tobacco use, EtOH 2 drinks/week
Family History:
Non-contributory
Physical Exam:
Vitals: T 95, BP 111/89, HR 69, RR 15, O2 100% 2L CVP 16
General: Ill-appearing. Confused
HEENT: Pupils 2mm symmetric
Neck: non-tender, full ROM
CV: no JVD, RRR, III/VI systolic crescendo murmur, and [**2-1**] RSB
early diastolic murmur
Resp: CTAB, no WRR
Breast: well-healing sternal wound; 3-4 cm inferior aspect with
good granulation tissue, no purulent drainage
GI: + BS NT/ND, NABS
GU: foley, scant urine
Neuro: moving all 4 extremities, follows simple commands
Patient was discharged to death. Above is physical exam on
presentation.
Pertinent Results:
Admission Labs:
[**2131-9-6**] 10:54PM LACTATE-7.4*
[**2131-9-6**] 10:30PM GLUCOSE-53* UREA N-94* CREAT-4.5* SODIUM-134
POTASSIUM-5.6* CHLORIDE-93* TOTAL CO2-23 ANION GAP-24*
[**2131-9-6**] 10:30PM WBC-17.9* RBC-3.22* HGB-8.7* HCT-28.1* MCV-88
MCH-27.1 MCHC-31.0 RDW-19.7*
[**2131-9-6**] 10:30PM NEUTS-89.9* LYMPHS-5.9* MONOS-4.0 EOS-0
BASOS-0.1
[**2131-9-6**] 10:30PM PLT COUNT-165
[**2131-9-6**] 09:22PM LACTATE-7.9*
[**2131-9-6**] 07:51PM LACTATE-6.6*
[**2131-9-6**] 06:53PM GLUCOSE-61* UREA N-94* CREAT-4.3* SODIUM-134
POTASSIUM-5.7* CHLORIDE-92* TOTAL CO2-23 ANION GAP-25*
[**2131-9-6**] 06:53PM TOT PROT-6.3*
[**2131-9-6**] 06:53PM CORTISOL-42.8*
[**2131-9-6**] 06:53PM CRP-102.6*
[**2131-9-6**] 06:51PM COMMENTS-GREEN
[**2131-9-6**] 06:51PM LACTATE-7.5*
[**2131-9-6**] 06:50PM TYPE-ART PO2-78* PCO2-42 PH-7.33* TOTAL
CO2-23 BASE XS--3
[**2131-9-6**] 06:10PM PO2-42* PCO2-49* PH-7.29* TOTAL CO2-25 BASE
XS--3
[**2131-9-6**] 06:10PM O2 SAT-68
[**2131-9-6**] 05:15PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.012
[**2131-9-6**] 05:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2131-9-6**] 05:15PM URINE RBC-[**5-8**]* WBC-21-50* BACTERIA-MOD
YEAST-NONE EPI-
[**2131-9-6**] 02:02PM PT-25.5* PTT-33.8 INR(PT)-2.5*
[**2131-9-6**] 12:01PM COMMENTS-GREEN TOP
[**2131-9-6**] 12:01PM LACTATE-8.9*
[**2131-9-6**] 11:40AM GLUCOSE-100 UREA N-93* CREAT-4.5* SODIUM-134
POTASSIUM-5.5* CHLORIDE-90* TOTAL CO2-22 ANION GAP-28*
[**2131-9-6**] 11:40AM estGFR-Using this
[**2131-9-6**] 11:40AM AST(SGOT)-824* CK(CPK)-103 ALK PHOS-203* TOT
BILI-4.3*
[**2131-9-6**] 11:40AM LIPASE-58
[**2131-9-6**] 11:40AM CK-MB-4 cTropnT-0.16*
[**2131-9-6**] 11:40AM ALBUMIN-3.0* CALCIUM-9.7 PHOSPHATE-7.5*#
MAGNESIUM-2.5
[**2131-9-6**] 11:40AM WBC-19.8*# RBC-3.37* HGB-9.1* HCT-29.7*
MCV-88 MCH-27.1 MCHC-30.8* RDW-19.5*
[**2131-9-6**] 11:40AM NEUTS-93.2* LYMPHS-4.0* MONOS-2.7 EOS-0.1
BASOS-0.1
[**2131-9-6**] 11:40AM PLT COUNT-212
[**2131-9-7**] 12:55AM BLOOD Neuts-90.6* Lymphs-5.5* Monos-3.8 Eos-0.1
Baso-0.1
[**2131-9-6**] 06:53PM BLOOD Cortsol-42.8*
[**2131-9-6**] 06:53PM BLOOD CRP-102.6*
RULE OUT MI
[**2131-9-7**] 07:18AM BLOOD CK-MB-6 cTropnT-0.15*
[**2131-9-6**] 11:40AM BLOOD CK-MB-4 cTropnT-0.16*
LABS PRIOR TO CMO:
[**2131-9-8**] 03:25AM BLOOD PT-32.7* PTT-34.2 INR(PT)-3.4*
[**2131-9-8**] 02:09PM BLOOD Glucose-85 UreaN-116* Creat-5.7* Na-139
K-5.3* Cl-96 HCO3-23 AnGap-25*
[**2131-9-8**] 03:25AM BLOOD ALT-665* AST-834* LD(LDH)-1116*
AlkPhos-191* TotBili-3.5*
[**2131-9-8**] 02:09PM BLOOD Calcium-8.9 Phos-7.8* Mg-2.5
[**2131-9-7**] 01:17AM BLOOD Type-MIX Temp-36.6 O2 Flow-3 pO2-34*
pCO2-48* pH-7.33* calTCO2-26 Base XS--1 Intubat-NOT INTUBA
[**2131-9-8**] 03:02PM BLOOD Lactate-3.7*
MICROBIOLOGICAL STUDIES:
[**2131-9-6**] 11:40 am BLOOD CULTURE LABS OFF PICC LINE.
**FINAL REPORT [**2131-9-9**]**
Blood Culture, Routine (Final [**2131-9-9**]):
ENTEROCOCCUS FAECIUM.
DR [**Last Name (STitle) **] CALLED AND REQUESTED
DAPTOMYCIN,LINEZOLID,SYNERCID,TETRACYCLINE AND RIFAMPIN
[**2131-9-8**].
DAPTOMYCIN = 2UG/ML BY E-TEST .
SYNERCID = SENSITIVE <=0.25 UG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
RIFAMPIN-------------- R
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
[**2131-9-6**] 5:15 pm URINE Site: CATHETER
**FINAL REPORT [**2131-9-8**]**
URINE CULTURE (Final [**2131-9-8**]):
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 4 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
[**2131-9-6**] 10:30 pm CATHETER TIP-IV PICC LINE TIP.
**FINAL REPORT [**2131-9-9**]**
WOUND CULTURE (Final [**2131-9-9**]): No significant growth.
-------------------
Blood Cultures from [**9-7**] and [**9-8**]: No growth at time of
patient death
IMAGING STUDIES:
ECHO [**2131-9-6**]
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild global left ventricular
hypokinesis (LVEF = 40-45 %). The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
There is abnormal systolic septal motion/position consistent
with right ventricular pressure overload. A bioprosthetic aortic
valve prosthesis is present. A paravalvular aortic valve leak is
probably present. Moderate (2+) aortic regurgitation is seen.
There is a mass on the mitral valve. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2131-8-30**],
the findings are similar.
CT Head [**2131-9-6**]
FINDINGS: There is no acute intracranial hemorrhage, shift of
normally
midline structures, hydrocephalus, major or minor vascular
territorial
infarction. Calcifications of the cavernous portion of the
carotid arteries
is noted. The density values of the brain parenchyma are
maintained. Mild low
attenuation in the periventricular white matter is consistent
with chronic
small vessel ischemia. The visualized paranasal sinuses and
mastoid air cells
appear well aerated. Soft tissues and osseous structures are
unremarkable.
Brief Hospital Course:
Patient is a 73 year old male with a past medical history of
AVR/MVR for VRE endocarditis and abscess [**7-6**], discharged
[**2131-9-4**] with recurrent abscess and new MVR vegetation, who was
admitted with altered mental status. Patient was admitted to
MICU for multisystem organ failure in setting of likely
recurrent VRE endocarditis on multiple valves breaking through
therapy. Of note, cultures grew vancomycin sensitive
enterococcus.
MICU Course: Initial lactate 8.9 with improvement to 6.6 on
dobutamine. Patient was placed on Daptomycin/Zosyn in MICU.
Patient weaned off pressors. Lacate improved to 3.7. Patient
noted to have liver dysfunction, acute on chronic renal failure,
and worsening diastolic and valvular function. Patient was also
noted to have multidrug resistant pseudomonal urinary tract
infection. Despite aggressive treatment, patient remained
altered and oriented only to self and clinically continued to
deteriorate. Patient was not considered a surgical candidate.
After detailed discussion with family, decision was made to make
patient DNR/DNI, Comfort Measures, No dialysis. Patient self
discontinued his central line and family agreed with no further
antibiotics. Patient followed by Palliative Care team. Patient
started on scopolamine patch, hyoscyamine, ativan, dilaudid and
haldol prn for comfort. Patient originally from [**State 108**] and
unable to go home. Patient transferred to floor for palliative
care.
Patient was transferred to floor where he was provided with pain
control as needed. He expired within one day of transfer to the
floor with family at his bedside.
Medications on Admission:
Medications: (Rehab med list not available, taken from DC
summary of [**9-4**]
Daptomycin 900 mg Recon Soln Sig: 500 mg Recon Solns
Intravenous Q48H (every 48 hours).
Linazolid 600mg IV Q12 hours
Simvastatin 80 mg Tablet daily
Aspirin 81 mg Tablet, daily
Metolazone 5 mg Tablet [**Hospital1 **]
Potassium Chloride 20 mEq Packet PO Q12H
Docusate Sodium 100 mg P [**Hospital1 **]
Acetaminophen 325 mg Tablet 2 PO Q4H
Heparin (Porcine) 5,000 unit/mL TID
Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-29**]
Drops Ophthalmic PRN (as needed).
Bisacodyl 5 mg Tablet, Delayed Release 2 tab po DAILY
Furosemide 10 mg/mL Solution Sig: 120mg Injection Q12H
Sodium Chloride 0.45 % 0.45 % Parenteral Solution Sig: Ten
(10) ML Intravenous PRN (as needed) as needed for line flush.
Tramadol 50 mg Tablet Sig: 1 Tablet PO Q4H
Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Amiodarone 200 mg Tablet Sig: One (1) Tablet PO daily
Discharge Medications:
Not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Enterococcus endocarditis
Acute on chronic renal failure
Valvular Systolic Cardiomyopathy
Pseudomonal urinary tract infection
Sepsis with multisystem organ failure
Discharge Condition:
discharged to death
Discharge Instructions:
not applicable
Followup Instructions:
not applicable
Completed by:[**2131-9-10**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"38.93"
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icd9pcs
|
[
[
[]
]
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11719, 11728
|
8904, 10520
|
335, 366
|
11945, 11966
|
2757, 2757
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1638, 2008
|
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|
7440, 8881
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Subsets and Splits
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